The selection landscape and genetic legacy of ancient Eurasians.

The Holocene (beginning around 12,000 years ago) encompassed some of the most significant changes in human evolution, with far-reaching consequences for the dietary, physical and mental health of present-day populations. Using a dataset of more than 1,600 imputed ancient genomes1, we modelled the selection landscape during the transition from hunting and gathering, to farming and pastoralism across West Eurasia. We identify key selection signals related to metabolism, including that selection at the FADS cluster began earlier than previously reported and that selection near the LCT locus predates the emergence of the lactase persistence allele by thousands of years. We also find strong selection in the HLA region, possibly due to increased exposure to pathogens during the Bronze Age. Using ancient individuals to infer local ancestry tracts in over 400,000 samples from the UK Biobank, we identify widespread differences in the distribution of Mesolithic, Neolithic and Bronze Age ancestries across Eurasia. By calculating ancestry-specific polygenic risk scores, we show that height differences between Northern and Southern Europe are associated with differential Steppe ancestry, rather than selection, and that risk alleles for mood-related phenotypes are enriched for Neolithic farmer ancestry, whereas risk alleles for diabetes and Alzheimer's disease are enriched for Western hunter-gatherer ancestry. Our results indicate that ancient selection and migration were large contributors to the distribution of phenotypic diversity in present-day Europeans.

Model-informed assessment of ethnic sensitivity and dosage justification for Asian populations in the global clinical development and use of cladribine tablets.

Cladribine tablets have been approved in many countries for the treatment of patients with various forms of relapsing multiple sclerosis (MS). Cladribine has a unique pharmacokinetic/pharmacodynamic (PK/PD) profile with a short elimination half-life (~ 1 day) relative to a prolonged PD effect on specific immune cells (most notably a reversible reduction in B and T lymphocyte counts). This results in a short dosing schedule (up to 20 days over 2 years of treatment) to sustain efficacy for at least another 2 years. Global clinical studies were conducted primarily in White patients, in part due to the distinctly higher prevalence of MS in White patients. Given the very low prevalence in Asian countries, MS is considered as a rare disease there. In spite of the limited participation of Asian patients, to demonstrate favorable benefit/risk profile in the treatment of MS demanded application of a Totality of Evidence approach to assess ethnic sensitivity for informing regulatory filings in Asian countries and supporting clinical use of cladribine in Asian patients. Population PD modeling and simulation of treatment-related reduction in absolute lymphocyte count, as a mechanism-related biomarker of drug effect, confirmed consistent PDs in Asian and non-Asian patients with MS, supporting absence of ethnic sensitivity and a common dosage across populations. Through this example, we demonstrate the value of holistic integration of all available data using a model-informed drug development (MIDD) framework and a Totality of Evidence mindset to evaluate ethnic sensitivity in support of Asia-inclusive development and use of the drug across populations.

Alcohol, tobacco and coffee consumption and liver disease severity among individuals with Chronic Hepatitis B infection in North America.

INTRODUCTION AND OBJECTIVES: The prevalence of alcohol, tobacco, and coffee use and association with liver health among North Americans with Chronic Hepatitis B (CHB) infection has not been well described. MATERIALS AND METHODS: The Hepatitis B Research Network includes an observational study of untreated CHB adults enrolled at 21 sites in the United States and Canada. Alcohol use was categorized as none, moderate, and at-risk based on the definition from the National Institute on Alcohol Abuse and Alcoholism; tobacco use as never, current and former; coffee use as none, 1-2 cups/day, and ≥3 cups/day. Linear regression and linear mixed models were used to associate lifestyle behaviors with ALT and FIB-4 values. RESULTS: 1330 participants met eligibility: 53% males, 71% Asian and the median age was 42 years (IQR: 34-52). Median ALT was 33U/L (IQR: 22-50), 37% had HBV DNA <103IU/mL, 71% were HBeAg negative, and 65% had a FIB-4 <1.45. At baseline, 8% of participants were at-risk alcohol drinkers, 11% were current smokers and 92% drank <3 cups of coffee/day. Current tobacco and 'at-risk' alcohol use, were significantly associated with elevated ALT levels in univariable analyses, however, these associations were not statistically significant when controlling for sociodemographic and HBV characteristics. CONCLUSIONS: In this large diverse cohort of untreated CHB participants, at-risk alcohol use, current tobacco use and limited coffee consumption did not have an association with high ALT and FIB-4 values. In contrast, significant associations were found between the frequency of these lifestyle behaviors and sociodemographic factors.

