Volunteers' experiences of providing telephone-based breast-feeding peer support in the RUBY randomised controlled trial.

OBJECTIVE: The Ringing Up About Breastfeeding earlY (RUBY) randomised controlled trial (RCT) found that a telephone-based peer volunteer support intervention increased breast-feeding duration in a setting with high breast-feeding initiation. This sub-study of the RUBY RCT describes the motivation, preparation and experiences of volunteers who provided the peer support intervention. DESIGN: An online survey was completed by 154 (67 %) volunteers after ceasing volunteering. SETTING: Volunteers provided peer support to primiparous women (n 574) who birthed at one of three public hospitals in Melbourne, Australia, between February 2013 and December 2015. PARTICIPANTS: Volunteers (n 230) had themselves breastfed for at least 6 months and received 4 h of training for the role. RESULTS: The median number of mothers supported was two (range 1-11), and two-thirds of respondents supported at least one mother for 6 months. Volunteers were motivated by a strong desire to support new mothers to establish and continue breast-feeding. Most (93 %) considered the training session adequate. The majority (60 %) reported following the call schedule 'most of the time', but many commented that 'it depends on the mother'. Overall, 84 % of volunteers were satisfied with the role and reported that the experience was enjoyable (85 %) and worthwhile (90 %). Volunteers agreed that telephone support for breast-feeding was valued by women (88 %) and that the programme would be effective in helping women to breastfeed (93 %). CONCLUSIONS: These findings are important for those developing similar peer support programmes in which recruiting volunteers and developing training requirements are an integral and recurrent part of volunteer management.

In vivo characterisation of a therapeutically relevant self-assembling 18 F-labelled ß-sheet forming peptide and its hydrogel using positron emission tomography.

Positron emission tomography (PET) and fluorescence labelling have been used to assess the pharmacokinetics, biodistribution and eventual fate of a hydrogel-forming nonapeptide, FEFKFEFKK (F9), in healthy mice, using 18 F-labelled and fluorescein isothiocyanate (FITC)-labelled F9 analogues. F9 was site-specifically radiolabelled with 2-[18 F]fluoro-3-pyridinecarboxaldehyde ([18 F]FPCA) via oxime bond formation. [18 F]FPCA-F9 in vivo fate was evaluated both as a solution, following intravenous administration, and as a hydrogel when subcutaneously injected. The behaviour of FITC-F9 hydrogel was assessed following subcutaneous injection. [18 F]FPCA-F9 demonstrated high plasma stability and primarily renal excretion; [18 F]FPCA-F9 when in solution and injected into the bloodstream displayed prompt bladder uptake (53.4 ± 16.6 SUV at 20 minutes postinjection) and rapid renal excretion, whereas [18 F]FPCA-F9 hydrogel, formed by co-assembly of [18 F]FPCA-F9 monomer with unfunctionalised F9 peptide and injected subcutaneously, showed gradual bladder accumulation of hydrogel fragments (3.8 ± 0.4 SUV at 20 minutes postinjection), resulting in slower renal excretion. Gradual disaggregation of the F9 hydrogel from the site of injection was monitored using FITC-F9 hydrogel in healthy mice (60 ± 3 over 96 hours), indicating a biological half-life between 1 and 4 days. The in vivo characterisation of F9, both as a gel and a solution, highlights its potential as a biomaterial.

The effect of primary midwife-led care on women's experience of childbirth: results from the COSMOS randomised controlled trial.

OBJECTIVE: To determine the effect of primary midwife-led care ('caseload midwifery') on women's experiences of childbirth. DESIGN: Randomised controlled trial. SETTING: Tertiary care women's hospital in Melbourne, Australia. POPULATION: A total of 2314 low-risk pregnant women. METHODS: Women randomised to caseload care received antenatal, intrapartum and postpartum care from a primary midwife, with some care provided by a 'back-up' midwife. Women in standard care received midwifery-led care with varying levels of continuity, junior obstetric care or community-based medical care. MAIN OUTCOME MEASURES: The primary outcome of the study was caesarean section. This paper presents a secondary outcome, women's experience of childbirth. Women's views and experiences were sought using seven-point rating scales via postal questionnaires 2 months after the birth. RESULTS: A total of 2314 women were randomised between September 2007 and June 2010; 1156 to caseload and 1158 to standard care. Response rates to the follow-up questionnaire were 88 and 74%, respectively. Women in the caseload group were more positive about their overall birth experience than women in the standard care group (adjusted odds ratio 1.50, 95% CI 1.22-1.84). They also felt more in control during labour, were more proud of themselves, less anxious, and more likely to have a positive experience of pain. CONCLUSIONS: Compared with standard maternity care, caseload midwifery may improve women's experiences of childbirth. TWEETABLE ABSTRACT: Primary midwife-led care ('caseload midwifery') improves women's experiences of childbirth.

