A global analysis of the determinants of maternal health and transitions in maternal mortality.

The reduction of maternal mortality and the promotion of maternal health and wellbeing are complex tasks. This Series paper analyses the distal and proximal determinants of maternal health, as well as the exposures, risk factors, and micro-correlates related to maternal mortality. This paper also examines the relationship between these determinants and the gradual shift over time from a pattern of high maternal mortality to a pattern of low maternal mortality (a phenomenon described as the maternal mortality transition). We conducted two systematic reviews of the literature and we analysed publicly available data on indicators related to the Sustainable Development Goals, specifically, estimates prepared by international organisations, including the UN and the World Bank. We considered 23 frameworks depicting maternal health and wellbeing as a multifactorial process, with superdeterminants that broadly affect women's health and wellbeing before, during, and after pregnancy. We explore the role of social determinants of maternal health, individual characteristics, and health-system features in the production of maternal health and wellbeing. This paper argues that the preventable deaths of millions of women each decade are not solely due to biomedical complications of pregnancy, childbirth, and the postnatal period, but are also tangible manifestations of the prevailing determinants of maternal health and persistent inequities in global health and socioeconomic development. This paper underscores the need for broader, multipronged actions to improve maternal health and wellbeing and accelerate sustainable reductions in maternal mortality. For women who have pregnancy, childbirth, or postpartum complications, the health system provides a crucial opportunity to interrupt the chain of events that can potentially end in maternal death. Ultimately, expanding the health sector ecosystem to mitigate maternal health determinants and tailoring the configuration of health systems to counter the detrimental effects of eco-social forces, including though increased access to quality-assured commodities and services, are essential to improve maternal health and wellbeing and reduce maternal mortality.

Socioeconomic and lifestyle factors associated with mental health problems among Mongolian elementary school children.

PURPOSE: Lifestyle factors of children and adolescents' mental health problems are an emerging health issue in low- and middle-income countries (LMICs). However, there is a lack of studies on lifestyle factors in LMICs. This study examined the socioeconomic and lifestyle factors associated with mental health problems among school-age children in Mongolia. METHODS: A population-based cross-sectional survey was conducted among 4th-year students at public elementary schools in one district in Ulaanbaatar. The Strengths and Difficulties Questionnaire (SDQ) and a self-administrated socioeconomic and lifestyle questionnaire were completed by participants' guardians. A multivariate logistic regression analysis was performed. RESULTS: Of the 2301 children surveyed, 1694 without missing responses were included in the analysis. The multivariate logistic regression analysis showed that male gender [adjusted odds ratio (AOR) 1.64 (1.29-2.10)], low maternal education [AOR 1.89 (1.16-3.05)], short sleep [AOR 1.41 (1.10-1.80)], no physical activity [AOR 1.31 (1.03-1.67)], and long screen time (AOR 1.53 (1.20-1.94)) were associated with high risk of mental health problems. Low maternal education, low household income, no physical activity habit, and long screen time were associated with internalising problems. Meanwhile, male gender, low maternal education, and long screen time were associated with externalising problems. CONCLUSION: The results are consistent with previous studies in high-income countries, indicating that there are globally common socioeconomic and lifestyle risk factors. The findings of this study may help develop a targeted preventive intervention for high-risk groups, such as socioeconomically disadvantaged groups, as well as a universal preventive intervention to foster a healthy lifestyle in Mongolia.

Schedules for home visits in the early postpartum period.