Vitamin D deficiency in western dwelling South Asian populations: an unrecognised epidemic.

Vitamin D deficiency (25-hydroxyvitamin D; 25(OH)D) is at epidemic proportions in western dwelling South Asian populations, including severe deficiency (<12⋅5 nmol/l) in 27-60% of individuals, depending on season. The paper aimed to review the literature concerning vitamin D concentrations in this population group. Research from the UK and Europe suggests a high prevalence of South Asians with 25(OH)D concentration <25 nmol/l, with most having a 25(OH)D concentration of <50 nmol/l. In Canada, South Asians appear to have a slightly higher 25(OH)D concentration. There are few studies from the United States, South Africa and Australasia. Reasons for vitamin D deficiency include low vitamin D intake, relatively high adiposity, sun exposure avoidance and wearing of a covered dress style for cultural reasons. Possible health effects of deficiency include bone diseases such as rickets and hypocalcaemia in children and osteomalacia in adults. Vitamin D deficiency may also increase the risk of other chronic diseases. Increased fortification of food items relevant to South Asian groups (e.g. chapatti flour), as well as increased use of vitamin D supplements may help reduce this epidemic. Introducing culturally acceptable ways of increasing skin exposure to the sun in South Asian women may also be beneficial but further research is needed to assess the effectiveness of different approaches. There may be a need for a South Asian specific vitamin D dietary intake guideline in western countries. To conclude, vitamin D deficiency is epidemic in South Asians living in western countries and there is a clear need for urgent public health action.

From ethnobotany to emancipation: Slaves, plant knowledge, and gardens on eighteenth-century Isle de France.

This essay examines the relationship between slavery and plant knowledge for cultivational activities and medicinal purposes on Isle de France (Mauritius) in the second half of the eighteenth century. It builds on recent scholarship to argue for the significance of slaves in the acquisition of plant material and related knowledge in pharmaceutical, acclimatization, and private gardens on the French colonial island. I highlight the degree to which French colonial officials relied on slaves' ethnobotanical knowledge but neglected to include such information in their published works. Rather than seeking to explore the status of such knowledge within European frameworks of natural history as an endpoint of knowledge production, this essay calls upon us to think about the plant knowledge that slaves possessed for its practical implementations in the local island context. Both female and male slaves' plant-based knowledge enriched - even initiated - practices of cultivation and preparation techniques of plants for nourishment and medicinal uses. Here, cultivational knowledge and skills determined a slave's hierarchical rank. As the case of the slave gardener Rama and his family reveals, plant knowledge sometimes offered slaves opportunities for social mobility and, even though on extremely rare occasions, enabled them to become legally free.

Late Pleistocene exploration and settlement of the Americas by modern humans.

North and South America were the last continents to be explored and settled by modern humans at the end of the Pleistocene. Genetic data, derived from contemporary populations and ancient individuals, show that the first Americans originated from Asia and after several population splits moved south of the continental ice sheets that covered Canada sometime between ~17.5 and ~14.6 thousand years (ka) ago. Archaeological evidence shows that geographically dispersed populations lived successfully, using biface, blade, and osseous technologies, in multiple places in North and South America between ~15.5 and ~14 ka ago. Regional archaeological complexes emerged by at least ~13 ka ago in North America and ~12.9 ka ago in South America. Current genetic and archaeological data do not support an earlier (pre-17.5 ka ago) occupation of the Americas.

The population history of northeastern Siberia since the Pleistocene.

Northeastern Siberia has been inhabited by humans for more than 40,000 years but its deep population history remains poorly understood. Here we investigate the late Pleistocene population history of northeastern Siberia through analyses of 34 newly recovered ancient genomes that date to between 31,000 and 600 years ago. We document complex population dynamics during this period, including at least three major migration events: an initial peopling by a previously unknown Palaeolithic population of 'Ancient North Siberians' who are distantly related to early West Eurasian hunter-gatherers; the arrival of East Asian-related peoples, which gave rise to 'Ancient Palaeo-Siberians' who are closely related to contemporary communities from far-northeastern Siberia (such as the Koryaks), as well as Native Americans; and a Holocene migration of other East Asian-related peoples, who we name 'Neo-Siberians', and from whom many contemporary Siberians are descended. Each of these population expansions largely replaced the earlier inhabitants, and ultimately generated the mosaic genetic make-up of contemporary peoples who inhabit a vast area across northern Eurasia and the Americas.

