Assessment of multiple mycotoxin exposure and its association with food consumption: a human biomonitoring study in a pregnant cohort in rural Bangladesh.

Aflatoxins (AFs), ochratoxin A (OTA), citrinin (CIT), fumonisin B1 (FB1), zearalenone (ZEN), and deoxynivalenol (DON) are mycotoxins that may contaminate diets, especially in low-income settings, with potentially severe health consequences. This study investigates the exposure of 439 pregnant women in rural Bangladesh to 35 mycotoxins and their corresponding health risks and links their exposure to certain foods and local stimulants. Overall, 447 first-morning urine samples were collected from pregnant women between July 2018 and November 2019. Mycotoxin biomarkers were quantified by DaS-HPLC-MS/MS. Urinary concentration of frequently occurring mycotoxins was used to estimate dietary mycotoxin exposure. Median regression analyses were performed to investigate the association between the consumption of certain foods and local stimulants, and urinary concentration of frequently occurring mycotoxins. Only in 17 of 447 urine samples (4%) were none of the investigated mycotoxins detected. Biomarkers for six major mycotoxins (AFs, CIT, DON, FB1, OTA, and ZEN) were detected in the urine samples. OTA (95%), CIT (61%), and DON (6%) were most frequently detected, with multiple mycotoxins co-occurring in 281/447 (63%) of urine samples. Under the lowest exposure scenario, dietary exposure to OTA, CIT, and DON was of public health concern in 95%, 16%, and 1% of the pregnant women, respectively. Consumption of specific foods and local stimulants-betel nut, betel leaf, and chewing tobacco-were associated with OTA, CIT, and DON urine levels. In conclusion, exposure to multiple mycotoxins during early pregnancy is widespread in this rural community and represents a potential health risk for mothers and their offspring.

Comparing socioeconomic inequalities between early neonatal mortality and facility delivery: Cross-sectional data from 72 low- and middle-income countries.

Facility delivery should reduce early neonatal mortality. We used the Slope Index of Inequality and logistic regression to quantify absolute and relative socioeconomic inequalities in early neonatal mortality (0 to 6 days) and facility delivery among 679,818 live births from 72 countries with Demographic and Health Surveys. The inequalities in early neonatal mortality were compared with inequalities in postneonatal infant mortality (28 days to 1 year), which is not related to childbirth. Newborns of the richest mothers had a small survival advantage over the poorest in unadjusted analyses (-2.9 deaths/1,000; OR 0.86) and the most educated had a small survival advantage over the least educated (-3.9 deaths/1,000; OR 0.77), while inequalities in postneonatal infant mortality were more than double that in absolute terms. The proportion of births in health facilities was an absolute 43% higher among the richest and 37% higher among the most educated compared to the poorest and least educated mothers. A higher proportion of facility delivery in the sampling cluster (e.g. village) was only associated with a small  decrease in early neonatal mortality. In conclusion, while socioeconomically advantaged mothers had much higher use of a health facility at birth, this did not appear to convey a comparable survival advantage.

Dietary Patterns and Determinants of Changing Diets in Bangladesh from 1985 to 2010.

BACKGROUND: The government of Bangladesh has implemented multiple policies since 1971 to provide the population with more diverse and nutritious diets. OBJECTIVE: The aim of this study was to examine the drivers of dietary change over time and the roles agriculture and economic development have played. METHODS: We used principal component analysis to derive dietary patterns from 7 cross-sectional rounds of the Bangladesh Household [Income and] Expenditure Survey. We then used linear probability models to estimate associations of adherence to dietary patterns with socio-economic characteristics of households, and with agricultural production on the household and regional level. For dietary patterns that increased or decreased over time, Blinder-Oaxaca decomposition was used to assess factors associated with these changes. RESULTS: Seven dietary patterns were identified: modern, traditional, festival, winter, summer, monotonous, and spices. All diets were present in all survey rounds. In 1985, over 40% of households had diets not associated with any identified pattern, which declined to 12% by 2010. The proportion of the population in households adhering to the modern, winter, summer, and monotonous diets increased over time, whereas the proportion adhering to the traditional diet decreased. Although many factors were associated with adherence to dietary patterns in the pooled sample, changes in observed factors only explained a limited proportion of change over time due to variation in coefficients between periods. Increased real per capita expenditure was the largest driver of elevated adherence to dietary patterns over time, whereas changes in the agricultural system increased adherence to less diverse dietary patterns. CONCLUSIONS: These findings highlight the need for both diversified agricultural production and a continued reduction in poverty in order to drive dietary improvement. This study lays the groundwork for further analysis of the impact of changing diets on health and nutrition.

