Estimates of burden and consequences of infants born small for gestational age in low and middle income countries with INTERGROWTH-21st standard: analysis of CHERG datasets.

Objectives To estimate small for gestational age birth prevalence and attributable neonatal mortality in low and middle income countries with the INTERGROWTH-21st birth weight standard.Design Secondary analysis of data from the Child Health Epidemiology Reference Group (CHERG), including 14 birth cohorts with gestational age, birth weight, and neonatal follow-up. Small for gestational age was defined as infants weighing less than the 10th centile birth weight for gestational age and sex with the multiethnic, INTERGROWTH-21st birth weight standard. Prevalence of small for gestational age and neonatal mortality risk ratios were calculated and pooled among these datasets at the regional level. With available national level data, prevalence of small for gestational age and population attributable fractions of neonatal mortality attributable to small for gestational age were estimated.Setting CHERG birth cohorts from 14 population based sites in low and middle income countries.Main outcome measures In low and middle income countries in the year 2012, the number and proportion of infants born small for gestational age; number and proportion of neonatal deaths attributable to small for gestational age; the number and proportion of neonatal deaths that could be prevented by reducing the prevalence of small for gestational age to 10%.Results In 2012, an estimated 23.3 million infants (uncertainty range 17.6 to 31.9; 19.3% of live births) were born small for gestational age in low and middle income countries. Among these, 11.2 million (0.8 to 15.8) were term and not low birth weight (≥2500 g), 10.7 million (7.6 to 15.0) were term and low birth weight (<2500 g) and 1.5 million (0.9 to 2.6) were preterm. In low and middle income countries, an estimated 606 500 (495 000 to 773 000) neonatal deaths were attributable to infants born small for gestational age, 21.9% of all neonatal deaths. The largest burden was in South Asia, where the prevalence was the highest (34%); about 26% of neonatal deaths were attributable to infants born small for gestational age. Reduction of the prevalence of small for gestational age from 19.3% to 10.0% in these countries could reduce neonatal deaths by 9.2% (254 600 neonatal deaths; 164 800 to 449 700).Conclusions In low and middle income countries, about one in five infants are born small for gestational age, and one in four neonatal deaths are among such infants. Increased efforts are required to improve the quality of care for and survival of these high risk infants in low and middle income countries.

Inequality in malnutrition by maternal education levels in early childhood: the Prospective Cohort of Thai Children (PCTC).

BACKGROUND AND OBJECTIVES: As tackling socioeconomic inequality in child malnutrition still remains one of the greatest challenges in developing countries, we examined maternal educational differences in malnutrition and the magnitude of its inequality among 4,198 children from the Prospective Cohort study of Thai Children (PCTC). METHODS AND STUDY DESIGN: Prevalence of stunting, underweight, and wasting from birth to 24 months was calculated using the new WHO growth chart. The Relative Index of Inequality (RII) was used to examine the magnitude and trend of inequality in malnutrition between maternal educational levels. RESULTS: The low education group had lower weight and height in most ages than the high education group. Faltering in height was observed in all education levels, but was most remarkable in the low education group. On the other hand, while upward trends for weight-for-age and weight-for-height across ages were observed in the high education group, a marked decline between 6 to 12 months was observed in the low education group. An increasing trend in inequality in The RII revealed an increasing trend in inequality in stunting, underweight, and wasting by maternal education levels was observed during infancy with an almost monotonic increase until 24 months, although the inequality in wasting decreased after 18 months of age. CONCLUSION: Inequality in malnutrition remarkably increased during infancy, and for stunting and underweight it remained until 24 months. These findings shed light on the extent of malnutrition inequality during the first 2 years of life and they suggest sustainable efforts must be established at the national level to tackle the malnutrition inequality in infancy.

Knowledge, attitudes, and practices about tuberculosis and choice of communication channels in Thailand.