BACKGROUND: Maternal complications, including psychological/mental health problems and neonatal morbidity, have commonly been observed in the postpartum period. Home visits by health professionals or lay supporters in the weeks following birth may prevent health problems from becoming chronic, with long-term effects. This is an update of a review last published in 2017. OBJECTIVES: The primary objective of this review is to assess the effects of different home-visiting schedules on maternal and newborn mortality during the early postpartum period. The review focuses on the frequency of home visits (how many home visits in total), the timing (when visits started, e.g. within 48 hours of the birth), duration (when visits ended), intensity (how many visits per week), and different types of home-visiting interventions. SEARCH METHODS: For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (19 May 2021), and checked reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) (including cluster-, quasi-RCTs and studies available only as abstracts) comparing different home-visiting interventions that enrolled participants in the early postpartum period (up to 42 days after birth) were eligible for inclusion. We excluded studies in which women were enrolled and received an intervention during the antenatal period (even if the intervention continued into the postnatal period), and studies recruiting only women from specific high-risk groups (e.g. women with alcohol or drug problems). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: We included 16 randomised trials with data for 12,080 women. The trials were carried out in countries across the world, in both high- and low-resource settings. In low-resource settings, women receiving usual care may have received no additional postnatal care after early hospital discharge. The interventions and controls varied considerably across studies. Trials focused on three broad types of comparisons, as detailed below. In all but four of the included studies, postnatal care at home was delivered by healthcare professionals. The aim of all interventions was broadly to assess the well-being of mothers and babies, and to provide education and support. However, some interventions had more specific aims, such as to encourage breastfeeding, or to provide practical support. For most of our outcomes, only one or two studies provided data, and results were inconsistent overall. All studies had several domains with high or unclear risk of bias. More versus fewer home visits (five studies, 2102 women) The evidence is very uncertain about whether home visits have any effect on maternal and neonatal mortality (very low-certainty evidence). Mean postnatal depression scores as measured with the Edinburgh Postnatal Depression Scale (EPDS) may be slightly higher (worse) with more home visits, though the difference in scores was not clinically meaningful (mean difference (MD) 1.02, 95% confidence interval (CI) 0.25 to 1.79; two studies, 767 women; low-certainty evidence). Two separate analyses indicated conflicting results for maternal satisfaction (both low-certainty evidence); one indicated that there may be benefit with fewer visits, though the 95% CI just crossed the line of no effect (risk ratio (RR) 0.96, 95% CI 0.90 to 1.02; two studies, 862 women). However, in another study, the additional support provided by health visitors was associated with increased mean satisfaction scores (MD 14.70, 95% CI 8.43 to 20.97; one study, 280 women; low-certainty evidence). Infant healthcare utilisation may be decreased with more home visits (RR 0.48, 95% CI 0.36 to 0.64; four studies, 1365 infants) and exclusive breastfeeding at six weeks may be increased (RR 1.17, 95% CI 1.01 to 1.36; three studies, 960 women; low-certainty evidence). Serious neonatal morbidity up to six months was not reported in any trial. Different models of postnatal care (three studies, 4394 women) In a cluster-RCT comparing usual care with individualised care by midwives, extended up to three months after the birth, there may be little or no difference in neonatal mortality (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 infants). The proportion of women with EPDS scores ≥ 13 at four months is probably reduced with individualised care (RR 0.68, 95% CI 0.53 to 0.86; one study, 1295 women). One study suggests there may be little to no difference between home visits and telephone screening in neonatal morbidity up to 28 days (RR 0.97, 95% CI 0.85 to 1.12; one study, 696 women). In a different study, there was no difference between breastfeeding promotion and routine visits in exclusive breastfeeding rates at six months (RR 1.47, 95% CI 0.81 to 2.69; one study, 656 women). Home versus facility-based postnatal care (eight studies, 5179 women) The evidence suggests there may be little to no difference in postnatal depression rates at 42 days postpartum and also as measured on an EPDS scale at 60 days. Maternal satisfaction with postnatal care may be better with home visits (RR 1.36, 95% CI 1.14 to 1.62; three studies, 2368 women). There may be little to no difference in infant emergency health care visits or infant hospital readmissions (RR 1.15, 95% CI 0.95 to 1.38; three studies, 3257 women) or in exclusive breastfeeding at two weeks (RR 1.05, 95% CI 0.93 to 1.18; 1 study, 513 women). AUTHORS' CONCLUSIONS: The evidence is very uncertain about the effect of home visits on maternal and neonatal mortality. Individualised care as part of a package of home visits probably improves depression scores at four months and increasing the frequency of home visits may improve exclusive breastfeeding rates and infant healthcare utilisation. Maternal satisfaction may also be better with home visits compared to hospital check-ups. Overall, the certainty of evidence was found to be low and findings were not consistent among studies and comparisons. Further well designed RCTs evaluating this complex intervention will be required to formulate the optimal package.

How do Japanese rate the severity of different diseases and injuries?-an assessment of disability weights for 231 health states by 37,318 Japanese respondents.

BACKGROUND: Disability weights (DWs) are weight factors that reflect the severity of health states for estimates of disability-adjusted life years. A new set of global DWs was published for the Global Burden of Diseases and Injuries (GBD) 2013 study, which relied on sampling from various world regions, but included little data for countries in East Asia. This study aimed to measure DWs in Japan using comparable methods, and compare the results with previous estimates from the GBD 2013 DW study. METHODS: We conducted a web-based survey in 2019 to estimate DWs for 231 health states for the Japanese population. The survey included five new health states but otherwise followed the method of the GBD DW measurement study. The survey consisted of 15 paired comparison (PC) questions and 3 population health equivalence questions (PHE) per respondent. We analyzed PC data using probit regression and rescaled results to DW units between 0 (equivalent to full health) and 1 (equivalent to death). FINDINGS: We considered 37,318 nationally representative respondents. The values of the resulting DWs ranged from 0.707 (95% uncertainty interval (UI) 0.527-0.842) for spinal cord injury at neck level (untreated) to 0.004 (UI 0.001-0.009) for mild anemia. High correlation between Japanese DW and GBD 2013 DW was observed, but there was considerable disagreement. Out of 226 comparable health states, 55 (24.3%) showed more than a factor-of-two difference, of which 41 (74.6%) had a higher value in Japanese DW. Many of the health states with higher DW in the Japan study were injuries, including amputation and fracture, and hearing and vision loss, while mental, behavioral, and substance use disorders generally tended to be lower. CONCLUSIONS: This study has created an empirical basis for assessment of Japanese DWs of health status. The findings from this study based on the Japanese population suggest that there might be contextual differences in rating the severity of health states compared to previous surveys conducted elsewhere.

