Transcutaneous bilirubinometry for detecting jaundice in term or late preterm neonates.

BACKGROUND: The American Academy of Pediatrics and the Canadian Paediatric Society both advise that all newborns should undergo bilirubin screening before leaving the hospital, and this has become the standard practice in both countries. However, the US Preventive Task Force has found no strong evidence to suggest that this practice of universal screening for bilirubin reduces the occurrence of significant outcomes such as bilirubin-induced neurologic dysfunction or kernicterus. OBJECTIVES: To evaluate the effectiveness of transcutaneous screening compared to visual inspection for hyperbilirubinemia to prevent the readmission of newborns (infants greater than 35 weeks' gestation) for phototherapy. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, ICTRP, and ISRCTN in June 2023. We also searched conference proceedings, and the reference lists of included studies. SELECTION CRITERIA: We included randomized controlled trials (RCTs), quasi-randomized, cluster-randomized, or prospective cohort studies with control arm that evaluated the use of transcutaneous bilirubin (TcB) screening for hyperbilirubinemia in newborns before hospital discharge. DATA COLLECTION AND ANALYSIS: We used standard methodologic procedures expected by Cochrane. We evaluated treatment effects using a fixed-effect model with risk ratio (RR) and 95% confidence intervals (CI) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. We used the GRADE approach to evaluate the certainty of evidence. MAIN RESULTS: We identified one RCT (1858 participants) that met our inclusion criteria. The study included 1858 African newborns at 35 weeks' gestation or greater who were receiving routine care at a well-baby nursery, and were randomly recruited prior to discharge to undergo TcB screening. The study had good methodologic quality. TcB screening versus visual assessment of hyperbilirubinemia in newborns: - may reduce readmission to the hospital for hyperbilirubinemia (RR 0.25, 95% CI 0.14 to 0.46; P < 0.0001; moderate-certainty evidence); - probably has little or no effect on the rate of exchange transfusion (RR 0.20, 95% CI 0.01 to 14.16; low-certainty evidence); - may increase the number of newborns who require phototherapy prior to discharge (RR 2.67, 95% CI 1.56 to 4.55; moderate-certainty evidence). - probably has little or no effect on the rate of acute bilirubin encephalopathy (RR 0.33, 95% CI 0.01 to 8.18; low-certainty evidence). The study did not evaluate or report cost of care. AUTHORS' CONCLUSIONS: Moderate-certainty evidence suggests that TcB screening may reduce readmission for hyperbilirubinemia compared to visual inspection. Low-certainty evidence also suggests that TcB screening probably has little or no effect on the rate of exchange transfusion compared to visual inspection. However, moderate-certainty evidence suggests that TcB screening may increase the number of newborns that require phototherapy before discharge compared to visual inspection. Low-certainty evidence suggests that TcB screening probably has little or no effect on the rate of acute bilirubin encephalopathy compared to visual inspection. Given that we have only identified one RCT, further studies are necessary to determine whether TcB screening can help to reduce readmission and complications related to neonatal hyperbilirubinemia. In settings with limited newborn follow-up after hospital discharge, identifying newborns at risk of severe hyperbilirubinemia before hospital discharge will be important to plan targeted follow-up of these infants.

Support for sexual and reproductive health and rights in Sub-Saharan Africa: a new index based on World Values Survey data.

BACKGROUND: Addressing attitudes is central to achieving sexual and reproductive health and rights (SRHR) and Agenda 2030. We aimed to develop a comprehensive index to measure attitudinal support for SRHR, expanding opportunities for global trend analyses and tailored interventions. METHODS: We designed a new module capturing attitudes towards different dimensions of SRHR, collected via the nationally representative World Values Survey in Ethiopia, Kenya, and Zimbabwe during 2020-2021 (n = 3,711). We used exploratory factor analysis of 58 items to identify sub-scales and an overall index. Adjusted regression models were used to evaluate the index according to sociodemographic characteristics, stratified by country and sex. RESULTS: A 23-item, five-factor solution was identified and used to construct sub-indices reflecting support for: (1) sexual and reproductive rights, (2) neighborhood sexual safety, (3) gender-equitable relationships, (4) equitable masculinity norms, and (5) SRHR interventions. These five sub-indices performed well across countries and socioeconomic subgroups and were combined into a comprehensive "SRHR Support Index", standardized on a 1-100 scale (mean = 39.19, SD = 15.27, Cronbach's alpha = 0.80) with higher values indicating more support for SRHR. Mean values were highest in Kenya (45.48, SD = 16.78) followed by Ethiopia (40.2, SD = 13.63), and lowest in Zimbabwe (32.65, SD = 13.77), with no differences by sex. Higher education and being single were associated with more support, except in Ethiopia. Younger age and urban residence correlated with more support among males only. CONCLUSION: The SRHR Support Index has the potential to broaden SRHR attitude research from a comprehensive perspective - addressing the need for a common measure to track progress over time.

