Vital Signs: Trends and Disparities in Infant Safe Sleep Practices - United States, 2009-2015.

INTRODUCTION: There have been dramatic improvements in reducing infant sleep-related deaths since the 1990s, when recommendations were introduced to place infants on their backs for sleep. However, there are still approximately 3,500 sleep-related deaths among infants each year in the United States, including those from sudden infant death syndrome, accidental suffocation and strangulation in bed, and unknown causes. Unsafe sleep practices, including placing infants in a nonsupine (on side or on stomach) sleep position, bed sharing, and using soft bedding in the sleep environment (e.g., blankets, pillows, and soft objects) are modifiable risk factors for sleep-related infant deaths.

Timing and Determinants of the Introduction of Complementary Foods in Kuwait: Results of a Prospective Cohort Study.

BACKGROUND: The early introduction of complementary foods is common in Middle Eastern countries but little is known about the determinants of this practice in this region. OBJECTIVES: This prospective cohort study conducted from October 2007 to October 2008 investigated the determinants of the very early (before 17 weeks) introduction of complementary foods in Kuwait and compared rates of this practice against rates reported in the mid-1990s. METHODS: A total of 373 women were recruited from maternity hospitals in Kuwait City and followed to 26 weeks postpartum. Data on complementary feeding practices were available from 303 women. Multivariate logistic regression was used to estimate the association of very early introduction of complementary foods with infant sex and maternal characteristics including age, years of education, employment intentions at 6 months postpartum, parity, prepregnancy body mass index, and prepregnancy smoking status. RESULTS: All infants had received complementary foods by 26 weeks of age, with 30.4% receiving complementary foods before 17 weeks of age. Women born in other Arabic countries were less likely to introduce complementary foods before 17 weeks (adjusted odds ratio [adj OR] = 0.40; 95% confidence interval [CI], 0.22-0.73) than women born in Kuwait. Women who were exclusively formula feeding at 6 weeks postpartum were less likely to introduce complementary foods before 17 weeks (adj OR = 0.40; 95% CI, 0.23-0.71) than women who were still breastfeeding. CONCLUSION: Compared to the mid-1990s, fewer infants in Kuwait were receiving complementary foods before 17 weeks. Nevertheless, all infants had received complementary foods by 6 months of age.

Who has been caring for the baby?

Nearly a decade ago, The Lancet published the Neonatal Survival Series, with an ambitious call for integration of newborn care across the continuum of reproductive, maternal, newborn, and child health and nutrition (RMNCH). In this first of five papers in the Every Newborn Series, we consider what has changed during this decade, assessing progress on the basis of a systematic policy heuristic including agenda-setting, policy formulation and adoption, leadership and partnership, implementation, and evaluation of effect. Substantial progress has been made in agenda setting and policy formulation for newborn health, as witnessed by the shift from maternal and child health to maternal, newborn, and child health as a standard. However, investment and large-scale implementation have been disappointingly small, especially in view of the size of the burden and potential for rapid change and synergies throughout the RMNCH continuum. Moreover, stillbirths remain invisible on the global health agenda. Hence that progress in improvement of newborn survival and reduction of stillbirths lags behind that of maternal mortality and deaths for children aged 1-59 months is not surprising. Faster progress is possible, but with several requirements: clear communication of the interventions with the greatest effect and how to overcome bottlenecks for scale-up; national leadership, and technical capacity to integrate and implement these interventions; global coordination of partners, especially within countries, in provision of technical assistance and increased funding; increased domestic investment in newborn health, and access to specific commodities and equipment where needed; better data to monitor progress, with local data used for programme improvement; and accountability for results at all levels, including demand from communities and mortality targets in the post-2015 framework. Who will step up during the next decade to ensure decision making in countries leads to implementation of stillbirth and newborn health interventions within RMNCH programmes?

Trends and factors associated with infant bed sharing, 1993-2010: the National Infant Sleep Position Study.

