Small babies, big risks: global estimates of prevalence and mortality for vulnerable newborns to accelerate change and improve counting.

Small newborns are vulnerable to mortality and lifelong loss of human capital. Measures of vulnerability previously focused on liveborn low-birthweight (LBW) babies, yet LBW reduction targets are off-track. There are two pathways to LBW, preterm birth and fetal growth restriction (FGR), with the FGR pathway resulting in the baby being small for gestational age (SGA). Data on LBW babies are available from 158 (81%) of 194 WHO member states and the occupied Palestinian territory, including east Jerusalem, with 113 (58%) having national administrative data, whereas data on preterm births are available from 103 (53%) of 195 countries and areas, with only 64 (33%) providing national administrative data. National administrative data on SGA are available for only eight countries. Global estimates for 2020 suggest 13·4 million livebirths were preterm, with rates over the past decade remaining static, and 23·4 million were SGA. In this Series paper, we estimated prevalence in 2020 for three mutually exclusive types of small vulnerable newborns (SVNs; preterm non-SGA, term SGA, and preterm SGA) using individual-level data (2010-20) from 23 national datasets (∼110 million livebirths) and 31 studies in 18 countries (∼0·4 million livebirths). We found 11·9 million (50% credible interval [Crl] 9·1-12·2 million; 8·8%, 50% Crl 6·8-9·0%) of global livebirths were preterm non-SGA, 21·9 million (50% Crl 20·1-25·5 million; 16·3%, 14·9-18·9%) were term SGA, and 1·5 million (50% Crl 1·2-4·2 million; 1·1%, 50% Crl 0·9-3·1%) were preterm SGA. Over half (55·3%) of the 2·4 million neonatal deaths worldwide in 2020 were attributed to one of the SVN types, of which 73·4% were preterm and the remainder were term SGA. Analyses from 12 of the 23 countries with national data (0·6 million stillbirths at ≥22 weeks gestation) showed around 74% of stillbirths were preterm, including 16·0% preterm SGA and approximately one-fifth of term stillbirths were SGA. There are an estimated 1·9 million stillbirths per year associated with similar vulnerability pathways; hence integrating stillbirths to burden assessments and relevant indicators is crucial. Data can be improved by counting, weighing, and assessing the gestational age of every newborn, whether liveborn or stillborn, and classifying small newborns by the three vulnerability types. The use of these more specific types could accelerate prevention and help target care for the most vulnerable babies.

Neonatal mortality risk of vulnerable newborns by fine stratum of gestational age and birthweight for 230 679 live births in nine low- and middle-income countries, 2000-2017.

OBJECTIVE: To describe the mortality risks by fine strata of gestational age and birthweight among 230 679 live births in nine low- and middle-income countries (LMICs) from 2000 to 2017. DESIGN: Descriptive multi-country secondary data analysis. SETTING: Nine LMICs in sub-Saharan Africa, Southern and Eastern Asia, and Latin America. POPULATION: Liveborn infants from 15 population-based cohorts. METHODS: Subnational, population-based studies with high-quality birth outcome data were invited to join the Vulnerable Newborn Measurement Collaboration. All studies included birthweight, gestational age measured by ultrasound or last menstrual period, infant sex and neonatal survival. We defined adequate birthweight as 2500-3999 g (reference category), macrosomia as ≥4000 g, moderate low as 1500-2499 g and very low birthweight as <1500 g. We analysed fine strata classifications of preterm, term and post-term: ≥42+0 , 39+0 -41+6 (reference category), 37+0 -38+6 , 34+0 -36+6 ,34+0 -36+6 ,32+0 -33+6 , 30+0 -31+6 , 28+0 -29+6 and less than 28 weeks. MAIN OUTCOME MEASURES: Median and interquartile ranges by study for neonatal mortality rates (NMR) and relative risks (RR). We also performed meta-analysis for the relative mortality risks with 95% confidence intervals (CIs) by the fine categories, stratified by regional study setting (sub-Saharan Africa and Southern Asia) and study-level NMR (≤25 versus >25 neonatal deaths per 1000 live births). RESULTS: We found a dose-response relationship between lower gestational ages and birthweights with increasing neonatal mortality risks. The highest NMR and RR were among preterm babies born at <28 weeks (median NMR 359.2 per 1000 live births; RR 18.0, 95% CI 8.6-37.6) and very low birthweight (462.8 per 1000 live births; RR 43.4, 95% CI 29.5-63.9). We found no statistically significant neonatal mortality risk for macrosomia (RR 1.1, 95% CI 0.6-3.0) but a statistically significant risk for all preterm babies, post-term babies (RR 1.3, 95% CI 1.1-1.5) and babies born at 370 -386 weeks (RR 1.2, 95% CI 1.0-1.4). There were no statistically significant differences by region or underlying neonatal mortality. CONCLUSIONS: In addition to tracking vulnerable newborn types, monitoring finer categories of birthweight and gestational age will allow for better understanding of the predictors, interventions and health outcomes for vulnerable newborns. It is imperative that all newborns from live births and stillbirths have an accurate recorded weight and gestational age to track maternal and neonatal health and optimise prevention and care of vulnerable newborns.