Sexual and reproductive health and rights (SRHR) are becoming increasingly polarized worldwide, but researchers have previously not been able to fully measure what people think about SRHR. More research about this topic is needed to address discriminatory norms and advance SRHR for all. In this study, we added new questions to the World Values Survey collected in Ethiopia, Kenya, and Zimbabwe during 2020­2021. We used statistical methods to develop an index capturing to what extent individuals' attitudes were supportive of SRHR. This index, which we call the SRHR Support Index, included 23 survey questions reflecting support for five related dimensions of SRHR. Those dimensions were (1) sexual and reproductive rights, (2) neighborhood sexual safety, (3) gender-equitable relationships, (4) equitable masculinity norms, and (5) SRHR interventions. We found that individuals in Kenya were more supportive of SRHR, followed by Ethiopia and then Zimbabwe. There were no differences in support of SRHR between men and women, but individuals who were single and those with higher education were more supportive of SRHR, except in Ethiopia. Younger men living in urban areas were also more supportive. Our SRHR Support Index enables researchers, policymakers, and others to measure attitudes to SRHR in countries across the world and over time, based on new data from the World Values Survey that are readily available online. If combined with other sources of data, researchers can also investigate how people's support of SRHR is linked to, for example, health and policy.

Transcutaneous bilirubinometry versus total serum bilirubin measurement for newborns.

BACKGROUND: Jaundice is a very common condition in newborns, affecting up to 60% of term newborns and 80% of preterm newborns in the first week of life. Jaundice is caused by increased bilirubin in the blood from the breakdown of red blood cells. The gold standard for measuring bilirubin levels is obtaining a blood sample and processing it in a laboratory. However, noninvasive transcutaneous bilirubin (TcB) measurement devices are widely available and used in many settings to estimate total serum bilirubin (TSB) levels. OBJECTIVES: To determine the diagnostic accuracy of transcutaneous bilirubin measurement for detecting hyperbilirubinaemia in newborns. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries up to 18 August 2022. We also checked the reference lists of all included studies and relevant systematic reviews for other potentially eligible studies. SELECTION CRITERIA: We included cross-sectional and prospective cohort studies that evaluated the accuracy of any TcB device compared to TSB measurement in term or preterm newborn infants (0 to 28 days postnatal age). All included studies provided sufficient data and information to create a 2 × 2 table for the calculation of measures of diagnostic accuracy, including sensitivities and specificities. We excluded studies that only reported correlation coefficients. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the eligibility criteria to all citations from the search and extracted data from the included studies using a standard data extraction form. We summarised the available results narratively and, where possible, we combined study data in a meta-analysis. MAIN RESULTS: We included 23 studies, involving 5058 participants. All studies had low risk of bias as measured by the QUADAS 2 tool. The studies were conducted in different countries and settings, included newborns of different gestational and postnatal ages, compared various TcB devices (including the JM 101, JM 102, JM 103, BiliChek, Bilitest and JH20-1C) and used different cutoff values for a positive result. In most studies, the TcB measurement was taken from the forehead, sternum, or both. The sensitivity of various TcB cutoff values to detect significant hyperbilirubinaemia ranged from 74% to 100%, and specificity ranged from 18% to 89%. AUTHORS' CONCLUSIONS: The high sensitivity of TcB to detect hyperbilirubinaemia suggests that TcB devices are reliable screening tests for ruling out hyperbilirubinaemia in newborn infants. Positive test results would require confirmation through serum bilirubin measurement.

Determinants of partial and adequate maternal health services utilization in Nigeria: analysis of cross-sectional survey.

