Marketing of commercial milk formula: a system to capture parents, communities, science, and policy.

Despite proven benefits, less than half of infants and young children globally are breastfed in accordance with the recommendations of WHO. In comparison, commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more infants and young children receiving formula products than ever. This Series paper describes the CMF marketing playbook and its influence on families, health professionals, science, and policy processes, drawing on national survey data, company reports, case studies, methodical scoping reviews, and two multicountry research studies. We report how CMF sales are driven by multifaceted, well resourced marketing strategies that portray CMF products, with little or no supporting evidence, as solutions to common infant health and developmental challenges in ways that systematically undermine breastfeeding. Digital platforms substantially extend the reach and influence of marketing while circumventing the International Code of Marketing of Breast-milk Substitutes. Creating an enabling policy environment for breastfeeding that is free from commercial influence requires greater political commitment, financial investment, CMF industry transparency, and sustained advocacy. A framework convention on the commercial marketing of food products for infants and children is needed to end CMF marketing.

Breastfeeding: crucially important, but increasingly challenged in a market-driven world.

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

Exploring the "Urban Advantage" in Access to Immunization Services: A Comparison of Zero-Dose Prevalence Between Rural, and Poor and Non-poor Urban Households Across 97 Low- and Middle-Income Countries.

Urban children are more likely to be vaccinated than rural children, but that advantage is not evenly distributed. Children living in poor urban areas face unique challenges, living far from health facilities and with lower-quality health services, which can impact their access to life-saving vaccines. Our goal was to compare the prevalence of zero-dose children in poor and non-poor urban and rural areas of low- and middle-income countries (LMICs). Zero-dose children were those who failed to receive any dose of a diphtheria-pertussis-tetanus (DPT) containing vaccine. We used data from nationally representative household surveys of 97 LMICs to investigate 201,283 children aged 12-23 months. The pooled prevalence of zero-dose children was 6.5% among the urban non-poor, 12.6% for the urban poor, and 14.7% for the rural areas. There were significant differences between these areas in 43 countries. In most of these countries, the non-poor urban children were at an advantage compared to the urban poor, who were still better off or similar to rural children. Our results emphasize the inequalities between urban and rural areas, but also within urban areas, highlighting the challenges faced by poor urban and rural children. Outreach programs and community interventions that can reach poor urban and rural communities-along with strengthening of current vaccination programs and services-are important steps to reduce inequalities and ensure that no child is left unvaccinated.

Effects of early-life poverty on health and human capital in children and adolescents: analyses of national surveys and birth cohort studies in LMICs.

The survival and nutrition of children and, to a lesser extent, adolescents have improved substantially in the past two decades. Improvements have been linked to the delivery of effective biomedical, behavioural, and environmental interventions; however, large disparities exist between and within countries. Using data from 95 national surveys in low-income and middle-income countries (LMICs), we analyse how strongly the health, nutrition, and cognitive development of children and adolescents are related to early-life poverty. Additionally, using data from six large, long-running birth cohorts in LMICs, we show how early-life poverty can have a lasting effect on health and human capital throughout the life course. We emphasise the importance of implementing multisectoral anti-poverty policies and programmes to complement specific health and nutrition interventions delivered at an individual level, particularly at a time when COVID-19 continues to disrupt economic, health, and educational gains achieved in the recent past.

Health and development from preconception to 20 years of age and human capital.

Optimal health and development from preconception to adulthood are crucial for human flourishing and the formation of human capital. The Nurturing Care Framework, as adapted to age 20 years, conceptualises the major influences during periods of development from preconception, through pregnancy, childhood, and adolescence that affect human capital. In addition to mortality in children younger than 5 years, stillbirths and deaths in 5-19-year-olds are important to consider. The global rate of mortality in individuals younger than 20 years has declined substantially since 2000, yet in 2019 an estimated 8·6 million deaths occurred between 28 weeks of gestation and 20 years of age, with more than half of deaths, including stillbirths, occurring before 28 days of age. The 1000 days from conception to 2 years of age are especially influential for human capital. The prevalence of low birthweight is high in sub-Saharan Africa and even higher in south Asia. Growth faltering, especially from birth to 2 years, occurs in most world regions, whereas overweight increases in many regions from the preprimary school period through adolescence. Analyses of cohort data show that growth trajectories in early years of life are strong determinants of nutritional outcomes in adulthood. The accrual of knowledge and skills is affected by health, nutrition, and home resources in early childhood and by educational opportunities in older children and adolescents. Linear growth in the first 2 years of life better predicts intelligence quotients in adults than increases in height in older children and adolescents. Learning-adjusted years of schooling range from about 4 years in sub-Saharan Africa to about 11 years in high-income countries. Human capital depends on children and adolescents surviving, thriving, and learning until adulthood.