Secular trends in longevity among people with Down syndrome in Japan, 1995-2016.

BACKGROUND: Life expectancy in Japan has increased dramatically and is one of the longest in the world. However, the changes in lifespan in Japanese individuals with congenital diseases remain unknown. We investigated secular changes in the lifespan of people with Down syndrome over the last 20 years. METHODS: We observed secular trends in the number of stillbirths, deaths and the mortality rates at ages 20, 40, and 60 among all deaths registered with Down syndrome as the cause of death (ICD10 code: Q90) in the Japan national death registry database between 1995 and 2016. Changes in the median age at death between 1995-2005 and 2006-2016 were investigated based on sex and history of surgery. RESULTS: We identified 240 stillbirths and 1,099 deaths in this period. The annual number of stillbirths and deaths above the age of 1 year increased, whereas the number of deaths below 1 year did not change. The proportional mortality indicator at ages 20, 40, and 60 increased from 21.7%, 11.7%, and 1.7% in 1995 to 69.9%, 66.7%, and 36.6% in 2016, respectively. The median age at death was higher in females, individuals without a surgical history, and deaths occurring in 2006-2016. The median age at death increased over the period in those without a surgical history. CONCLUSIONS: The age at death among people with Down syndrome has increased over the last 20 years, with currently 1 in 3 persons living over 60 years, necessitating adequate social welfare services in this aging population.

Economic Evaluations of Gestational Diabetes Mellitus Screening: A Systematic Review.

BACKGROUND: This study aims to find evidence of the cost-effectiveness of gestational diabetes mellitus (GDM) screening and assess the quality of current economic evaluations, which have shown different conclusions with a variation in screening methods, data sources, outcome indicators, and implementation in diverse organizational contexts. METHODS: Embase, Medline, Web of Science, Health Technology Assessment, database, and National Health Service Economic Evaluation Database databases were searched through June 2019. Studies on economic evaluation reporting both cost and health outcomes of GDM screening programs in English language were selected, and the quality of the studies was assessed using Drummond's checklist. The general characteristics, main assumptions, and results of the economic evaluations were summarized. RESULTS: Our search yielded 10 eligible economic evaluations with different screening strategies compared in different settings and perspectives. The selected papers scored 81% (68-97%) on the items in Drummond's checklist on average. In general, a screening program is cost-effective or even dominant over no screening. The one-step screening, with more cases detected, is more likely to be cost-effective than the two-step screening. Universal screening is more likely to be cost-effective than screening targeting the high-risk population. Parameters affecting cost-effectiveness include: diagnosis criteria, epidemiological characteristics of the population, efficacy of screening and treatment, and costs. CONCLUSIONS: Most studies found GDM screening to be cost-effective, though uncertainties remain due to many factors. The quality assessment identified weaknesses in the economic evaluations in terms of integrating existing data, measuring costs and consequences, analyzing perspectives, and adjusting for uncertainties.

Coronary heart disease and stroke disease burden attributable to fruit and vegetable intake in Japan: projected DALYS to 2060.

BACKGROUND: Fruit and vegetable consumption was considered a protective effect against cardiovascular and cerebrovascular diseases (CVDs). This study aimed to project the reduction in the CVD burden under different scenarios of increased fruit and vegetable intake in Japan by 2060. METHODS: Population attributable fractions (PAF) were calculated by gender and age in 2015. The projection considered five scenarios for 2015, 2030, 2045, and 2060: 1) a baseline of no changes in intake; 2) a moderate increase in fruit intake (extra 50 g/day or 1/2 serving); 3) an high increase in fruit intake (extra 100 g/day or 1 serving); 4) a moderate increase in vegetable intake (extra 70 g/day or 1 serving); and 5) an high increase in vegetable intake (extra 140 g/day or 2 servings). Potentially preventable disability-adjusted life years (DALYs) for CVDs were estimated for each scenario. Monte Carlo simulations were performed to calculate the 95% confidence intervals of the estimates. RESULTS: Across all age groups, men had a higher daily vegetable intake than women (292.7 g/d > 279.3 g/d) but a lower daily fruit intake (99.3 g/d < 121.0 g/d). Comparing with recommended intake level (350 g/d of vegetable and 200 g/d of fruit), the total CVD burden was estimated to be 302,055 DALYs attributable to inadequate fruit consumption in 2015, which accounted for 12.6% of the total CVD burden (vegetable: 202,651 DALYs; 8.5%). In 2060, the percentage of the CVD burden due to insufficient intake of fruit is estimated to decrease to 7.9% under the moderate increase scenario and to decrease to 4.5% under the high increase scenario (vegetable: 5.4%; 2.4%). CONCLUSIONS: The study suggested that a relevantly large percentage of the CVD burden can be alleviated by promoting even modest increases in fruit and vegetable consumption in Japan.