Service readiness for inpatient care of small and sick newborns: what do we need and what can we measure now?

BACKGROUND: Each year an estimated 2.6 million newborns die, mainly from complications of prematurity, neonatal infections, and intrapartum events. Reducing these deaths requires high coverage of good quality care at birth, and inpatient care for small and sick newborns. In low- and middle-income countries, standardised measurement of the readiness of facilities to provide emergency obstetric care has improved tracking of readiness to provide care at birth in recent years. However, the focus has been mainly on obstetric care; service readiness for providing inpatient care of small and sick newborns is still not consistently measured or tracked. METHODS: We reviewed existing international guidelines and resources to create a matrix of the structural characteristics (infrastructure, equipment, drugs, providers and guidelines) for service readiness to deliver a package of inpatient care interventions for small and sick newborns. To identify gaps in existing measurement systems, we reviewed three multi-country health facility survey tools (the Service Availability and Readiness Assessment, the Service Provision Assessment and the Emergency Obstetric and Newborn Care Assessment) against our service readiness matrix. FINDINGS: For service readiness to provide inpatient care for small and sick newborns, our matrix detailed over 600 structural characteristics. Our review of the SPA, the SARA and the EmONC assessment tools identified several measurement omissions to capture information on key intervention areas, such as thermoregulation, feeding and respiratory support, treatment of specific complications (seizures, jaundice), and screening and follow up services, as well as specialised staff and service infrastructure. CONCLUSIONS: Our review delineates the required inputs to ensure readiness to provide inpatient care for small and sick newborns. Based on these findings, we detail where questions need to be added to existing tools and describe how measurement systems can be adapted to reflect small and sick newborns interventions. Such work can inform investments in health systems to end preventable newborn death and disability as part of the Every Newborn Action Plan.

Women's dietary diversity in rural Bangladesh: Pathways through women's empowerment.

The relationship between women's empowerment and women's nutrition is understudied. We aimed to elucidate this relationship by quantifying possible pathways between empowerment and dietary diversity among women in rural Bangladesh. In 2015, we conducted a cross-sectional survey of 2,599 married women ages 15-40 (median: 25) living in 96 settlements of Habiganj District, Bangladesh, as a baseline for the Food and Agricultural Approaches to Reducing Malnutrition trial. We collected data on women's empowerment (highest completed grade of schooling and agency), dietary diversity, and demographic factors, including household wealth. We used exploratory factor analysis and confirmatory factor analysis on random split-half samples, followed by structural equation modelling, to test pathways from schooling, through domains of women's agency, to dietary diversity. Factor analysis revealed 3 latent domains of women's agency: social solidarity, decision-making, and voice with husband. In the adjusted mediation model, having any postprimary schooling was positively associated with voice with husband (ß41  = .051, p = .010), which was positively associated with dietary diversity (ß54  = .39, p = .002). Schooling also had a direct positive association with women's dietary diversity (ß51  = .22, p < .001). Neither women's social solidarity nor decision-making mediated the relationship between schooling and dietary diversity. The link between schooling and dietary diversity was direct and indirect, through women's voice with husband but not through women's social solidarity or decision-making. In this population, women with postprimary schooling seem to be better able to negotiate improved diets for themselves.

Access to maternal health services: geographical inequalities, United Republic of Tanzania.