Quality of vital event data for infant mortality estimation in prospective, population-based studies: an analysis of secondary data from Asia, Africa, and Latin America.

INTRODUCTION: Infant and neonatal mortality estimates are typically derived from retrospective birth histories collected through surveys in countries with unreliable civil registration and vital statistics systems. Yet such data are subject to biases, including under-reporting of deaths and age misreporting, which impact mortality estimates. Prospective population-based cohort studies are an underutilized data source for mortality estimation that may offer strengths that avoid biases. METHODS: We conducted a secondary analysis of data from the Child Health Epidemiology Reference Group, including 11 population-based pregnancy or birth cohort studies, to evaluate the appropriateness of vital event data for mortality estimation. Analyses were descriptive, summarizing study designs, populations, protocols, and internal checks to assess their impact on data quality. We calculated infant and neonatal morality rates and compared patterns with Demographic and Health Survey (DHS) data. RESULTS: Studies yielded 71,760 pregnant women and 85,095 live births. Specific field protocols, especially pregnancy enrollment, limited exclusion criteria, and frequent follow-up visits after delivery, led to higher birth outcome ascertainment and fewer missing deaths. Most studies had low follow-up loss in pregnancy and the first month with little evidence of date heaping. Among studies in Asia and Latin America, neonatal mortality rates (NMR) were similar to DHS, while several studies in Sub-Saharan Africa had lower NMRs than DHS. Infant mortality varied by study and region between sources. CONCLUSIONS: Prospective, population-based cohort studies following rigorous protocols can yield high-quality vital event data to improve characterization of detailed mortality patterns of infants in low- and middle-income countries, especially in the early neonatal period where mortality risk is highest and changes rapidly.

Neonatal mortality risk of vulnerable newborns: A descriptive analysis of subnational, population-based birth cohorts for 238 203 live births in low- and middle-income settings from 2000 to 2017.

OBJECTIVE: We aimed to understand the mortality risks of vulnerable newborns (defined as preterm and/or born weighing smaller or larger compared to a standard population), in low- and middle-income countries (LMICs). DESIGN: Descriptive multi-country, secondary analysis of individual-level study data of babies born since 2000. SETTING: Sixteen subnational, population-based studies from nine LMICs in sub-Saharan Africa, Southern and Eastern Asia, and Latin America. POPULATION: Live birth neonates. METHODS: We categorically defined five vulnerable newborn types based on size (large- or appropriate- or small-for-gestational age [LGA, AGA, SGA]), and term (T) and preterm (PT): T + LGA, T + SGA, PT + LGA, PT + AGA, and PT + SGA, with T + AGA (reference). A 10-type definition included low birthweight (LBW) and non-LBW, and a four-type definition collapsed AGA/LGA into one category. We performed imputation for missing birthweights in 13 of the studies. MAIN OUTCOME MEASURES: Median and interquartile ranges by study for the prevalence, mortality rates and relative mortality risks for the four, six and ten type classification. RESULTS: There were 238 203 live births with known neonatal status. Four of the six types had higher mortality risk: T + SGA (median relative risk [RR] 2.6, interquartile range [IQR] 2.0-2.9), PT + LGA (median RR 7.3, IQR 2.3-10.4), PT + AGA (median RR 6.0, IQR 4.4-13.2) and PT + SGA (median RR 10.4, IQR 8.6-13.9). T + SGA, PT + LGA and PT + AGA babies who were LBW, had higher risk compared with non-LBW babies. CONCLUSIONS: Small and/or preterm babies in LIMCs have a considerably increased mortality risk compared with babies born at term and larger. This classification system may advance the understanding of the social determinants and biomedical risk factors along with improved treatment that is critical for newborn health.

Changes in prenatal care and vaccine willingness among pregnant women during the COVID-19 pandemic.

