Association between fish and shellfish consumption, n-3 polyunsaturated fatty acids, and gastric cancer risk: the Japan Public Health Center-based Prospective Study.

PURPOSE: Fish and shellfish consumption is suggested to be a cancer-protective factor. However, studies investigating this association for gastric cancer, especially considering Helicobacter pylori (H. pylori) and atrophic gastritis (AG), are limited. We investigated gastric cancer risk associated with fish, shellfish, and n-3 polyunsaturated fatty acids (n-3 PUFAs) consumption among Japanese adults. METHODS: 90,504 subjects enrolled in the Japan Public Health Center-based Prospective Study (JPHC Study) were followed until December 2013. Dietary intake data were collected using a food frequency questionnaire. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for gastric cancer risk associated with fish and shellfish consumption and marine n-3 PUFAs (sum of eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), and docosahexaenoic acid (DHA)) using Cox proportional hazards models. Among those with avaliable data, we conducted a subgroup analysis taking H. pylori infection and AG status  into consideration. RESULTS: There were 2,701 gastric cancer cases during an average of 15 years of follow-up. We observed an increased gastric cancer risk for salted fish consumption for men [HR for fifth quintile versus first quintile 1.43 (95% CI 1.18-1.75)] and for women [HR 1.33 (95% CI 1.00-1.77)]. We observed a weak risk reduction trend for women as the intake of marine n-3 PUFAs increased (p-trend:0.07). When we included H. pylori infection and atrophic gastritis status in the analysis, the associations diminished. CONCLUSION: Our results suggest that salted fish increases gastric cancer risk for men and women, while marine n-3 PUFAs marginally decreases this risk among women in Japan.

Potential effectiveness of integrating human milk banking and lactation support on neonatal outcomes at Pumwani Maternity Hospital, Kenya.

We assessed the potential effectiveness of human milk banking and lactation support on provision of human milk to neonates admitted in the newborn unit (NBU) at Pumwani Maternity Hospital, Kenya. This pre-post intervention study collected data from mothers/caregivers and their vulnerable neonates or term babies who lacked sufficient mother's milk for several reasons admitted in the NBU. The intervention included establishing a human milk bank and strengthening lactation support. Preintervention data were collected between 5 October 2018 and 11 November 2018, whereas postintervention data were collected between 4 September 2019 and 6 October 2019. Propensity score-matched analysis was performed to assess the effect of the intervention on exclusive use of human milk, use of human milk as the first feed, feeding intolerance and duration of NBU stay. The surveys included 123 and 116 newborns at preintervention and postintervention, respectively, with 160 newborns (80 in each group) being included in propensity score matched analysis. The proportion of neonates who exclusively used human milk during NBU stay increased from 41.3% preintervention to 63.8% postintervention (adjusted odds ratio [OR]: 2.68; 95% confidence interval [CI]: 1.31, 5.53) and those whose first feed was human milk increased from 55.0% preintervention to 83.3% postintervention (adjusted OR: 5.09; 95% CI: 2.18, 11.88). The mean duration of NBU stay was 27% (95% CI: 5.8%, 44.0%) lower in the postintervention group than in the preintervention group. The intervention did not affect feeding intolerance. Integrating human milk banking and lactation support may improve exclusive use of human milk among vulnerable neonates in a resource limited setting.

Treatment of moderate acute malnutrition through community health volunteers is a cost-effective intervention: Evidence from a resource-limited setting.

Treatment outcomes for acute malnutrition can be improved by integrating treatment into community case management (iCCM). However, little is known about the cost-effectiveness of this integrated nutrition intervention. The present study investigates the cost-effectiveness of treating moderate acute malnutrition (MAM) through community health volunteer (CHV) and integrating it with routine iCCM. A cost-effectiveness model compared the costs and effects of CHV sites plus health facility-based treatment (intervention) with the routine health facility-based treatment strategy alone (control). The costing assessments combined both provider and patient costs. The cost per DALY averted was the primary metric for the comparison, on which sensitivity analysis was performed. Additionally, the integrated strategy's relative value for money was evaluated using the most recent country-specific gross domestic product threshold metrics. The intervention dominated the health facility-based strategy alone on all computed cost-effectiveness outcomes. MAM treatment by CHVs plus health facilities was estimated to yield a cost per death and DALY averted of US$ 8743 and US$ 397, respectively, as opposed to US$ 13,846 and US$ 637 in the control group. The findings also showed that the intervention group spent less per child treated and recovered than the control group: US$ 214 versus US$ 270 and US$ 306 versus US$ 485, respectively. Compared with facility-based treatment, treating MAM by CHVs and health facilities was a cost-effective intervention. Additional gains could be achieved if more children with MAM are enrolled and treated.