OBJECTIVE: To determine if improved geographical accessibility led to increased uptake of maternity care in the south of the United Republic of Tanzania. METHODS: In a household census in 2007 and another large household survey in 2013, we investigated 22 243 and 13 820 women who had had a recent live birth, respectively. The proportions calculated from the 2013 data were weighted to account for the sampling strategy. We examined the association between the straight-line distances to the nearest primary health facility or hospital and uptake of maternity care. FINDINGS: The percentages of live births occurring in primary facilities and hospitals rose from 12% (2571/22 243) and 29% (6477/22 243), respectively, in 2007 to weighted values of 39% and 40%, respectively, in 2013. Between the two surveys, women living far from hospitals showed a marked gain in their use of primary facilities, but the proportion giving birth in hospitals remained low (20%). Use of four or more antenatal visits appeared largely unaffected by survey year or the distance to the nearest antenatal clinic. Although the overall percentage of live births delivered by caesarean section increased from 4.1% (913/22 145) in the first survey to a weighted value of 6.5% in the second, the corresponding percentages for women living far from hospital were very low in 2007 (2.8%; 35/1254) and 2013 (3.3%). CONCLUSION: For women living in our study districts who sought maternity care, access to primary facilities appeared to improve between 2007 and 2013, however access to hospital care and caesarean sections remained low.

Estimates of average energy requirements in Bangladesh: Adult Male Equivalent values for use in analyzing household consumption and expenditure surveys.

This dataset contains Adult Male Equivalent (AME) values for use in Bangladesh. These were constructed using prescriptive nutritional constructs adapted to the actual growth and weight pattern seen in Bangladesh. This dataset provides a common base to facilitate for future work with household consumption and expenditure data in Bangladesh while updating the average energy requirements for infants and young children for the WHO 2006 growth standards and 2007 growth reference curves.

Where women go to deliver: understanding the changing landscape of childbirth in Africa and Asia.

Growing evidence from a number of countries in Asia and Africa documents a large shift towards facility deliveries in the past decade. These increases have not led to the improvements in health outcomes that were predicted by health policy researchers in the past. In light of this unexpected evidence, we have assessed data from multiple sources, including nationally representative data from 43 countries in Asia and Africa, to understand the size and range of changing delivery location in Asia and Africa. We have reviewed the policies, programs and financing experiences in multiple countries to understand the drivers of changing practices, and the consequences for maternal and neonatal health and the health systems serving women and newborns. And finally, we have considered what implications changes in delivery location will have for maternal and neonatal care strategies as we move forward into the next stage of global action. As a result of our analysis we make four major policy recommendations. (1) An expansion of investment in mid-level facilities for delivery services and a shift away from low-volume rural delivery facilities. (2) Assured access for rural women through funding for transport infrastructure, travel vouchers, targeted subsidies for services and residence support before and after delivery. (3) Increased specialization of maternity facilities and dedicated maternity wards within larger institutions. And (4) a renewed focus on quality improvements at all levels of delivery facilities, in both private and public settings.

Competence of health workers in emergency obstetric care: an assessment using clinical vignettes in Brong Ahafo region, Ghana.

OBJECTIVES: To assess health worker competence in emergency obstetric care using clinical vignettes, to link competence to availability of infrastructure in facilities, and to average annual delivery workload in facilities. DESIGN: Cross-sectional Health Facility Assessment linked to population-based surveillance data. SETTING: 7 districts in Brong Ahafo region, Ghana. PARTICIPANTS: Most experienced delivery care providers in all 64 delivery facilities in the 7 districts. PRIMARY OUTCOME MEASURES: Health worker competence in clinical vignette actions by cadre of delivery care provider and by type of facility. Competence was also compared with availability of relevant drugs and equipment, and to average annual workload per skilled birth attendant. RESULTS: Vignette scores were moderate overall, and differed significantly by respondent cadre ranging from a median of 70% correct among doctors, via 55% among midwives, to 25% among other cadres such as health assistants and health extension workers (p<0.001). Competence varied significantly by facility type: hospital respondents, who were mainly doctors and midwives, achieved highest scores (70% correct) and clinic respondents scored lowest (45% correct). There was a lack of inexpensive key drugs and equipment to carry out vignette actions, and more often, lack of competence to use available items in clinical situations. The average annual workload was very unevenly distributed among facilities, ranging from 0 to 184 deliveries per skilled birth attendant, with higher workload associated with higher vignette scores. CONCLUSIONS: Lack of competence might limit clinical practice even more than lack of relevant drugs and equipment. Cadres other than midwives and doctors might not be able to diagnose and manage delivery complications. Checking clinical competence through vignettes in addition to checklist items could contribute to a more comprehensive approach to evaluate quality of care. TRIAL REGISTRATION NUMBER: NCT00623337.