INTRODUCTION: Concerns about SARS-CoV-2 infection risk in health care settings have resulted in changes in prenatal care and birth plans, such as shifts to in-person visits and increased Cesarean delivery. These changes may affect quality of care and limit opportunities for clinicians to counsel pregnant individuals, who are at higher risk of severe COVID-19 disease and adverse pregnancy outcomes, about prevention and vaccination. METHODS: We conducted a cross-sectional online survey of United States adults on changes in prenatal care, COVID-19 vaccine willingness, and reasons for unwillingness to receive a vaccine. We summarized changes in access to care and examined differences in vaccine willingness between pregnant and propensity-score matched non-pregnant controls using chi-squared tests and multivariable conditional logistic regression. RESULTS: Between December 15-23, 2020, 8481 participants completed the survey, of which 233 were pregnant. Three-quarters of pregnant women (n = 186) experienced a change in prenatal care, including format of care (n = 84, 35%) and reduced visits (n = 69, 24%). Two-thirds experienced a change in birth plans, from a hospital birth to home birth (n = 45, 18%) or vaginal birth to a Cesarean delivery (n = 42, 17%). Although 40% of pregnant women (n = 78) were unwilling to receive COVID-19 vaccination, they had higher, though non-significant, odds of reporting willingness to receive vaccination compared to similar non-pregnant women (aOR 1.38, 95% CI: 0.95, 2.00). CONCLUSION: To support pregnant women through the perinatal care continuum, maternity care teams should develop protocols to foster social support, patient-centered education around infection prevention that focuses on improved risk perception, expected changes in care due to COVID-19, and vaccine effectiveness and safety.

Communication lessons learned from the 2017 measles-rubella campaign in India: perspectives from vaccine decision-makers.

In 2017, to reduce the burden of measles and rubella, a nation-wide measles-rubella campaign was launched in India. Despite detailed planning efforts that involved many stakeholders, vaccine refusal arose in several communities during the campaign. As strategic health communication and promotion is critical in any vaccine campaign, we sought to document lessons learned from the 2017 MR campaign from a strategic health communication and promotion perspective to capture lessons learned. To inform future campaigns, we conducted in-depth interviews through a perspective that is not usually captured, that of government and civil society stakeholders that had experience in vaccine campaign implementation (n = 21). We interviewed stakeholders at the national level and within three states that had diverse experiences with the campaign. Three key themes related to strategic health communication and promotion emerged: the importance of sensitizing communities at all levels through relevant and timely information about the vaccine and the vaccine campaign, leveraging key influencers to deliver tailored messaging about the importance of vaccines and mitigating vaccine misinformation rapidly. Our study findings have important implications for health communication and promotion research related to vaccine campaigns. The field must continue to enhance vaccine campaign efforts by identifying important health communication and promotion factors, including the importance of sensitization, trusted messengers that use tailored messaging and mitigating misinformation, as vaccine campaigns are crucial in improving vaccine acceptance.

Measles and rubella are diseases that cause sickness and death. Both are preventable as there are safe and effective vaccines available. Measles and rubella are significant in India. These vaccines are generally delivered to the public through vaccine campaigns. A measles­rubella vaccine campaign was implemented in 2017. In this study, we interviewed 21 government and civil society stakeholders that are involved in vaccine campaigns in India to capture lessons learned. We were interested in understanding how vaccine campaigns could be improved through health communication and promotion efforts. Stakeholders suggested to use trusted community members to inform people about the vaccine campaign, and that it was important for trusted community leaders to dispel rumors about vaccines quickly. To increase vaccine acceptance, it is critical that health communication and promotion efforts target concerns that people may have about the vaccine as well as the vaccine campaign.

Change in full immunization inequalities in Indian children 12-23 months: an analysis of household survey data.

BACKGROUND: India has made substantial progress in improving child health in recent years. However, the country continues to account for a large number of vaccine preventable child deaths. We estimated wealth-related full immunization inequalities in India. We also calculated the degree to which predisposing, reinforcing, and enabling factors contribute to these inequalities. METHODS: We used data from the two rounds of a large nationally representative survey done in all states in India in 2005-06 (n = 9582) and 2015-16 (n = 49,284). Full immunization status was defined as three doses of diphtheria-tetanus-pertussis vaccine, three doses of polio vaccine, one dose of Bacillus Calmette-Guérin vaccine, and one dose of measles vaccine in children 12-23 months. We compared full immunization coverage by wealth quintiles using descriptive statistics. We calculated concentration indices for full immunization coverage at the national and state levels. Using predisposing, reinforcing, and enabling factors associated with full immunization status identified from the literature, we applied a generalized linear model (GLM) framework with a binomial distribution and an identity link to decompose the concentration index. RESULTS: National full immunization coverage increased from 43.65% in 2005-06 to 62.46% in 2015-16. Overall, full immunization coverage in both 2005-06 and 2015-16 in all states was lowest in children from poorer households and improved with increasing socioeconomic status. The national concentration index decreased from 0.36 to 0.13 between the two study periods, indicating a reduction in poor-rich inequality. Similar reductions were observed for most states, except in states where inequalities were already minimal (i.e., Tamil Nadu) and in some northeastern states (i.e., Meghalaya and Manipur). In 2005-06, the contributors to wealth-related full immunization inequality were antenatal care, maternal education, and socioeconomic status. The same factors contributed to full immunization inequality in 2015-16 in addition to difficulty reaching a health facility. CONCLUSIONS: Immunization coverage and wealth-related equality have improved nationally and in most states over the last decade in India. Targeted, context-specific interventions could help address overall wealth-related full immunization inequalities. Intensified government efforts could help in this regard, particularly in high-focus states where child mortality remains high.

