Evaluation of neural tube defects from 2014 to 2019 in Turkey.

OBJECTIVE: The aim of this study is to determine the frequency of neural tube defects (NTDs) and to examine the epidemiological characteristics of NTD related deaths in Turkey. METHODS: This nationwide descriptive study was included NTD related infant deaths, termination of pregnancy for fetal anomaly (ToPFA) and stillbirth cases registered in Death Notification System between 2014 and 2019, and patients diagnosed with NTD in the 2018 birth cohort. FINDINGS: In the 2018 birth cohort, there were 3475 cases of NTD at birth (27.5 per 10,000). The fatality rates for live-born babies with NTD in this cohort were 13.5% at first year, and 15.6% at the end of March, 2022. NTDs were associated with 11.7% of ToPFA cases, 2.5% of stillbirths and 2.8% of infant deaths in 2014-2019. NTD related stillbirth rate was 1.74 per 10,000 births, while NTD related ToPFA rate and infant mortality rate were 0.61 and 2.70 per 10,000 live births respectively. NTD-related stillbirth and infant mortality rate were highest in the Eastern region (3.64 per 10,000 births; 4.65 per 10,000 live births respectively), while ToPFA rate was highest in the North and West regions (1.17 and 0.79 per 10,000 live births respectively) (p < 0.05). Prematurity and low birth weight were the variables with the highest NTD related rates for stillbirths (11.26 and 16.80 per 10,000 birth), ToPFA (9.25 and 12.74) per 10,000 live birth), and infant deaths (13.91 and 20.11 per 10,000 live birth) (p < 0.05). CONCLUSION: NTDs are common and have an important place among the mortality causes in Turkey. Primary prevention through mandatory folic acid fortification should be considered both to reduce the frequency of NTD and related mortality rates.

Reducing maternal and child mortality in rural Ghana.

The lack of health infrastructure in developing countries to provide women with modern obstetric care and universal access to maternal and child health services has largely contributed to the existing high maternal and infant deaths. Access to basic obstetric care for pregnant women and their unborn babies is a key to reducing maternal and infants´ deaths, especially at the community-level. This calls for the strengthening of primary health care systems in all developing countries, including Ghana. Financial access and utilization of maternal and child health care services need action at the community-level across rural Ghana to avoid preventable deaths. Financial access and usage of maternal and child health services in rural Ghana is poor. Lack of financial access is a strong barrier to the use of maternal and child health services, particularly in rural Ghana. The sustainability of the national health insurance scheme is vital in ensuring full access to care in remote communities.

Education of family members to support weaning to solids and nutrition in later infancy in term-born infants.

BACKGROUND: Education of family members about infant weaning practices could affect nutrition, growth, and development of children in different settings across the world. OBJECTIVES: To compare effects of family nutrition educational interventions for infant weaning with conventional management on growth and neurodevelopment in childhood. SEARCH METHODS: We used the standard strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 5), MEDLINE via PubMed (1966 to 26 June 2018), Embase (1980 to 26 June 2018), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 26 June 2018). We searched clinical trials databases, conference proceedings, and references of retrieved articles. We ran an updated search from 1 January 2018 to 12 December 2019 in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost. SELECTION CRITERIA: We included randomised controlled trials that examined effects of nutrition education for weaning practices delivered to families of infants born at term compared to conventional management (standard care in the population) up to one year of age. DATA COLLECTION AND ANALYSIS: Two review authors independently identified eligible trial reports from the literature search and performed data extraction and quality assessments for each included trial. We synthesised effect estimates using risk ratios (RRs), risk differences (RDs), and mean differences (MDs), with 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We included 21 trials, recruiting 14,241 infants. Five of the trials were conducted in high-income countries and the remaining 16 were conducted in middle- and low-income countries. Meta-analysis showed that nutrition education targeted at improving weaning-related feeding practices probably increases both weight-for-age z scores (WAZ) (MD 0.15 standard deviations, 95% CI 0.07 to 0.22; 6 studies; 2551 infants; I² = 32%; moderate-certainty evidence) and height-for-age z scores (0.12 standard deviations, 95% CI 0.05 to 0.19; 7 studies; 3620 infants; I² = 49%; moderate-certainty evidence) by 12 months of age. Meta-analysis of outcomes at 18 months of age was heterogeneous and inconsistent in the magnitude of effects of nutrition education on WAZ and weight-for-height z score across studies. One trial that assessed effects of nutrition education on growth at six years reported an uncertain effect on change in height and body mass index z score. Two studies investigated effects of nutrition education on neurodevelopment at 12 to 24 months of age with conflicting results. No trials assessed effects of nutrition education on long-term neurodevelopmental outcomes. AUTHORS' CONCLUSIONS: Nutrition education for families of infants may reduce the risk of undernutrition in term-born infants (evidence of low to moderate certainty due to limitations in study design and substantial heterogeneity of included studies). Modest effects on growth during infancy may not be of clinical significance. However, it is unclear whether these small improvements in growth parameters in the first two years of life affect long-term childhood growth and development. Further studies are needed to resolve this question.