Recent trends in maternal and child health inequalities in Latin America and the Caribbean: analysis of repeated national surveys.

BACKGROUND: Although most Latin American and the Caribbean (LAC) countries made important progress in maternal and child health indicators from the 1990s up to 2010, little is known about such progress in the last decade. This study aims at documenting progress for each country as a whole, and to assess how within-country socioeconomic inequalities are evolving over time. METHODS: We identified LAC countries for which a national survey was available between 2011-2015 and a second comparable survey in 2018-2020. These included Argentina, Costa Rica, Cuba, the Dominican Republic, Guyana, Honduras, Peru, and Suriname. The 16 surveys included in the analysis collected nationally representative data on 221,989 women and 152,983 children using multistage sampling. Twelve health-related outcomes were studied, seven of which related to intervention coverage: the composite coverage index, demand for family planning satisfied with modern methods, antenatal care (four or more visits and eight or more visits), skilled attendant at birth, postnatal care for the mother and full immunization coverage. Five additional impact indicators were also investigated: stunting prevalence among under-five children, tobacco use by women, adolescent fertility rate, and under-five and neonatal mortality rates. For each of these indicators, average annual relative change rates were calculated between the baseline and endline national level estimates, and changes in socioeconomic inequalities over time were assessed using the slope index of inequality. RESULTS: Progress over time and the magnitude of inequalities varied according to country and indicator. For countries and indicators where baseline levels were high, as Argentina, Costa Rica and Cuba, progress was slow and inequalities small for most indicators. Countries that still have room for improvements, such as Guyana, Honduras, Peru and Suriname, showed faster progress for some but not all indicators, although also had wider inequalities. Among the countries studied, Peru was the top performer in terms of increasing coverage and reducing inequalities over time, followed by Honduras. Declines in family planning and immunization coverage were observed in some countries, and the widest inequalities were present for adolescent fertility and antenatal care coverage with eight or more visits. CONCLUSIONS: Although LAC countries are well placed in terms of current levels of health indicators compared to most low- and middle-income countries, important inequalities remain, and reversals are being observed in some areas. More targeted efforts and actions are needed in order to leave no one behind. Monitoring progress with an equity lens is essential, but this will require further investment in conducting surveys routinely.

Time trends in ethnic inequalities in child health and nutrition: analysis of 59 low and middle-income countries.

BACKGROUND: Although ethnicity is a key social determinant of health, there are no global analyses aimed at identifying countries that succeeded in reducing ethnic gaps in child health and nutrition. METHODS: We identified 59 low and middle-income countries with at least two surveys since 2010 providing information on ethnicity or language and on three outcomes: under-five mortality, child stunting prevalence and a composite index (CCI) based on coverage with eight maternal and child health interventions. Firstly, we calculated population-weighted and unweighted measures of inequality among ethnic or language groups within each country. These included the mean difference from the overall national mean (absolute inequality), mean ratio relative to the overall mean (relative inequality), and the difference and ratio between the best- and worst-performing ethnic groups. Second, we examined annual changes in these measures in terms of annual absolute and relative changes. Thirdly, we compared trends for each of the three outcome indicators and identified exemplar countries with marked progress in reducing inequalities. RESULTS: For each outcome indicator, annual changes in summary measures tended to show moderate (Pearson correlation coefficients of 0.4 to 0.69) or strong correlations (0.7 or higher) among themselves, and we thus focused on four of the 12 measures: absolute and relative annual changes in mean differences and ratios from the overall national mean. On average, absolute ethnic or language group inequalities tended to decline slightly for the three outcomes, and relative inequality declined for stunting and CCI, but increased for mortality. Correlations for annual trends across the three outcomes were inconsistent, with several countries showing progress in terms of one outcome but not in others. Togo and Uganda showed with the most consistent progress in reducing inequality, whereas the worst performers were Nigeria, Moldova, Kyrgyzstan, Sao Tome and Principe, and Burkina Faso. CONCLUSIONS: Although measures of annual changes in ethnic or language group inequalities in child health were consistently correlated within each outcome, analyses of such inequalities should rely upon multiple measures. Countries showing progress in one child health outcome did not necessarily show improvements in the remaining outcomes. In-depth analyses at country level are needed to understand the drivers of success in reducing ethnic gaps.

Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda.