BACKGROUND: Access to health services during pregnancy, childbirth and the period after birth provides a substantial opportunity to limit cases of maternal mortality. In sub-Saharan Africa, the proportions of women who utilize health services remain below 70%. This study examined the factors associated with partial and adequate maternal health services utilization in Nigeria. METHODS: This paper used data from 2018 Nigeria Demographic and Health Survey (DHS) comprising 21,792 women aged 15-49 years who had given births within five years of the survey. The study focused on antenatal care attendance, place of birth and postnatal care using a combined model. Multinomial logistic regression was applied in the analysis. RESULTS: About 74% of the women attended antenatal care, 41% gave birth in health facilities and 21% attended postnatal care. While 68% of the women partially utilized health services, 11% adequately utilized the services. The odds of partially and adequately utilizing health services increased for ever married women, women with secondary or higher education, from richest households, living in urban area, having no problem either getting permission to visit health facility or reaching health facility. CONCLUSIONS: This study has revealed the factors associated with partial and adequate utilization of maternal health services in Nigeria. Such factors include education, household wealth, marital status, employment status, residence, region, media exposure, getting permission to use health service, unwillingness to visit health facility without being accompanied and distance to health facility. Efforts aimed at improving maternal health services utilization should place emphasis on these factors.

Association between gender-based violence and hypertension among women in the Kyrgyzstan Republic.

BACKGROUND: Gender-based violence (GBV) is a significant global public health problem and the most prominent human rights violation severely impacting women's health and wellbeing. Therefore, the aim of this study is to evaluate the association between gender-based violence and hypertension in Kyrgyzstan Republic. METHODS: This study was conducted using population-based data of women from the 2018 Kyrgyzstan Demographic and Health Survey. The odds ratio was calculated to measure the association between GBV and hypertension, and p-values < 0.005 was considered statistically significant. RESULT: We included data of 4793 participants, and 621 (13%) of them had hypertension. Participants exposed to GBV were 24% more likely to have hypertension than unexposed participants (OR = 1.24, 95% CI: 1.03-1.48). Of all women with hypertension, 206 (33.0%) were exposed to GBV. Participants with secondary education or higher exposed to GBV were 24% more likely to be hypertensive than GBV unexposed women with the same education levels OR = 1.24, 95% CI: 1.04-1.49). Unemployed participants exposed to GBV were 45% more likely to develop hypertension than their unexposed counterparts (OR = 1.45, 95%CI: 1.15-1.81). Rural residents exposed to GBV were also 29% more likely to have hypertension than those unexposed to GBV (OR = 1.29, 95% CI: 1.04-1.59). The odds of hypertension among those exposed to GBV increase with age. CONCLUSION: The study revealed that GBV is a significant factor of having hypertension among Kyrgyz women.

Variation in financial protection and its association with health expenditure indicators: an analysis of low- and middle-income countries.

BACKGROUND: An insight into variation in financial protection among countries and the underpinning factors associated with the variations observed will help to inform public health policy and practice. METHOD: Secondary datasets from Global Health Expenditure Database and World Bank Development Indicators collected between 2000 and 2016 were used. Financial protection was measured in 75 low- and middle-income countries (LMICs) using the sustainable development goals framework. Funnel plot charts were used to explore the variation, and regression models were used to measure associations. RESULT: Fifty-three (67%) countries were within the 99% control limits indicating common-cause variation; 11 countries were above the upper control limit and 15 countries were below the lower control limit. In the fully adjusted model, country, spending on health relative to their economy had the strongest association with the variation in catastrophic spending. Every 1% increase in health spending relative to gross domestic product (GDP) was found to be associated with a reduction of 0.13% in the number of people that incurred catastrophic health spending. CONCLUSION: There is substantial variation in financial protection, as measured by the number of people that incurred catastrophic health spending, in LMICs; a proportion of this could be explained by the difference in GDP and external health expenditure.

Equity of national publicly funded health insurance schemes under the universal health coverage agenda: a systematic review of studies conducted in Africa.

BACKGROUND: The implementation of publicly funded health insurance schemes (PFHIS) is the major strategy to drive progress and achievement of universal health coverage (UHC) by 2030. We appraised evidence on the equity of insurance schemes across Africa. METHODS: We conducted a systematic review of published studies that assessed equity in health insurance schemes implemented under the UHC agenda in Africa. Seven databases, Web of Science, Medline, CINAHL, Scopus, Cochrane Library, EMBASE and World Bank eLibrary, were searched; we operationalized the PROGRESS-Plus (place of residence; race/ethnicity/culture/language; occupation; gender/sex religion; education; socioeconomic status; social capital) equity framework to assess equity areas. RESULTS: Forty-five studies met the inclusion criteria and were included in the study, in which 90% assessed equity by socioeconomic status. Evidence showed that rural residents, those self-employed or working in the informal sector, men, those with lower educational attainment, and the poor were less likely to be covered by health insurance schemes. Broadly, the insurance schemes, especially, community-based health insurance (CBI) schemes improved utilization by disadvantaged groups, however, the same groups were less likely to benefit from health services. CONCLUSIONS: Evidence on equity of PFHIS is mixed, however, CBI schemes seem to offer more equitable coverage and utilization of essential health services in Africa.