Feasibility of training community health workers to conduct periodontal examinations: a validation study in rural Nepal.

BACKGROUND: In many low- and middle-income countries, insufficient human resources limit access to oral health services. Shifting clinical tasks to less specialized health professionals, such as community health workers, has been used as a strategy to expand the health workforce, especially in remote or underserved locations. The objective of this study was to evaluate the validity of periodontal examinations conducted by auxiliary nurse midwives in a rural home setting in Nepal. METHODS: Twenty-one pregnant women < 26 weeks gestation from Sarlahi District, Nepal, underwent full mouth periodontal examinations measuring probing depth (PD) and bleeding on probing (BOP) on 6 sites per tooth by one of five auxiliary nurse midwives, who were trained for this study but had no previous training in dentistry. After a 15-min break, each participant was examined again by an experienced dentist. Measures of validity for PD and BOP were calculated comparing the pooled and individual auxiliary nurse midwives to the dentist. A multivariable GEE model estimated the effect of periodontal characteristics on agreement between the auxiliary nurse midwives and the dentist. RESULTS: Participant mean age was 22 years (SD: ±3 years), mean PD was 1.4 mm (SD: 03 mm), and 86% of women had BOP (according to the dentist). Percent agreement, weighted kappa scores, and intraclass correlation coefficients for PD, with an allowance of ±1 mm, exceeded 99%, 0.7, and 0.9, respectively, indicating an acceptable level of agreement. Auxiliary nurse midwives tended to report higher PD scores relative to the dentist, although this over-estimation was small and unlikely to impact population-based estimates of important indicators of oral health status. GEE regression modeling indicated similar agreement for mandible vs. maxilla, left vs. right side, and PD (≤2 mm, > 2 mm), and lower agreement for posterior teeth and lingual and proximal sites. CONCLUSION: Auxiliary nurse midwives were able to accurately conduct periodontal examinations in a rural home setting, suggesting the potential to shift tasks away from highly trained dentists and periodontal examiners in low-resource communities. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study); registered on August 6th, 2010.

COVID-19 vaccine hesitancy, trust, and communication in Sarlahi District, Nepal.

BACKGROUND: Strategies to increase COVID-19 vaccine coverage require an understanding of the extent and drivers of vaccine hesitancy and trust in government related to COVID-19 vaccine programs, especially in low-resource communities. METHODS: We conducted a cross-sectional household survey post-COVID-19 vaccine introduction among adults (n = 362) in four municipalities in Sarlahi District, Nepal from August to December 2022. The survey included modules on participant demographics and socioeconomic factors and vaccine hesitancy, information seeking, and trust in authorities related to COVID-19 vaccination. RESULTS: Of the study participants, 38.4 % expressed hesitancy related to COVID-19 vaccination. The adjusted odds of being "vaccine hesitant" were significantly lower among the older adults (51+ years) relative to younger (<30 years) (aOR: 0.49, CI: 0.24-0.97) and among males relative to females (aOR: 0.51, CI: 0.26, 0.95). The study population highly trusted the government's handling of the COVID-19 pandemic. While for most, self-reported access to vaccination opportunities was high (88.4 %), 70.4 % of participants did not know if vaccines were in stock at their local vaccination facility. Commonly reported statements of misinformation include the vaccine being developed in a rush or too fast (21.5 %), COVID-19 infection can be effectively treated with ayurvedic medicine(16.3 %) and obtaining immunity from natural infection is better than through vaccination (19.9 %). The primary sources of information on COVID-19 programs were family and friends (98.6 %), healthcare professionals (67.7 %), Female Community Health Volunteers (FCHVs) (61.9 %), television (56.4 %), and radio (43.1 %). CONCLUSION: Although many respondents expressed concerns about COVID-19 effectiveness and safety, a high proportion trusted COVID-19 information provided by healthcare workers and approved of the government's response to the pandemic. This study highlights an opportunity to design new evidence-based communication strategies to improve vaccine confidence delivered through frontline government healthcare workers. Approaches could be targeted to certain communities in the region shown to have higher vaccine hesitancy, including younger people and women.

Targeting strategies for balanced energy and protein (BEP) supplementation in pregnancy: study protocol for the TARGET-BEP cluster-randomized controlled trial in rural Bangladesh.

