A composite index; socioeconomic deprivation and coverage of reproductive and maternal health interventions.

Objective: To examine inequalities in the coverage of reproductive and maternal health interventions in low- and middle-income countries and territories using a composite index of socioeconomic deprivation status. Methods: We obtained data on education and living standards from national household surveys conducted between 2015 and 2019 to calculate socioeconomic deprivation status. We assessed the coverage of reproductive and maternal health interventions, using three indicators: (i) demand for family planning satisfied with modern methods; (ii) women who received antenatal care in at least four visits; and (iii) the presence of a skilled attendant at delivery. Absolute and relative inequalities were evaluated both directly and using the slope index of inequality and the concentration index. Findings: In the 73 countries and territories with available data, the median proportions of deprivation were 41% in the low-income category, 11% in the lower-middle-income category and less than 1% in the upper-middle-income category. The coverage analysis, conducted for 48 countries with sufficient data, showed consistently lower median coverage among deprived households across all health indicators. The coverage of skilled attendant at delivery showed the largest inequalities, where coverage among the socioeconomically deprived was substantially lower in almost all countries. Antenatal care visits and demand for family planning satisfied with modern methods also showed significant disparities, favouring the less deprived population. Conclusion: The findings highlight persistent disparities in the coverage of reproductive and maternal health interventions, requiring efforts to reduce those disparities and improve coverage, particularly for skilled attendant at delivery.

Accelerometer-based sleep metrics and gut microbiota during adolescence: Association findings from a Brazilian population-based birth cohort.

BACKGROUND: Sleep and gut microbiota are emerging putative risk factors for several physical, mental, and cognitive conditions. Sleep deprivation has been shown to be linked with unhealthy microbiome environments in animal studies. However, in humans, the results are mixed. Epidemiological studies evaluating the effect of accelerometer-based sleep measures on gut microbiome are scarce. This study aims to explore the relationship between sleep duration and efficiency with the gut microbiota in adolescence. METHODS: A subsample of 352 participants from the 2004 Pelotas (Brazil) Birth Cohort Study with sleep and fecal microbiota data available were included in the study. Sleep duration and sleep efficiency were obtained from actigraphy information at 11 years old whereas microbiota information from fecal samples was collected at 12 years. The fecal microbiota was analyzed via Illumina MiSeq (16S rRNA V3-V4 region) and the UNOISE pipeline. Alpha was assessed in QIIME2. Association measures for sleep variables and microbial α-diversity, and bacterial relative abundance were assessed through generalized models (linear and logistic regression), adjusting for maternal and child variables confounders. RESULTS: Adjusted models showed that sleep duration was positively associated with Simpson index of α-diversity (ß = 0.003; CI95 %: 0.00004; 0.01). Both sleep duration (OR = 0.43; CI95 % 0.25; 0.74) and efficiency (OR = 0.55; CI95 % 0.38; 0.78) were associated with lower Bacteroidetes abundance. CONCLUSION: Our results suggest that sleep duration and efficiency are linked to gut microbiota diversity and composition even with 1-2 years gap from exposure to outcome. The findings support the role of sleep in the gut-brain axis as well as provide insights on how to improve microbiota health.

Women's marital status and use of family planning services across male- and female-headed households in low- and middle-income countries.

Background: As more households are being led by women, who are often seen as disadvantaged, more attention is being given to the potential association of female household headship with health. We aimed to assess how demand for family planning satisfied by modern methods (mDFPS) is associated with residence in female or male headed households and how this intersects with marital status and sexual activity. Methods: We used data from national health surveys carried out in 59 low- and middle-income countries between 2010 and 2020. We included all women aged 15 to 49 years in our analysis, regardless of their relationship with the household head. We explored mDFPS according to household headship and its intersectionality with the women's marital status. We identified households as male-headed households (MHH) or female-headed households (FHH), and classified marital status as not married/in a union, married with the partner living in the household, and married with the partner living elsewhere. Other descriptive variables were time since the last sexual intercourse and reason for not using contraceptives. Results: We found statistically significant differences in mDFPS by household headship among reproductive age women in 32 of the 59 countries, with higher mDFPS among women living in MHH in 27 of these 32 countries. We also found large gaps in Bangladesh (FHH = 38%, MHH = 75%), Afghanistan (FHH = 14%, MHH = 40%) and Egypt (FHH = 56%, MHH = 80%). mDFPS was lower among married women with the partner living elsewhere, a common situation in FHH. The proportions of women with no sexual activity in the last six months and who did not use contraception due to infrequent sex were higher in FHH. Conclusions: Our findings indicate that a relationship exists between household headship, marital status, sexual activity, and mDFPS. The lower mDFPS we observed among women from FHH seems to be primarily associated with their lower risk of pregnancy; although women from FHH are married, their partners frequently do not live with them, and they are less sexually active than women in MHH.