Determinants of unmet need for family planning in Gambia & Mozambique: implications for women's health.

BACKGROUND: In low-middle-income countries, unmet need for family planning (FP) constitutes a major challenge for prevention of unintended pregnancies and associated health and psychological morbidities for women. The factors associated with unmet need for family planning have been studied for several countries in sub-Saharan Africa, but not much is known about the situation in Gambia and Mozambique. The purpose of this study was to perform a comparative analysis of the prevalence of unmet need for FP, and its sociodemographic correlates in Gambia and Mozambique to better inform FP policies and programs aimed at reducing associated negative health outcomes for women and their families. METHODS: In this analysis we used nationally representative data from Demographic and Health Surveys in Gambia (2013) and Mozambique (2011). Sample population were 23,978 women (n = 10,037 for Gambia and 13,745 for Mozambique) aged 15-49 years. Women who want to stop or delay childbearing but were not using any contraceptive method were considered to have unmet need for FP. Association between unmet need for FP and the explanatory variables was measured using binary logistic regression models RESULTS: Prevalence of unmet need for FP was 17.86% and 20.79% for Gambia and Mozambique, respectively. Having employment in professional/technical/managerial position showed an inverse association with unmet need both in Gambia [OR = 0.843, 95% CI 0.730, 0.974] and Mozambique [OR = 0.886, 95% CI 0.786, 0.999]. Education and household wealth level did not show any significant association with unmet need. The only positive association was observed for rural [OR = 1.213, 95% CI 1.022, 1.441] women in the richer households in Gambia. Having access to electronic media [OR = 0.698, 95% CI 0.582, 0.835] showed a negative effect on having unmet need in Mozambique. Women from female headed households in Gambia [OR = 0.780, 95% CI 0.617, 0.986] and Mozambique [OR = 0.865, 95% CI 0.768, 0.973] had lower odds of unmet need for FP. CONCLUSION: The situation of unmet need for FP in Gambia and Mozambique was better than the Sub-Saharan African average (25%). Nonetheless, there is room for improvement in both countries. Significant assocations with lower unmet need for family planning and women's occupational status (more education & higher skilled employment), access to mass media communication, and female-headed households provide possible areas for intervention for improved FP opportunities in the region.

Women's empowerment and female genital mutilation intention for daughters in Sierra Leone: a multilevel analysis.

BACKGROUND: Female genital mutilation is common in Sierra Leone. Evidence indicates that empowering women provides protective benefits against female genital mutilation/cutting (FGM/C). Yet, the relationship between women's empowerment and their intention to cut their daughters has not been explored in Sierra Leone. The aim of this study was to assess the association between women's empowerment and their intention to have their daughters undergo FGM/C in the country. METHODS: Data for this study are from the 2013 Sierra Leone Demographic and Health Survey. A total of 7,706 women between the ages of 15 and 49 were included in the analysis. Analysis entailed generation of descriptive statistics (frequencies and percentages), and estimation of multi-level logistic regression models to examine the association between women's empowerment, contextual factors and their intentions to cut their daughters. RESULTS: A significantly higher proportion of women who participated in labour force reported that they intended to cut their daughters compared to those who did not (91.2%, CI = 90.4-91.9 and 86.0%, CI = 84.1-87.8, respectively). Similarly, the proportion intending to cut their daughters was significantly higher among women who accepted wife beating than among those who rejected the practice (94.9%, CI = 93.8-95.8 and 86.4% CI = 84.9-87.8, respectively). A significantly higher proportion of women with low decision-making power intended to cut their daughters compared to those with high decision-making power (91.0%, CI = 89.0-92.8 and 85.0% CI = 82.2-87.4, respectively). Results from multivariate regression analysis showed that the odds of intending to cut daughters were significantly higher among women who participated in labour force (aOR = 2.5, CI = 1.3-4.7) and those who accepted wife beating than among those who did not (aOR = 2.7, CI = 1.7-4.5). In contrast, the likelihood of intending to cut daughters was significantly lower among women with high than low knowledge (aOR = 0.4, CI = 0.3-0.7), and among those aged 45-49  than among those aged 15-19  (aOR = 0.2, CI = 0.0-0.6). CONCLUSION: The findings underscore the need to align anti-FGM/C policies and programmes to women who have undergone FGM/C, those with low knowledge, women who support wife beating and young women. Such interventions could highlight the adverse implications of the practice by stressing the psychological, health and social implications of FGM/C on its survivors.