Evaluating WHO-Recommended Interventions for Preterm Birth: A Mathematical Model of the Potential Reduction of Preterm Mortality in Sub-Saharan Africa.

BACKGROUND: Preterm birth, a leading cause of neonatal mortality, has the highest burden in low-income countries. In 2015, the World Health Organization (WHO) published recommendations for interventions to improve preterm outcomes. Our analysis uses the Maternal and Neonatal Directed Assessment of Technology (MANDATE) model to evaluate the potential effects that WHO-recommended interventions could have had on preterm mortality in sub-Saharan Africa in 2015. METHODS: We modeled preterm birth subconditions causing mortality (respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, birth asphyxia, and low birth weight). For each subcondition, models were populated with estimates of WHO-recommended intervention prevalence, case fatality, coverage, and efficacy. Various scenarios modeled improved coverage of single and combined interventions compared with baseline. RESULTS: In 2015, approximately 500,000 neonatal deaths due to preterm birth occurred in sub-Saharan Africa. Single interventions with the greatest impact on preterm mortality included oxygen/continuous positive airway pressure (44,000 lives saved), cord care (38,500 lives saved), and breastfeeding (30,200 lives saved). Combined with improved diagnosis/transfer to a hospital, the impact of interventions showed greater reductions in mortality (oxygen/continuous positive airway pressure, 134,100 lives saved; antibiotics, 28,600 lives saved). Combined interventions had the greatest impact. Together, hospital delivery with comprehensive care for respiratory distress syndrome saved 190,600 lives, and comprehensive thermal care, breastfeeding, and prevention/treatment for sepsis saved 94,400 lives. CONCLUSION: In 2015, WHO-recommended interventions could have saved the lives of nearly 300,000 infants born preterm in sub-Saharan Africa. Combined interventions are necessary to maximize impact. Mathematical models such as MANDATE can estimate effects on health outcomes to allow health officials to prioritize implementation strategies.

Death of preceding child and maternal healthcare services utilisation in Nigeria: investigation using lagged logit models.

BACKGROUND: One of the factors responsible for high level of childhood mortality in Nigeria is poor utilization of maternal healthcare (MHC) services. Another important perspective which has been rarely explored is the influence of childhood death on MHC service utilization. In this study, we examined the relationship between death of preceding child and MHC services utilization [antenatal care (ANC), skilled attendant at birth (SAB), and postnatal care (PNC)] among Nigerian women and across the six geo-political zones of the country. METHODOLOGY: We analyzed reproductive history dataset for 16,747 index births extracted from the 2013 Nigeria Demographic and Health Survey. The main explanatory variable was survival status of preceding child; therefore, only second or higher order births were considered. Analysis involved the use of descriptive statistics and lagged logit models fitted for each measure of MHC utilization. Association and statistical significance were expressed as adjusted odds ratio (AOR) with 95% confidence interval. RESULTS: The use of MCH services for most recent births in the 2013 Nigeria DHS were ANC (56.0%), SAB (34.7%), and PNC (27.3%). Univariate models revealed that the death of preceding child was associated with lesser likelihood of ANC (OR = 0.64, CI 0.57-0.71), SAB (OR = 0.56, CI 0.50-0.63), and PNC (OR = 0.65, CI 0.55-0.69). Following adjustment for maternal socio-economic and bio-demographic variables, statistical significance in the relationship disappeared for the three MHC indicators: ANC (AOR = 1.00, CI 0.88-1.14), SAB (AOR = 0.97, CI 0.81-1.15), and PNC (AOR = 0.95, CI 0.83-1.11). There were no significant variations across the six geo-political regions in Nigeria. The likelihood of ANC utilization was higher when the preceding child died in Northcentral (AOR = 1.19, CI 0.84-1.70), Northeast (AOR = 1.26, CI 0.99-1.59), and South-south (AOR = 1.19, CI 0.72-1.99) regions while the reverse is the case in Southeast (AOR = 0.39, CI 0.23-0.60). For the Southeast, similar result was obtained for ANC, SAB, and PNC. CONCLUSION: Death of a preceding child does not predict MHC services use in Nigeria especially when maternal socio-economic characteristics are controlled. Variations across the Northern and Southern regions did not attain statistical significance. Interventions are needed to reverse the pattern such that greater MHC utilization is recorded among women who have experienced child death.