INTRODUCTION: The aim of this study was to assess tuberculosis (TB) knowledge, attitudes, and practices in both the general population and risk groups in Thailand. METHODOLOGY: In a cross-sectional survey, a general population (n = 3,074) and family members of a TB patient (n = 559) were randomly selected, using stratified multistage sampling, and interviewed. RESULTS: The average TB knowledge score was 5.7 (maximum = 10) in the Thai and 5.1 in the migrant and ethnic minorities general populations, 6.3 in Thais with a family member with TB, and 5.4 in migrants and ethnic minorities with a family member with TB. In multivariate linear regression among the Thai general population, higher education, higher income, and knowing a person from the community with TB were all significantly associated with level of TB knowledge. Across the different study populations, 18.6% indicated that they had undergone a TB screening test. Multivariate logistic regression found that older age, lower education, being a migrant or belonging to an ethnic minority group, residing in an area supported by the Global Fund, better TB knowledge, having a family member with TB, and knowing other people in the community with TB was associated having been screened for TB. CONCLUSION: This study revealed deficiencies in the public health knowledge about TB, particularly among migrants and ethnic minorities in Thailand. Sociodemographic factors should be considered when designing communication strategies and TB prevention and control interventions.

Comparison of Prevalence of Nutritional Status of Thai Children in the First 2 Years of Life Using National and International Growth Charts.

OBJECTIVE: Identify the difference of the nutritional status of Thai children from birth to 24 months of age using the national and international growth charts. MATERIAL AND METHOD: The analytic sample was of 4,224 children from the Prospective Cohort Study of Thai Children (PCTC). Age-specific prevalence of malnutrition was estimated using the NCHS, WHO, and Thai growth charts. RESULTS: Rapid growth faltering was found in both genders during the first two years, regardless of the reference, but the Thai charts reflected better Thai children. When using the Thai and NCHS charts, a steep fluctuation was observed in infancy, although the prevalence of wasting, underweight, and overweight between the references became narrower at 24 months. Meanwhile, the WHO standards identified a higher number of stunted children and showed a linear increasing trend of overweight with age, compared to the Thai reference. CONCLUSION: Although the Thai growth charts better reflect the Thai children, in consideration of a double burden of stunting and overweight in Thailand, the WHO standards can be used to identify Thai children at risk of stunting and overweight in the first two years of life.

Short Maternal Stature Increases Risk of Small-for-Gestational-Age and Preterm Births in Low- and Middle-Income Countries: Individual Participant Data Meta-Analysis and Population Attributable Fraction.

BACKGROUND: Small-for-gestational-age (SGA) and preterm births are associated with adverse health consequences, including neonatal and infant mortality, childhood undernutrition, and adulthood chronic disease. OBJECTIVES: The specific aims of this study were to estimate the association between short maternal stature and outcomes of SGA alone, preterm birth alone, or both, and to calculate the population attributable fraction of SGA and preterm birth associated with short maternal stature. METHODS: We conducted an individual participant data meta-analysis with the use of data sets from 12 population-based cohort studies and the WHO Global Survey on Maternal and Perinatal Health (13 of 24 available data sets used) from low- and middle-income countries (LMIC). We included those with weight taken within 72 h of birth, gestational age, and maternal height data (n = 177,000). For each of these studies, we individually calculated RRs between height exposure categories of < 145 cm, 145 to < 150 cm, and 150 to < 155 cm (reference: ≥ 155 cm) and outcomes of SGA, preterm birth, and their combination categories. SGA was defined with the use of both the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st) birth weight standard and the 1991 US birth weight reference. The associations were then meta-analyzed. RESULTS: All short stature categories were statistically significantly associated with term SGA, preterm appropriate-for-gestational-age (AGA), and preterm SGA births (reference: term AGA). When using the INTERGROWTH-21st standard to define SGA, women < 145 cm had the highest adjusted risk ratios (aRRs) (term SGA-aRR: 2.03; 95% CI: 1.76, 2.35; preterm AGA-aRR: 1.45; 95% CI: 1.26, 1.66; preterm SGA-aRR: 2.13; 95% CI: 1.42, 3.21). Similar associations were seen for SGA defined by the US reference. Annually, 5.5 million term SGA (18.6% of the global total), 550,800 preterm AGA (5.0% of the global total), and 458,000 preterm SGA (16.5% of the global total) births may be associated with maternal short stature. CONCLUSIONS: Approximately 6.5 million SGA and/or preterm births in LMIC may be associated with short maternal stature annually. A reduction in this burden requires primary prevention of SGA, improvement in postnatal growth through early childhood, and possibly further intervention in late childhood and adolescence. It is vital for researchers to broaden the evidence base for addressing chronic malnutrition through multiple life stages, and for program implementers to explore effective, sustainable ways of reaching the most vulnerable populations.