IMPORTANCE: A strong association between infant bed sharing and sudden infant death syndrome or unintentional sleep-related death in infants has been established. Occurrences of unintentional sleep-related deaths among infants appear to be increasing. OBJECTIVES: To determine the trends and factors associated with infant bed sharing from 1993 through 2010, including the association of physician advice on bed sharing. DESIGN: National Infant Sleep Position study conducted with annual telephone surveys. SETTING: The 48 contiguous states. PARTICIPANTS: Nighttime caregivers of infants born within 7 months of each survey administration. Approximately 1000 interviews were completed annually. MAIN OUTCOMES AND MEASURES: Infant bed sharing as a usual practice. RESULTS: Of 18 986 participants, 11.2% reported an infant sharing a bed as a usual practice. Bed sharing increased from 1993 (6.5%) to 2010 (13.5%). Although bed sharing increased significantly among white respondents from 1993 to 2000 (P < .001), the increase from 2001 to 2010 was not significant (P = .48). Black and Hispanic respondents reported an increase in bed sharing throughout the study period, with no difference between the earlier and later periods (P = .63 and P = .77, respectively). After accounting for the study year, factors associated with increase in infant bed sharing as a usual practice included maternal educational level of less than high school compared with college or greater (adjusted odds ratio, 1.42 [95% CI, 1.12-1.79]); black (3.47 [2.97-4.05]), Hispanic (1.33 [1.10-1.61]), and other (2.46 [2.03-2.97]) maternal race or ethnicity compared with white race; household income of less than $20,000 (1.69 [1.44-1.99]) and $20,000 to $50,000 (1.29 [1.14-1.45]) compared with greater than $50,000; living in the West (1.61 [1.38-1.88]) or the South (1.47 [1.30-1.66]) compared with the Midwest; infants younger than 8 weeks (1.45 [1.21-1.73]) or ages 8 to 15 weeks (1.31 [1.17-1.45]) compared with 16 weeks or older; and being born prematurely compared with full-term (1.41 [1.22-1.62]). Almost 46% of the participants reported talking to a physician about bed sharing. Compared with those who did not receive advice from a physician, those who reported their physicians had a negative attitude were less likely to have the infant share a bed (adjusted odds ratio, 0.66 [95% CI, 0.53-0.82]), whereas a neutral attitude was associated with increased bed sharing (1.38 [1.05-1.80]). CONCLUSIONS AND RELEVANCE: Our finding of a continual increase in bed sharing throughout the study period among black and Hispanic infants suggests that the current American Academy of Pediatrics recommendation about bed sharing is not universally followed. The factors associated with infant bed sharing may be useful in evaluating the impact of a broad intervention to change behavior.

Influence of bedsharing activity on breastfeeding duration among US mothers.

IMPORTANCE: Some professional associations advocate bedsharing to facilitate breastfeeding, while others recommend against it to reduce the risk of sudden infant death syndrome and suffocation deaths. A better understanding of the quantitative influence of bedsharing on breastfeeding duration is needed to guide policy. OBJECTIVE: To quantify the influence of bedsharing on breastfeeding duration. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal data were from the Infant Feeding Practices Study II, which enrolled mothers while pregnant and followed them through the first year of infant life. Questionnaires were sent at infant ages 1 to 7, 9, 10, and 12 months, and 1846 mothers answered at least 1 question regarding bedsharing and were breastfeeding at infant age 2 weeks. EXPOSURES: Bedsharing, defined as the mother lying down and sleeping with her infant on the same bed or other sleeping surfaces for nighttime sleep or during the major sleep period. MAIN OUTCOMES AND MEASURES: Survival analysis to investigate the effect of bedsharing on duration of any and exclusive breastfeeding. RESULTS: Longer duration of bedsharing, indicated by a larger cumulative bedsharing score, was associated with a longer duration of any breastfeeding but not exclusive breastfeeding, after adjusting for covariates. Breastfeeding duration was longer among women who were better educated, were white, had previously breastfed, had planned to breastfeed, and had not returned to work in the first year postpartum. CONCLUSIONS AND RELEVANCE: Multiple factors were associated with breastfeeding, including bedsharing. Given the risk of sudden infant death syndrome related to bedsharing, multipronged strategies to promote breastfeeding should be developed and tested.

The interconnections between maternal and newborn health--evidence and implications for policy.

The past decade has witnessed increasing global attention and political support for maternal, newborn and child health. Despite this increased attention, actual progress has been slow and sporadic: coverage of key maternal and newborn health interventions remains low and there are wide disparities in access to care, within and across countries. Strategies for improving maternal and newborn health are closely linked, and can be delivered most effectively through a continuum of care approach. While these interventions are largely known, there is little information on which interventions have a positive health impact for both women and newborns. This supplement identifies the interventions during the preconception, pregnancy, intrapartum and postnatal periods found to have a positive, synergistic effect on maternal and neonatal outcomes. These interventions are then grouped into packages of care for delivery at the community, health center or hospital levels.

Donor funding for newborn survival: an analysis of donor-reported data, 2002-2010.