Association Between Vitamin D Supplementation During Pregnancy and Offspring Growth, Morbidity, and Mortality: A Systematic Review and Meta-analysis.

Importance: Whether vitamin D supplementation during pregnancy is beneficial and safe for offspring is unclear. Objective: To systematically review studies of the effects of vitamin D supplementation during pregnancy on offspring growth, morbidity, and mortality. Data Sources: Searches of Medline, Embase, and the Cochrane Database of Systematic Reviews were conducted up to October 31, 2017. Key search terms were vitamin D, pregnancy, randomized controlled trials, and offspring outcomes. Study Selection: Randomized clinical trials of vitamin D supplementation during pregnancy and offspring outcomes. Data Extraction and Synthesis: Two authors independently extracted data, and the quality of the studies was assessed. Summary risk ratio (RR), risk difference (RD) or mean difference (MD), and 95% CI were calculated using fixed-effects or random-effects meta-analysis. Main Outcomes and Measures: Main outcomes were fetal or neonatal mortality, small for gestational age (SGA), congenital malformation, admission to a neonatal intensive care unit, birth weight, Apgar scores, neonatal 25-hydroxyvitamin D (25[OH]D) and calcium concentrations, gestational age, preterm birth, infant anthropometry, and respiratory morbidity during childhood. Results: Twenty-four clinical trials involving 5405 participants met inclusion criteria. Vitamin D supplementation during pregnancy was associated with a lower risk of SGA (RR, 0.72; 95% CI, 0.52 to 0.99; RD, -5.60%; 95% CI, -0.86% to -10.34%) without risk of fetal or neonatal mortality (RR, 0.72; 95% CI, 0.47 to 1.11) or congenital abnormality (RR, 0.94; 95% CI, 0.61 to 1.43). Neonates with prenatal vitamin D supplementation had higher 25(OH)D levels (MD, 13.50 ng/mL; 95% CI, 10.12 to 16.87 ng/mL), calcium levels (MD, 0.19 mg/dL; 95% CI, 0.003 to 0.38 mg/dL), and weight at birth (MD, 75.38 g; 95% CI, 22.88 to 127.88 g), 3 months (MD, 0.21 kg; 95% CI, 0.13 to 0.28 kg), 6 months (MD, 0.46 kg; 95% CI, 0.33 to 0.58 kg), 9 months (MD, 0.50 kg; 95% CI, 0.01 to 0.99 kg), and 12 months (MD, 0.32 kg; 95% CI, 0.12 to 0.52 kg). Subgroup analysis by doses showed that low-dose vitamin D supplementation (≤2000 IU/d) was associated with a reduced risk of fetal or neonatal mortality (RR, 0.35; 95% CI, 0.15 to 0.80), but higher doses (>2000 IU/d) did not reduce this risk (RR, 0.95; 95% CI, 0.59 to 1.54). Conclusions and Relevance: Vitamin D supplementation during pregnancy is associated with a reduced risk of SGA and improved infant growth without risk of fetal or neonatal mortality or congenital abnormality. Vitamin D supplementation with doses of 2000 IU/d or lower during pregnancy may reduce the risk of fetal or neonatal mortality.

A Synthesis of Coping Experiences After Infant Death.

The purpose of this article was to synthesize qualitative research data that examine parental coping strategies following infant death. This qualitative synthesis found that parents who effectively cope with the death of their infant would continue the bond with the deceased child, have differences in the way they manage their emotions about the loss, and have intergenerational support in the form of family being present, acknowledging the death, performing immediate tasks, and providing helpful information. Nurses should be vigilant to ensure parents receive "memories" of their infant after an in-hospital death. Knowledge of the coping process can assist nurses and clinicians to better care and support parents following an infant death and, in turn, facilitate the healing process.