"Safe, connected, supported in a complex system." Exploring the views of women who had a First Nations baby at one of three maternity services offering culturally tailored continuity of midwife care in Victoria, Australia. A qualitative analysis of free-text survey responses.

BACKGROUND: In Australia, continuity of midwife care is recommended for First Nations women to address the burden of inequitable perinatal outcomes experienced by First Nations women and newborns. AIMS: This study aimed to explore the experiences of women having a First Nations baby who received care at one of three maternity services in Naarm (Melbourne), Victoria, where culturally tailored midwife continuity models had been implemented. METHODS: Women having a First Nations baby who were booked for care at one of three study sites were invited to participate in an evaluation of care. Thematic analysis was used to analyse qualitative data from responses to free-text, open ended questions that were included in a follow-up questionnaire at 3-6 months after the birth. RESULTS: In total, 213 women (of whom 186 had continuity of midwife care) participated. The global theme for what women liked about their care was 'Safe, connected, supported' including emotional and clinical safety, having a known midwife and being supported 'my way'. The global theme for what women did not like about their care was 'A complex, fragmented and unsupportive system' including not being listened to, things not being explained, and a lack of cultural safety. CONCLUSIONS: Culturally tailored caseload midwifery models appear to make maternity care feel safer for women having a First Nations baby, however, the mainstream maternity care system remained challenging for some. These models should be implemented for First Nations women, and evidence-based frameworks, such as the RISE framework, should be used to facilitate change.

Origin of the chromosomal radiation of Madeiran house mice: a microsatellite analysis of metacentric chromosomes.

Chromosome races of Mus musculus domesticus are characterised by particular sets of metacentric chromosomes formed by Robertsonian fusions and whole-arm reciprocal translocations. The Atlantic island of Madeira is inhabited by six chromosome races of house mice with 6-9 pairs of metacentric chromosomes. Three of these races are characterised by the metacentric 3.8 also found elsewhere in the distribution of M. m. domesticus, including Denmark and Spain. We investigated the possibility that metacentric 3.8 was introduced to Madeira during the initial colonisation, as this could have 'seeded' the cascade of chromosomal mutation that is the basis of the extraordinary chromosomal radiation observed on the island. Variation at 24 microsatellite loci mapping to three different chromosomal regions (proximal, interstitial and distal) of mouse chromosomes 3 and 8 was investigated in 179 mice from Madeira, Denmark, Portugal, Spain, Italy and Scotland. Analyses of microsatellite loci closely linked to the centromeres of these chromosomes ('proximal loci') do not support a common evolutionary origin of metacentric 3.8 among Madeiran, Danish and Spanish mouse populations. Our results suggest that Madeiran mice are genetically more similar to standard karyotype mice from Portugal than to metacentric mice from elsewhere. There is expected to be an interruption to gene flow between hybridising metacentric races on Madeira, particularly in the chromosomal regions close to the rearrangement breakpoints. Consistent with this, relating to differentiation involving chromosomes 3 and 8 on Madeira, we found greater genetic structure among races for proximal than interstitial or distal loci.

Infant feeding practices in the first 24-48 h of life in healthy term infants.

AIM: To examine in-hospital infant feeding practices, focusing on initiation and prevalence of breastmilk expression and to describe the proportion of women having a breast pump immediately after birth. METHODS: Postpartum women were recruited from three hospitals in Melbourne, Australia, between 2009 and 2011. INCLUSION CRITERIA: having had a healthy singleton term infant, intending to breastfeed and fluency in English. Data were collected using a structured questionnaire. RESULTS: Just over 1000 women were recruited at 24-48 h postpartum; 50% were primiparous. Forty-seven per cent of infants had been fully breastfeeding at the breast from birth, and another 47% had received at least some expressed breastmilk. Forty per cent of first-time mothers reported having had a problem breastfeeding, and 46% already had a breast pump prior to the birth of their infant. CONCLUSIONS: Early breastfeeding problems were common, and less than half the infants had fed only at the breast in the first days of life. Given the normalization of breastmilk expression, more evidence is needed regarding the impact of expressing on duration of breastmilk feeding and maternal health outcomes.