Perspectives of value-based policy making in child health care in Japan.

In Japan, epidemiological transition has profoundly influenced the priorities of child healthcare. As pediatric care is shifting from a disease-driven curative approach to an integrated approach, the value of child health care now needs to be redefined with an integrated scope. With the trend to emphasize a rational judgement on the social value in terms of resource allocation and health policy, a value-based approach is necessary for child health care. This study aims to provide an overview and perspective of value-based policy making in child health care, under a context of epidemiological transition, health care system and social changes. The current methodology scheme of CEA and outcome evaluation has limitations, not meeting the urgent need of the application. The outcomes of child health care are no longer limited in clinical and health indicators such as survival rate, cure rate and health related quality of life, but also various aspects other than health, such as education, well-being of children and their primary caregivers, especially when treatment of diseases is no longer the dominant role of health care. Such the evaluation should reflect the impacts of the integrated approach in a long-term scope.

Social marketing including financial incentive programs at worksite cafeterias for preventing obesity: a systematic review.

BACKGROUND: As with food-taxation strategies, such interventions as discounted healthy menus, point-of-purchase advertisements, and sugar-free beverages for employees at worksites could help prevent obesity. This study assessed the effectiveness of food environment interventions incorporating financial incentive or social marketing strategies at workplace cafeterias, vending machines, and kiosks toward preventing obesity and improving dietary habits. METHODS: We conducted searches on CENTRAL, MEDLINE, EMBASE, CINAHL, and PsycINFO databases. The study designs included were randomized control trials (RCTs) and cluster RCTs. We evaluated the effectiveness of financial incentive or social marketing strategies interventions (such as discounts) on health outcomes or food intake behavior. Two reviewers independently screened the studies for inclusion. We assessed the risk of bias using the Cochrane Collaboration's tool. This protocol was published in 2014. RESULTS: We included three trials, with a combined total of 3013 participants. There were limited available data from RCTs on changes in body weight. No eligible social marketing studies were retrieved. In some cases, a meta-analysis could not be conducted owing to differences in the analytic methods for the outcomes. CONCLUSIONS: Lack of evidence made it difficult to draw any conclusions. In future surveys, it will be necessary to conduct interventions focusing only on financial incentive intervention versus no intervention in order to determine whether the incentive strategy has a clear impact. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD4201401056.

A community-based cluster randomized controlled trial (cRCT) to evaluate the impact and operational assessment of "safe motherhood and newborn health promotion package": study protocol.

BACKGROUND: Despite considerable progress in reduction of both under-five and maternal mortality in recent decades, Bangladesh is still one of the low and middle income countries with high burden of maternal and neonatal mortality. The primary objective of the current study is to measure the impact of a comprehensive package of interventions on maternal and neonatal mortality. In addition, changes in coverage, quality and utilization of maternal and newborn health (MNH) services, social capital, and cost effectiveness of the interventions will be measured. METHODS: A community-based, cluster randomized controlled trial design will be adopted and implemented in 30 unions of three sub-districts of Chandpur district of Bangladesh. Every union, the lowest administrative unit of the local government with population of around 20,000-30,000, will be considered a cluster. Based on the baseline estimates, 15 clusters will be paired for random assignment as intervention and comparison clusters. The primary outcome measure is neonatal mortality, and secondary outcomes are coverage of key interventions like ANC, PNC, facility and skilled provider delivery. Baseline, midterm and endline household survey will be conducted to assess the key coverage of interventions. Health facility assessment surveys will be conducted periodically to assess facility readiness and utilization of MNH services in the participating health facilities. DISCUSSION: The current study is expected to provide essential strong evidences on the impact of a comprehensive package of interventions to the Bangladesh government, and other developmental partners. The study results may help in prioritizing, planning, and scaling-up of Safe Motherhood Promotional interventions in other geographical areas of Bangladesh as well as to inform other developing countries of similar settings. TRIAL REGISTRATION: NCT03032276 .

Mobile-health tool to improve maternal and neonatal health care in Bangladesh: a cluster randomized controlled trial.