Examining the complex dynamics influencing acute malnutrition in Turkana and Samburu counties: Study protocol.

Acute malnutrition in children under 5 years is persistent in Eastern Africa's arid and semiarid lands. This study aimed to identify the drivers of acute malnutrition in Turkana and Samburu counties, Kenya. This was a population-based longitudinal mixed-methods observational study. Qualitative and quantitative data were collected at Wave 1, but only quantitative data were collected during follow-up. Participants were a representative sample of children and their primary caregivers from households with children under 3 years at Wave 1. Anthropometric measurements of all children under 5 years in the sampled households were taken at Wave 1 (May to July 2021), and one child under 3 years was randomly selected for follow-up about every 4 months over 2 years for six data collection waves. The study also collected data on sociodemographics; child feeding practices and morbidity; household water and food insecurity; shocks; coping strategies, social safety nets and economic safeguards; water, sanitation and hygiene; women's decision-making and food consumption. Qualitative data were collected through community dialogues, focus group discussions, in-depth interviews, photovoice and key informant interviews with mothers and fathers with children under 5 years, community leaders, county officials and staff of nongovernmental organisations. Data collection is complete and analysis is ongoing. The analysis includes thematic analysis of qualitative data and descriptive and multi-variable regression analyses of quantitative data.

Association of women's empowerment with anaemia and haemoglobin concentration in children in sub-Saharan Africa: A multilevel analysis.

We assessed the associations between women's empowerment and anaemia and haemoglobin concentration among children (6-59 months) in 31 sub-Saharan African (SSA) countries. We included 72,032 mother-child pairs from Demographic and Health Surveys conducted between 2006 and 2019. A three-dimensional women's empowerment index (attitude towards violence, decision making and social independence) was constructed using principal components analysis, and associations between the index and any anaemia and Hb concentration were assessed using multilevel regression. The mean (standard deviation) haemoglobin concentration was 102.3 (16.0 g/L) and 65.8% of the children were anaemic. The odds of anaemia reduced with increasing empowerment in the dimensions of attitude towards violence [quintile (Q5) versus Q1, OR 0.77; 95% confidence interval [CI] 0.65-0.89, ptrend = 0.006], decision making (Q5 vs. Q1, OR 0.72; 95% CI 0.61-0.84, ptrend < 0.001) and social independence (Q5 vs. Q1, OR 0.86; 95% CI 0.76-0.97, ptrend = 0.015). The mean Hb concentration increased with increasing women's empowerment in the dimensions of attitude towards violence (Q5 vs. Q1, mean difference [MD] 1.40 g/L; 95% CI 0.63-2.17, ptrend < 0.001) and social independence (Q5 vs. Q1, MD 1.32 g/L; 95% CI 0.36-2.28, ptrend = 0.001). There was no evidence for a linear trend in the association between decision making and haemoglobin concentration (ptrend = 0.051). Women's empowerment was associated with reduced odds of any anaemia and higher haemoglobin concentration in children. The promotion of women's empowerment may play a role in reducing the burden of childhood anaemia in SSA.

Sleep duration and risk of cancer incidence and mortality: A pooled analysis of six population-based cohorts in Japan.