Trust, privacy, community, and culture: Important elements of maternity care for Aboriginal and Torres Strait Islander women giving birth in Victoria.

BACKGROUND: The Australian maternity system must enhance its capacity to meet the needs of Aboriginal and Torres Strait Islander (First Nations) mothers and babies, however evidence regarding what is important to women is limited. AIMS: The aim of this study was to explore what women having a First Nations baby rate as important for their maternity care as well as what life stressors they may be experiencing. METHODS: Women having a First Nations baby who booked for care at one of three urban Victorian maternity services were invited to complete a questionnaire. RESULTS: 343 women from 76 different language groups across Australia. Almost one third of women reported high levels of psychological distress, mental illness and/or were dealing with serious illness or death of relatives or friends. Almost one quarter reported three or more coinciding life stressors. Factors rated as most important were privacy and confidentiality (98 %), feeling that staff were trustworthy (97 %), unrestricted access to support people during pregnancy appointments, (87 %) birth (66 %) and postnatally (75 %), midwife home visits (78 %), female carers (66 %), culturally appropriate artwork, brochures (68 %) and access to Elders (65 %). CONCLUSIONS: This study provides important information about what matters to women who are having a First Nations baby in Victoria, Australia, bringing to the forefront social and cultural complexities experienced by many women that need to be considered in programme planning. It is paramount that maternity services partner with First Nations communities to implement culturally secure programmes that respond to the needs of local communities.

Exploring satisfaction among women having a First Nations baby at one of three maternity hospitals offering culturally specific continuity of midwife care in Victoria, Australia: A cross-sectional survey.

BACKGROUND: Continuity of midwife care is recommended to redress the inequitable perinatal outcomes experienced by Aboriginal and Torres Strait Islander (First Nations) mothers and babies, however more evidence is needed about First Nations women's views and experiences of their care. AIMS: This study aimed to explore levels of satisfaction among women having a First Nations baby, who received maternity care at one of three maternity services, where new culturally specific midwife continuity models had been recently implemented. METHODS: Women having a First Nations baby who were booked for care at one of three study sites in Naarm (Melbourne), Victoria, were invited to complete one questionnaire during pregnancy and then a follow up questionnaire, 3 months after the birth. RESULTS: Follow up questionnaires were completed by 213 women, of whom 186 had received continuity of midwife care. Most women rated their pregnancy (80 %) and labour and birth care (81 %) highly ('6 or '7' on a scale of 1-7). Women felt informed, that they had an active say in decisions, that their concerns were taken seriously, and that the midwives were kind, understanding and there when needed. Ratings of inpatient postnatal care were lower (62 %), than care at home (87 %). CONCLUSIONS: Women having a First Nations baby at one of three maternity services, where culturally specific, continuity of midwife care models were implemented reported high levels of satisfaction with care. It is recommended that these programs are upscaled, implemented and sustained.

Effects of Alzheimer's disease transgenes on neurochemical expression in the mouse brain determined by ¹H MRS in vitro.

Transgenic models of human disease can be used to understand pathology and to discover biomarkers of disease presence, progression and response to therapy. Here we report a study of longitudinal metabolic differences between TASTPM transgenic Alzheimer's disease (AD) mice and their wild type counterparts using (1)H magnetic resonance spectroscopy (MRS) to look for potential biomarkers for use in AD research and drug discovery. Chloroform methanol extractions were performed on the brains of mice aged between 3 and 18 months. (1)H MR spectra were recorded from the aqueous fractions. Absolute metabolite concentrations, determined from resonance integrals relative to an internal standard, were analysed by 2-way ANOVA (genotype x age). Significant effects of age alone were identified for creatine, glutamine and total choline-containing compounds. There was a marked increase in creatine in the oldest (15-18 mo) TASTPM mice. The increase in creatine was unexpected and may be caused by osmotic stress in older animals as plaque load increases. Care should be taken when using creatine as a reference metabolite during scans of these animals in vivo. A significant effect of genotype alone was identified for myo-inositol (MI), which was higher in TASTPM mice at all ages. Succinate, glycerophosphocholine and choline all showed significant effects of age and genotype. No significant effects were detected in N-acetylaspartate (NAA) levels. Increased MI could be a marker of gliosis or microglial activation in TASTPM mice, but the absence of an age dependence for MI levels means it may be a biomarker of disease, but not of disease progression. Decreased succinate is indicative of disrupted neuronal energy metabolism, an effect that has been seen in human AD.

Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.

OBJECTIVE: To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care. DESIGN: Randomised controlled trial. SETTING: Tertiary-care women's hospital in Melbourne, Australia. POPULATION: A total of 2314 low-risk pregnant women. METHODS: Women randomised to caseload received antenatal, intrapartum and postpartum care from a primary midwife with some care by 'back-up' midwives. Women randomised to standard care received either midwifery or obstetric-trainee care with varying levels of continuity, or community-based general practitioner care. PRIMARY OUTCOME: caesarean birth. Secondary outcomes included instrumental vaginal births, analgesia, perineal trauma, induction of labour, infant admission to special/neonatal intensive care, gestational age, Apgar scores and birthweight. RESULTS: In total 2314 women were randomised-1156 to caseload and 1158 to standard care. Women allocated to caseload were less likely to have a caesarean section (19.4% versus 24.9%; risk ratio [RR] 0.78; 95% CI 0.67-0.91; P = 0.001); more likely to have a spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI 1.06-1.21; P < 0.001); less likely to have epidural analgesia (30.5% versus 34.6%; RR 0.88; 95% CI 0.79-0.996; P = 0.04) and less likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95% CI 0.67-0.92; P = 0.003). Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care (4.0% versus 6.4%; RR 0.63; 95% CI 0.44-0.90; P = 0.01). No infant outcomes favoured standard care. CONCLUSION: In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk in early pregnancy shows promise for reducing caesarean births.

Sources of information during pregnancy and the early parenting period: Exploring the views of women and their partners.

OBJECTIVE: There are a wide variety of information sources available during pregnancy and the early parenting period, but limited understanding of their usefulness, particularly for partners. We explored the views of both women and their partners regarding sources of information, their frequency of use, and their preferred formats. DESIGN AND SETTING: Data were collected as part of a large cluster randomised controlled trial at a tertiary maternity hospital in 2015-2016, in Melbourne, Australia. The overall evaluation was of a parenting kit ('Growing Together'), an evidence-based information source for prospective and new parents covering the period from conception until one year postpartum. This paper uses data collected from women when their baby was two months of age, and women's partners when the baby was six months of age, via postal or online survey. PARTICIPANTS: Women were eligible if they booked for pregnancy care at The Royal Women's Hospital during the recruitment period, were having their first baby, able to read and speak English without an interpreter, and <30 weeks pregnant at their first hospital appointment (n = 1034). All eligible women were included unless they opted out. MEASUREMENTS AND FINDINGS: In total 92 women were excluded. Of the women sent the two-month survey, 42% (392/941) responded. Partner surveys were returned by 252/791 partners (32%). Respondents received information from a range of sources, most frequently face to face from health professionals through childbirth education or midwife discussion/education, followed by friends and family members. Information received from a health professional was also reported as being the most useful. For both women and their partners, the most important factor related to information was that it was from a trusted and reliable source. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Women and their partners highlighted the importance of quality and access to evidence based resources and information. The internet is frequently favoured by women and their partners due to its convenience, accessibility, and timely access to information. Overall, women and their partners reported information directly from a health care professional to be the most useful and health services should ensure that women and their partners have adequate access to their health care professional.

Molecular insights into the colonization and chromosomal diversification of Madeiran house mice.

The colonization history of Madeiran house mice was investigated by analysing the complete mitochondrial (mt) D-loop sequences of 156 mice from the island of Madeira and mainland Portugal, extending on previous studies. The numbers of mtDNA haplotypes from Madeira and mainland Portugal were substantially increased (17 and 14 new haplotypes respectively), and phylogenetic analysis confirmed the previously reported link between the Madeiran archipelago and northern Europe. Sequence analysis revealed the presence of four mtDNA lineages in mainland Portugal, of which one was particularly common and widespread (termed the 'Portugal Main Clade'). There was no support for population bottlenecks during the formation of the six Robertsonian chromosome races on the island of Madeira, and D-loop sequence variation was not found to be structured according to karyotype. The colonization time of the Madeiran archipelago by Mus musculus domesticus was approached using two molecular dating methods (mismatch distribution and Bayesian skyline plot). Time estimates based on D-loop sequence variation at mainland sites (including previously published data from France and Turkey) were evaluated in the context of the zooarchaeological record of M. m. domesticus. A range of values for mutation rate (mu) and number of mouse generations per year was considered in these analyses because of the uncertainty surrounding these two parameters. The colonization of Portugal and Madeira by house mice is discussed in the context of the best-supported parameter values. In keeping with recent studies, our results suggest that mutation rate estimates based on interspecific divergence lead to gross overestimates concerning the timing of recent within-species events.