Severe early childhood caries and social determinants in three-year-old children from Northern Thailand: a birth cohort study.

BACKGROUND: The purpose of this study was to investigate the prevalence and social risk factors of severe early childhood caries in three-year-old children in Northern Thailand, using a birth-cohort study METHODS: The data utilized in this study were from the prospective cohort study of Thai children (PCTC) from the 28 to 38 weeks gestational age until the children reached the age of 36 months (N = 597) in Mueang Nan district, Northern Thailand. Questionnaires were administered at different time points and dental examination was conducted at the age of 3 years of the child. RESULTS: 44.1% of the 3 year old children had S-ECC. In multivariate logistic regression analysis, environmental factors (the use of rain or well water as drinking water, no schooling of mother of child, being male), and risk behaviour (sleeping with a bottle at 30 months) were associated with S-ECC. Further, in bivariate analysis, psychological distress in the mother, lack of spousal relationship support, suckle to sleep when going to bed, introduction of soft drinks at 12 months, having had more frequently sweet food, and less than daily tooth brushing before 30 months were associated with S-ECC. CONCLUSIONS: A very high rate of S-ECC was observed, and oral health may be influenced by social factors.

Comparison of US Birth Weight References and the International Fetal and Newborn Growth Consortium for the 21st Century Standard.

IMPORTANCE: This study introduces how the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st) international birth weight standards alter our previous understanding and interpretations of fetal growth restriction as represented by small for gestational age (SGA) status. OBJECTIVES: To compare the birth weight distributions of the INTERGROWTH-21st international standard to commonly used US references and examine the differences in the prevalence and neonatal mortality risk of SGA status (below the 10th percentile of a population reference). DESIGN, SETTING, AND PARTICIPANTS: We analyzed data from 16 prospective cohorts of newborns on gestational age, birth weight, and systematic mortality follow-up through 28 days from 10 low- and middle-income countries. The studies included were conducted between 1983 and 2008. The analysis was conducted in 2014. Infants were categorized as SGA using the 1991 US birth weight reference, the 1999-2000 US birth weight reference, and the new INTERGROWTH-21st standard. For each study, we compared the SGA prevalence and the risk ratio between SGA status and neonatal mortality, calculated using Poisson regression with robust error variance. MAIN OUTCOMES AND MEASURES: We examine neonatal mortality (death within the first 28 days after birth) as the main outcome measure. RESULTS: The pooled SGA prevalence was 23.7% (95% CI, 16.5%-31.0%) using the INTERGROWTH-21st standard compared with 36.0% (95% CI, 27.0%-45.0%) with the US 2000 reference. The relative decrease in prevalence was larger among infants born at 33 to less than 37 weeks' gestation compared with term infants. The pooled neonatal mortality risk did not differ significantly; the adjusted risk ratios were 2.13 (95% CI, 1.78-2.54; P < .001) for the INTERGROWTH-21st standard and 2.12 (95% CI, 1.81-2.48; P < .001) for the US 2000 reference. CONCLUSIONS AND RELEVANCE: To our knowledge, INTERGROWTH-21st is the first international newborn standard for size for gestational age for healthy fetal growth. We observed a greater-than-one-quarter reduction in SGA prevalence and no significant change in the associated neonatal mortality risk, resulting in a decrease in the percentage of neonatal death attributable to SGA. Our study sheds light on how previously published studies on SGA status may be reinterpreted with the introduction of this new birth weight standard.