Signal functions for measuring the ability of health facilities to provide abortion services: an illustrative analysis using a health facility census in Zambia.

BACKGROUND: Annually, around 44 million abortions are induced worldwide. Safe termination of pregnancy (TOP) services can reduce maternal mortality, but induced abortion is illegal or severely restricted in many countries. All abortions, particularly unsafe induced abortions, may require post-abortion care (PAC) services to treat complications and prevent future unwanted pregnancy. We used a signal-function approach to look at abortion care services and illustrated its utility with secondary data from Zambia. METHODS: We refined signal functions for basic and comprehensive TOP and PAC services, including family planning (FP), and assessed functions currently being collected via multi-country facility surveys. We then used the 2005 Zambian Health Facility Census to estimate the proportion of 1369 health facilities that could provide TOP and PAC services under three scenarios. We linked facility and population data, and calculated the proportion of the Zambian population within reach of such services. RESULTS: Relevant signal functions are already collected in five facility assessment tools. In Zambia, 30 % of facilities could potentially offer basic TOP services, 3.7 % comprehensive TOP services, 2.6 % basic PAC services, and 0.3 % comprehensive PAC services (four facilities). Capability was highest in hospitals, except for FP functions. Nearly two-thirds of Zambians lived within 15 km of a facility theoretically capable of providing basic TOP, and one-third within 15 km of comprehensive TOP services. However, requiring three doctors for non-emergency TOP, as per Zambian law, reduced potential access to TOP services to 30 % of the population. One-quarter lived within 15 km of basic PAC and 13 % of comprehensive PAC services. In a scenario not requiring FP functions, one-half and one-third of the population were within reach of basic and comprehensive PAC respectively. There were huge urban-rural disparities in access to abortion care services. Comprehensive PAC services were virtually unavailable to the rural population. CONCLUSIONS: Secondary data from facility assessments can highlight gaps in abortion service provision and coverage, but it is necessary to consider TOP and PAC separately. This approach, especially when combined with population data using geographic coordinates, can also be used to model the impact of various policy scenarios on access, such as requiring three medical doctors for non-emergency TOP. Data collection instruments could be improved with minor modifications and used for multi-country comparisons.

Decreasing child mortality, spatial clustering and decreasing disparity in North-Western Burkina Faso.

Within relatively small areas, there exist high spatial variations of mortality between villages. In rural Burkina Faso, with data from 1993 to 1998, clusters of particularly high child mortality were identified in the population of the Nouna Health and Demographic Surveillance System (HDSS), a member of the INDEPTH Network. In this paper, we report child mortality with respect to temporal trends, spatial clustering and disparity in this HDSS from 1993 to 2012. Poisson regression was used to describe village-specific child mortality rates and time trends in mortality. The spatial scan statistic was used to identify villages or village clusters with higher child mortality. Clustering of mortality in the area is still present, but not as strong as before. The disparity of child mortality between villages has decreased. The decrease occurred in the context of an overall halving of child mortality in the rural area of Nouna HDSS between 1993 and 2012. Extrapolated to the Millennium Development Goals target period 1990-2015, this yields an estimated reduction of 54%, which is not too far off the aim of a two-thirds reduction.

The quality of clinical maternal and neonatal healthcare - a strategy for identifying 'routine care signal functions'.

BACKGROUND: A variety of clinical process indicators exists to measure the quality of care provided by maternal and neonatal health (MNH) programs. To allow comparison across MNH programs in low- and middle-income countries (LMICs), a core set of essential process indicators is needed. Although such a core set is available for emergency obstetric care (EmOC), the 'EmOC signal functions', a similar approach is currently missing for MNH routine care evaluation. We describe a strategy for identifying core process indicators for routine care and illustrate their usefulness in a field example. METHODS: We first developed an indicator selection strategy by combining epidemiological and programmatic aspects relevant to MNH in LMICs. We then identified routine care process indicators meeting our selection criteria by reviewing existing quality of care assessment protocols. We grouped these indicators into three categories based on their main function in addressing risk factors of maternal or neonatal complications. We then tested this indicator set in a study assessing MNH quality of clinical care in 33 health facilities in Malawi. RESULTS: Our strategy identified 51 routine care processes: 23 related to initial patient risk assessment, 17 to risk monitoring, 11 to risk prevention. During the clinical performance assessment a total of 82 cases were observed. Birth attendants' adherence to clinical standards was lowest in relation to risk monitoring processes. In relation to major complications, routine care processes addressing fetal and newborn distress were performed relatively consistently, but there were major gaps in the performance of routine care processes addressing bleeding, infection, and pre-eclampsia risks. CONCLUSION: The identified set of process indicators could identify major gaps in the quality of obstetric and neonatal care provided during the intra- and immediate postpartum period. We hope our suggested indicators for essential routine care processes will contribute to streamlining MNH program evaluations in LMICs.