Sleep duration is emerging as an important modifiable risk factor for morbidity and mortality. We assessed the association between sleep duration and cancer incidence and mortality among Japanese adults using data from six population-based cohorts with 271 694 participants. During a total follow-up period of about 5.9 million person-years, we identified 40 751 incident cancer cases and 18 323 cancer deaths. We computed study-specific hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression models and pooled the estimates using random-effects meta-analysis. Sleep duration of ≥10 hours (vs 7 hours) was associated with increased risk of cancer incidence among women (HR 1.19, 95% CI 1.02-1.38), but not men, and increased risk of cancer mortality among men (HR 1.18, 95% CI 1.00-1.39) and women (HR 1.44, 95% CI 1.20-1.73). Sleep duration of ≤5 hours (vs 7 hours) was not associated with cancer incidence and mortality. However, among postmenopausal women, sleep durations of both ≤5 and ≥10 hours (vs 7 hours) were associated with an increased risk of cancer mortality. Among Japanese adults, sleep duration of ≥10 hours is associated with increased risk of cancer incidence and mortality among women and cancer mortality among men.

Associations between changes in fruit and vegetable consumption and weight change in Japanese adults.

BACKGROUND: Fruits and vegetables may induce greater satiety, reduce hunger, decrease energy intake, and modulate energy metabolism, thereby playing a role in weight loss. OBJECTIVE: To determine the associations between changes in fruit and vegetable consumption and weight change over a 5-year interval in Japanese adults. METHODS: This cohort study included 54,015 subjects (54.6% female, mean age 56.5 years) of the Japan Public Health Center-based Prospective Cohort Study who had no known history of major chronic diseases at baseline. Data on fruit and vegetable consumption were collected using a validated food frequency questionnaire. Body weight was self-reported. We used multivariable linear mixed-effects regression models to examine the associations between changes in fruit and vegetable consumption and change in body weight. RESULTS: On average, body weight decreased by 25 g [95% confidence interval (CI), 3, 47] for every 100 g/d increase in total vegetable consumption. Change in fruit consumption was nonlinearly associated with weight change. Fruit consumption was directly associated with weight change among subjects who increased consumption (70 g; 95% CI, 39, 101) but was not associated with weight change among subjects who reduced or did not change fruit consumption. These associations did not vary by sex, age, and body mass index (BMI) at baseline. The association with vegetables was restricted to yellow/red vegetables (- 74 g; 95% CI, - 129, - 18) and allium vegetables (- 129 g; 95% CI, - 231, - 28). Lower-fiber vegetables were inversely associated with weight change, whereas lower-fiber fruits or higher-energy fruits were directly associated with weight change beyond 0 g/d change in consumption. CONCLUSIONS: Change in vegetable consumption was inversely associated with weight change while fruit consumption was positively associated with weight change among subjects who increased consumption. The influence of fruits and vegetables on weight change may depend on the characteristics of the fruits and vegetables.

Effectiveness of the baby-friendly community initiative on exclusive breastfeeding in Kenya.

The baby-friendly hospital initiative (BFHI) promotes exclusive breastfeeding (EBF) in hospitals, but this is not accessible in rural settings where mothers give birth at home, hence the need for a community intervention. We tested the effectiveness of the baby-friendly community initiative (BFCI) on EBF in rural Kenya. This cluster randomized study was conducted in 13 community units in Koibatek sub-county. Pregnant women aged 15-49 years were recruited and followed up until their children were 6 months old. Mothers in the intervention group received standard maternal, infant and young child nutrition counselling, support from trained community health volunteers, health professionals and community and mother support groups, whereas those in the control group received standard counselling only. Data on breastfeeding practices were collected longitudinally. The probability of EBF up to 6 months of age and the restricted mean survival time difference were estimated. A total of 823 (intervention group n = 351) pregnant women were recruited. Compared with children in the control group, children in the intervention group were more likely to exclusively breastfeed for 6 months (79.2% vs. 54.5%; P < .05). Children in the intervention group were also exclusively breastfed for a longer time, mean difference (95% confidence interval [CI]) 0.62 months (0.38, 0.85; P < .001). The BFCI implemented within the existing health system and including community and mother support groups led to a significant increase in EBF in a rural Kenyan setting. This intervention has the potential to improve EBF rates in similar settings.

Effect of a baby-friendly workplace support intervention on exclusive breastfeeding in Kenya.