BACKGROUND: Neonatal mortality accounts for 43% of global under-five deaths and is decreasing more slowly than maternal or child mortality. Donor funding has increased for maternal, newborn, and child health (MNCH), but no analysis to date has disaggregated aid for newborns. We evaluated if and how aid flows for newborn care can be tracked, examined changes in the last decade, and considered methodological implications for tracking funding for specific population groups or diseases. METHODS AND FINDINGS: We critically reviewed and categorised previous analyses of aid to specific populations, diseases, or types of activities. We then developed and refined key terms related to newborn survival in seven languages and searched titles and descriptions of donor disbursement records in the Organisation for Economic Co-operation and Development's Creditor Reporting System database, 2002-2010. We compared results with the Countdown to 2015 database of aid for MNCH (2003-2008) and the search strategy used by the Institute for Health Metrics and Evaluation. Prior to 2005, key terms related to newborns were rare in disbursement records but their frequency increased markedly thereafter. Only two mentions were found of "stillbirth" and only nine references were found to "fetus" in any spelling variant or language. The total value of non-research disbursements mentioning any newborn search terms rose from US$38.4 million in 2002 to US$717.1 million in 2010 (constant 2010 US$). The value of non-research projects exclusively benefitting newborns fluctuated somewhat but remained low, at US$5.7 million in 2010. The United States and the United Nations Children's Fund (UNICEF) provided the largest value of non-research funding mentioning and exclusively benefitting newborns, respectively. CONCLUSIONS: Donor attention to newborn survival has increased since 2002, but it appears unlikely that donor aid is commensurate with the 3.0 million newborn deaths and 2.7 million stillbirths each year. We recommend that those tracking funding for other specific population groups, diseases, or activities consider a key term search approach in the Creditor Reporting System along with a detailed review of their data, but that they develop their search terms and interpretations carefully, taking into account the limitations described. Please see later in the article for the Editors' Summary.

Newborn survival in Uganda: a decade of change and future implications.

Each year in Uganda 141 000 children die before reaching their fifth birthday; 26% of these children die in their first month of life. In a setting of persistently high fertility rates, a crisis in human resources for health and a recent history of civil unrest, Uganda has prioritized Millennium Development Goals 4 and 5 for child and maternal survival. As part of a multi-country analysis we examined change for newborn survival over the past decade through mortality and health system coverage indicators as well as national and donor funding for health, and policy and programme change. Between 2000 and 2010 Uganda's neonatal mortality rate reduced by 2.2% per year, which is greater than the regional average rate of decline but slower than national reductions in maternal mortality and under-five mortality after the neonatal period. While existing population-based data are insufficient to measure national changes in coverage and quality of services, national attention for maternal and child health has been clear and authorized from the highest levels. Attention and policy change for newborn health is comparatively recent. This recognized gap has led to a specific focus on newborn health through a national Newborn Steering Committee, which has been given a mandate from the Ministry of Health to advise on newborn survival issues since 2006. This multi-disciplinary and inter-agency network of stakeholders has been able to preside over a number of important policy changes at the level of facility care, education and training, community-based service delivery through Village Health Teams and changes to essential drugs and commodities. The committee's comprehensive reach has enabled rapid policy change and increased attention to newborn survival in a relatively short space of time. Translating this favourable policy environment into district-level implementation and high quality services is now the priority.

Newborn survival in Bangladesh: a decade of change and future implications.

Remarkable progress over the last decade has put Bangladesh on track for Millennium Development Goal (MDG) 4 for child survival and achieved a 40% decline in maternal mortality. However, since neonatal deaths make up 57% of under-five mortality in the country, increased scale up and equity in programmes for neonatal survival are critical to sustain progress. We examined change for newborn survival from 2000 to 2010 considering mortality, coverage and funding indicators, as well as contextual factors. The national neonatal mortality rate has undergone an annual decline of 4.0% since 2000, reflecting greater progress than both the regional and global averages, but the mortality reduction for children 1-59 months was double this rate, at 8.6%. Examining policy and programme change, and national and donor funding for health, we identified various factors which contributed to an environment favourable to newborn survival. Locally-generated evidence combined with re-packaged global evidence, notably The Lancet Neonatal Series, has played a role, although pathways between research and policies and programme change are often complex. Several high-profile champions have had major influence. Attention for community initiatives and considerable donor funding also appear to have contributed. There have been some increases in coverage of key interventions, such as skilled attendance at birth and postnatal care, however these are low and reach less than one-third of families. Major reductions in total fertility, some change in gross national income and other contextual factors are likely to also have had an influence in mortality reduction. However, other factors such as socio-economic and geographic inequalities, frequent changes in government and pluralistic implementation structures have provided challenges. As coverage of health services increases, a notable gap remains in quality of facility-based care. Future gains for newborn survival in Bangladesh rest upon increased implementation at scale and greater consistency in content and quality of programmes and services.