Azithromycin to prevent post-discharge morbidity and mortality in Kenyan children: a protocol for a randomised, double-blind, placebo-controlled trial (the Toto Bora trial).

INTRODUCTION: Child mortality due to infectious diseases remains unacceptably high in much of sub-Saharan Africa. Children who are hospitalised represent an accessible population at particularly high risk of death, both during and following hospitalisation. Hospital discharge may be a critical time point at which targeted use of antibiotics could reduce morbidity and mortality in high-risk children. METHODS AND ANALYSIS: In this randomised, double-blind, placebo-controlled trial (Toto Bora Trial), 1400 children aged 1-59 months discharged from hospitals in Western Kenya, in Kisii and Homa Bay, will be randomised to either a 5-day course of azithromycin or placebo to determine whether a short course of azithromycin reduces rates of rehospitalisation and/or death in the subsequent 6-month period. The primary analysis will be modified intention-to-treat and will compare the rates of rehospitalisation or death in children treated with azithromycin or placebo using Cox proportional hazard regression. The trial will also evaluate the effect of a short course of azithromycin on enteric and nasopharyngeal infections and cause-specific morbidities. We will also identify risk factors for postdischarge morbidity and mortality and subpopulations most likely to benefit from postdischarge antibiotic use. Antibiotic resistance in Escherichia coli and Streptococcus pneumoniae among enrolled children and their primary caregivers will also be assessed, and cost-effectiveness analyses will be performed to inform policy decisions. ETHICS AND DISSEMINATION: Study procedures were reviewed and approved by the institutional review boards of the Kenya Medical Research Institute, the University of Washington and the Kenyan Pharmacy and Poisons Board. The study is being externally monitored, and a data safety and monitoring committee has been assembled to monitor patient safety and to evaluate the efficacy of the intervention. The results of this trial will be published in peer-reviewed scientific journals and presented at relevant academic conferences and to key stakeholders. TRIAL REGISTRATION NUMBER: NCT02414399.

Itinerário terapêutico: a busca por cuidados de mães cujos filhos faleceram com menos de um ano / La ruta terapéutica: la búsqueda de las madres lactantes cuyos hijos murieron en menos de un año / Therapeutic rout: the search for care of mothers whose children have died less than a year

Recognizing the care trajectories of mothers whose children have died less than a year. Methods: this was a qualitative study conducted with pregnant women who reported fetal or neonatal death during the year 2012 in the countryside of Bahia municipality. To collect data, we used the in-depth interview and analysis content analysis technique proposed by Bardin. Results: one can see the clutter on the network of health care of women with predominance of dehumanization traits and difficulty by professionals in continuing care in other levels of care. Conclusions: the study of the care trajectories revealed itself as a tool of therapeutic routin valuable to assess the functioning of health care networks, making visible successes and difficulties presented in the context of care to pregnant women...

Conhecer as trajetórias assistenciais de mães cujos filhos faleceram com menos de um ano. Métodos: tratou-se de um estudo com abordagem qualitativa, realizado com gestantes que referiram óbito fetal ou neonatal durante o ano de 2012 num município do interior da Bahia. Para a coleta de dados utilizou-se da entrevista em profundidade e para análise a técnica de análise de conteúdo. Resultados: pode-se perceber a desorganização na rede de atenção à saúde da mulher com predominância de traços de desumanização e dificuldade por parte dos profissionais em dar continuidade ao cuidado em outros níveis de atenção. Conclusão: o estudo das trajetórias assistenciais revelou-se como uma ferramenta do itinerário terapêutico inestimável para avaliar o funcionamento de redes de atenção à saúde, tornando visíveis acertos e dificuldades apresentados no âmbito da assistência prestada à gestante...

Conocer las trayectorias de atención de las madres cuyos hijos murieron en menos de un año. Métodos: este fue un estudio cualitativo realizado con las mujeres embarazadas que informaron de la muerte fetal o neonatal durante el año 2012 en el interior del municipio de Bahía. Para recopilar los datos, se utilizó la técnica de análisis de contenido de la entrevista en profundidad. Resultados: uno puede ver el desorden en la red de atención de salud de las mujeres con predominio de rasgos dela deshumanización y la dificultad de profesionales de atención continua en otros niveles de atención. Conclusiones: el estudio de las trayectorias de atención se reveló como una herramienta de itinerario terapéutico de gran valor para evaluar el funcionamiento de las redes de atención de salud, haciendo visibles los éxitos y las dificultades que se presentan en el contexto de la atención a las mujeres embarazadas...