Association between intimate partner violence during pregnancy and risk of preterm birth.

BACKGROUND: Preterm birth is a risk factor for child survival in both the short and long term. In Zimbabwe, the prevalence of preterm birth is rising, and there are growing concerns about the adverse consequences. This study explored the association between intimate partner violence (IPV) during pregnancy and preterm birth in Zimbabwe. METHODS: Using data from the 2015 Zimbabwe Demographic and Health Survey, we applied propensity score matching to estimate the effect of IPV during pregnancy on preterm birth among women of reproductive age (15-49 years). A total of 4833 pregnant women who gave birth during the five years preceding the survey were analysed. RESULTS: We successfully matched 79 women who were exposed to IPV during pregnancy to 372 unexposed during pregnancy. Using the matched sample, the probability of preterm delivery was significantly higher among women who were exposed to IPV during pregnancy than those who were not exposed. The findings showed that 7 out of 79 (8.9%) of women exposed to IPV during pregnancy experienced preterm delivery, and 11 out of 372 (3.0%) of those who were not exposed to IPV during pregnancy experienced preterm delivery. In the urban areas, those exposed to IPV during pregnancy were almost five times more likely to experience preterm delivery (OR = 4.8, 95% CI 2.0-11.6), but the association was not significantly different among women in rural areas. CONCLUSION: The findings showed that women exposed to IPV during pregnancy were at increased risk of preterm birth. Some of the risk factors associated with IPV were urban residence, low economic status and unemployment. Effective policies and programmes are required to address the issue of IPV in Zimbabwe.

Influence of contextual socioeconomic position on hypertension risk in low- and middle-income countries: disentangling context from composition.

BACKGROUND: Hypertension has emerged as the single most significant modifiable risk factor for cardiovascular disease and death worldwide. Resource-limited settings are currently experiencing the epidemiological transition from infectious diseases to chronic non-communicable diseases, primarily due to modifications in diet and lifestyle behaviour. The objective of this study was to examine the influence of individual-, community- and country-level factors associated with hypertension in low- and middle-income countries (LMICs). METHODS: Multivariable multi-level logistic regression analysis was applied using 12 Demographic and Health Survey (DHS) datasets collected between 2011 and 2018 in LMICs. We included 888,925 respondents (Level 1) nested within 33,883 neighbourhoods (Level 2) from 12 LMICs (Level 3). RESULTS: The prevalence of hypertension ranged from 10.3% in the Kyrgyz Republic to 52.2% in Haiti. After adjusting for the individual-, neighbourhood- and country-level factors, we found respondents living in the least deprived areas were 14% more likely to have hypertension than those from the most deprived areas (OR = 1.14, 95% CI 1.10 to 1.17). We observed a significant variation in the odds of hypertension across the countries and the neighbourhoods. Approximately 26.3 and 47.6% of the variance in the odds of hypertension could be attributed to country- and neighbourhood-level factors, respectively. We also observed that respondents moving to a different neighbourhood or country with a higher risk of hypertension had an increased chance of developing hypertension, the median increase in their odds of hypertension was 2.83-fold (95% CI 2.62 to 3.07) and 4.04- fold (95% CI 3.98 to 4.08), respectively. CONCLUSIONS: This study revealed that individual compositional and contextual measures of socioeconomic status were independently associated with the risk of developing hypertension. Therefore, prevention strategies should be implemented at the individual level and the socioeconomic and contextual levels to reduce the burden of hypertension.

Caesarean section and increased neonatal mortality risk in meta-analysis of 33 sub-Saharan Africa Demographic and Health Surveys.

AIM: To examine the factors associated with the risk of neonatal mortality following caesarean births at country-level in sub-Saharan Africa. METHODS: We used meta-analytic procedure to synthesize the results of most recent nationally representative cross-sectional Demographic and Health Survey (DHS) datasets for 33 sub-Saharan Africa countries conducted between 2010 and 2018. Pooled odds ratio (OR) and 95% confidence intervals (CI) were computed for all countries. RESULTS: The overall caesarean section (CS) rate was 4.9%, neonatal mortality was 2.8% and Post-CS neonatal mortality was 4.3%. The rates of CS were generally low and only five countries had CS rates at or above 10%. The overall pooled result showed a statistically significant increase in the odds of neonatal mortality after a caesarean section (CS) OR 1.7 (95% CI 1.53 -1.89; I2  = 39.3%, p < 0.012); such that children delivered via CS were 70% more likely not to survive beyond the first 30 days. Geographical variations existed in the measure of association between caesarean section and neonatal mortality. CONCLUSION: This paper has provided evidence on the low rates of CS and the associated neonatal mortality risk compared to normal deliveries in sub-Saharan Africa.