Newborn survival: a multi-country analysis of a decade of change.

Neonatal deaths account for 40% of global under-five mortality and are ever more important if we are to achieve the Millennium Development Goal 4 (MDG 4) on child survival. We applied a results framework to evaluate global and national changes for neonatal mortality rates (NMR), healthy behaviours, intervention coverage, health system change, and inputs including funding, while considering contextual changes. The average annual rate of reduction of NMR globally accelerated between 2000 and 2010 (2.1% per year) compared with the 1990s, but was slower than the reduction in mortality of children aged 1-59 months (2.9% per year) and maternal mortality (4.2% per year). Regional variation of NMR change ranged from 3.0% per year in developed countries to 1.5% per year in sub-Saharan Africa. Some countries have made remarkable progress despite major challenges. Our statistical analysis identifies inter-country predictors of NMR reduction including high baseline NMR, and changes in income or fertility. Changes in intervention or package coverage did not appear to be important predictors in any region, but coverage data are lacking for several neonatal-specific interventions. Mortality due to neonatal infection deaths, notably tetanus, decreased, and deaths from complications of preterm birth are increasingly important. Official development assistance for maternal, newborn and child health doubled from 2003 to 2008, yet by 2008 only 6% of this aid mentioned newborns, and a mere 0.1% (US$4.56m) exclusively targeted newborn care. The amount of newborn survival data and the evidence based increased, as did recognition in donor funding. Over this decade, NMR reduction seems more related to change in context, such as socio-economic factors, than to increasing intervention coverage. High impact cost-effective interventions hold great potential to save newborn lives especially in the highest burden countries. Accelerating progress requires data-driven investments and addressing context-specific implementation realities.

Newborn survival in Malawi: a decade of change and future implications.

Malawi is one of two low-income sub-Saharan African countries on track to meet the Millennium Development Goal (MDG 4) for child survival despite high fertility and HIV and low health worker density. With neonatal deaths becoming an increasing proportion of under-five deaths, addressing newborn survival is critical for achieving MDG 4. We examine change for newborn survival in the decade 2000-10, analysing mortality and coverage indicators whilst considering other contextual factors. We assess national and donor funding, as well as policy and programme change for newborn survival using standard analyses and tools being applied as part of a multi-country analysis. Compared with the 1990s, progress towards MDG 4 and 5 accelerated considerably from 2000 to 2010. Malawi's neonatal mortality rate (NMR) reduced slower than annual reductions in mortality for children 1-59 months and maternal mortality (NMR reduced 3.5% annually). Yet, the NMR reduced at greater pace than the regional and global averages. A significant increase in facility births and other health system changes, including increased human resources, likely contributed to this decline. High level attention for maternal health and associated comprehensive policy change has provided a platform for a small group of technical and programme experts to link in high impact interventions for newborn survival. The initial entry point for newborn care in Malawi was mainly through facility initiatives, such as Kangaroo Mother Care. This transitioned to an integrated and comprehensive approach at community and facility level through the Community-Based Maternal and Newborn Care package, now being implemented in 17 of 28 districts. Addressing quality gaps, especially for care at birth in facilities, and including newborn interventions in child health programmes, will be critical to the future agenda of newborn survival in Malawi.

Newborn survival in Nepal: a decade of change and future implications.

Nepal is on target to meet the Millennium Development Goals for maternal and child health despite high levels of poverty, poor infrastructure, difficult terrain and recent conflict. Each year, nearly 35,000 Nepali children die before their fifth birthday, with almost two-thirds of these deaths occurring in the first month of life, the neonatal period. As part of a multi-country analysis, we examined changes for newborn survival between 2000 and 2010 in terms of mortality, coverage and health system indicators as well as national and donor funding. Over the decade, Nepal's neonatal mortality rate reduced by 3.6% per year, which is faster than the regional average (2.0%) but slower than national annual progress for mortality of children aged 1-59 months (7.7%) and maternal mortality (7.5%). A dramatic reduction in the total fertility rate, improvements in female education and increasing change in skilled birth attendance, as well as increased coverage of community-based child health interventions, are likely to have contributed to these mortality declines. Political commitment and support for newborn survival has been generated through strategic use of global and national data and effective partnerships using primarily a selective newborn-focused approach for advocacy and planning. Nepal was the first low-income country to have a national newborn strategy, influencing similar strategies in other countries. The Community-Based Newborn Care Package is delivered through the nationally available Female Community Health Volunteers and was piloted in 10 of 75 districts, with plans to increase to 35 districts in mid-2013. Innovation and scale up, especially of community-based packages, and public health interventions and commodities appear to move relatively rapidly in Nepal compared with some other countries. Much remains to be done to achieve high rates of effective coverage of community care, and especially to improve the quality of facility-based care given the rapid shift to births in facilities.