Quality along the continuum: a health facility assessment of intrapartum and postnatal care in Ghana.

OBJECTIVE: To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate "effective coverage" of skilled attendance in Brong Ahafo, Ghana. METHODS: We conducted an assessment of all 86 health facilities in seven districts in Brong Ahafo. Using performance of key signal functions and the availability of relevant drugs, equipment and trained health professionals, we created composite quality categories in four dimensions: routine delivery care, emergency obstetric care (EmOC), emergency newborn care (EmNC) and non-medical quality. Linking the health facility assessment to surveillance data we estimated "effective coverage" of skilled attendance as the proportion of births in facilities of high quality. FINDINGS: Delivery care was offered in 64/86 facilities; only 3-13% fulfilled our requirements for the highest quality category in any dimension. Quality was lowest in the emergency care dimensions, with 63% and 58% of facilities categorized as "low" or "substandard" for EmOC and EmNC, respectively. This implies performing less than four EmOC or three EmNC signal functions, and/or employing less than two skilled health professionals, and/or that no health professionals were present during our visit. Routine delivery care was "low" or "substandard" in 39% of facilities, meaning 25/64 facilities performed less than six routine signal functions and/or had less than two skilled health professionals and/or less than one midwife. While 68% of births were in health facilities, only 18% were in facilities with "high" or "highest" quality in all dimensions. CONCLUSION: Our comprehensive facility assessment showed that quality of routine and emergency intrapartum and postnatal care was generally low in the study region. While coverage with facility delivery was 68%, we estimated "effective coverage" of skilled attendance at 18%, thus revealing a large "quality gap." Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.

Relationship between financial speculation and food prices or price volatility: applying the principles of evidence-based medicine to current debates in Germany.

There is an unresolved debate about the potential effects of financial speculation on food prices and price volatility. Germany's largest financial institution and leading global investment bank recently decided to continue investing in agricultural commodities, stating that there is little empirical evidence to support the notion that the growth of agricultural-based financial products has caused price increases or volatility. The statement is supported by a recently published literature review, which concludes that financial speculation does not have an adverse effect on the functioning of the agricultural commodities market. As public health professionals concerned with global food insecurity, we have appraised the methodological quality of the review using a validated and reliable appraisal tool. The appraisal revealed major shortcomings in the methodological quality of the review. These were particularly related to intransparencies in the search strategy and in the selection/presentation of studies and findings; the neglect of the possibility of publication bias; a lack of objective or rigorous criteria for assessing the scientific quality of included studies and for the formulation of conclusions. Based on the results of our appraisal, we conclude that it is not justified to reject the hypothesis that financial speculation might have adverse effects on food prices/price volatility. We hope to initiate reflections about scientific standards beyond the boundaries of disciplines and call for high quality, rigorous systematic reviews on the effects of financial speculation on food prices or price volatility.

Quality of newborn care: a health facility assessment in rural Ghana using survey, vignette and surveillance data.