13 years after the first Lancet Series on maternal and child undernutrition, we reviewed the progress achieved on the basis of global estimates and new analyses of 50 low-income and middle-income countries with national surveys from around 2000 and 2015. The prevalence of childhood stunting has fallen, and linear growth faltering in early life has become less pronounced over time, markedly in middle-income countries but less so in low-income countries. Stunting and wasting remain public health problems in low-income countries, where 4·7% of children are simultaneously affected by both, a condition associated with a 4·8-times increase in mortality. New evidence shows that stunting and wasting might already be present at birth, and that the incidence of both conditions peaks in the first 6 months of life. Global low birthweight prevalence declined slowly at about 1·0% a year. Knowledge has accumulated on the short-term and long-term consequences of child undernutrition and on its adverse effect on adult human capital. Existing data on vitamin A deficiency among children suggest persisting high prevalence in Africa and south Asia. Zinc deficiency affects close to half of all children in the few countries with data. New evidence on the causes of poor growth points towards subclinical inflammation and environmental enteric dysfunction. Among women of reproductive age, the prevalence of low body-mass index has been reduced by half in middle-income countries, but trends in short stature prevalence are less evident. Both conditions are associated with poor outcomes for mothers and their children, whereas data on gestational weight gain are scarce. Data on the micronutrient status of women are conspicuously scarce, which constitutes an unacceptable data gap. Prevalence of anaemia in women remains high and unabated in many countries. Social inequalities are evident for many forms of undernutrition in women and children, suggesting a key role for poverty and low education, and reinforcing the need for multisectoral actions to accelerate progress. Despite little progress in some areas, maternal and child undernutrition remains a major global health concern, particularly as improvements since 2000 might be offset by the COVID-19 pandemic.

Consumption of breast milk, formula and other non-human milk by children aged under 2 years: analysis of eighty-six low- and middle-income countries.

OBJECTIVE: To investigate the prevalence and socio-economic inequalities in breast milk, breast milk substitutes (BMS) and other non-human milk consumption, by children under 2 years in low- and middle-income countries (LMIC). DESIGN: We analysed the prevalence of continued breast-feeding at 1 and 2 years and frequency of formula and other non-human milk consumption by age in months. Indicators were estimated through 24-h dietary recall. Absolute and relative wealth indicators were used to describe within- and between-country socio-economic inequalities. SETTING: Nationally representative surveys from 2010 onwards from eighty-six LMIC. PARTICIPANTS: 394 977 children aged under 2 years. RESULTS: Breast-feeding declined sharply as children became older in all LMIC, especially in upper-middle-income countries. BMS consumption peaked at 6 months of age in low/lower-middle-income countries and at around 12 months in upper-middle-income countries. Irrespective of country, BMS consumption was higher in children from wealthier families, and breast-feeding in children from poorer families. Multilevel linear regression analysis showed that BMS consumption was positively associated with absolute income, and breast-feeding negatively associated. Findings for other non-human milk consumption were less straightforward. Unmeasured factors at country level explained a substantial proportion of overall variability in BMS consumption and breast-feeding. CONCLUSIONS: Breast-feeding falls sharply as children become older, especially in wealthier families in upper-middle-income countries; this same group also consumes more BMS at any age. Country-level factors play an important role in explaining BMS consumption by all family wealth groups, suggesting that BMS marketing at national level might be partly responsible for the observed differences.

Birth registration coverage according to the sex of the head of household: an analysis of national surveys from 93 low- and middle-income countries.

BACKGROUND: Within-country inequalities in birth registration coverage (BRC) have been documented according to wealth, place of residence and other household characteristics. We investigated whether sex of the head of household was associated with BRC. METHODS: Using data from nationally-representative surveys (Demographic and Health Survey or Multiple Indicator Cluster Survey) from 93 low and middle-income countries (LMICs) carried out in 2010 or later, we developed a typology including three main types of households: male-headed (MHH) and female-led with or without an adult male resident. Using Poisson regression, we compared BRC for children aged less than 12 months living the three types of households within each country, and then pooled results for all countries. Analyses were also adjusted for household wealth quintiles, maternal education and urban-rural residence. RESULTS: BRC ranged from 2.2% Ethiopia to 100% in Thailand (median 79%) while the proportion of MHH ranged from 52.1% in Ukraine to 98.3% in Afghanistan (median 72.9%). In most countries the proportion of poor families was highest in FHH (no male) and lowest in FHH (any male), with MHH occupying an intermediate position. Of the 93 countries, in the adjusted analyses, FHH (no male) had significantly higher BRC than MHH in 13 countries, while in eight countries the opposite trend was observed. The pooled analyses showed t BRC ratios of 1.01 (95% CI: 1.00; 1.01) for FHH (any male) relative to MHH, and also 1.01 (95% CI: 1.00; 1.01) for FHH (no male) relative to MHH. These analyses also showed a high degree of heterogeneity among countries. CONCLUSION: Sex of the head of household was not consistently associated with BRC in the pooled analyses but noteworthy differences in different directions were found in specific countries. Formal and informal benefits to FHH (no male), as well as women's ability to allocate household resources to their children in FHH, may explain why this vulnerable group has managed to offset a potential disadvantage to their children.