Vitamin D supplement use and associated demographic, dietary and lifestyle factors in 8024 South Asians aged 40-69 years: analysis of the UK Biobank cohort.

OBJECTIVE: Vitamin D deficiency (serum 25-hydroxyvitamin D<25nmol/L) is extremely common in western-dwelling South Asians but evidence regarding vitamin D supplement usage in this group is very limited. This work identifies demographic, dietary and lifestyle predictors associated with vitamin D supplement use. DESIGN: Cross-sectional analysis of baseline vitamin D supplement use data. SETTING: UK Biobank cohort. SUBJECTS: In total, n 8024 South Asians (Bangladeshi, Indian, Pakistani), aged 40-69 years. RESULTS: Twenty-three % of men and 39% of women (P<0.001) [22% of Bangladeshis, 32% of Indians, 25% of Pakistanis (P<0.001)] took a vitamin D containing supplement. Median vitamin D intakes from diet were low at 1.0-3.0 micrograms per day, being highest in Bangladeshis and lowest in Indians (P<0.001). Logistic regression modelling showed that females had a higher odds of vitamin D supplement use than males (odds ratio (OR) = 2.02; 95% confidence interval (CI) 1.79 to 2.28). A lower supplement usage was seen in younger persons (40-60 years) (OR=0.75; 95% CI 0.65 to 0.86 reference= >60 years), and those living outside of Greater London (OR=0.53 to 0.77), with borderline trends for a lower body mass index, higher oily fish intake and higher household income associated with increased odds of vitamin D supplement use. CONCLUSIONS: Vitamin D supplements were not used by most South Asians and intakes from diet alone are likely to be insufficient to maintain adequate vitamin D status. Public health strategies are now urgently required to promote the use of vitamin D supplements in these specific UK South Asian subgroups.

137 ancient human genomes from across the Eurasian steppes.

For thousands of years the Eurasian steppes have been a centre of human migrations and cultural change. Here we sequence the genomes of 137 ancient humans (about 1× average coverage), covering a period of 4,000 years, to understand the population history of the Eurasian steppes after the Bronze Age migrations. We find that the genetics of the Scythian groups that dominated the Eurasian steppes throughout the Iron Age were highly structured, with diverse origins comprising Late Bronze Age herders, European farmers and southern Siberian hunter-gatherers. Later, Scythians admixed with the eastern steppe nomads who formed the Xiongnu confederations, and moved westward in about the second or third century BC, forming the Hun traditions in the fourth-fifth century AD, and carrying with them plague that was basal to the Justinian plague. These nomads were further admixed with East Asian groups during several short-term khanates in the Medieval period. These historical events transformed the Eurasian steppes from being inhabited by Indo-European speakers of largely West Eurasian ancestry to the mostly Turkic-speaking groups of the present day, who are primarily of East Asian ancestry.

Randomised Controlled Trial Comparing Daily Versus Depot Vitamin D3 Therapy in 0-16-Year-Old Newly Settled Refugees in Western Australia Over a Period of 40 Weeks.

Vitamin D deficiency is highly prevalent in newly settled refugees in Western Australia (WA). If adherence to daily vitamin D therapy is problematic, depot therapy is a therapeutic alternative. The aim of this study was to compare daily versus depot treatment and factors influencing the therapeutic outcome. Newly settled refugees (n = 151) with 25(OH)D levels less than 78 nmol/L were randomised to receive daily or depot vitamin D therapy with eight weekly interval follow up to 40 weeks. Biochemical and clinical parameters were collected at each visit. Generalized Linear Mixed Models (GLMM) examined the longitudinal changes over time controlling for confounders including age, gender, treatment arm, season, country of refuge/origin and sun exposure score. Participants were aged 5.5 months to 16.0 years (75 males, 83 females). Both treatment groups achieved vitamin D sufficiency. The daily treatment group had significantly higher 25(OH)D levels at each visit post baseline and a higher proportion of participants with levels above 50 nmol/L at all time points. Time, treatment group, calcium and sun exposure score were significant predictors of 25(OH)D serum levels. Depot vitamin D therapy is an alternative to daily treatment in this at-risk group of children and adolescents in whom treatment adherence is problematic.

The genomic history of southeastern Europe.