BACKGROUND: The World Health Organization (WHO) recommends balanced energy and protein (BEP) supplementation be provided to all pregnant women living in undernourished populations, usually defined as having a prevalence > 20% of underweight women, to reduce the risk of stillbirths and small-for-gestational-age neonates. Few geographies meet this threshold, however, and a large proportion of undernourished women and those with inadequate gestational weight gain could miss benefiting from BEP. This study compares the effectiveness of individual targeting approaches for supplementation with micronutrient-fortified BEP vs. multiple micronutrient supplements (MMS) alone as control in pregnancy in improving birth outcomes. METHODS: The TARGET-BEP study is a four-arm, cluster-randomized controlled trial conducted in rural northwestern Bangladesh. Eligible participants are married women aged 15-35 years old identified early in pregnancy using a community-wide, monthly, urine-test-based pregnancy detection system. Beginning at 12-14 weeks of gestation, women in the study area comprising 240 predefined sectors are randomly assigned to one of four intervention arms, with sector serving as the unit of randomization. The interventions involving daily supplementation through end of pregnancy are as follows: (1) MMS (control); (2) BEP; (3) targeted BEP for those with pre-pregnancy body mass index (BMI) < 18.5 kg/m2 and MMS for others; (4) targeted BEP for those with pre-pregnancy BMI < 18.5 kg/m2, MMS for others, and women with inadequate gestational weight gain switched from MMS to BEP until the end of pregnancy. Primary outcomes include birth weight, low birth weight (< 2500 g), and small for gestational age, defined using the 10th percentile of the INTERGROWTH-21st reference, for live-born infants measured within 72 h of birth. Project-hired local female staff visit pregnant women monthly to deliver the assigned supplements, monitor adherence biweekly, and assess weight regularly during pregnancy. Trained data collectors conduct pregnancy outcome assessment and measure newborn anthropometry in the facility or home depending on the place of birth. DISCUSSION: This study will assess the effectiveness of targeted balanced energy and protein supplementation to improve birth outcomes among pregnant women in rural Bangladesh and similar settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05576207. Registered on October 5th, 2022.

Supplementation with fortified balanced energy-protein during pregnancy and lactation and its effects on birth outcomes and infant growth in southern Nepal: protocol of a 2×2 factorial randomised trial.

INTRODUCTION: Many women in low and middle-income countries enter pregnancy with low nutritional reserves with increased risk of fetal growth restriction and poor birth outcomes, including small-for-gestational-age (SGA) and preterm birth. Balanced energy-protein (BEP) supplements have shown reductions in risk of stillbirth and SGA, yet variations in intervention format and composition and limited evidence on the impact of BEP during lactation on growth outcomes warrant further study. This paper describes the protocol of the Maternal Infant Nutrition Trial (MINT) Study, which aims to evaluate the impact of a fortified BEP supplement during pregnancy and lactation on birth outcomes and infant growth in rural Nepal. METHODS AND ANALYSIS: MINT is a 2×2 factorial, household randomised, unblinded, efficacy trial conducted in a subarea of Sarlahi District, Nepal. The study area covers six rural municipalities with about 27 000 households and a population of approximately 100 000. Married women (15-30 years) who become pregnant are eligible for participation in the trial and are randomly assigned at enrolment to supplementation with fortified BEP or not and at birth to fortified BEP supplementation or not until 6 months post partum. The primary pregnancy outcome is incidence of SGA, using the INTERGROWTH-21st standard, among live born infants with birth weight measured within 72 hours of delivery. The primary infant growth outcome is mean length-for-age z-score at 6 months using the WHO international growth reference. ETHICS AND DISSEMINATION: The study was approved by the Institutional Review Board (IRB) at Johns Hopkins Bloomberg School of Public Health, Baltimore, USA (IRB00009714), the Committee on Human Research IRB at The George Washington University, Washington, DC, USA (081739), and the Ethical Review Board of the Nepal Health Research Council, Kathmandu, Nepal (174/2018). TRIAL REGISTRATION NUMBER: NCT03668977.

Neonatal, Infant, and Child Mortality in India: Progress and Future Directions.

In India, considerable progress has been made in reducing child mortality rates. Despite this achievement, wide disparities persist across and socio-economic strata, and persistent challenges, such as malnutrition, poor sanitation, and lack of clean water. This paper provides a comprehensive review of the state of child health in India, examining key risk factors and causes of child mortality, assessing the coverage of child health interventions, and highlighting critical public health programs and policies. The authors also discuss future directions and recommendations for bolstering ongoing efforts to improve child health. These include state- and region-specific interventions, prioritizing social determinants of health, strengthening data systems, leveraging existing programs like the National Health Mission (NHM) and Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), and the proposed Public Health Management Cadre (PHMC). The authors argue that reducing child mortality requires not only scaled-up interventions but a comprehensive approach that addresses all dimensions of health, from social determinants to system strengthening.

Comparison of pregnancy and neonatal outcomes in a retrospective full pregnancy history survey versus population-based prospective records: a validation study in rural Sarlahi District, Nepal.