[SDG3-related inequalities in women's, children's and adolescents' health: an SDG monitoring baseline for Latin America and the Caribbean using national cross-sectional surveysDesigualdades relacionadas ao ODS 3 na saúde da mulher, da criança e do adolescente: linha de base para o monitoramento do ODS na América Latina e no Caribe por meio de pesquisas transversais nacionais]. / Desigualdades relacionadas con el ODS 3 en la salud de las mujeres, los niños y los adolescentes: línea de base para el monitoreo de los ODS en América Latina y el Caribe por medio de encuestas transversales nacionales.

Objectives: Latin America and the Caribbean (LAC) countries have made important progress towards achieving the Sustainable Development Goal (SDG) targets related to health (SDG3) at the national level. However, vast within-country health inequalities remain. We present a baseline of health inequalities in the region, against which progress towards the SDGs can be monitored. Setting: We studied 21 countries in LAC using data from Demographic and Health Surveys and Multiple Indicator Cluster Survey carried out from 2011 to 2016. Participants: The surveys collect nationally representative data on women and children using multistage sampling. In total, 288 207 women and 195 092 children made part of the surveys in the 21 countries. Outcome measures: Five health intervention indicators were studied, related to reproductive and maternal health, along with adolescent fertility and neonatal and under-five mortality rates. Inequalities in these indicators were assessed through absolute and relative measures. Results: In most countries, subnational geographical health gradients were observed for nearly all women, child, and adolescent (WCA) indicators. Coverage of key interventions was higher in urban areas and among the richest, compared with rural areas and poorer quintiles. Analyses by woman's age showed that coverage was lower in adolescent girls than older women for family planning indicators. Pro-urban and pro-rich inequalities were also seen for mortality in most countries. Conclusions: Regional averages hide important health inequalities between countries, but national estimates hide still greater inequalities between subgroups of women, children and adolescents. To achieve the SDG3 targets and leave no one behind, it is essential to close health inequality gaps within as well as between countries.

Objetivos: Os países da América Latina e do Caribe obtiveram avanços significativos rumo à consecução do Objetivo de Desenvolvimento Sustentável relacionado à saúde (ODS 3) no nível nacional. No entanto, enormes desigualdades em saúde persistem nos países. Apresenta-se uma linha de base das desigualdades em saúde na região, com referência à qual é possível monitorar o progresso rumo aos ODS. Contexto: Foram estudados 21 países da América Latina e do Caribe usando dados de pesquisas de demografia e saúde e pesquisas de grupos de indicadores múltiplos feitas de 2011 a 2016. Participantes: As pesquisas coletam dados nacionalmente representativos sobre mulheres e crianças, por meio de amostragem multietápica. No total, 288.207 mulheres e 195.092 crianças participaram das pesquisas nos 21 países. Medição dos resultados: Foram estudados cinco indicadores de intervenções de saúde relacionadas à saúde reprodutiva e materna, à fertilidade das adolescentes e às taxas de mortalidade neonatal e de menores de cinco anos. As desigualdades nesses indicadores foram então avaliadas, empregando medidas absolutas e relativas. Resultados: Gradientes geográficos de saúde nos níveis subnacionais foram observados na maioria dos países para quase todos os indicadores referentes às mulheres e à população infantil e adolescente. A cobertura das principais intervenções foi maior nas áreas urbanas e nos quintis mais ricos do que nas áreas rurais e nos quintis mais pobres. As análises por idade das mulheres mostraram que a cobertura das adolescentes era inferior à cobertura das mulheres adultas no que se refere aos indicadores de planejamento familiar. Além disso, foram observadas desigualdades na mortalidade que favoreciam as áreas urbanas e os ricos, na maioria dos países. Conclusões: As médias regionais mascaram desigualdades significativas na saúde entre os países, mas as estimativas nacionais mascaram desigualdades ainda maiores entre os subgrupos de mulheres, crianças e adolescentes. Para alcançar as metas do ODS 3 e não deixar ninguém para trás, é essencial abordar não apenas as lacunas da desigualdade em saúde entre os países, mas também dentro deles.