Farming was first introduced to Europe in the mid-seventh millennium bc, and was associated with migrants from Anatolia who settled in the southeast before spreading throughout Europe. Here, to understand the dynamics of this process, we analysed genome-wide ancient DNA data from 225 individuals who lived in southeastern Europe and surrounding regions between 12000 and 500 bc. We document a west-east cline of ancestry in indigenous hunter-gatherers and, in eastern Europe, the early stages in the formation of Bronze Age steppe ancestry. We show that the first farmers of northern and western Europe dispersed through southeastern Europe with limited hunter-gatherer admixture, but that some early groups in the southeast mixed extensively with hunter-gatherers without the sex-biased admixture that prevailed later in the north and west. We also show that southeastern Europe continued to be a nexus between east and west after the arrival of farmers, with intermittent genetic contact with steppe populations occurring up to 2,000 years earlier than the migrations from the steppe that ultimately replaced much of the population of northern Europe.

Traditional beliefs and practices in pregnancy, childbirth and postpartum: A review of the evidence from Asian countries.

INTRODUCTION: Asian women suffer the largest proportion of the world's maternal deaths. To reduce this, policymakers and healthcare providers must encourage women with traditionally low rates of maternal health care utilization to access services. OBJECTIVE: The purpose of this study is to provide a comprehensive review of the most common traditional practices in Asia relating to pregnancy, childbirth and the postpartum period. DESIGN: We conducted a literature search of articles: a) focusing on Asia; b) relating to pregnancy, childbirth or postpartum, c) relating to traditional beliefs and/or cultural practices; and 4) published in English in the year 2000 or more recently. FINDINGS: A total of 74 articles are included in this review; 20 articles related to pregnancy, 44 to childbirth, and 45 to postpartum. More than one-half (38) of the articles focused on South Asia and 13 related to China. In the pregnancy category, the majority of the studies focused on dietary recommendations and behavioral taboos. For the childbirth category, many articles examined beliefs and practices that helped to explain women's aversion to institutional births, such as preference for traditional birth positions, and fear of medical interventions. In the postpartum period, confinement was common because postpartum women were perceived to be weak, fragile and vulnerable to illness. Other prevalent beliefs and practices across Asian countries included massage, the state of pollution after childbirth, the use of traditional healers and traditional medicine and herbs, beliefs relating to hot/cold imbalance, behavioral taboos, magic, and superstition. KEY CONCLUSIONS: Many Asian women continue to practice a wide range of traditional beliefs and practices during pregnancy, childbirth, and the postpartum period. More information is needed on the benefits of formal maternal healthcare services; such educational programs should be geared towards not only women but also husbands, parents, and in-laws. By recognizing and appreciating common local beliefs, providers can be better positioned to provide culturally competent care. Instead of reducing the choices available to women during the birth experience, providers should understand, respect, and integrate cultural interpretations of childbirth and the needs of women and their families.

The Multiple Histories of Western Asia: Perspectives from Ancient and Modern Genomes.

Western Asia lies at the heart of the Old World, in the midst of Africa, Asia, and Europe. As such, this region has been populated and repopulated by myriad peoples, starting with the first migrants from Africa. All evidence points to Western Asia for the beginnings of sedentary life, and indeed, first the villages and later the cities of this land remain as archaeological wonders, revealing complex histories of multiple peoples and their interactions. With the wondrous breakthroughs in genomic studies, we now have the power to look at these histories with a truly quantitative lens. Here, we review the recent anthropological genomics literature pertaining to this region, with an outlook for the future challenges and exciting possibilities for the field.

Dare to Dream: Personal Values, Life Goals, and International Students in New Zealand.

It has been well identified and supported in the literature that values and life goals are associated with one's general well-being. However, there have been few studies on values and life goals among international students in New Zealand. This study addressed this lack of research by focusing on the life goals and personal values among international students in three tertiary institutes in New Zealand. Based on the literature review, the hypothesis of this study is that international students' intrinsic life goals are positively correlated with their spiritual values. In contrast, extrinsic goals did not have similar effects. The Aspirations Index, which was used to assess life goals, and the Schwartz' value survey, which measured the students' personal values, were both distributed to the participants. Follow-up interviews with 24 of the participants were also conducted. Findings revealed that spiritual values were positively correlated with intrinsic goals and that extrinsic goals did not have similar effects. As the research findings showed that spiritual values were positively correlated with intrinsic goals, helping international students to find meaning and purpose in life may promote their well-being, and the learning and growth of international students can be improved by incorporating spiritual values and cultural aspects in college education. The authors also argue that a holistic approach to college education for international students is needed.