BACKGROUND: In Bangladesh, the targets on reduction of maternal mortality and utilization of related obstetric services provided by skilled health personnel in Millennium Development Goals 5 remains unmet, and the progress in reduction of neonatal mortality lag behind that in the reduction of infant and under-five mortalities, remaining as an essential issue towards the achievement of maternal and neonatal health targets in health related Sustainable Development Goals (SDGs). As access to appropriate perinatal care is crucial to reduce maternal and neonatal deaths, recently several mobile platform-based health programs sponsored by donor countries and Non-Governmental Organizations have targeted to reduce maternal and child mortality. On the other hand, good health-care is necessary for the development. Thus, we designed this implementation research to improve maternal and child health care for targeting SDGs. METHODS/DESIGN: This cluster randomized trial will be conducted in Lohagora of Narail District and Dhamrai of Dhaka District. Participants are pregnant women in the respective areas. The total sample size is 3000 where 500 pregnant women will get Mother and Child Handbook (MCH) and messages using mobile phone on health care during pregnancy and antenatal care about one year in each area. The other 500 in each area will get health education using only MCH book. The rest 1000 participants will be controlled; it means 500 in each area. We randomly assigned the intervention and controlled area based on smallest administrative area (Unions) in Bangladesh. The data collection and health education will be provided through trained research officers starting from February 2017 to August 2018. Each health education session is conducting in their house. The study proposal was reviewed and approved by NCCD, Japan and Bangladesh Medical Research Council (BMRC), Bangladesh. The data will be analyzed using STATA and SPSS software. DISCUSSION: For the improvement of maternal and neonatal care, this community-based intervention using mobile phone and handbook will do great contribution. Thus, a developing country where resources are limited received the highest benefit. Such intervention will guide to design for prevention of other diseases too. TRIAL REGISTRATION: UMIN000025628 Registered June 13, 2016.

Maternal socio-demographic and psychological predictors for risk of developmental delays among young children in Mongolia.

BACKGROUND: Factors influencing child development are not well studied in developing settings, and especially in Mongolia. This cohort study examined the relationship between maternal socio-demographic and psychological conditions on risk of young child developmental delay. METHODS: A total of 150 children aged between 13 ~ 24 months old participated in this study. The participants were randomly selected from a pre-existing cohort of 1297 children who were involved in a study on infant bilirubin nomogram development conducted at a tertiary health facility in Mongolia between 2012 and 2013. Child development was evaluated using the Mongolian Rapid Baby Scale (MORBAS), a validated scale for child development. The potential factors for child developmental delay were assessed using a pre-tested questionnaire comprising of 52 questions. Fisher's exact test and multivariable logistic regression analysis were conducted. RESULTS: Seventeen (11%) out of the 150 children that participated in the study were at risk of developmental delay. There was a negative association between the risk of child developmental delay and higher maternal education (AOR 0.15, 95% CI: 0.03-0.66). Increasing maternal age (AOR 1.12, 95%CI: 0.98-1.27), maternal depression symptoms (AOR 4.93, 95%CI: 0.93-26.10), child gender being female (AOR 0.25, 95%CI: 0.06-1.00) and being from single mother household (AOR 0.14, 95%CI: 0.01-1.11) were also predictors for risk of developmental delay - although the association was marginal. CONCLUSIONS: Our findings suggest that being of underprivileged social status, and poor psychological condition of mothers in Mongolia possibly increases the risk of child developmental delays. Interventions targeting these modifiable predictors are needed to develop prevention strategies for child developmental delay.

A scoping review of palliative care for children in low- and middle-income countries.

BACKGROUND: Ninety-eight percent of children needing palliative care live in low- and middle-income countries (LMICs), and almost half of them live in Africa. In contrast to the abundance of data on populations in high income countries, the current data on populations in LMICs is woefully inadequate. This study aims to identify and summarize the published literature on the need, accessibility, quality, and models for palliative care for children in LMICs. METHODS: A scoping review was performed following the method of Arksey and O'Malley. Systematic searches were conducted on PubMed and Google Scholar using the main keywords, 'children AND palliative care OR terminal care OR hospice OR end of life AND developing countries OR LMICs.' Additional publications were obtained by handsearching. Papers were only included if they reported on the need, accessibility, quality, and models for palliative care for children in LMICs. RESULTS: Fifteen papers met the inclusion criteria for review. Of these, 10 assessed need, seven examined availability and/or accessibility, one assessed quality, and one examined the models. We found an urgent need for palliative care, particularly in the training for health workers and improving poor availability and/or accessibility to palliative care in terms of factors such as medication and bereavement support. The best practice models demonstrated feasibility and sustainability through cooperation with governments and community organizations. The quality of pain management and emotional support was lower in LMICs compared to HICs. CONCLUSION: Although we found limited evidence in this review, we identified common challenges such as the need for further training for health workers and greater availability of opioid analgesics. While efforts to change the current systems and laws applying to children in LMICs are important, we should also tackle underlying factors including the need to raise awareness about palliative care in public health and improve the accuracy of data collection.

Cost-effectiveness analysis of neonatal screening of critical congenital heart defects in China.