Complementary Feeding Practices in 80 Low- and Middle-Income Countries: Prevalence of and Socioeconomic Inequalities in Dietary Diversity, Meal Frequency, and Dietary Adequacy.

BACKGROUND: Adequate complementary feeding practices in early childhood contribute to better food preferences and health outcomes throughout the life course. OBJECTIVES: The aim of this study was to describe patterns and socioeconomic inequalities in complementary feeding practices among children aged 6-23 mo in 80 low- and middle-income countries. METHODS: We analyzed national surveys carried out since 2010. Complementary feeding indicators for children aged 6-23 mo included minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD). Between- and within-country inequalities were documented using relative (wealth deciles), gross domestic product (GDP) per capita, and absolute (estimated household income) socioeconomic indicators. Statistical analyses included calculation of the slope index of inequality, Pearson correlation and linear regression, and scatter diagrams. RESULTS: Only 21.3%, 56.2%, and 10.1% of the 80 countries showed prevalence levels >50% for MDD, MMF, and MAD, respectively. Western & Central Africa showed the lowest prevalence for all indicators, whereas the highest for MDD and MAD was Latin America & Caribbean, and for MMF it was East Asia & the Pacific. Log GDP per capita was positively associated with MDD (R2 = 48.5%), MMF (28.2%), and MAD (41.4%). Pro-rich within-country inequalities were observed in most countries for the 3 indicators; pro-poor inequalities were observed in 2 countries for MMF, and in none for the other 2 indicators. Breast milk was the only type of food with a pro-poor distribution, whereas animal-source foods (dairy products, flesh foods, and eggs) showed the most pronounced pro-rich inequality. Dietary diversity improved sharply when absolute annual household incomes exceeded ∼US$20,000. All 3 dietary indicators improved by age and no consistent differences were observed between boys and girls. CONCLUSIONS: Monitoring complementary feeding indicators across the world and implementing policies and programs to reduce wealth-related inequalities are essential to achieve optimal child nutrition.

Patterns of Growth in Childhood in Relation to Adult Schooling Attainment and Intelligence Quotient in 6 Birth Cohorts in Low- and Middle-Income Countries: Evidence from the Consortium of Health-Oriented Research in Transitioning Societies (COHORTS).

BACKGROUND: Growth faltering has been associated with poor intellectual performance. The relative strengths of associations between growth in early and in later childhood remain underexplored. OBJECTIVES: We examined the association between growth in childhood and adult human capital in 5 low- and middle-income countries (LMICs). METHODS: We analyzed data from 9503 participants in 6 prospective birth cohorts from 5 LMICs (Brazil, Guatemala, India, the Philippines, and South Africa). We used linear and quasi-Poisson regression models to assess the associations between measures of height and relative weight at 4 age intervals [birth, age ∼2 y, midchildhood (MC), adulthood] and 2 dimensions of adult human capital [schooling attainment and Intelligence Quotient (IQ)]. RESULTS: Meta-analysis of site- and sex-specific estimates showed statistically significant associations between size at birth and height at ∼2 y and the 2 outcomes (P < 0.001). Weight and length at birth and linear growth from birth to ∼2 y of age (1 z-score difference) were positively associated with schooling attainment (ß: 0.13; 95% CI: 0.08, 0.19, ß: 0.17; 95% CI: 0.07, 0.32, and ß: 0.25, 95% CI: 0.10, 0.40, respectively) and adult IQ (ß: 0.74, 95% CI: 0.35, 1.14, ß: 0.73, 95% CI: 0.35, 1.10, and ß: 1.52, 95% CI: 0.96, 2.08, respectively). Linear growth from age 2 y to MC and from MC to adulthood was not associated with higher school attainment or IQ. Change in relative weight in early childhood, MC, and adulthood was not associated with either outcome. CONCLUSIONS: Linear growth in the first 1000 d is a predictor of schooling attainment and IQ in adulthood in LMICs. Linear growth in later periods was not associated with either of these outcomes. Changes in relative weight across the life course were not associated with schooling and IQ in adulthood.

Fetal growth velocity standards from the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project.