OBJECTIVE: To assess the structural capacity for, and quality of, immediate and essential newborn care (ENC) in health facilities in rural Ghana, and to link this with demand for facility deliveries and admissions. DESIGN: Health facility assessment survey and population-based surveillance data. SETTING: Seven districts in Brong Ahafo Region, Ghana. PARTICIPANTS: Heads of maternal/neonatal wards in all 64 facilities performing deliveries. MAIN OUTCOME MEASURES: Indicators include: the availability of essential infrastructure, newborn equipment and drugs, and personnel; vignette scores and adequacy of reasons given for delayed discharge of newborn babies; and prevalence of key immediate ENC practices that facilities should promote. These are matched to the percentage of babies delivered in and admitted to each type of facility. RESULTS: 70% of babies were delivered in health facilities; 56% of these and 87% of neonatal admissions were in four referral level hospitals. These had adequate infrastructure, but all lacked staff trained in ENC and some essential equipment (including incubators and bag and masks) and/or drugs. Vignette scores for care of very low-birth-weight babies were generally moderate-to-high, but only three hospitals achieved high overall scores for quality of ENC. We estimate that only 33% of babies were born in facilities capable of providing high quality, basic resuscitation as assessed by a vignette plus the presence of a bag and mask. Promotion of immediate ENC practices in facilities was also inadequate, with coverage of early initiation of breastfeeding and delayed bathing both below 50% for babies born in facilities; this represents a lost opportunity. CONCLUSIONS: Unless major gaps in ENC equipment, drugs, staff, practices and skills are addressed, strategies to increase facility utilisation will not achieve their potential to save newborn lives. TRIAL REGISTRATION: http://clinicaltrials.gov NCT00623337.

Quality of antenatal care in Zambia: a national assessment.

BACKGROUND: Antenatal care (ANC) is one of the recommended interventions to reduce maternal and neonatal mortality. Yet in most Sub-Saharan African countries, high rates of ANC coverage coexist with high maternal and neonatal mortality. This disconnect has fueled calls to focus on the quality of ANC services. However, little conceptual or empirical work exists on the measurement of ANC quality at health facilities in low-income countries. We developed a classification tool and assessed the level of ANC service provision at health facilities in Zambia on a national scale and compared this to the quality of ANC received by expectant mothers. METHODS: We analysed two national datasets with detailed antenatal provider and user information, the 2005 Zambia Health Facility Census and the 2007 Zambia Demographic and Health Survey (DHS), to describe the level of ANC service provision at 1,299 antenatal facilities in 2005 and the quality of ANC received by 4,148 mothers between 2002 and 2007. RESULTS: We found that only 45 antenatal facilities (3%) fulfilled our developed criteria for optimum ANC service, while 47% of facilities provided adequate service, and the remaining 50% offered inadequate service. Although 94% of mothers reported at least one ANC visit with a skilled health worker and 60% attended at least four visits, only 29% of mothers received good quality ANC, and only 8% of mothers received good quality ANC and attended in the first trimester. CONCLUSIONS: DHS data can be used to monitor "effective ANC coverage" which can be far below ANC coverage as estimated by current indicators. This "quality gap" indicates missed opportunities at ANC for delivering effective interventions. Evaluating the level of ANC provision at health facilities is an efficient way to detect where deficiencies are located in the system and could serve as a monitoring tool to evaluate country progress.

Reducing maternal mortality: better monitoring, indicators and benchmarks needed to improve emergency obstetric care. Research summary for policymakers.

Several limitations of emergency obstetric care (EmOC) indicators and benchmarks are analysed in this short paper, which synthesises recent research on this topic. A comparison between Sri Lanka and Zambia is used to highlight the inconsistencies and shortcomings in current methods of monitoring EmOC. Recommendations are made to improve the usefulness and accuracy of EmOC indicators and benchmarks in the future.

Emergency obstetric care availability: a critical assessment of the current indicator.

Monitoring progress in reducing maternal and perinatal mortality requires suitable indicators. The density of emergency obstetric care (EmOC) facilities has been proposed as a potentially useful indicator, but different UN documents make inconsistent recommendations, and its current formulation is not associated with maternal mortality. We compiled recently published indicator benchmarks and distinguished three sources of inconsistency: (i) use of different denominator metrics (per birth and per population), (ii) different assumptions on need for EmOC and for EmOC facilities and (iii) failure to specify facility capacity (birth load). The UN guidelines and handbook require fewer EmOC facilities than the World Health Report 2005 and do not specify capacity for deliveries or staffing levels. We recommend (i) always using births as the denominator for EmOC facility density, (ii) clearly stating assumptions on the proportion of deliveries needing basic and comprehensive emergency obstetric care and the desired proportion of deliveries in EmOC facilities and (iii) specifying facility capacity and staffing and adapting benchmarks for settings with different population density to ensure geographical accessibility.