BACKGROUND: Pulse oximetry screening is a highly accurate tool for the early detection of critical congenital heart disease (CCHD) in newborn infants. As the technique is simple, noninvasive, and inexpensive, it has potentially significant benefits for developing countries. The aim of this study is to provide information for future clinical and health policy decisions by assessing the cost-effectiveness of CCHD screening in China. METHODS AND FINDINGS: We developed a cohort model to evaluate the cost-effectiveness of screening all Chinese newborns annually using 3 possible screening options compared to no intervention: pulse oximetry alone, clinical assessment alone, and pulse oximetry as an adjunct to clinical assessment. We calculated the incremental cost per averted disability-adjusted life years (DALYs) in 2015 international dollars to measure cost-effectiveness. One-way sensitivity analysis and multivariate probabilistic sensitivity analysis were performed to test the robustness of the model. Of the three screening options, we found that clinical assessment is the most cost-effective strategy compared to no intervention with an incremental cost-effectiveness ratio (ICER) of Int$5,728/DALY, while pulse oximetry plus clinical assessment with the highest ICER yielded the best health outcomes. Sensitivity analysis showed that when the treatment rate increased up to 57.5%, pulse oximetry plus clinical assessment showed the best expected values among the three screening options. CONCLUSION: In China, for neonatal screening for CCHD at the national level, clinical assessment was a very cost-effective preliminary choice and pulse oximetry plus clinical assessment was worth considering for the long term. Improvement in accessibility to treatment is crucial to expand the potential health benefits of screening.

Cost-effectiveness analysis of different types of human papillomavirus vaccination combined with a cervical cancer screening program in mainland China.

BACKGROUND: China has a high prevalence of human papillomavirus (HPV) and a consequently high burden of disease with respect to cervical cancer. The HPV vaccine has proved to be effective in preventing cervical cancer and is now a part of routine immunization programs worldwide. It has also proved to be cost effective. This study aimed to assess the cost-effectiveness of 2-, 4-, and 9-valent HPV vaccines (hereafter, HPV2, 4 or 9) combined with current screening strategies in China. METHODS: A Markov model was developed for a cohort of 100,000 HPV-free girls to simulate the natural history to HPV infection. Three recommended screening methods (1. liquid-based cytology test + HPV DNA test; 2. pap smear cytology test + HPV DNA test; 3. visual inspection with acetic acid) and three types of HPV vaccination program (HPV2/4/9) were incorporated into 15 intervention options, and the incremental cost-effectiveness ratio (ICER) was calculated to determine the dominant strategies. Costs, transition probabilities and utilities were obtained from a review of the literature and national databases. One-way sensitivity analyses and threshold analyses were performed for key variables in different vaccination scenarios. RESULTS: HPV9 combined with screening showed the highest health impact in terms of reducing HPV-related diseases and increasing the number of quality-adjusted life years (QALYs). Under the current thresholds of willingness to pay (WTP, 3 times the per capita GDP or USD$ 23,880), HPV4/9 proved highly cost effective, while HPV2 combined with screening cost more and was less cost effective. Only when screening coverage increased to 60% ~ 70% did the HPV2 and screening combination strategy become economically feasible. CONCLUSIONS: The combination of the HPV4/9 vaccine with current screening strategies for adolescent girls was highly cost-effective and had a significant impact on reducing the HPV infection-related disease burden in Mainland China.

Inter-prefecture disparity in under-5 mortality: 115 year trend in Japan.

BACKGROUND: Child poverty is a growing, serious issue in Japan, where various social disparities are increasing. Numerous reports have focused on the relationship between social inequity and health, but few studies have assessed how the overall magnitude of disparities in child health has changed in the course of drastic social and economic transitions from 1899 to more recent times. In this study, we assessed the trend of the under-5 mortality rate (U5MR) and its inter-prefecture disparity in Japan. METHODS: This is a secondary analysis of Japan's vital statistics data from 1899 to 2014 (115 years), which covers a core period of modern Japan. We calculated the U5MR of each prefecture and its Theil index by year to assess the trend of inter-prefecture disparity in child health from 1899 to 2014. RESULTS: The U5MR monotonically decreased from 238 per 1,000 births in 1899 to 3 in 2014. The Theil index of the U5MR increased in the post-war period, peaked in 1962 (0.027) and gradually reduced to <0.01 in the 1970s. In the 2000s, however, even though U5MR continued to decrease, the Theil index started to increase, and in 2014 (0.013) it exceeded that in 1970 and was more similar to that before World War II. CONCLUSIONS: The disparities in child health appear to be widening, and may serve as a warning to today's society that increasing socioeconomic gradients may lead to rising health inequity among children. Further investigations into the causes, mechanisms, and possible interventions are needed.

Assessing health-related quality of life in young Japanese children with chronic conditions: Preliminary validation of the DISABKIDS smiley measure.