BACKGROUND: Human growth is susceptible to damage from insults, particularly during periods of rapid growth. Identifying those periods and the normative limits that are compatible with adequate growth and development are the first key steps toward preventing impaired growth. OBJECTIVE: This study aimed to construct international fetal growth velocity increment and conditional velocity standards from 14 to 40 weeks' gestation based on the same cohort that contributed to the INTERGROWTH-21st Fetal Growth Standards. STUDY DESIGN: This study was a prospective, longitudinal study of 4321 low-risk pregnancies from 8 geographically diverse populations in the INTERGROWTH-21st Project with rigorous standardization of all study procedures, equipment, and measurements that were performed by trained ultrasonographers. Gestational age was accurately determined clinically and confirmed by ultrasound measurement of crown-rump length at <14 weeks' gestation. Thereafter, the ultrasonographers, who were masked to the values, measured the fetal head circumference, biparietal diameter, occipitofrontal diameter, abdominal circumference, and femur length in triplicate every 5 weeks (within 1 week either side) using identical ultrasound equipment at each site (4-7 scans per pregnancy). Velocity increments across a range of intervals between measures were modeled using fractional polynomial regression. RESULTS: Peak velocity was observed at a similar gestational age: 16 and 17 weeks' gestation for head circumference (12.2 mm/wk), and 16 weeks' gestation for abdominal circumference (11.8 mm/wk) and femur length (3.2 mm/wk). However, velocity growth slowed down rapidly for head circumference, biparietal diameter, occipitofrontal diameter, and femur length, with an almost linear reduction toward term that was more marked for femur length. Conversely, abdominal circumference velocity remained relatively steady throughout pregnancy. The change in velocity with gestational age was more evident for head circumference, biparietal diameter, occipitofrontal diameter, and femur length than for abdominal circumference when the change was expressed as a percentage of fetal size at 40 weeks' gestation. We have also shown how to obtain accurate conditional fetal velocity based on our previous methodological work. CONCLUSION: The fetal skeleton and abdomen have different velocity growth patterns during intrauterine life. Accordingly, we have produced international Fetal Growth Velocity Increment Standards to complement the INTERGROWTH-21st Fetal Growth Standards so as to monitor fetal well-being comprehensively worldwide. Fetal growth velocity curves may be valuable if one wants to study the pathophysiology of fetal growth. We provide an application that can be used easily in clinical practice to evaluate changes in fetal size as conditional velocity for a more refined assessment of fetal growth than is possible at present (https://lxiao5.shinyapps.io/fetal_growth/). The application is freely available with the other INTERGROWTH-21st tools at https://intergrowth21.tghn.org/standards-tools/.

Slow Spread of SARS-CoV-2 in Southern Brazil Over a 6-Month Period: Report on 8 Sequential Statewide Serological Surveys Including 35 611 Participants.

Objectives. To evaluate the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) over 6 months in the Brazilian State of Rio Grande do Sul (population 11.3 million), based on 8 serological surveys. Methods. In each survey, 4151 participants in round 1 and 4460 participants in round 2 were randomly sampled from all state regions. We assessed presence of antibodies against SARS-CoV-2 using a validated lateral flow point-of-care test; we adjusted figures for the time-dependent decay of antibodies. Results. The SARS-CoV-2 antibody prevalence increased from 0.03% (95% confidence interval [CI] = 0.00%, 0.34%; 1 in every 3333 individuals) in mid-April to 1.89% (95% CI = 1.36%, 2.54%; 1 in every 53 individuals) in early September. Prevalence was similar across gender and skin color categories. Older adults were less likely to be infected than younger participants. The proportion of the population who reported leaving home daily increased from 21.4% (95% CI = 20.2%, 22.7%) to 33.2% (95% CI = 31.8%, 34.5%). Conclusions. SARS-CoV-2 infection increased slowly during the first 6 months in the state, differently from what was observed in other Brazilian regions. Future survey rounds will continue to document the spread of the pandemic.

Levels and potential drivers of under-five mortality sex ratios in low- and middle-income countries.

BACKGROUND: Non-biological childhood mortality sex ratios may reflect community sex preferences and gender discrimination in health care. OBJECTIVE: We assessed the association between contextual factors and gender bias in under-five mortality rates (U5MR) in low- and middle-income countries. METHODS: Full birth histories available from Demographic and Health Surveys and Multiple Indicator Cluster Surveys (2010-2018) in 80 countries were used to estimate U5MR male-to-female sex ratios. Expected sex ratios and their residuals (difference of observed and expected) were derived from a linear regression model, adjusted for overall mortality. Negative residuals indicate more likelihood of discrimination against girls, and we refer to this as a measure of potential gender bias. Associations between residuals and national development and gender inequality indices and with survey-derived child health care indicators were tested using Spearman's correlation. RESULTS: Mortality residuals for under-five mortality were not associated with national development, education, religion, or gender inequality indices. Negative residuals were more common in countries where boys were more likely to be taken to health services than girls (rho -0.24, 95% confidence interval -0.45, -0.01). CONCLUSIONS: Countries where girls were more likely to die than boys, accounting for overall mortality levels, were also countries where boys were more likely to receive health care than girls. Further research is needed to understand which national characteristics explain the presence of gender bias, given that the analyses of development levels and gender equality did not discriminate between countries with or without excess mortality of girls. Reporting on child mortality separately by sex is required to enable such advances.