Diagnóstico y tratamiento de la enfermedad diverticular del colon derecho: revisión de conjunto / Diagnosis and management of right colonic diverticular disease: A review

El objetivo de esta revisión es definir las características clínico-patológicas y aclarar el tratamiento de la enfermedad diverticular del colon derecho. Es poco frecuente en Europa, Estados Unidos y Australia, y más común en Asia. Durante los últimos años, su incidencia ha aumentado en Occidente, con diferentes distribuciones entre poblaciones. Muchos estudios han mostrado que es difícil diferenciar antes de la cirugía los síntomas de presentación de esta enfermedad de los de la apendicitis, ya que los síntomas y signos son similares, por lo que no es infrecuente encontrarse con un diagnóstico incorrecto. Con estudios de diagnóstico por la imagen exactos es posible establecer un diagnóstico preoperatorio preciso a fin de evaluar una estrategia de tratamiento adecuada. Actualmente, el tratamiento de esta enfermedad no está bien definido, no se han propuesto recomendaciones claras y no se sabe si también se pueden aplicar las recomendaciones para la enfermedad diverticular del colon izquierdo. Varios autores han señalado que el tratamiento conservador es el mejor enfoque, incluso en caso de reincidencia, y que la cirugía solo estaría indicada en determinados casos

The aim of this narrative review is to define the clinical-pathological characteristics and to clarify the management of right colonic diverticular disease. It is rare in Europe, USA and Australia and more common in Asia. In the recent years its incidence has increased in the West, with various distributions among populations. Many studies have reported that it is difficult to differentiate the presenting symptoms of this disease from those of appendicitis before surgery, because the signs and symptoms are similar, so misdiagnosis is not infrequent. With accurate imaging studies it is possible to reach a precise preoperative diagnosis, in order to assess an accurate treatment strategy. Currently the management of this disease is not well defined, no clear guidelines have been proposed and it is not known whether the guidelines for left colonic diverticular disease can also be applied for it. Several authors have stated that conservative management is the best approach, even in case of recurrence, and surgery should be indicated in selected cases

Chad Genetic Diversity Reveals an African History Marked by Multiple Holocene Eurasian Migrations.

Understanding human genetic diversity in Africa is important for interpreting the evolution of all humans, yet vast regions in Africa, such as Chad, remain genetically poorly investigated. Here, we use genotype data from 480 samples from Chad, the Near East, and southern Europe, as well as whole-genome sequencing from 19 of them, to show that many populations today derive their genomes from ancient African-Eurasian admixtures. We found evidence of early Eurasian backflow to Africa in people speaking the unclassified isolate Laal language in southern Chad and estimate from linkage-disequilibrium decay that this occurred 4,750-7,200 years ago. It brought to Africa a Y chromosome lineage (R1b-V88) whose closest relatives are widespread in present-day Eurasia; we estimate from sequence data that the Chad R1b-V88 Y chromosomes coalesced 5,700-7,300 years ago. This migration could thus have originated among Near Eastern farmers during the African Humid Period. We also found that the previously documented Eurasian backflow into Africa, which occurred ∼3,000 years ago and was thought to be mostly limited to East Africa, had a more westward impact affecting populations in northern Chad, such as the Toubou, who have 20%-30% Eurasian ancestry today. We observed a decline in heterozygosity in admixed Africans and found that the Eurasian admixture can bias inferences on their coalescent history and confound genetic signals from adaptation and archaic introgression.

Iron status of young children from immigrant families.

OBJECTIVES: Children from immigrant families may be at risk for iron deficiency (ID) due to differences in pre-migration and post-migration exposures. Our objectives were to determine whether there is an association between family immigrant status and iron stores and to evaluate whether known dietary, environmental or biological determinants of low iron status influence this relationship. DESIGN: This was a cross-sectional study of healthy urban preschool children (12-72 months) recruited from seven primary care practices in Toronto. Laboratory assessment of serum ferritin and haemoglobin and standardised parent-completed surveys were completed between 2008 and 2013 during routine health maintenance visits. Multiple regression analyses were used to evaluate the association between family immigrant status and serum ferritin, ID (ferritin <14 µg/L) and iron deficiency anaemia (IDA) (ferritin <14 µg/L and haemoglobin ≤110 g/L). RESULTS: Of 2614 children included in the analysis, 47.6% had immigrant family status. The median serum ferritin was 30 µg/L and 10.4% of all children had ID and 1.9% had IDA. After adjusting for maternal ethnicity and education, age, sex, income quintile, cow's milk intake, breastfeeding duration and bottle use, there were no significant associations between immigrant status and ferritin, ID or IDA. Significant predictors of low iron status included age, sex, cow's milk intake and breastfeeding duration. CONCLUSIONS: We found no association between family immigrant status and iron status after including clinically important covariates in the models. These data suggest immigrant children may not need enhanced screening for iron status or targeted interventions for iron supplementation.