Exclusive breastfeeding (EBF) during the first 6 months of life is crucial for optimizing child growth, development and survival, as well as the mother's wellbeing. Mother's employment may hinder optimal breastfeeding, especially in the first 6 months. We assessed the effectiveness of a baby-friendly workplace support intervention on EBF in Kenya. This pre-post intervention study was conducted between 2016 and 2018 on an agricultural farm in Kericho County. The intervention targeted pregnant/breastfeeding women residing on the farm and consisted of workplace support policies and programme interventions including providing breastfeeding flexi-time and breaks for breastfeeding mothers; day-care centres (crèches) for babies near the workplace and lactation centres with facilities for breast milk expression and storage at the crèches; creating awareness on available workplace support for breastfeeding policies; and home-based nutritional counselling for pregnant and breastfeeding women. EBF was measured through 24-h recall. The effect of the intervention on EBF was estimated using propensity score weighting. The study included 270 and 146 mother-child dyads in the nontreated (preintervention) group and treated (intervention) group, respectively. The prevalence of EBF was higher in the treated group (80.8%) than in the nontreated group (20.2%); corresponding to a fourfold increased probability of EBF [risk ratio (RR) 3.90; 95% confidence interval (CI) 2.95-5.15]. The effect of the intervention was stronger among children aged 3-5 months (RR 8.13; 95% CI 4.23-15.64) than among those aged <3 months (RR 2.79; 95% CI 2.09-3.73). The baby-friendly workplace support intervention promoted EBF especially beyond 3 months in this setting.

Soy food and isoflavones are not associated with changes in serum lipids and glycohemoglobin concentrations among Japanese adults: a cohort study.

PURPOSE: It is unclear whether habitual intake of soy or isoflavones induces long-term changes in the concentrations of blood lipids and glycaemia. We examined the associations of soy food and isoflavone consumption with changes in blood lipids and HbA1c concentrations over 5 years among Japanese adults. METHODS: This cohort study included 7252 subjects with no known history of major chronic disease at baseline. Soy intake was measured using a food frequency questionnaire; while the concentrations of serum lipids and HbA1c were measured using standard laboratory methods. We used multivariable linear mixed-effects models to examine the associations of changes in lipids and HbA1c concentrations with intakes of soy food and isoflavones. RESULTS: Among the participants, mean age was 61 years, 67% were females and median intakes of soy and isoflavones were 95.3 g/day and 47.4 mg/day, respectively. Soy food and isoflavone intakes were not associated with 5-year changes in blood lipids or HbA1c concentrations. However, stratified analyses showed inverse associations between fermented soy intake and serum lipids among obese/overweight subjects. In particular, intake of 20 g/day of natto was associated with a reduction of 1.4 (95% CI 0.3, 2.5) mg/dL in TC, 1.5 (95% CI 0.4, 2.6) mg/dL in non-high-density lipoprotein cholesterol, 1.0 (95% CI - 0.0, 2.0) mg/dL in low-density lipoprotein cholesterol and 4.0 (95% CI 0.6, 7.5) mg/dL in triglycerides. CONCLUSIONS: Overall, habitual consumption of soy or isoflavones was not associated with changes in serum lipids or HbA1c concentrations. The negative associations between intake of natto and changes in serum lipids among overweight/obese subjects deserve further investigation.

Exposure to tobacco smoke prenatally and during infancy and risk of hearing impairment among children in Japan: A retrospective cohort study.

BACKGROUND: Previous studies of the association between tobacco smoke and hearing loss in children are limited, involve small samples and are cross-sectional. We investigated the association of maternal smoking during pregnancy and exposure to tobacco smoke at age 4 months with hearing impairment at age 3 years in children. METHODS: This population-based retrospective cohort study included 50 734 children born between 2004 and 2010 in Kobe City, Japan. Smoking during pregnancy and exposure to tobacco smoke at 4 months was measured using parent-reported questionnaires. Hearing impairment was determined by the whispered voice test. RESULTS: Of the included children, 3.8% were exposed to smoking only during pregnancy; 3.9% were exposed only to second-hand smoke at 4 months; and 0.9% were exposed to tobacco smoke during pregnancy and at 4 months. The prevalence of hearing impairment at age 3 years was 4.6%. Compared with children not exposed to tobacco smoke prenatally and at 4 months, the risk of hearing impairment was elevated in children exposed to only maternal past smoking during pregnancy (RR 1.26, 95% CI 1.13, 1.40), only second-hand smoke at 4 months (RR 1.30, 95% CI 1.07, 1.56), only smoking during pregnancy (RR 1.68, 95% CI 1.42, 2.00) and smoking during pregnancy and second-hand smoke at 4 months (RR 2.35, 95% CI 1.79, 3.10). CONCLUSIONS: Exposure to tobacco smoke prenatally and postnatally was associated with hearing impairment in children. A prevention of smoking before and during pregnancy and exposure to second-hand smoke postnatally may reduce hearing impairment risk in children.