Determinants of cervical cancer screening adherence in urban areas of Nakhon Ratchasima Province, Thailand.

Cervical cancer is the most common disease among Thai women. The cervical cancer mortality rate has increased in the previous decade. Therefore, this cross-sectional study was conducted to examine the factors associated with cervical cancer screening adherence. Stratified sampling with the proportional to size method was used to select registered women aged 30-60 years. Of the 700 self-administered questionnaires distributed during July and September of 2012, 675 were returned, resulting in a response rate of 96.2%. Approximately 65.4% of the women were considered to be adherent to cervical cancer screening (i.e., maintainers) as defined by at least one screening within the recommended 5-year screening interval and the expectation of attending a screening in the future. Chi-square tests revealed that occupation, marital status, number of children, sexual activity, health insurance scheme, history of oral contraceptive pill use, perceived barriers, perceived benefits, and knowledge about cervical cancer prevention were significantly associated with cervical cancer screening adherence. After adjusting for occupation, marital status, number of children, and health insurance in the model, perceived barriers (Adj OR=1.97, 95% CI=1.24-3.10) and knowledge (Adj OR=1.65, 95% CI=1.13-2.41) remained significant predictors of cervical cancer screening adherence. These findings suggest that the non-housewives, women of single/separated/divorced/widowed status, and women with no children should be the first priorities for getting Pap tests. Strategies for overcoming the barriers of these women, such as using mobile units for cervical cancer screening, should be promoted. Education programs should be strengthened and promoted to overcome negative perceptions and knowledge deficiencies.

Determinants of postnatal service utilisation among mothers in rural settings of Malawi.

The aim of this study was to determine significant predictors for the utilisation of postnatal service among mothers. A total of 295 postnatal mothers were enrolled in a cross-sectional study design undertaken in six health facilities of Lilongwe District using two-stage cluster sampling with a response rate of 100%. The data were collected by interview from December 2012 to January 2013 using a structured questionnaire. The result showed that over half of the mothers (56.6%) utilised postnatal service within 6 weeks after delivery. A stepwise multiple logistic regression was used to determine significant determinants of utilisation of postnatal service among mothers. After adjusting for confounding factors, utilisation of an alternative local source of care in home after delivery [adjusted odds ratio (aOR): 7.77, 95% CI: 4.14-14.58], women's perception on performance of health workforce during delivery and postnatal service (aOR: 6.56, 95% CI: 3.09-13.94), health education before hospital discharge of postnatal mothers (aOR: 4.08, 95% CI: 2.11-7.92), place of delivery (aOR: 4.32, 95% CI: 1.32-14.12), family income (aOR: 1.89, 95% CI: 1.03-3.46) and the occurrence of no complications during delivery (aOR: 1.90, 95% CI: 1.03-3.50) were significantly associated with the utilisation of postnatal service. Hence, this study suggests that improved health workforce performance coupled with effective health education may increase the utilisation of postnatal service. Furthermore, the utilisation of postnatal service may also be increased through reducing home deliveries, delivery complications and the use of alternative local care at home after delivery. Integration of postnatal service in outreach clinics might also assist through reducing the cost of accessing postnatal service among mothers.

Sociobehavioral factors associated with caries increment: a longitudinal study from 24 to 36 months old children in Thailand.