Individual and contextual correlates of mosquito net use among women in Nigeria.

BACKGROUND: Malaria has been described as an urgent public health priority with almost half of the world's population being at risk. Use of insecticide-treated nets is considered one of the effective ways of preventing malaria. Nigeria, which is ranked among the five countries that are responsible for almost half of the global malaria cases, has less than half of its women population using mosquito nets. This study examined the effects of individual and contextual factors on the use of mosquito nets among women of reproductive age in Nigeria. METHODS: This study used data obtained from 2015 Nigeria Malaria Indicator Survey (NMIS) which involved 6048 women aged 15-49 who possessed at least one mosquito net. Multilevel binary logistic regression models were applied in the multivariable analysis. RESULTS: About 53% of the women used mosquito nets with more than 60% of uneducated and poor women in this category. The use of mosquito nets was significantly associated with being from poor households, having knowledge about the cause of malaria, having access to malaria messages, possessing knowledge about the efficacy of malaria prevention drugs during pregnancy, having knowledge about the importance of tests to detect malaria, maintaining small household size and living in the most socioeconomically disadvantaged communities and states. CONCLUSIONS: The study revealed that mosquito net use among women in Nigeria is affected by individual and contextual factors. It is important for policy makers to design a mosquito-net-use model which would take individual and contextual factors into consideration.

The prevalence of obstructive sleep apnoea in women with polycystic ovary syndrome: a systematic review and meta-analysis.

BACKGROUND: Obesity is a common risk factor for polycystic ovary syndrome (PCOS) and obstructive sleep apnoea (OSA). Both PCOS and OSA are associated with increased risk of type 2 diabetes and cardiovascular disease. Hence, it is important to determine the burden of OSA in women with PCOS. METHODS: We searched electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, OpenGrey, CENTRAL), conference abstracts, and reference lists of relevant articles, up to January 2019. No restriction for language or publication status. Studies that examined the presence of OSA in women with PCOS using polysomnography and/or level III devices were eligible for inclusion. RESULTS: Seventeen studies involving 648 participants were included. Our meta-analysis showed that 35.0% (95% CI 22.2-48.9%) of women with PCOS had OSA. This prevalence was not affected by variation in PCOS definition between studies. Approximately one-tenth of the variation in OSA prevalence was related to differences in study population (higher in adults than adolescents and mixed populations), and around one-tenth was related to sample size (higher in smaller studies). OSA prevalence was markedly higher in obese versus lean women with PCOS, and in women with PCOS compared to controls (odds ratio = 3.83, 95% CI 1.43-10.24, eight studies, 957 participants (349 PCOS and 608 controls)). However, most of the studies were at high risk of selection bias, did not account for important confounders, included predominantly women with class II obesity, and were conducted in one country (USA). CONCLUSIONS: Future studies need to examine the true prevalence of OSA in a more representative sample of women with PCOS. Nevertheless, our results suggest that the prevalence of OSA in women with PCOS and obesity is high and clinicians should have a high index of suspicion of OSA in these women.

Socio-demographic determinants of post-caesarean neonatal mortality in Nigeria.

Neonatal mortality remains a major health concern in sub-Saharan Africa. We conducted a cross-sectional, population-based, retrospective analysis of 31,828 births between 2009 and 2013 to explore the relationship between socio-demographic variables and post-caesarean neonatal mortality in Nigeria. We calculated the caesarean section (CS) rates, the odds of having a CS and post-CS neonatal mortality within variable subgroups. The national average CS rate was 2.1%. The CS rate increased with the increasing wealth index, educational attainment, maternal age, higher among urban residents and among those from the Southern part of Nigeria. The odds of experiencing post-CS neonatal mortality was significantly higher in the Northern regions (OR 2.51-3.17) among rural residents (OR 2.63), economically poorer groups (OR 3.68), with no formal education (OR 3.01) and older maternal age groups (OR 1.76-2.0). Efforts to increase the rate and quality of peripartum services delivered to pregnant women are needed among both advantaged and disadvantaged groups.Impact statementWhat is already known on this subject? In sub-Saharan Africa, a caesarean section is a lifesaving procedure for both the women and their unborn babies. The neonatal mortalities that occur following the procedure need to be explored and quantified.What do the results of this study add? Socioeconomic differentials exist in the access to a caesarean section. However, these differentials have a limited influence on neonatal mortality post-caesarean section in Nigeria.What are the implications of these findings for clinical practice and/or further research? While socio-demographic variables influence access to health care services, timeliness and quality of care are factors to be considered in ensuring societies get the benefits of caesarean section as a lifesaving procedure.