Prenatal Alcohol Exposure and Suspected Hearing Impairment Among Children: A Population-based Retrospective Cohort Study.

AIMS: This study aimed to examine the association between prenatal alcohol exposure and hearing impairment among Japanese children using early childhood health check-up data. METHODS: This retrospective cohort study used population-based health check-up data for children who were born between April 2000 and March 2013 in Hofu city, Japan. Logistic regression models were used to evaluate the association between prenatal alcohol exposure and hearing impairment among children at the age of 36 months. The models were adjusted for mother's age, smoking habit, child sex, birth weight, birth order, history of otitis media and familial history of hearing impairment. RESULTS: Among the 16,211 registered children, 10,680 children had maternal gestational information and underwent a health check-up at the age of 36 months. A total of 10,562 children were included in the analyses, which revealed that 640 children required a re-examination for hearing impairment, 157 children required a detailed examination for hearing impairment and 83 children were receiving treatment for hearing impairment at 36 months. Prenatal alcohol exposure was independently associated with suspected hearing impairment among children after adjusting for potential confounders. CONCLUSIONS: Our findings suggest that prenatal alcohol exposure may adversely affect the auditory system of children. SHORT SUMMARY: Prenatal alcohol exposure was associated with suspected hearing impairment among children at 36 months, based on the findings of a population-based retrospective cohort study that used health check-up data from 10,562 Japanese children.

Evaluation of Alcohol Screening and Community-Based Brief Interventions in Rural Western Kenya: A Quasi-Experimental Study.

AIMS: To assess the effectiveness of community-based alcohol brief interventions (ABI) implemented by community-health workers with and without motivational talks (MT) by former drinkers, in reducing harmful and hazardous alcohol consumption. METHODS: We conducted a three-arm quasi-experimental study (one control and two intervention groups) between May and December 2015 in Kakamega County, Kenya. Participants were hazardous or harmful alcohol drinkers with an Alcohol Use Disorders Identification Test (AUDIT) score of 8-19 at baseline. One intervention group received only ABI while the other received ABI + MT. The interventions' effects on AUDIT scores were analysed using linear mixed models. Logistic regression was used to analyse the interventions' effects on low-risk drinking (AUDIT score <8) after 6 months. RESULTS: The study included 161 participants: 52 in the control group, 52 in the only ABI group and 57 in the ABI + MT group. The mean AUDIT scores were lower in the intervention groups at 1, 3 and 6 months post-intervention; the ABI + MT group showed a greater reduction. The mean AUDIT scores over a 6-month period were lower in both intervention groups compared with the control group. The odds of low-risk drinking were almost two times higher in both intervention groups than in the control group, although the effect of only ABI on low-risk drinking was not significant. CONCLUSIONS: ABI + MT and only ABI were associated with a reduced mean AUDIT score among hazardous and high-risk drinkers in this resource-limited setting. ABI + MT was also associated with low-risk drinking in this population. SHORT SUMMARY: Community-based alcohol brief interventions implemented by community-health workers accompanied by motivational talks by former drinkers were associated with reduced hazardous and harmful alcohol consumption in a rural setting in western Kenya.

Caesarean delivery and anaemia risk in children in 45 low- and middle-income countries.