The aim of this study is to investigate sociobehavioral risk factors from the prenatal period until 36 months of age, and the caries increment from 24 to 36 months of the child in Thailand. The data utilized in this study come from the prospective cohort study of Thai children (PCTC) from prenatal to 36 months of the child in Mueang Nan district, Northern Thailand. The total sample size recruited was 783 infants. The sample size with dental caries data was 603 and 597, at 24 months and at 36 months, respectively. The sample size of having two assessment points with a dental examination (at 24 months and at 36 months) was 597. Results indicate that the caries increment was 52.9%, meaning from 365 caries free children at 24 months 193 had developed dental caries at 36 months. The prevalence of dental caries was 34.2% at 24 months (n = 206) and 68.5% at 36 months of age (n = 409). In bivariate analysis, higher education of the mother, lower household income, bottle feeding of the infant, frequent sweet candy consumptions, and using rain or well water as drinking water were associated with dental caries increment, while in multivariate conditional logistic regression analysis lower household income, higher education of the mother, and using rain or well water as drinking water remained associated with dental caries increment. In conclusion, a very significant increase in caries development was observed, and oral health may be influenced by sociobehavioural risk factors.

Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries: a pooled country analysis.

BACKGROUND: Babies with low birthweight (<2500 g) are at increased risk of early mortality. However, low birthweight includes babies born preterm and with fetal growth restriction, and not all these infants have a birthweight less than 2500 g. We estimated the neonatal and infant mortality associated with these two characteristics in low-income and middle-income countries. METHODS: For this pooled analysis, we searched all available studies and identified 20 cohorts (providing data for 2,015,019 livebirths) from Asia, Africa, and Latin America that recorded data for birthweight, gestational age, and vital statistics through 28 days of life. Study dates ranged from 1982 through to 2010. We calculated relative risks (RR) and risk differences (RD) for mortality associated with preterm birth (<32 weeks, 32 weeks to <34 weeks, 34 weeks to <37 weeks), small-for-gestational-age (SGA; babies with birthweight in the lowest third percentile and between the third and tenth percentile of a US reference population), and preterm and SGA combinations. FINDINGS: Pooled overall RRs for preterm were 6·82 (95% CI 3·56-13·07) for neonatal mortality and 2·50 (1·48-4·22) for post-neonatal mortality. Pooled RRs for babies who were SGA (with birthweight in the lowest tenth percentile of the reference population) were 1·83 (95% CI 1·34-2·50) for neonatal mortality and 1·90 (1·32-2·73) for post-neonatal mortality. The neonatal mortality risk of babies who were both preterm and SGA was higher than that of babies with either characteristic alone (15·42; 9·11-26·12). INTERPRETATION: Many babies in low-income and middle-income countries are SGA. Preterm birth affects a smaller number of neonates than does SGA, but is associated with a higher mortality risk. The mortality risks associated with both characteristics extend beyond the neonatal period. Differentiation of the burden and risk of babies born preterm and SGA rather than with low birthweight could guide prevention and management strategies to speed progress towards Millennium Development Goal 4--the reduction of child mortality. FUNDING: Bill & Melinda Gates Foundation.

The associations of parity and maternal age with small-for-gestational-age, preterm, and neonatal and infant mortality: a meta-analysis.

BACKGROUND: Previous studies have reported on adverse neonatal outcomes associated with parity and maternal age. Many of these studies have relied on cross-sectional data, from which drawing causal inference is complex. We explore the associations between parity/maternal age and adverse neonatal outcomes using data from cohort studies conducted in low- and middle-income countries (LMIC). METHODS: Data from 14 cohort studies were included. Parity (nulliparous, parity 1-2, parity ≥ 3) and maternal age (<18 years, 18-<35 years, ≥ 35 years) categories were matched with each other to create exposure categories, with those who are parity 1-2 and age 18-<35 years as the reference. Outcomes included small-for-gestational-age (SGA), preterm, neonatal and infant mortality. Adjusted odds ratios (aOR) were calculated per study and meta-analyzed. RESULTS: Nulliparous, age <18 year women, compared with women who were parity 1-2 and age 18-<35 years had the highest odds of SGA (pooled adjusted OR: 1.80), preterm (pooled aOR: 1.52), neonatal mortality (pooled aOR: 2.07), and infant mortality (pooled aOR: 1.49). Increased odds were also noted for SGA and neonatal mortality for nulliparous/age 18-<35 years, preterm, neonatal, and infant mortality for parity ≥ 3/age 18-<35 years, and preterm and neonatal mortality for parity ≥ 3/≥ 35 years. CONCLUSIONS: Nulliparous women <18 years of age have the highest odds of adverse neonatal outcomes. Family planning has traditionally been the least successful in addressing young age as a risk factor; a renewed focus must be placed on finding effective interventions that delay age at first birth. Higher odds of adverse outcomes are also seen among parity ≥ 3 / age ≥ 35 mothers, suggesting that reproductive health interventions need to address the entirety of a woman's reproductive period. FUNDING: Funding was provided by the Bill & Melinda Gates Foundation (810-2054) by a grant to the US Fund for UNICEF to support the activities of the Child Health Epidemiology Reference Group.