BACKGROUND: Although there is an increasing need to investigate the health-related quality of life (HRQOL) of children and adolescents with chronic conditions in Japan, there is currently no standardized measure in which young children can directly answer questions about their HRQOL. The DISABKIDS Smiley measure uses face emoticons to measure HRQOL and distress caused by illness and related treatments among young children. We tested the reliability and validity of the DISABKIDS Smiley measure in a sample of young Japanese children. METHODS: After translating the child and parent questionnaires into Japanese, a pre-test was performed to test the content validity in accordance with guidelines from the DISABKIDS Group. In total, 60 child-parent pairs were recruited to participate in the survey. We measured internal consistency of the scales using Cronbach's alpha as well as Guttman split-half, test-retest reliability using intraclass correlation coefficients (ICCs) at a two-week interval, and ICCs between child- and parent-reported scores. Convergent validity of the scale was also examined against the Kiddy-KINDL scale. RESULTS: Both child-reported and parent-reported scales showed good internal consistency and split-half reliability. Test-retest reliability of the child-reported version (ICC = 0.53, p = 0.004) was lower than that of the parent-reported version (ICC = 0.80, p < 0.001). Moderate to good agreement between child- and parent- reported scales was observed in both the first (ICC = 0.75, p < 0.001) and second administration (ICC = 0.71, p < 0.001). Moderate to very strong positive correlations were observed with the total score of the Kiddy-KINDL child-reported version (r = 0.51, p < 0.001), and facets of the Kiddy-KINDL parent-reported version (ranging from r = 0.364 to r = 0.60, p < 0.001) and total score (r = 0.71, p < 0.001). CONCLUSIONS: The psychometric property of the instrument showed that the Japanese version of the DISABKIDS Smiley can be applied to assess the HRQOL of Japanese children with chronic conditions. Further investigation will be needed to explore the reliability and validity for repeated use of the instrument in clinical practice as an indicator of clinical significance.

Assessment and support during early labour for improving birth outcomes.

BACKGROUND: The progress of labour in the early or latent phase is usually slow and may include painful uterine contractions. Women may feel distressed and lose their confidence during this phase. Support and assessment interventions have been assessed in two previous Cochrane Reviews. This review updates and replaces these two reviews, which have become out of date. OBJECTIVES: To investigate the effectiveness of assessment and support interventions for women during early labour.In order to measure the effectiveness of the interventions, we compared the duration of labour, the rate of obstetrical interventions, and the rate of other maternal or neonatal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (31 October 2016) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials of any assessment or support intervention in the latent phase of labour. We planned to include cluster-randomised trials if they were eligible. We did not include quasi-randomised trials. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We resolved any disagreement by discussion or by involving a third assessor. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: We included five trials with a total of 10,421 pregnant women in this review update. The trials were conducted in the UK, Canada and America. The trials compared interventions in early labour versus usual care. We examined three comparisons: early labour assessment versus immediate admission to hospital; home visits by midwives versus usual care (telephone triage); and one-to-one structured midwifery care versus usual care. These trials were at moderate- risk of bias mainly because blinding women and staff to these interventions is not generally feasible. For important outcomes we assessed evidence using GRADE; we downgraded evidence for study design limitations, imprecision, and where we carried out meta-analysis, for inconsistency.One trial with 209 women compared early labour assessment with direct admission to hospital. Duration of labour from the point of hospital admission was reduced for women in the assessment group (mean difference (MD) -5.20 hours, 95% confidence interval (CI) -7.06 to -3.34; 209 women, low-quality evidence). There were no clear differences between groups for the number of women undergoing caesarean section or instrumental vaginal birth (risk ratio (RR) 0.72, 95% CI 0.30 to 1.72, very low quality evidence; and, RR 0.86, 95% CI 0.58 to 1.26, very low quality evidence, respectively). Serious maternal morbidity was not reported. Women in the early assessment group were slightly less likely to have epidural anaesthesia (RR 0.87, 95% CI 0.78 to 0.98, low-quality evidence), and considerably less likely to have oxytocin for labour augmentation (RR 0.57, 95% CI 0.37 to 0.86) and this group also had increased satisfaction with their care compared with women in the immediate admission group (MD 16.00, 95% CI 7.53 to 24.47). No babies were born before admission to hospital and only one infant had a low Apgar score at five minutes after the birth (very low quality evidence). Admission to neonatal special care was not reported.Three studies examined home assessment and midwifery support versus telephone triage. One trial reported the duration of labour; home visits did not appear to have any clear impact compared with usual care (MD 0.29 hours, 95% CI -0.14 to 0.72; 1 trial, 3474 women, low-quality evidence). There was no clear difference for the rate of caesarean section (RR 1.05, 95% CI 0.95 to 1.17; 3 trials, 5170 women; I² = 0%; moderate-quality evidence) or the rate of instrumental vaginal birth (average RR 0.95, 95% CI 0.79 to 1.15; 2 trials, 4933 women; I² = 69%; low-quality evidence). One trial reported birth before arrival at hospital or unplanned home birth; there was no clear difference between the groups (RR 1.33, 95% CI 0.30 to 5.95; 1 trial, 3474 women). No clear differences were identified for serious maternal morbidity (RR 0.93, 95% CI 0.61 to 1.42; 1 trial, 3474 women; low-quality evidence), or use of epidural (average RR 0.95, 95% CI 0.87 to 1.05; 3 trials, 5168 women; I² = 60%; low-quality evidence). There were no clear differences for neonatal admission to special care (average RR 0.84, 95% CI 0.50 to 1.42; 3 trials, 5170 infants; I² = 71%; very low quality evidence), or for Apgar score less than seven at five minutes after birth (RR 1.19, 95% CI 0.71 to 1.99; 3 trials, 5170 infants; I² = 0%; low-quality evidence).One study, with 5002 women, examined one-to-one structured care in early labour versus usual care. Length of labour was not reported. There were no clear differences between groups for the rate of caesarean section (RR 0.93, 95% CI 0.84 to 1.02; 4996 women, high-quality evidence), or for instrumental vaginal birth (RR 0.94, 95% CI 0.82 to 1.08; 4996 women, high-quality evidence). No clear differences between groups were reported for serious maternal morbidity (RR 1.13, 95% CI 0.84 to 1.52; 4996 women, moderate-quality evidence). Use of epidural was similar in the two groups (RR 1.00, 95% CI 0.99 to 1.01; 4996 women, high-quality evidence). For infant outcomes, there were no clear differences between groups (admission to neonatal intensive care unit: RR 0.98, 95% CI 0.80 to 1.21; 4989 infants, high-quality evidence; Apgar score less than seven at five minutes: RR 1.07, 95% CI 0.64 to 1.79; 4989 infants, moderate-quality evidence). AUTHORS' CONCLUSIONS: Assessment and support in early labour does not have a clear impact on rate of caesarean section or instrumental vaginal birth, or whether the baby was born before arrival at hospital or in an unplanned home birth. However, evidence suggested that interventions may have an impact on reducing the use of epidural anaesthesia, labour augmentation and on increasing maternal satisfaction with giving birth. Evidence about the effectiveness of early labour assessment versus immediate admission was very limited and more research is needed in this area.