Caesarean delivery (CD) may reduce placental transfusion and cause poor iron-related haematological indices in the neonate. We aimed to explore the association between CD and anaemia in children aged <5 years utilising data from Demographic and Health Surveys conducted between 2005 and 2015 in 45 low- and middle-income countries (N = 132,877). We defined anaemia categories based on haemoglobin levels, analysed each country's data separately using propensity-score weighting, pooled the country-specific odds ratios (ORs) using random effects meta-analysis, and performed meta-regression to determine whether the association between CD and anaemia varies by national CD rate, anaemia prevalence, and gross national income. Individual-level CD was not associated with any anaemia (OR 0.95, 95% confidence interval (CI) [0.86, 1.06]; I2  = 40.2%), mild anaemia (OR 0.91, 95% CI [0.81, 1.02]; I2  = 24.8%), and moderate/severe anaemia (OR 0.97, 95% CI [0.85, 1.11]; I2  = 47.7%). CD tended to be positively associated with moderate/severe anaemia in upper middle-income countries and negatively associated with mild anaemia in lower middle-income countries; however, meta-regression did not detect any variation in the association between anaemia and CD by the level of income, CD rate, and anaemia prevalence. In conclusion, there was no evidence for an association between CD and anaemia in children younger than 5 years in low- and middle-income countries. Our conclusions were consistent when we looked at only countries with CD rate >15% with data stratified by individual-level wealth status and type of health facility of birth.

Correlates of alcohol consumption in rural western Kenya: A cross-sectional study.

BACKGROUND: Studies on alcohol consumption in rural areas in sub-Saharan Africa are scarce. This study aimed to determine the prevalence and determinants of alcohol consumption in rural western Kenya. The study was conducted as a preliminary stage of a community-based intervention to reduce hazardous alcohol consumption. METHODS: A cross-sectional survey of 478 participants aged 18-65 years residing in Ikolomani Sub-county, Kakamega County was conducted in April 2015. Data were collected using an interviewer-administered questionnaire. We defined current drinkers as participants who consumed any alcoholic product in the preceding one month, and hazardous/high-risk drinkers as participants with an Alcohol Use Disorders Identification Test (AUDIT) score of 8 and above. We summarised data using descriptive statistics and used logistic regression to explore for the correlates of each of current alcohol consumption and hazardous/high-risk alcohol consumption. RESULTS: The sex-standardized prevalence of current alcohol drinkers was 31.7% (95% confidence interval (CI): 26.8%-37.2%). The prevalence was higher in men (54.6%) than in women (8.9%). The mean AUDIT score among current drinkers was 16.9 (SD 8.2) and the sex-standardized prevalence of hazardous/high-risk alcohol drinking was 28.7% (95% CI: 24.1%-34.0%). Traditional brews were the most commonly consumed types of alcohol and most drinkers took alcohol in the homes of alcohol sellers/brewers. In multivariate analyses, the number of drinkers in the family, the number of friends who are drinkers and the attitude towards alcohol intake were positively associated with current alcohol drinking status, and with hazardous/high-risk alcohol consumption. Women were less likely to be current drinkers and hazardous/high-risk drinkers than were men. Other socio-demographic factors were not significantly associated with alcohol consumption. CONCLUSIONS: The prevalence of alcohol consumption in the study area was higher than the national level estimate of 13.3%. The results suggest that the social environment is the main determinant of alcohol consumption in this setting. These findings imply that interventions to mitigate alcohol consumption in this area will have to target the social networks of the alcohol consumers, change the drinkers' attitude towards alcohol, and tackle the issue of availability of unlicensed homemade brews.

Effects of demand-side incentives in improving the utilisation of delivery services in Oyam District in northern Uganda: a quasi-experimental study.