Different treatment regimens of magnesium sulphate for tocolysis in women in preterm labour.

BACKGROUND: Magnesium sulphate has been used to inhibit preterm labour to prevent preterm birth. There is no consensus as to the safety profile of different treatment regimens with respect to dose, duration, route and timing of administration. OBJECTIVES: To assess the efficacy and safety of alternative magnesium sulphate regimens when used as single agent tocolytic therapy during pregnancy. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised trials comparing different magnesium sulphate treatment regimens when used as single agent tocolytic therapy during pregnancy in women in preterm labour. Quasi-randomised trials were eligible for inclusion but none were identified. Cross-over and cluster trials were not eligible for inclusion. Health outcomes were considered at the level of the mother, the infant/child and the health service. INTERVENTION: intravenous or oral magnesium sulphate given alone for tocolysis.Comparison: alternative dosing regimens of magnesium sulphate given alone for tocolysis. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility and quality and extracted data. MAIN RESULTS: Three trials including 360 women and their infants were identified as eligible for inclusion in this review. Two trials were rated as low risk of bias for random sequence generation and concealment of allocation. A third trial was assessed as unclear risk of bias for these domains but did not report data for any of the outcomes examined in this review. No trials were rated to be of high quality overall.Intravenous magnesium sulphate was administered according to low-dose regimens (4 g loading dose followed by 2 g/hour continuous infusion and/or increased by 1 g/hour hourly until successful tocolysis or failure of treatment), or high-dose regimens (4 g loading dose followed by 5 g/hour continuous infusion and increased by 1 g/hour hourly until successful tocolysis or failure of treatment, or 6 g loading dose followed by 2 g/hour continuous infusion and increased by 1 g/hour hourly until successful tocolysis or failure of treatment).There were no differences seen between high-dose magnesium sulphate regimens compared with low-dose magnesium sulphate regimens for the primary outcome of fetal, neonatal and infant death (risk ratio (RR) 0.43, 95% confidence interval (CI) 0.12 to 1.56; one trial, 100 infants). Using the GRADE approach, the evidence for fetal, neonatal and infant death was considered to be VERY LOW quality. No data were reported for any of the other primary maternal and infant health outcomes (birth less than 48 hours after trial entry; composite serious infant outcome; composite serious maternal outcome).There were no clear differences seen between high-dose magnesium sulphate regimens compared with low-dose magnesium sulphate regimens for the secondary infant health outcomes of fetal death; neonatal death; and rate of hypocalcaemia, osteopenia or fracture; and secondary maternal health outcomes of rate of caesarean birth; pulmonary oedema; and maternal self-reported adverse effects. Pulmonary oedema was reported in two women given high-dose magnesium sulphate, but not in any of the women given low-dose magnesium sulphate.In a single trial of high and low doses of magnesium sulphate for tocolysis including 100 infants, the risk of respiratory distress syndrome was lower with use of a high-dose regimen compared with a low-dose regimen (RR 0.31, 95% CI 0.11 to 0.88; one trial, 100 infants). Using the GRADE approach, the evidence for respiratory distress syndrome was judged to be LOW quality. No difference was seen in the rate of admission to the neonatal intensive care unit. However, for those babies admitted, a high-dose regimen was associated with a reduction in the length of stay in the neonatal intensive care unit compared with a low-dose regimen (mean difference -3.10 days, 95% confidence interval -5.48 to -0.72).We found no data for the majority of our secondary outcomes. AUTHORS' CONCLUSIONS: There are limited data available (three studies, with data from only two studies) comparing different dosing regimens of magnesium sulphate given as single agent tocolytic therapy for the prevention of preterm birth. There is no evidence examining duration of therapy, timing of therapy and the role for repeat dosing.Downgrading decisions for our primary outcome of fetal, neonatal and infant death were based on wide confidence intervals (crossing the line of no effect), lack of blinding and a limited number of studies. No data were available for any of our other important outcomes: birth less than 48 hours after trial entry; composite serious infant outcome; composite serious maternal outcome. The data are limited by volume and the outcomes reported. Only eight of our 45 pre-specified primary and secondary maternal and infant health outcomes were reported on in the included studies. No long-term outcomes were reported. Downgrading decisions for the evidence on the risk of respiratory distress were based on wide confidence intervals (crossing the line of no effect) and lack of blinding.There is some evidence from a single study suggesting a reduction in the length of stay in the neonatal intensive care unit and a reduced risk of respiratory distress syndrome where a high-dose regimen of magnesium sulphate has been used compared with a low-dose regimen. However, given that evidence has been drawn from a single study (with a small sample size), these data should be interpreted with caution.Magnesium sulphate has been shown to be of benefit in a wide range of obstetric settings, although it has not been recommended for tocolysis. In clinical settings where health benefits are established, further trials are needed to address the lack of evidence regarding the optimal dose (loading dose and maintenance dose), duration of therapy, timing of therapy and role for repeat dosing in terms of efficacy and safety for mothers and their children. Ongoing examination of different regimens with respect to important health outcomes is required.