Prevalence of early initiation of breastfeeding and determinants of delayed initiation of breastfeeding: secondary analysis of the WHO Global Survey.

Early initiation of breastfeeding (EIBF) within 1 hour of birth can decrease neonatal death. However, the prevalence of EIBF is approximately 50% in many developing countries, and data remains unavailable for some countries. We conducted a secondary analysis using the WHO Global Survey on Maternal and Perinatal Health to identify factors hampering EIBF. We described the coverage of EIBF among 373 health facilities for singleton neonates for whom breastfeeding was initiated after birth. Maternal and facility characteristics of EIBF were compared to those of breastfeeding >1 hour after birth, and multiple logistic regression analysis was performed. In total, 244,569 singleton live births without severe adverse outcomes were analysed. The EIBF prevalence varied widely among countries and ranged from 17.7% to 98.4% (average, 57.6%). There was less intra-country variation for BFI <24 hours. After adjustment, EIBF was significantly lower among women with complications during pregnancy and caesarean delivery. Globally, EIBF varied considerably across countries. Maternal complications during pregnancy, caesarean delivery and absence of postnatal/neonatal care guidelines at hospitals may affect EIBF. Our findings suggest that to better promote EIBF, special support for breastfeeding promotion is needed for women with complications during pregnancy and those who deliver by caesarean section.

Needs assessment for collaborative network in pediatric clinical research and education.

BACKGROUND: A collaborative network for pediatric research has not been fully established in Japan. To identify the network infrastructure, we conducted a survey on the support and education for clinical research currently available in children's hospitals. METHODS: In November 2014, a 27-question survey was distributed to 31 hospitals belonging to the Japanese Association of Children's Hospitals and Related Institutions (JACHRI) to assess clinical research support, research education, research achievements, and their expectations. RESULTS: All the hospitals responded to the survey. Overall, 74.2% of hospitals had clinical research support divisions. Although all hospitals had ethics committees, <30% of the hospitals had a data manager, intellectual property management unit, biostatistician, and English-language editor. Seven hospitals had education programs for clinical research. The number of seminars and workshops for clinical research had significant correlations with the number of physicians (r = 0.927), pediatricians (r = 0.922), and clinical trial management physicians (r = 0.962). There was a significant difference in the number of clinical trials initiated by physicians between hospitals with research education programs and those without (P < 0.01). The number of education programs was significantly correlated with the number of original articles and case reports in English (r = 0.788), and the number of publications in Japanese (r = 0.648). All hospitals recognized the need for a leader to establish a collaborative network for clinical research. CONCLUSIONS: Important factors for creating a collaborative system for pediatric research in Japan were identified. Human resources to support clinical research are a key factor to improve clinical research education and research achievements.