Inequalities in antenatal care coverage and quality: an analysis from 63 low and middle-income countries using the ANCq content-qualified coverage indicator.

BACKGROUND: Antenatal care (ANC) is an essential intervention associated with a reduction of maternal and new-born morbidity and mortality. However, evidence suggested substantial inequalities in maternal and child health, mainly in low- and middle-income countries (LMICs). We aimed to conduct a global analysis of socioeconomic inequalities in ANC using national surveys from LMICs. METHODS: ANC was measured using the ANCq, a novel content-qualified ANC coverage indicator, created and validated using national surveys, based upon contact with the health services and content of care received. We performed stratified analysis to explore the socioeconomic inequalities in ANCq. We also estimated the slope index of inequality, which measures the difference in coverage along the wealth spectrum. RESULTS: We analyzed 63 national surveys carried out from 2010 to 2017. There were large inequalities between and within countries. Higher ANCq scores were observed among women living in urban areas, with secondary or more level of education, belonging to wealthier families and with higher empowerment in nearly all countries. Countries with higher ANCq mean presented lower inequalities; while countries with average ANCq scores presented wide range of inequality, with some managing to achieve very low inequality. CONCLUSIONS: Despite all efforts in ANC programs, important inequalities in coverage and quality of ANC services persist. If maternal and child mortality Sustainable Development Goals are to be achieved, those gaps we documented must be bridged.

A scoping review of methods for assessment of sex differentials in early childhood mortality.

BACKGROUND: While assessment of sex differentials in child mortality is straightforward, their interpretation must consider that, in the absence of gender bias, boys are more likely to die than girls. The expected differences are also influenced by levels and causes of death. However, there is no standard approach for determining expected sex differences. METHODS: We performed a scoping review of studies on sex differentials in under-five mortality, using PubMed, Web of Science, and Scopus databases. Publication characteristics were described, and studies were grouped according to their methodology. RESULTS: From the 17,693 references initially retrieved we included 154 studies published since 1929. Indian, Bangladeshi, and Chinese populations were the focus of 44% of the works, and most studies addressed infant mortality. Fourteen publications were classified as reference studies, as these aimed to estimate expected sex differentials based upon the demographic experience of selected populations, either considered as gender-neutral or not. These studies used a variety of methods - from simple averages to sophisticated modeling - to define values against which observed estimates could be compared. The 21 comparative studies mostly used life tables from European populations as standard for expected values, but also relied on groups without assuming those values as expected, otherwise, just as comparison parameters. The remaining 119 studies were categorized as narrative and did not use reference values, being limited to reporting observed sex-specific estimates or used a variety of statistical models, and in general, did not account for mortality levels. CONCLUSION: Studies aimed at identifying sex differentials in child mortality should consider overall mortality levels, and report on more than one age group. The comparison of results with one or more reference values, and the use of statistical testing, are strongly recommended. Time trends analyses will help understand changes in population characteristics and interpret findings from a historical perspective.

Implications of Zika virus and congenital Zika syndrome for the number of live births in Brazil.

An increase in microcephaly, associated with an epidemic of Zika virus (ZIKV) in Brazil, prompted the World Health Organization to declare a Public Health Emergency of International Concern in February 2016. While knowledge on biological and epidemiological aspects of ZIKV has advanced, demographic impacts remain poorly understood. This study uses time-series analysis to assess the impact of ZIKV on births. Data on births, fetal deaths, and hospitalizations due to abortion complications for Brazilian states, from 2010 to 2016, were used. Forecasts for September 2015 to December 2016 showed that 119,095 fewer births than expected were observed, particularly after April 2016 (a reduction significant at 0.05), demonstrating a link between publicity associated with the ZIKV epidemic and the decline in births. No significant changes were observed in fetal death rates. Although no significant increases in hospitalizations were forecasted, after the ZIKV outbreak hospitalizations happened earlier in the gestational period in most states. We argue that postponement of pregnancy and an increase in abortions may have contributed to the decline in births. Also, it is likely that an increase in safe abortions happened, albeit selective by socioeconomic status. Thus, the ZIKV epidemic resulted in a generation of congenital Zika syndrome (CZS) babies that reflect and exacerbate regional and social inequalities. Since ZIKV transmission has declined, it is unlikely that reductions in births will continue. However, the possibility of a new epidemic is real. There is a need to address gaps in reproductive health and rights, and to understand CZS risk to better inform conception decisions.