INTRODUCTION: Countries without complete civil registration and vital statistics systems rely on retrospective full pregnancy history surveys (FPH) to estimate incidence of pregnancy and mortality outcomes, including stillbirth and neonatal death. Yet surveys are subject to biases that impact demographic estimates, and few studies have quantified these effects. We compare data from an FPH vs. prospective records from a population-based cohort to estimate validity for maternal recall of live births, stillbirths, and neonatal deaths in a rural population in Sarlahi District, Nepal. METHODS: We used prospective data, collected through frequent visits of women from early pregnancy through the neonatal period, from a population-based randomized trial spanning 2010-2017. We randomly selected 76 trial participants from three pregnancy outcome groups: live birth (n = 26), stillbirth (n = 25), or neonatal death (n = 25). Data collectors administered the Nepal 2016 Demographic and Health Surveys (DHS)-VII pregnancy history survey between October 22, 2021, and November 18, 2021. We compared total pregnancy outcomes and numbers of pregnancy and neonatal outcomes between the two data sources. We matched pregnancy outcomes dates in the two sources within ± 30 days and calculated measures of validity for adverse outcomes. RESULTS: Among 76 participants, we recorded 122 pregnancy outcomes in the prospective data and 104 outcomes in the FPH within ± 30 days of each woman's total observation period in the trial. Among 226 outcomes, we observed 65 live births that survived to 28 days, 25 stillbirths, and 32 live births followed by neonatal death in the prospective data and participants reported 63 live births that survived to 28 days, 15 stillbirths, and 26 live births followed by neonatal death in the pregnancy history survey. Sixty-two FPH outcomes were matched by date within ± 30 days to an outcome in prospective data. Stillbirth, neonatal death, higher parity, and delivery at a health facility were associated with likelihood of a non-matched pregnancy outcome. CONCLUSIONS: Stillbirth and neonatal deaths were underestimated overall by the FPH, potentially underestimating the burden of mortality in this population. There is a need to develop tools to reduce or adjust for biases and errors in retrospective surveys to improve reporting of pregnancy and mortality outcomes.

A Clinical Competency Framework for the Basic Package of Oral Care: Perceptions of Primary Oral Health Providers in Rural Nepal.

Introduction: The basic package of Oral Care (BPOC) was developed to improve oral health care for underserved populations worldwide. However, systematic delivery of the BPOC has been difficult to achieve, and training efforts have in some cases contributed to proliferation of malpractice. Standard Competency Frameworks (CF), increasingly used in dental and medical education to improve quality assurance, have not been established to date for the BPOC. Methods: To evaluate provider perceptions of a BPOC-specific CF, in-depth interviews were conducted with 7 Primary Oral Health Providers (POHPs) and 5 Clinic Assistants working in the Jevaia Oral Health Care project (Jevaia) in Nepal. Participants were limited to providers who have used the CF. Interviews were audio recorded, transcribed in Nepali, and translated into English. A qualitative thematic analysis was applied through a multi-stage review process, and emergent themes were further grouped and categorized to draw final conclusions. Results: Findings were categorized into four groups: (1) "What is the CF to Me": Respondents frequently conflated the CF with professional development training. These activities together were essentially felt to offer clear performance guidance and a pathway for learning. (2) "Relationship to the Work": Respondents reported that the CF's guidelines increased confidence, peer accountability, and job satisfaction. (3) "Practical Improvements": Providers felt the CF improved their clinical skills, communication, crowd management, and teamwork. (4) "Community Impact": Many participants felt that improved skills had led to a more efficient workflow, greater community acceptance, and increased utilization of services. Conclusions: Clinicians broadly felt that the CF improved both their professional satisfaction and the quality of patient care. CFs should be considered integral to BPOC implementation, along with opportunities for continuous professional learning, and these activities will likely be most meaningful and impactful when recognized by government and other licensing bodies.

What message appeal and messenger are most persuasive for COVID-19 vaccine uptake: Results from a 5-country survey in India, Indonesia, Kenya, Nigeria, and Ukraine.

Effective strategies to encourage COVID-19 vaccination should consider how health communication can be tailored to specific contexts. Our study aimed to evaluate the influence of three specific messaging appeals from two kinds of messengers on COVID-19 vaccine acceptance in diverse countries. We surveyed 953 online participants in five countries (India, Indonesia, Kenya, Nigeria, and Ukraine). We assessed participants' perceptions of three messaging appeals of vaccination-COVID-19 disease health outcomes, social norms related to COVID-19 vaccination, and economic impact of COVID-19-from two messengers, healthcare providers (HCP), and peers. We examined participants' ad preference and vaccine hesitancy using multivariable multinomial logistic regression. Participants expressed a high level of approval for all the ads. The healthcare outcome-healthcare provider ad was most preferred among participants from India, Indonesia, Nigeria, and Ukraine. Participants in Kenya reported a preference for the health outcome-peer ad. The majority of participants in each country expressed high levels of vaccine hesitancy. However, in a final logistic regression model participant characteristics were not significantly related to vaccine hesitancy. These findings suggest that appeals related to health outcomes, economic benefit, and social norms are all acceptable to diverse general populations, while specific audience segments (i.e., mothers, younger adults, etc.) may have preferences for specific appeals over others. Tailored approaches, or approaches that are developed with the target audience's concerns and preferences in mind, will be more effective than broad-based or mass appeals.