Implementation of midwifery continuity of care models for Indigenous women in Australia: Perspectives and reflections for the United Kingdom.

Maternity models that provide midwifery continuity of care have been established to increase access to appropriate services for Indigenous Australian women. Understanding the development and implementation of continuity models for Indigenous women in Australia provides useful insights for the development and implementation of similar models in other contexts such as those for vulnerable and socially disadvantaged women living in the United Kingdom. To ensure better health outcomes for mothers and babies, it is crucial to promote culturally competent and safe public health models in which midwives work collaboratively with the multidisciplinary team.

Is parity a risk factor for excessive weight gain during pregnancy and postpartum weight retention? A systematic review and meta-analysis.

The aim of this study was to systematically review and meta-analyse the associations between parity, pre-pregnancy body mass index (BMI), gestational weight gain (GWG) and, when included, postpartum weight retention (PPWR). Papers reporting associations between parity and BMI and/or GWG in adult women were eligible: 2,195 papers were identified, and 41 longitudinal studies were included in the narrative synthesis; 17 studies were included in a meta-analysis. Findings indicated that parity was associated positively with pre-pregnancy BMI. In contrast, the role of parity in GWG was less clear; both positive and negative relationships were reported across studies. Parity was not associated directly with PPWR. This pattern of results was supported by our meta-analysis with the only significant association between parity and pre-pregnancy BMI. Overall, parity was associated with higher pre-pregnancy BMI; however, the role of parity in GWG and PPWR remains unclear, and it is likely that its influence is indirect and complex. Further research to better understand the contribution of parity to maternal obesity is warranted.

Bed, bath and beyond: pitfalls in prompt eradication of methicillin-resistant Staphylococcus aureus carrier status in healthcare workers.

Healthcare workers (HCWs) in close contact with patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) were screened for MRSA acquisition. From 1995 to 2001, MRSA was identified from the nasopharyngeal swabs of 87 HCWs, collected one to two weeks after contact with 592 known MRSA-positive patients. These HCWs were withdrawn from work and treated with topical antibiotics/antiseptics. They were advised to disinfect their bathrooms and personal hygiene articles, and to wash bed linen and pillows. They were screened for successful eradication for up to three months. Seventy-three (84%) HCWs lost their carrier status. The eradication regimen failed in 14 cases. In 11 of these MRSA was detected only in later nasopharyngeal swabs (suspected recolonization). Screening identified nasal colonization of close household contacts in eight of these 11 cases. Environmental sampling detected contamination in seven out of eight screened home environments. When eradication treatment was applied to household contacts and when household surfaces were cleaned and disinfected, the carriage cleared in most cases within a few weeks. However, when home environments are heavily contaminated, despite adequate medical treatment, eradication took upto two years. Due to withdrawal from work, the 14 carriers without prompt and lasting eradication after the first course of treatment accounted for about 70% of all lost working days. These experiences support the hypothesis that control measures should not be restricted to antibiotic or antiseptic treatment of long-term carriers (HCWs as well as patients), but must also include cleaning and disinfection of the household.

An anionic phosphenium complex as an ambident nucleophile.

A unique anionic phosphenium complex was prepared from reaction of an N-heterocyclic chlorophosphine with Collman's reagent or K[HFe(CO)4]/NaH and characterized by spectral and XRD data. The complex behaves as an ambident nucleophile. Reactions with acetic acid, ClSnPh3, and a further equivalent of an N-heterocyclic chlorophosphine proceed via electrophilic functionalization at the metal site to yield appropriate mono- or bis-phosphenium complexes. Reaction with MeI at -70 °C produces a P-alkylation product as the first spectroscopically detectable intermediate, which decays at a higher temperature to give a mixture of free P-methylated N-heterocyclic phosphine and its Fe(CO)4 complex. The different reaction products were characterized by spectral and XRD data. Computational studies indicate that the NHP units in all complexes display π-acceptor behaviour but show no disposition to adopt phosphide-like character or formally oxidize the metal centre.