[Maternal and child health inequalities among migrants: the case of Haiti and the Dominican RepublicDesigualdades na saúde materno-infantil entre migrantes: o caso do Haiti e da República Dominicana]. / Desigualdades en la salud maternoinfantil de los migrantes: el caso de Haití y la República Dominicana.

OBJECTIVE: To assess coverage and inequalities in maternal and child health interventions among Haitians, Haitian migrants in the Dominican Republic and Dominicans. METHODS: Cross-sectional study using data from nationally representative surveys carried out in Haiti in 2012 and in the Dominican Republic in 2014. Nine indicators were compared: demand for family planning satisfied with modern methods, antenatal care, delivery care (skilled birth attendance), child vaccination (BCG, measles and DPT3), child case management (oral rehydration salts for diarrhea and careseeking for suspected pneumonia), and the composite coverage index. Wealth was measured through an asset-based index, divided into tertiles, and place of residence (urban or rural) was established according to the country definition. RESULTS: Haitians showed the lowest coverage for demand for family planning satisfied with modern methods (44.2%), antenatal care (65.3%), skilled birth attendance (39.5%) and careseeking for suspected pneumonia (37.9%), and the highest for oral rehydration salts for diarrhea (52.9%), whereas Haitian migrants had the lowest coverage in DPT3 (44.1%) and oral rehydration salts for diarrhea (38%) and the highest in careseeking for suspected pneumonia (80.7%). Dominicans presented the highest coverage for most indicators, except oral rehydration salts for diarrhea and careseeking for suspected pneumonia. The composite coverage index was 79.2% for Dominicans, 69.0% for Haitian migrants, and 52.6% for Haitians. Socioeconomic inequalities generally had pro-rich and pro-urban pattern in all analyzed groups. CONCLUSION: Haitian migrants presented higher coverage than Haitians, but lower than Dominicans. Both countries should plan actions and policies to increase coverage and address inequalities of maternal health interventions.

OBJETIVO: Avaliar cobertura e desigualdades nas intervenções em saúde materno-infantil entre os haitianos, migrantes haitianos na República Dominicana e dominicanos. MÉTODOS: Estudo transversal utilizando dados de pesquisas representativas nacionalmente realizadas no Haiti em 2012, e na República Dominicana em 2014. Nove indicadores foram comparados: demanda por planejamento familiar atendida com métodos modernos, atendimento pré-natal, atendimento ao parto (presença de profissional qualificado no parto), vacinação de crianças (BCG, sarampo e DPT3), atendimento de crianças (sais de reidratação oral para diarreia e demanda por assistência por suspeita de pneumonia) e índice composto de cobertura. A riqueza foi medida por meio de índice baseado em recursos, dividido em tercis, e o local de residência (urbano ou rural) foi estabelecido segundo a definição dos países. RESULTADOS: Os haitianos apresentaram a menor cobertura de demanda por planejamento familiar atendida com métodos modernos (44,2%), atendimento pré-natal (65,3%), presença de profissional qualificado no parto (39,5%) e de atendimento por suspeita de pneumonia (37,9%), e a mais alta para sais de reidratação oral na diarreia (52,9%), enquanto os migrantes haitianos tiveram a menor cobertura de DPT3 (44,1%) e sais de reidratação oral para diarreia (38%), e a mais alta na assistência por suspeita de pneumonia (80,7%). Os dominicanos apresentaram a cobertura mais alta para a maioria dos indicadores, exceto para sais de reidratação oral para diarreia e demanda por assistência por suspeita de pneumonia. O índice composto de cobertura foi 79,2% para dominicanos, 69,0% para migrantes haitianos e 52,6% para os haitianos. De forma geral, as desigualdades socioeconômicas apresentaram padrão pró-riqueza e pró-urbano em todos os grupos analisados. CONCLUSÕES: Os migrantes haitianos apresentaram maior cobertura que os haitianos, mas coberturas inferiores aos dominicanos. Ambos os países devem planejar ações e políticas para aumentar a cobertura e abordar as desigualdades nas intervenções em saúde materna.