BACKGROUND: We evaluated the effects and financial costs of two interventions with respect to utilisation of institutional deliveries and other maternal health services in Oyam District in Uganda. METHODS: We conducted a quasi-experimental study involving intervention and comparable/control sub-counties in Oyam District for 12 months (January-December 2014). Participants were women receiving antenatal care, delivery and postnatal care services. We evaluated two interventions: the provision of (1) transport vouchers to women receiving antenatal care and delivering at two health centres (level II) in Acaba sub-county, and (2) baby kits to women who delivered at Ngai Health Centre (level III) in Ngai sub-county. The study outcomes included service coverage of institutional deliveries, four antenatal care visits, postnatal care, and the percentage of women 'bypassing' maternal health services inside their resident sub-counties. We calculated the effect of each intervention on study outcomes using the difference in differences analysis. We calculated the cost per institutional delivery and the cost per unit increment in institutional deliveries for each intervention. RESULTS: Overall, transport vouchers had greater effects on all four outcomes, whereas baby kits mainly influenced institutional deliveries. The absolute increase in institutional deliveries attributable to vouchers was 42.9%; the equivalent for baby kits was 30.0%. Additionally, transport vouchers increased the coverage of four antenatal care visits and postnatal care service coverage by 60.0% and 49.2%, respectively. 'Bypassing' was mainly related to transport vouchers and ranged from 7.2% for postnatal care to 11.9% for deliveries. The financial cost of institutional delivery was US$9.4 per transport voucher provided, and US$10.5 per baby kit. The incremental cost per unit increment in institutional deliveries in the transport-voucher system was US$15.9; the equivalent for the baby kit was US$30.6. CONCLUSION: The transport voucher scheme effectively increased utilisation of maternal health services whereas the baby-kit scheme was only effective in increasing institutional deliveries. The transport vouchers were less costly than the baby kits in the promotion of institutional deliveries. Such incentives can be sustainable if the Ministry of Health integrates them in the health system.

Barriers to utilisation of antenatal care services in South Sudan: a qualitative study in Rumbek North County.

BACKGROUND: Access to adequate antenatal care (ANC) is critical in ensuring a good maternal health and in preventing maternal and neonatal morbidity and mortality. South Sudan has one of the world's poorest health indicators due to a fragile health system and a combination of socio-cultural, economic, and political factors. This study was conducted to identify barriers to utilisation of ANC services in Rumbek North County. METHODS: Using a qualitative design, data were collected through 14 focus group discussions with 169 women and 45 men and 12 key informant interviews with community leaders, staff working in health facilities, and the staff of the County Health Department. Data were analysed using inductive content analysis. RESULTS: The perceived barriers to ANC utilisation were categorised as follows: 1) Issues related to access to health facilities and lack of resources. These included long distance to health facilities, lack of means of transportation to the health facilities, floods and poor roads, and demand for payment for health care at some health facilities; 2) The influence of the socio-cultural context and conflict including heavy burden of domestic chores, the negative influence of husbands who were reluctant to allow their wives to attend ANC, and insecurity; 3) Perceptions about pregnancy including misperceptions about the benefits of ANC and low perceived risk of pregnancy-related complications; and 4) Perceptions about the quality of care and the efficacy of medical treatment. CONCLUSIONS: This study identified a myriad of factors deeply entrenched in the society, which prevent women from utilising ANC services. It also elicits broad aspects of interconnectedness among the barriers. To ensure effectiveness, strategies to improve utilisation of ANC in the study area and in similar contexts need to take into account the barriers identified by this study.

Prenatal anemia control and anemia in children aged 6-23 months in sub-Saharan Africa.

It is unclear whether routine prenatal anemia control interventions can reduce anemia risk in young children. This study examines the associations between prenatal iron supplementation and/or deworming and anemia in children aged 6-23 months in sub-Saharan Africa (SSA). We analyzed data from Demographic and Health Surveys conducted between 2003 and 2014 in 25 SSA countries. The surveys collected data on prenatal iron supplementation and deworming and determined children's hemoglobin levels through blood testing. We assessed the associations between prenatal iron supplementation and/or deworming and anemia using multinomial logistic regression. The study included 31,815 mother-child pairs: 25.0%, 41.4%, and 4.8% of children had mild, moderate, and severe anemia, respectively. Compared with children whose mothers did not take iron and deworming drugs prenatally, the risk of moderate/severe anemia was reduced among children whose mothers took only iron supplements for ≥6 months (odds ratio [OR]: 0.58; 95% confidence interval [CI]: 0.45-0.76); only deworming drugs (OR: 0.73; 95% CI: 0.56-0.93); deworming drugs plus iron for <6 months (OR: 0.79; 95% CI: 0.67-0.93); and deworming drugs plus iron for ≥6 months (OR: 0.77; 95% CI: 0.59-0.99). Prenatal use of only iron for <6 months was not associated with moderate/severe anemia. Prenatal iron and/or deworming drugs had no effect on mild anemia. Prenatal anemia control interventions are associated with reduced risk of moderate/severe anemia but not with mild anemia in young children in SSA. Iron supplements should be taken for ≥6 months or with deworming drugs prenatally to reduce moderate/severe anemia risk in children.