Message testing in India for COVID-19 vaccine uptake: What appeal and what messenger are most persuasive?

Few studies have examined the relationships between the different aspects of vaccination communication and vaccine attitudes. We aimed to evaluate the influence of three unique messaging appeal framings of vaccination from two types of messengers on COVID-19 vaccine acceptance in India. We surveyed 534 online participants in India using Amazon Mechanical Turk (MTurk) from December 2021 through January 2022. We assessed participants' perception of three messaging appeals of vaccination - COVID-19 disease health outcomes, social norms related to vaccination, and economic impact of COVID-19 - from two messengers, healthcare providers (HCP) and peers. Using a multivariable multinomial logistic regression, we examined participants' ad preference and vaccine hesitancy. Participants expressed a high level of approval for all of the ads, with >80% positive responses for all questions across ads. Overall ads delivered by health care workers were preferred by a majority of participants in our study (n = 381, 71.4%). Ad preference ranged from 3.6% (n = 19) social norm/peer ad to 32.4% (n = 173) health outcome/HCP ad and half of participants preferred the health outcome ad (n = 279, 52.3%). Additionally, vaccine hesitancy was not related to preference (p = .513): HCP vs. peer ads (p = .522); message type (p = .284). The results suggest that all three appeals tested were generally acceptable, as well as the two messenger types, although preference was for the health care provider messenger and health outcome appeal. Individuals are motivated and influenced by a multitude of factors, requiring vaccine messaging that is persuasive, salient, and induces contextually relevant action.

Causes and age of neonatal death and associations with maternal and newborn care characteristics in Nepal: a verbal autopsy study.

BACKGROUND: In Nepal, neonatal mortality fell substantially between 2000 and 2018, decreasing 50% from 40 to 20 deaths per 1,000 live births. Nepal's success has been attributed to a decreasing total fertility rate, improvements in female education, increases in coverage of skilled care at birth, and community-based child survival interventions. METHODS: A verbal autopsy study, led by the Integrated Rural Health Development Training Centre (IRHDTC), conducted interviews for 338 neonatal deaths across six districts in Nepal between April 2012 and April 2013. We conducted a secondary analysis of verbal autopsy data to understand how cause and age of neonatal death are related to health behaviors, care seeking practices, and coverage of essential services in Nepal. RESULTS: Sepsis was the leading cause of neonatal death (n=159/338, 47.0%), followed by birth asphyxia (n=56/338, 16.6%), preterm birth (n=45/338, 13.3%), and low birth weight (n=17/338, 5.0%). Neonatal deaths occurred primarily on the first day of life (27.2%) and between days 1 and 6 (64.8%) of life. Risk of death due birth asphyxia relative to sepsis was higher among mothers who were nulligravida, had <4 antenatal care visits, and had a multiple birth; risk of death due to prematurity relative to sepsis was lower for women who made ≥1 delivery preparation and higher for women with a multiple birth. CONCLUSIONS: Our findings suggest cause and age of death distributions typically associated with high mortality settings. Increased coverage of preventive antenatal care interventions and counseling are critically needed. Delays in care seeking for newborn illness and quality of care around the time of delivery and for sick newborns are important points of intervention with potential to reduce deaths, particularly for birth asphyxia and sepsis, which remain common in this population.

Understanding determinants of vaccine hesitancy and acceptance in India: A qualitative study of government officials and civil society stakeholders.

INTRODUCTION: Few studies have described the drivers of vaccine hesitancy and acceptance in India from the perspective of those involved in the design and implementation of vaccine campaigns-such as government officials and civil society stakeholders-a prerequisite to developing approaches to address this barrier to high immunization coverage and further child health improvements. METHODS: We conducted a qualitative study to understand government officials and civil society stakeholders' perceptions of the drivers of vaccine hesitancy in India. We conducted in-depth phone interviews using a structured guide of open-ended questions with 21 participants from international and national non-governmental organizations, professional associations, and universities, and state and national government-six national-level stakeholders in New Delhi, six state-level stakeholders in Uttar Pradesh, six in Kerala, and three in Gujarat-from July 2020 to October 2020. We analyzed data through a multi-stage process following Grounded Theory. We present findings on individual-level, contextual, and vaccine/vaccination program-specific factors influencing vaccine hesitancy. RESULTS: We identified multiple drivers and complex ways they influence vaccine beliefs, attitudes, and behaviors from the perspective of government officials and civil society stakeholders involved in vaccine campaigns. Important individual-level influences were low awareness of the benefits of vaccination, safety concerns, especially related to mild adverse events following immunization, and mistrust in government and health service quality. Contextual-level factors included communications, the media environment, and social media, which serves as a major conduit of misinformation and driver of hesitancy, as well as sociodemographic factors-specific drivers varied widely by income, education, urban/rural setting, and across religious and cultural groups. Among vaccine/vaccination-level issues, vaccine program design and delivery and the role of health care professionals emerged as the strongest determinants of hesitancy. CONCLUSIONS: Drivers of vaccine hesitancy in India, as elsewhere, vary widely by local context; successful interventions should address individual, contextual, and vaccine-specific factors. While previous studies focused on individual-level factors, our study demonstrates the equal importance of contextual and vaccine-specific influences, especially the communication and media environment, influential leaders, sociodemographic factors, and frontline health workers.