Essential interventions for child health.

Child health is a growing concern at the global level, as infectious diseases and preventable conditions claim hundreds of lives of children under the age of five in low-income countries. Approximately 7.6 million children under five years of age died in 2011, calculating to about 19,000 children each day and almost 800 every hour. About 80 percent of the world's under-five deaths in 2011 occurred in only 25 countries, and about half in only five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan and China. The implications and burden of such statistics are huge and will have dire consequences if they are not corrected promptly. This paper reviews essential interventions for improving child health, which if implemented properly and according to guidelines have been found to improve child health outcomes, as well as reduce morbidity and mortality rates. It also includes caregivers and delivery strategies for each intervention. Interventions that have been associated with a decrease in mortality and disease rates include exclusive breastfeeding, complementary feeding strategies, routine immunizations and vaccinations for children, preventative zinc supplementation in children, and vitamin A supplementation in vitamin A deficient populations.

The BRAzil MAGnesium (BRAMAG) trial: a randomized clinical trial of oral magnesium supplementation in pregnancy for the prevention of preterm birth and perinatal and maternal morbidity.

BACKGROUND: Preterm birth is the leading cause of infant mortality globally, including Brazil. We will evaluate whether oral magnesium citrate reduces the risk of placental dysfunction and its negative consequences for both the fetus and mother, which, in turn, should reduce the need for indicated preterm delivery. METHODS/DESIGN: We will complete a multicenter, randomized double-blind clinical trial comparing oral magnesium citrate 150 mg twice daily (n = 2000 women) to matched placebo (n = 1000 women), starting at 121/7 to 206/7 weeks gestation and continued until delivery. We will include women at higher risk for placental dysfunction, based on clinical factors from a prior pregnancy (e.g., prior preterm delivery, stillbirth or preeclampsia) or the current pregnancy (e.g., chronic hypertension, pre-pregnancy diabetes mellitus, maternal age > 35 years or pre-pregnancy maternal body mass index > 30 kg/m2). The primary perinatal outcome is a composite of preterm birth < 37 weeks gestation, stillbirth > 20 weeks gestation, neonatal death < 28 days, or SGA birthweight < 3rd percentile. The primary composite maternal outcome is preeclampsia arising < 37 weeks gestation, severe non-proteinuric hypertension arising < 37 weeks gestation, placental abruption, maternal stroke during pregnancy or ≤ 7 days after delivery, or maternal death during pregnancy or ≤ 7 days after delivery. DISCUSSION: The results of this randomized clinical trial may be especially relevant in low and middle income countries that have high rates of prematurity and limited resources for acute newborn and maternal care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02032186, registered December 19, 2013.

Financial incentives and coverage of child health interventions: a systematic review and meta-analysis.