Maternal exposure to intimate partner violence and breastfeeding practices in 51 low-income and middle-income countries: A population-based cross-sectional study.

BACKGROUND: Intimate partner violence (IPV) against women is a major global health issue, particularly in low- and middle-income countries (LMICs), that is associated with poor physical and mental health, but its association with breastfeeding practices is understudied. Both the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend that children initiate breastfeeding within the first hour of birth and be exclusively breastfed for the first 6 months of life. Breastfeeding within the first hour of birth is critical to newborn survival, and exclusive breastfeeding for 6 months is recognised to offer significant health benefits to mothers and their infants. We examined the association of maternal exposure to IPV with early initiation of breastfeeding (within 1 hour of birth) and exclusive breastfeeding in the first 6 months. METHODS AND FINDINGS: We assessed population-based cross-sectional Demographic and Health Surveys (DHS) from 51 LMICs. Data from the most recent DHS in each country (conducted between January 2000 and January 2019) with data available on IPV and breastfeeding practices were used. By WHO region, 52.9% (27/51) were from Africa, 11.8% (6/51) from the Americas, 7.8% (4/51) from the Eastern Mediterranean, 11.8% (6/51) from Europe, 11.8% (6/51) from South-East Asia, and 3.9% (2/51) from the Western Pacific. We estimated multilevel logistic regression models for any IPV and each type of IPV separately (physical violence, sexual violence, and emotional violence), accounting for demographic and socioeconomic factors. Depending on specification, the sample size varied between 95,320 and 102,318 mother-infant dyads. The mean age of mothers was 27.5 years, and the prevalence of any lifetime exposure to IPV among mothers was 33.3% (27.6% for physical violence, 8.4% for sexual violence, and 16.4% for emotional violence). Mothers exposed to any IPV were less likely to initiate breastfeeding early (adjusted odds ratio [AOR]: 0.88 [95% CI 0.85-0.97], p < 0.001) and breastfeed exclusively in the first 6 months (AOR: 0.87 [95% CI 0.82-0.92], p < 0.001). The associations were similar for each type of IPV and were overall consistent across infant's sex and WHO regions. After simultaneously adjusting for all 3 types of IPV, all 3 types of IPV were independently associated with decreased likelihood of early breastfeeding initiation, but only exposure to physical violence was independently associated with a decreased likelihood of exclusively breastfeeding in the first 6 months. The main limitations of this study included the use of cross-sectional datasets, the possibility of residual confounding of the observed associations by household wealth, and the possibility of underreporting of IPV experiences attenuating the magnitude of observed associations. CONCLUSIONS: Our study indicates that mothers exposed to any form of IPV (physical, sexual, or emotional violence) were less likely to initiate breastfeeding early and breastfeed exclusively in the first 6 months. These findings may inform the argument for antenatal screening for IPV in LMICs and the provision of services to not only improve mothers' safety and well-being, but also support them in adopting recommended breastfeeding practices.

Women who have not utilized health Service for Delivery in Nigeria: who are they and where do they live?

BACKGROUND: Health facility delivery has been described as one of the major contributors to improved maternal and child health outcomes. In sub-Saharan Africa where 66% of the global maternal mortality occurred, only 56% of all births take place in health facility. This study examined the individual and contextual predictors of non-use of health service for delivery in Nigeria where less than 40% births occur in health facility. METHODS: Data from 2013 Nigeria Demographic and Health Survey (DHS) involving 20,192 women who had delivery within 5 years of the survey were used in the study. Multilevel multivariable logistics regression models which had the structure of non-use of health service for delivery defined at individual, community and state levels were applied in the analysis. Spatial analysis was also used to capture the locations where the phenomenon is prevalent in the country. RESULTS: About 62% of the women did not utilize health service during delivery. More than three-quarter of those with no education and 92% of those who did not attend antenatal clinic during pregnancy never utilized health service for delivery. The odds of non-use of health service during delivery increased for women who had no education, from poor households, aged 25-34 years, unmarried, never attended antenatal clinic, experienced difficulty getting to health facility and lived in the most socioeconomically disadvantaged communities and states. CONCLUSIONS: This study has demonstrated that non-utilization of health service for delivery is influenced by individual, community and state level factors, with substantial proportions of women not utilizing such service residing in the northern region of Nigeria. Each level should be adequately considered in the design of the appropriate interventions.