COVID-19 risk perceptions of social interaction and essential activities and inequity in the USA: results from a nationally representative survey.

INTRODUCTION: SARS-CoV-2 has disproportionately affected disadvantaged communities across the USA. Risk perceptions for social interactions and essential activities during the COVID-19 pandemic may vary by sociodemographic factors. METHODS: We conducted a nationally representative online survey of 1592 adults in the USA to understand risk perceptions related to transmission of COVID-19 for social (eg, visiting friends) and essential activities (eg, medical visits or returning to work). We assessed relationships for activities using bivariate comparisons and multivariable logistic regression modelling, between responses of safe and unsafe, and participant characteristics. Data were collected and analysed in 2020. RESULTS: Among 1592 participants, risk perceptions of unsafe for 13 activities ranged from 29.2% to 73.5%. Large gatherings, indoor dining and visits with elderly relatives had the highest proportion of unsafe responses (>58%), while activities outdoor, accessing healthcare and going to the grocery store had the lowest (<36%). Older respondents were more likely to view social gatherings and indoor activities as unsafe but less likely for other activities, such as going to the grocery store and accessing healthcare. Compared with white/Caucasian respondents, black/African-American and Hispanic/Latino respondents were more likely to view activities such as dining and visiting friends outdoor as unsafe. Generally, men versus women, Republicans versus Democrats and independents, and individuals with higher versus lower income were more likely to view activities as safe. CONCLUSION: Evidence-based interventions should be tailored to sociodemographic differences in risk perception, access to information and health behaviours when implementing efforts to control the COVID-19 pandemic.

Divergent age patterns of under-5 mortality in south Asia and sub-Saharan Africa: a modelling study.

BACKGROUND: Understanding the age pattern of under-5 mortality is essential for identifying the most vulnerable ages and underlying causes of death, and for assessing why the decline in child mortality is slower in some countries and subnational areas than others. The aim of this study is to detect age patterns of under-5 mortality that are specific to low-income and middle-income countries (LMICs). METHODS: In this modelling study, we used data from 277 Demographic and Health Surveys (DHSs), 58 Health and Demographic Surveillance Systems (HDSSs), two cohort studies, and two sample-registration systems. From these sources, we collected child date of birth and date of death (or age at death) from LMICs between 1966 and 2020. We computed 22 deaths rates from each survey with the following age breakdowns: 0, 7, 14, 21, and 28 days; 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 18, and 21 months; and 2, 3, 4, and 5 years. We assessed how probabilities of dying estimated for the 22 age groups deviated from predictions generated by a vital registration model that reflects the historical mortality of 25 high-income countries. FINDINGS: We calculated mortality rates of 81 LMICs between 1966 and 2020. In contrast with the other regions of the world, we found that under-5 mortality in south Asia and sub-Saharan Africa was characterised by increased mortality at both ends of the age range (ie, younger than 28 days and older than 6 months) at a given level of mortality. Observed mortality in these regions was up to 2 times higher than predicted by the vital registration model for the younger-than-28 days age bracket, and up to 10 times higher than predicted for the older-than-6 months age bracket. This age pattern of under-5 mortality is significant in 17 countries in south Asia and sub-Saharan Africa. Excess mortality in children older than 6 months without excess mortality in children younger than 28 days was found in 38 countries. In south Asia, results were consistent across data sources. In sub-Saharan Africa, excess mortality in children younger than 28 days was found mostly in DHSs; the majority of HDSSs did not show this excess mortality. We have attributed this difference in data sources mainly to omissions of early deaths in HDSSs. INTERPRETATION: In countries with age patterns of under-5 mortality that diverge from predictions, evidence-based public health interventions should focus on the causes of excess of mortality; notably, the effect of fetal growth restriction and infectious diseases. The age pattern of under-5 mortality will be instrumental in assessing progress towards the decline of under-5 mortality and the Sustainable Development Goals. FUNDING: Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health.