[Sick leaves motivated by severe diseases of children of less than one year of age]. / Evolución de las licencias por enfermedad grave del niño(a) menor de un año 2004-2008: certezas e interrogantes.

BACKGROUND: The increase in expenses of the health care system caused by sick leaves, especially those granted to mothers with children of less than one year of age with severe diseases, is a topic of concern. AIM: To describe the rates of sick leaves granted to mothers with children of less than one year of age with severe diseases from 2004 to 2008. MATERIAL AND METHODS: Analysis of databases containing information about sick leaves coming from Chilean public and private health care subsystems. Leaves granted to mothers with sick children of less than one year were specifically analyzed in terms of days off work and the amount of monetary benefits. RESULTS: A sustained increase, ranging from 20 to 120% in the number of sick leaves motivated by diseases of children of less than one year, was observed. Thirty four percent of maternity leaves concentrate immediately after finishing the legal period (24 weeks after birth) and almost 60% of them occured within the first 6 months after birth. The most frequent diagnoses that motivated the higher number of leaves were gas-troesophageal reflux and bronchitis. CONCLUSIONS: There is probably a bad use of the benefit in a percentage of leaves. The benefit is also regressive since it favors mostly mothers of a better socioeconomic condition. The law that will extend the postnatal maternity leave will solve in part these problems.

Evolución de las licencias por enfermedad grave del niño(a) menor de un año 2004-2008: certezas e interrogantes / Sick leaves motivated by severe diseases of children of less than one year of age

Background: The increase in expenses of the health care system caused by sick leaves, especially those granted to mothers with children of less than one year of age with severe diseases, is a topic of concern. Aim: To describe the rates of sick leaves granted to mothers with children of less than one year of age with severe diseases from 2004 to 2008. Material and Methods: Analysis of databases containing information about sick leaves coming from Chilean public and private health care subsystems. Leaves granted to mothers with sick children of less than one year were specifically analyzed in terms of days off work and the amount of monetary benefits. Results: A sustained increase, ranging from 20 to 120% in the number of sick leaves motivated by diseases of children of less than one year, was observed. Thirty four percent of maternity leaves concentrate immediately after finishing the legal period (24 weeks after birth) and almost 60% of them occured within the first 6 months after birth. The most frequent diagnoses that motivated the higher number of leaves were gas-troesophageal reflux and bronchitis. Conclusions: There is probably a bad use of the benefit in a percentage of leaves. The benefit is also regressive since it favors mostly mothers of a better socioeconomic condition. The law that will extend the postnatal maternity leave will solve in part these problems.

Changes in care and outcome of very preterm babies in the Parisian region between 1998 and 2003.

OBJECTIVE: To assess evolution in the care and health of very preterm babies between 1998 and 2003 after implementation of a regionalisation policy in France. DESIGN: Comparison of two population-based cohorts. SETTING: The Parisian region. PATIENTS: All live births at 24-31 weeks of gestation in 1997 (EPIPAGE study, n=488) and in 2003 (MOSAIC study, n=580). Interventions Implementation of regionalised perinatal networks. Main outcome measures In-hospital mortality and morbidity, including intraventricular haemorrhage (IVH) grade III and IV, cystic periventricular leucomalacia (PVL) and bronchopulmonary dysplasia (BPD). RESULTS: Over this period, babies born in level III units rose from 67% to 77% and use of antenatal corticosteroids, indicated deliveries and surfactant increased. In-hospital mortality and IVH grades III/IV declined, ORs of 0.66 (95% CI 0.46 to 0.95) and 0.27 (95% CI 0.15 to 0.47), respectively, while PVL and BPD stayed constant. The rate of very preterm babies discharged alive per 1000 total births increased by 18%, but declined for babies with severe brain lesions. CONCLUSIONS: The authors found improvements in mortality and morbidity for very preterm babies and changes in their care over a 6-year period following reinforcement of regionalisation policies.