Catalytic functionalization of polymers: a novel approach to site specific delivery of misoprostol to the stomach.

The application of functionalized polymers to site-directed delivery of the antiulcer prostaglandin, misoprostol, is described. By use of homogeneous catalysis, the simple polymer, polybutadiene, was modified to incorporate the specialized requirements for controlled delivery of misoprostol to the stomach. An acid labile silyl ether bond to the C-11 hydroxyl of misoprostol was installed as the primary rate determining step for drug release, and a series of analogs, in which the steric hindrance about the silicon atom was varied, was prepared and evaluated for in vitro release rates, efficacy against indomethacin induced gastric damage and diarrheagenic activity. The diisopropylsilyl analog, the slowest releasing system studied, showed efficacy equal to misoprostol against indomethacin-induced gastric damage and no diarrhea at the highest dose tested.

Factors influencing admission to hospital during terminal childhood illnesses in Kenya.

BACKGROUND: Access to essential clinical services offered by district hospitals or health centres forms an important component of primary health care activities in the developing world. Utilization of hospital facilities during life-threatening childhood illnesses will affect survivorship. METHODS: We have examined clinical, geographical, social, economic and demographic features of families of 49 children who consulted a hospital facility during a terminal illness and 88 who did not during a 1-year prospective demographic and hospital-based surveillance of a rural community on the Kenyan Coast. RESULTS: Of children who died without admission, 15% had symptoms which lasted only 1 day compared to no children who were admitted (P = 0.004). Furthermore, those who died without admission tended to live further away from the nearest bus stage (P = 0.01) and had made greater use of traditional healers (P = 0.08). Mothers' education or household socioeconomic status did not influence admission to hospital. CONCLUSION: Health education is required to improve early recognition of clinical signs warranting hospital care and traditional healers should be included in any community-based education programmes.

Maternal recall of symptoms associated with childhood deaths in rural east Africa.

Verbal autopsies (VA) are frequently used to determine causes of death for individuals for whom there is no reliable clinical information regarding the terminal illness. VA interviews are used to note key symptoms and signs recalled by relatives of the deceased and diagnoses ascribed according to the symptom complexes. The VA technique assumes that individual disease entities have discrete symptom complexes and that these can be accurately recognized and recalled by the interviewees. We have examined the accuracy with which specific symptoms are recalled over time by mothers or normal guardians of 491 children who died on the paediatric wards of two district hospitals in East Africa. Kwashiorkor, measles, trauma, generalized convulsions and neonatal tetanus were all reported with a high degree of accuracy for children who died of these conditions and had low false positive rates for children without these conditions. Recall was similar within 1 month of death compared to recall after 6 months for most symptoms and signs except neonatal tetanus where false positive reports by mothers increased with time since death. Symptoms and signs commonly used to describe malaria, respiratory tract and diarrhoea-related deaths were reported by mothers to have been present during the terminal illness in 43% of cases where these features were absent. Recall abilities differed between the two communities studied for some symptoms and signs highlighting the importance of such studies in every setting where VA are applied.

PIP: Verbal autopsies (VA) are widely used by population and health scientists to determine individual causes of death in areas where most deaths occur at home and well-documented clinical data on cause of death are usually unavailable. VA interviews are based upon key symptoms and signs recalled by relatives of the deceased. In order to assess the reliability of the technique, the accuracy with which mothers and normal guardians recognize and recalled specific symptoms and clinical signs over time was assessed in the cases of 491 children who died on the pediatric wards of 2 district hospitals in Ifakara, Tanzania, and Kilifi, Kenya. The bereaved were interviewed 3 days to 24 months after child death. Recall after 1 month was similar to recall after 6 months for most signs and symptoms except neonatal tetanus for which false positives reported by mothers increased with time after death. Kwashiorkor, measles, trauma, generalized convulsions, and neonatal tetanus were reported with a high degree of accuracy. Symptoms and signs commonly used to describe malaria, respiratory tract and diarrhea- related deaths, however, were reported by mothers to have been present during terminal illness in 43% of cases where the features were absent. Finally, recall abilities differed between the 2 communities studied.