Decomposing the rural-urban gap in the factors of under-five mortality in sub-Saharan Africa? Evidence from 35 countries.

BACKGROUND: Understanding urban-rural gap in childhood survival is essential for health care interventions and to explain disparities in the determinants of Under-5 mortality. There is dearth of information about the factors explaining differentials in urban-rural Under-5 mortality especially in sub-Saharan Africa (SSA). In this study, we sought to quantify the contributions of bio-demographic, socioeconomic and proximate factors in explaining the urban-rural gap in Under-5 mortality in SSA. METHODS: This study utilized secondary data from Demographic and Health Survey (DHS) in 35 sub-Saharan countries conducted between 2006 and 2016. Child (aged 0 and 59 months) death was the outcome variable in this study. Oaxaca-Blinder decomposition was used to decipher urban-rural gap in the factors of Under-5 mortality. RESULTS: Significant urban-rural differentials were observed in Under-5 mortality across bio-demographic, socioeconomic and proximate factors. In the decomposition model, about 44.27% of urban group and 74.71% of rural group had Under-5 mortality in sub-Saharan countries. Maternal age, education, use of newspaper, TV, wealth index, total children ever born, size of baby and age at first birth contributed towards explaining urban-rural gap inUnder-5 mortality. CONCLUSION: These findings could be contributory to health care system improvement and socioeconomic developmental plans to address under-5 mortality in SSA. Strengthening maternal and child health (MCH) programmes, specifically in rural areas and improving health care services would help to ensure overall child survival.

Maternal health care service utilization in post-war Liberia: analysis of nationally representative cross-sectional household surveys.

BACKGROUND: Post-war Liberia has a fast-growing population and an alarming maternal mortality ratio (MMR). To provide a better understanding about healthcare system recovery in post-war country, we explored the changes in maternal healthcare services utilization between 2007 and 2016. METHODS: We used 2007 and 2013 Liberia Demographic and Health Survey (LDHS) and the 2016 Malaria Indicator Survey (MIS) in this study. The outcomes of interest were: place of delivery and antenatal care visits. Univariate analysis was conducted using percentages and means (standard deviations) and multiple binary multivariable logistic models were used to examine the factors associated with the outcome variables. RESULTS: Between 2007 and 2016, the percentage of adequate ANC visits increased from 71.20 to 79.8%, and that of facility-based delivery increased from 40.90 to 74.60%. The odds of attending at least four ANC visits and formal institutional delivery were low among women residing in rural area, but high among women with higher education, used electronic media, and lived in high wealth index households. Additionally, attending ANC at least four times increased the odds of facility-based delivery by almost threefold. CONCLUSION: The findings suggest that key maternal healthcare utilization indicators have improved substantially, especially facility-based delivery. However, a large proportion of women remain deprived of these life-saving health services in the post-war era. Greater healthcare efforts are needed to improve the quality and coverage of maternal healthcare in order to enhance maternal survival in Liberia.

Statin use and all-cause mortality in people living with HIV: a systematic review and meta-analysis.

BACKGROUND: It is unknown whether statin use among people living with HIV results in a reduction in all-cause mortality. We aimed to evaluate the effect of statin use on all-cause mortality among people living with HIV. METHODS: We conducted comprehensive literature searches of Medline, Embase, CINAHL, the Cochrane Library, and cross-references up to April 2018. We included randomised, quasi-randomised trials and prospective cohort studies that examined the association between statin use and cardio-protective and mortality outcomes among people living with HIV. Two reviewers independently abstracted the data. Hazard ratios (HRs) were pooled using empirical Bayesian random-effect meta-analysis. A number of sensitivity analyses were conducted. RESULTS: We included seven studies with a total of 35,708 participants. The percentage of participants on statins across the studies ranged from 8 to 35%. Where reported, the percentage of participants with hypertension ranged from 14 to 35% and 7 to 10% had been diagnosed with diabetes mellitus. Statin use was associated with a 33% reduction in all-cause mortality (pooled HR = 0.67, 95% Credible Interval 0.39 to 0.96). The probability that statin use conferred a moderate mortality benefit (i.e. decreased risk of mortality of at least 25%, HR ≤ 0.75) was 71.5%. Down-weighting and excluding the lower quality studies resulted in a more conservative estimate of the pooled HR. CONCLUSION: Statin use appears to confer moderate mortality benefits in people living with HIV.