National and regional estimates of term and preterm babies born small for gestational age in 138 low-income and middle-income countries in 2010.

BACKGROUND: National estimates for the numbers of babies born small for gestational age and the comorbidity with preterm birth are unavailable. We aimed to estimate the prevalence of term and preterm babies born small for gestational age (term-SGA and preterm-SGA), and the relation to low birthweight (<2500 g), in 138 countries of low and middle income in 2010. METHODS: Small for gestational age was defined as lower than the 10th centile for fetal growth from the 1991 US national reference population. Data from 22 birth cohort studies (14 low-income and middle-income countries) and from the WHO Global Survey on Maternal and Perinatal Health (23 countries) were used to model the prevalence of term-SGA births. Prevalence of preterm-SGA infants was calculated from meta-analyses. FINDINGS: In 2010, an estimated 32·4 million infants were born small for gestational age in low-income and middle-income countries (27% of livebirths), of whom 10·6 million infants were born at term and low birthweight. The prevalence of term-SGA babies ranged from 5·3% of livebirths in east Asia to 41·5% in south Asia, and the prevalence of preterm-SGA infants ranged from 1·2% in north Africa to 3·0% in southeast Asia. Of 18 million low-birthweight babies, 59% were term-SGA and 41% were preterm-SGA. Two-thirds of small-for-gestational-age infants were born in Asia (17·4 million in south Asia). Preterm-SGA babies totalled 2·8 million births in low-income and middle-income countries. Most small-for-gestational-age infants were born in India, Pakistan, Nigeria, and Bangladesh. INTERPRETATION: The burden of small-for-gestational-age births is very high in countries of low and middle income and is concentrated in south Asia. Implementation of effective interventions for babies born too small or too soon is an urgent priority to increase survival and reduce disability, stunting, and non-communicable diseases. FUNDING: Bill & Melinda Gates Foundation by a grant to the US Fund for UNICEF to support the activities of the Child Health Epidemiology Reference Group (CHERG).

Prevalence and incidence of child stunting from birth to two years of life in Thai children: based on the Prospective Cohort Study of Thai Children (PCTC).

OBJECTIVE: To determine the percentages of prevalence and incidence in child stunting at birth, 6, 12, 18, and 24 months of age and to investigate the association between factors and child stunting outcome MATERIAL AND METHOD: The Prospective Cohort Study of Thai Children (PCTC) was carried out during 2000-2002, data from five districts were examined, and anthropometric measurements were performed by the physician and research assistants. WHO's growth reference standard year 2005 was used. RESULTS: Four thousand two hundred forty five children were included at the start of the present study of which 3,898 were in the final analysis. The prevalence in child stunting presented an increasing percentage at birth 6, 12, 18, and 24 months was 6.0, 6.9, 9.5, 14.6, and 16.6%, and incidence indicated decreasing at birth, 6, 12, 18, and 24 months was 6.0, 4.3, 4.1, 5.2, and 3.2% respectively. The GEE analysis showed that gender mother height, mother education, income, and Nan-Hill Tribe areas were significantly correlated with child stunting (p < 0.001). CONCLUSION: Finding from the present study indicates that to reduce child stunting in Thailand in early infant's life, early nutritional interventions and quality antenatal care are vital.