BACKGROUND: Financial incentives are widely used strategies to alleviate poverty, foster development, and improve health. Cash transfer programs, microcredit, user fee removal policies and voucher schemes that provide direct or indirect monetary incentives to households have been used for decades in Latin America, Sub-Saharan Africa, and more recently in Southeast Asia. Until now, no systematic review of the impact of financial incentives on coverage and uptake of health interventions targeting children under 5 years of age has been conducted. The objective of this review is to provide estimates on the effect of six types of financial incentive programs: (i) Unconditional cash transfers (CT), (ii) Conditional cash transfers (CCT), (iii) Microcredit (MC), (iv) Conditional Microcredit (CMC), (v) Voucher schemes (VS) and (vi) User fee removal (UFR) on the uptake and coverage of health interventions targeting children under the age of five years. METHODS: We conducted systematic searches of a series of databases until September 1st, 2012, to identify relevant studies reporting on the impact of financial incentives on coverage of health interventions and behaviors targeting children under 5 years of age. The quality of the studies was assessed using the CHERG criteria. Meta-analyses were undertaken to estimate the effect when multiple studies meeting our inclusion criteria were available. RESULTS: Our searches resulted in 1671 titles identified 25 studies reporting on the impact of financial incentive programs on 5 groups of coverage indicators: breastfeeding practices (breastfeeding incidence, proportion of children receiving colostrum and early initiation of breastfeeding, exclusive breastfeeding for six months and duration of breastfeeding); vaccination (coverage of full immunization, partial immunization and specific antigens); health care use (seeking healthcare when child was ill, visits to health facilities for preventive reasons, visits to health facilities for any reason, visits for health check-up including growth control); management of diarrhoeal disease (ORS use during diarrhea episode, continued feeding during diarrhea, healthcare during diarrhea episode) and other preventive health interventions (iron supplementation, vitamin A, zinc supplementation, preventive deworming). The quality of evidence on the effect of financial incentives on breastfeeding practices was low but seems to indicate a potential positive impact on receiving colostrum, early initiation of breastfeeding, exclusive breastfeeding and mean duration of exclusive breastfeeding. There is no effect of financial incentives on immunization coverage although there was moderate quality evidence of conditional cash transfers leading to a small but non-significant increase in coverage of age-appropriate immunization. There was low quality evidence of impact of CCT on healthcare use by children under age 5 (Risk difference: 0.14 [95%CI: 0.03; 0.26]) as well as low quality evidence of an effect of user fee removal on use of curative health services (RD=0.62 [0.41; 0.82]). CONCLUSIONS: Financial incentives may have potential to promote increased coverage of several important child health interventions, but the quality of evidence available is low. The more pronounced effects seem to be achieved by programs that directly removed user fees for access to health services. Some indication of effect were also observed for programs that conditioned financial incentives on participation in health education and attendance to health care visits. This finding suggest that the measured effect may be less a consequence of the financial incentive and more due to conditionalities addressing important informational barriers.

Impact of education and provision of complementary feeding on growth and morbidity in children less than 2 years of age in developing countries: a systematic review.

BACKGROUND: About one third of deaths in children less than 5 years of age are due to underlying undernutrition. According to an estimate, 19.4% of children <5 years of age in developing countries were underweight (weight-for-age Z score <-2) and about 29.9% were stunted in the year 2011 (height-for-age Z score <-2). It is well recognized that the period of 6-24 months of age is one of the most critical time for the growth of the infant. METHODS: We included randomized, non-randomized trials and programs on the effect of complementary feeding (CF) (fortified or unfortified, but not micronutrients alone) and education on CF on children less than 2 years of age in low and middle income countries (LMIC). Studies that delivered intervention for at least 6 months were included; however, studies in which intervention was given for supplementary and therapeutic purposes were excluded. Recommendations are made for input to the Lives Saved Tool (LiST) model by following standardized guidelines developed by Child Health Epidemiology Reference Group (CHERG). RESULTS: We included 16 studies in this review. Amongst these, 9 studies provided education on complementary feeding, 6 provided complementary feeding (with our without education) and 1 provided both as separate arms. Overall, education on CF alone significantly improved HAZ (SMD: 0.23; 95% CI: 0.09, 0.36), WAZ (SMD 0.16, 95% CI: 0.05, 0.27), and significantly reduced the rates of stunting (RR 0.71; 95% CI: 0.56, 0.91). While no significant impact were observed for height and weight gain. Based on the subgroup analysis; ten studies from food secure populations indicated education on CF had a significant impact on height gain, HAZ scores, and weight gain, however, stunting reduced non-significantly. In food insecure population, CF education alone significantly improved HAZ scores, WAZ scores and significantly reduced the rates of stunting, while CF provision with or without education improved HAZ and WAZ scores significantly. CONCLUSION: Complementary feeding interventions have a potential to improve the nutritional status of children in developing countries. However, large scale high quality randomized controlled trials are required to assess the actual impact of this intervention on growth and morbidity in children 6-24 months of age. Education should be combined with provision of complementary foods that are affordable, particularly for children in food insecure countries.