Prelacteal feeding and its relationship with exclusive breastfeeding and formula consumption among infants in low- and middle-income countries.

Background: Early feeding practices are important determinants of optimal feeding patterns later in life. We aimed to investigate if giving any fluids or foods other than breast milk during the first three days after birth (prelacteal feeds) affects exclusive breastfeeding and consumption of formula among children under six months of age in low and middle-income countries (LMICs). Methods: We conducted a retrospective cohort study using data from 85 nationally representative Demographic Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) in LMICs (2010-2019). We considered three exposures: any prelacteal feeding (PLF), milk-based only prelacteal feeding (MLK), and water-based only prelacteal feeding (WTR), according to the DHS/MICS definition. The outcomes were exclusive breastfeeding, based on the World Health Organization definition, and consumption of formula among infants under six months of age. We used Poisson models adjusting for sociodemographic indicators, antenatal care, birth assistance, and early initiation of breastfeeding to estimate the effects of the exposures on the outcomes. Findings were grouped by each country, as well as by regions of the world and national income classification. Results: We included data from 91 282 children. PLF, MLK, and WTR had a prevalence of 33.9% (95% confidence interval (CI) = 33.6-34.2), 22.2% (95% CI = 21.9-22.4), and 9.4% (95% CI = 9.2-9.6), respectively. Exclusive breastfeeding and consumption of formula had a prevalence of 35.2% (95% CI = 34.9-35.5) and 27.7% (95% CI = 27.4-28.0), respectively. In the crude analysis, children who were given PLF were 40% less likely to be exclusively breastfed (prevalence ratio (PR) = 0.60; 95% CI = 0.56-0.64) and nearly twice more likely to receive formula (PR = 1.89; 95% CI = 1.72-2.08); the direction of the associations was the same across income groups and regions of the world. In the adjusted analysis, the observed crude effects were only slightly reduced (exclusive breastfeeding - PR = 0.62; 95% CI = 0.59-0.66, consumption of formula - PR = 1.72; 95% CI = 1.59-1.85). MLK showed a stronger impact on the outcomes than PLF, especially for formula consumption (adjusted PR = 1.81; 95% CI = 1.67-1.97) and in low-income countries. WTR was only negatively associated with exclusive breastfeeding (adjusted PR = 0.69; 95% CI = 0.63-0.75), but not with formula consumption (adjusted PR = 1.09; 95% CI = 0.99-1.20). Conclusions: Feeding babies prelacteal foods shortens exclusive breastfeeding duration and increases the likelihood of formula consumption in children under six months of age in LMICs. Pro-breastfeeding interventions must be prioritized during antenatal care and throughout the stay in the maternity facility to properly protect, support, and promote exclusive breastfeeding since birth.

[SDG3-related inequalities in women's, children's and adolescents' health: an SDG monitoring baseline for Latin America and the Caribbean using national cross-sectional surveysDesigualdades relacionadas ao ODS 3 na saúde da mulher, da criança e do adolescente: linha de base para o monitoramento do ODS na América Latina e no Caribe por meio de pesquisas transversais nacionais]. / Desigualdades relacionadas con el ODS 3 en la salud de las mujeres, los niños y los adolescentes: línea de base para el monitoreo de los ODS en América Latina y el Caribe por medio de encuestas transversales nacionales.

Objectives: Latin America and the Caribbean (LAC) countries have made important progress towards achieving the Sustainable Development Goal (SDG) targets related to health (SDG3) at the national level. However, vast within-country health inequalities remain. We present a baseline of health inequalities in the region, against which progress towards the SDGs can be monitored. Setting: We studied 21 countries in LAC using data from Demographic and Health Surveys and Multiple Indicator Cluster Survey carried out from 2011 to 2016. Participants: The surveys collect nationally representative data on women and children using multistage sampling. In total, 288 207 women and 195 092 children made part of the surveys in the 21 countries. Outcome measures: Five health intervention indicators were studied, related to reproductive and maternal health, along with adolescent fertility and neonatal and under-five mortality rates. Inequalities in these indicators were assessed through absolute and relative measures. Results: In most countries, subnational geographical health gradients were observed for nearly all women, child, and adolescent (WCA) indicators. Coverage of key interventions was higher in urban areas and among the richest, compared with rural areas and poorer quintiles. Analyses by woman's age showed that coverage was lower in adolescent girls than older women for family planning indicators. Pro-urban and pro-rich inequalities were also seen for mortality in most countries. Conclusions: Regional averages hide important health inequalities between countries, but national estimates hide still greater inequalities between subgroups of women, children and adolescents. To achieve the SDG3 targets and leave no one behind, it is essential to close health inequality gaps within as well as between countries.