Effect of vitamin D3 supplementation on iron status: a randomized, double-blind, placebo-controlled trial among ethnic minorities living in Norway.

BACKGROUND: Both vitamin D and iron deficiencies are widespread globally, and a relationship between these deficiencies has been suggested. However, there is a paucity of randomised controlled trials assessing the effect of vitamin D supplementation on iron status. PURPOSE: We aimed to investigate whether 16 weeks of daily vitamin D3 supplementation had an effect on serum ferritin, haemoglobin, serum iron and transferrin saturation. METHODS: Overall, 251 participants from South Asia, Middle East and Africa aged 18-50 years who were living in Norway were randomised to receive daily oral supplementation of 10 µg vitamin D3, 25 µg vitamin D3, or placebo for 16 weeks during the late winter. Blood samples from baseline and after 16 weeks were analysed for serum 25-hydroxyvitamin D (s-25(OH) D), serum ferritin, haemoglobin and serum iron. In total, 214 eligible participants completed the intervention (86 % of those randomised). Linear regression analysis were used to test the effect of vitamin D3 supplementation combined (10 or 25 µg) and separate doses 10 or 25 µg compared to placebo on change (T2-T1) in each outcome variable adjusted for baseline s-25(OH)D values. RESULTS: There was no difference in change in the levels of s-ferritin (1.9 µg/L, 95 % CI: -3.2, 7.0), haemoglobin (-0.02 g/dL, 95 % CI: -0.12, 0.09), s-iron (0.4 µg/L, 95 % CI: -0.5, 1.3) or transferrin saturation (0.7 %, 95 % CI: -0.6.1, 2.0) between those receiving vitamin D3 or those receiving placebo. Serum 25-hydroxyvitamin D increased from 29 nmol/L at baseline to 49 nmol/L after the intervention, with little change in the placebo group. CONCLUSIONS: In this population of healthy ethnic minorities from South Asia, the Middle East and Africa who had low vitamin D status, 16 weeks of daily supplementation with 10 or 25 µg of vitamin D3 did not significantly affect the haemoglobin levels or other markers of iron status.

How natural is the supernatural? Synthesis of the qualitative literature from low and middle income countries on cultural practices and traditional beliefs influencing the perinatal period.

OBJECTIVE: to review qualitative research studies conducted in low resource settings around the perinatal continuum over the past two decades, with particular focus on the cultural realm; to identify common themes in the research-base, in order to provide policy direction for culturally appropriate perinatal interventions. DESIGN: systematic literature search of electronic databases from 1990 to 2014, including Medline, Embase, CINAHL and PsycINFO, using relevant search terms such as traditional beliefs, practices, pregnancy, childbirth; established criteria used to determine quality of studies; and thematic synthesis of the literature enabled by NVivo 10 software. SETTING: low and middle income countries using the World Bank classification. FINDINGS: religious and spiritual beliefs strongly influenced behaviour over the perinatal period. Beliefs in supernatural influences, particularly malevolent forces were widespread, such that pregnancy was concealed in many parts of Africa and Asia. In most low resource settings, pregnancy and childbirth were seen as normal phenomena. Rituals played an important part for women and their infants, reinforced by inter-generational support. Cross-cutting themes that emerged were: (1) the role of women as mothers, demonstrating their'goodness' by bearing pain and suffering; (2) the idea of the 'natural' incorporating the supernatural; and (3) negotiating change across generations. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: a diverse repertoire of cultural practices influences perinatal well-being across low resource settings. Health practitioners and policy-makers need to acknowledge the primacy of women's reproductive roles, the cultural constructions of motherhood; that supernatural forces are believed to exert powerful influences on the health of mother and infant; that inter-generational tensions result in resisting or embracing change. Public health planners and practitioners need to take culture seriously, not ignore the contribution of culture in shaping women's behaviours and choices throughout the perinatal continuum and deliver contextually specific, culturally responsive care to optimise perinatal health and well-being.