Evaluation of a maternal health care project in South West Shoa Zone, Ethiopia: before-and-after comparison.

BACKGROUND: Despite recent achievements in health targets, Ethiopia still faces challenges in health service delivery. Between 2012 and 2015, a non-governmental organisation (NGO), Doctors with Africa CUAMM, implemented a multifaceted project aimed at improving access to maternal and child health services in three districts in Ethiopia. This paper evaluates the performance of this project, based on four maternal health indicators. METHODS: A before-and-after study utilising data collected through cross-sectional surveys involving 999 women was conducted. The date of delivery was used to stratify the intervention period as follows: pre-intervention, early intervention, and late intervention. Changes during the intervention in the coverage of four antenatal care (ANC) visits, receipt of three basic components of ANC, skilled birth attendant (SBA) at delivery, and postnatal care (PNC) in seven days were assessed using logistic regression, adjusting for socio-demographic factors. RESULTS: There was an increase in the coverage of receipt of all three ANC components and SBA at delivery between the pre-intervention period and the late intervention period. The percent of health centre deliveries increased from 7.3 % in the pre-intervention period to 35.6 % in the late intervention period. The odds of receiving all three components of ANC were twice higher in the late intervention period than in the pre-intervention period (OR 2.09; 95 % CI 1.12-3.89). The odds of SBA at delivery were five times higher in the late intervention period than in the pre-intervention period (OR 5.04; 95 % CI 2.53-10.06). There was no significant change in the coverage of four ANC visits and PNC after accounting for sociodemographic factors. CONCLUSIONS: This NGO implemented maternal health project in three districts in Ethiopia was associated with increased likelihood that a pregnant woman would receive three basic components of ANC and be assisted by a SBA at delivery. Increase in skilled birth attendance was driven by increased utilisation of health centres. More efforts are needed to bolster the coverage of ANC and PNC.

Determinants of utilisation of antenatal care and skilled birth attendant at delivery in South West Shoa Zone, Ethiopia: a cross sectional study.

BACKGROUND: Ethiopia has high maternal mortality ratio and poor access to maternal health services. Attendance of at least four antenatal care (ANC) visits and delivery by a skilled birth attendant (SBA) are important in preventing maternal deaths. Understanding the reasons behind the poor use of these services is important in designing strategies to address the problem. This study aimed to determine the coverage of at least four ANC visits and delivery by a SBA and to identify determinants of utilisation of these services in three districts in South West Shoa Zone, Ethiopia. METHODS: A cross-sectional survey of 500 women aged 15-49 years with a delivery in two years prior to the survey was conducted in Wolisso, Wonchi and Goro districts in February 2013. Data were collected using an interviewer administered questionnaire. Logistic regression models were used to explore determinants of ANC attendance and SBA at delivery. RESULTS: Coverage of at least four ANC visits and SBA at delivery were 45.5 and 28.6 %, respectively. Most institutional deliveries (69 %) occurred at the single hospital that serves the study districts. Attendance of at least four ANC visits was positively associated with wealth status, knowledge of the recommended number of ANC visits, and attitude towards maternal health care, but was negatively associated with woman's age. SBA at delivery was negatively associated with parity and time to the health facility, but was positively associated with urban residence, wealth, knowledge of the recommended number of ANC visits, perceived good quality of maternal health services, experience of a pregnancy/delivery related problem, involvement of the partner/family in decision making on delivery place, and birth preparedness. CONCLUSIONS: Raising awareness about the minimum recommended number of ANC visits, tackling geographical inaccessibility, improving the quality of care, encouraging pregnant women to have a birth and complication readiness plan and community mobilisation targeting women, husbands, and families for their involvement in maternal health care have the potential to increase use of maternal health services in this setting. Furthermore, supporting health centres to increase uptake of institutional delivery services may rapidly increase coverage of delivery by SBA and reduce inequity.