Objetivos: Os países da América Latina e do Caribe obtiveram avanços significativos rumo à consecução do Objetivo de Desenvolvimento Sustentável relacionado à saúde (ODS 3) no nível nacional. No entanto, enormes desigualdades em saúde persistem nos países. Apresenta-se uma linha de base das desigualdades em saúde na região, com referência à qual é possível monitorar o progresso rumo aos ODS. Contexto: Foram estudados 21 países da América Latina e do Caribe usando dados de pesquisas de demografia e saúde e pesquisas de grupos de indicadores múltiplos feitas de 2011 a 2016. Participantes: As pesquisas coletam dados nacionalmente representativos sobre mulheres e crianças, por meio de amostragem multietápica. No total, 288.207 mulheres e 195.092 crianças participaram das pesquisas nos 21 países. Medição dos resultados: Foram estudados cinco indicadores de intervenções de saúde relacionadas à saúde reprodutiva e materna, à fertilidade das adolescentes e às taxas de mortalidade neonatal e de menores de cinco anos. As desigualdades nesses indicadores foram então avaliadas, empregando medidas absolutas e relativas. Resultados: Gradientes geográficos de saúde nos níveis subnacionais foram observados na maioria dos países para quase todos os indicadores referentes às mulheres e à população infantil e adolescente. A cobertura das principais intervenções foi maior nas áreas urbanas e nos quintis mais ricos do que nas áreas rurais e nos quintis mais pobres. As análises por idade das mulheres mostraram que a cobertura das adolescentes era inferior à cobertura das mulheres adultas no que se refere aos indicadores de planejamento familiar. Além disso, foram observadas desigualdades na mortalidade que favoreciam as áreas urbanas e os ricos, na maioria dos países. Conclusões: As médias regionais mascaram desigualdades significativas na saúde entre os países, mas as estimativas nacionais mascaram desigualdades ainda maiores entre os subgrupos de mulheres, crianças e adolescentes. Para alcançar as metas do ODS 3 e não deixar ninguém para trás, é essencial abordar não apenas as lacunas da desigualdade em saúde entre os países, mas também dentro deles.

Desigualdades relacionadas con el ODS 3 en la salud de las mujeres, los niños y los adolescentes: línea de base para el monitoreo de los ODS en América Latina y el Caribe por medio de encuestas transversales nacionales

[RESUMEN]. Objetivos. Los países de América Latina y el Caribe han realizado importantes avances hacia la consecución de las metas del Objetivo de Desarrollo Sostenible relacionado con la salud (ODS 3) a escala nacional. Sin embargo, persisten enormes desigualdades en salud en los países. Se presenta una línea de base de las desigualdades en salud en la región, contra la cual se puede monitorear el progreso hacia los ODS. Contexto. Se estudiaron 21 países de América Latina y el Caribe usando datos de encuestas de demografía y salud y encuestas de indicadores múltiples por conglomerados realizadas del 2011 al 2016. Participantes. En las encuestas se recopilan datos representativos a nivel nacional de mujeres y niños por medio del muestreo polietápico. En total, 288 207 mujeres y 195 092 niños participaron en las encuestas en los 21 países. Medición de los resultados. Se estudiaron cinco indicadores de intervenciones de salud relacionadas con la salud reproductiva y materna, la fecundidad de las adolescentes y las tasas de mortalidad neonatal y de menores de 5 años. Después se evaluaron las desigualdades en estos indicadores por medio de mediciones absolutas y relativas. Resultados. En la mayoría de los países se observaron gradientes geográficos en salud a escala subnacional en casi todos los indicadores correspondientes a las mujeres y la población infantil y adolescente. La cobertura de las principales intervenciones fue mayor en las zonas urbanas y los quintiles más ricos que en las zonas rurales y los quintiles más pobres. Los análisis por edad de la mujer mostraron que la cobertura de las adolescentes era menor que la cobertura de las mujeres adultas en lo que se refiere a los indicadores de planificación familiar. En la mayoría de los países se observaron también desigualdades en la mortalidad que favorecían a las zonas urbanas y a los ricos. Conclusiones. Los promedios regionales ocultan importantes desigualdades en salud entre los países, pero las estimaciones nacionales ocultan desigualdades incluso mayores entre subgrupos de mujeres, niños y adolescentes. Para alcanzar las metas del ODS 3 y no dejar a nadie atrás es esencial subsanar no solo las brechas de la desigualdad en salud entre los países sino también dentro de ellos.

[ABSTRACT]. Objectives. Latin America and the Caribbean (LAC) countries have made important progress towards achieving the Sustainable Development Goal (SDG) targets related to health (SDG3) at the national level. However, vast within-country health inequalities remain. We present a baseline of health inequalities in the region, against which progress towards the SDGs can be monitored. Setting. We studied 21 countries in LAC using data from Demographic and Health Surveys and Multiple Indicator Cluster Survey carried out from 2011 to 2016. Participants. The surveys collect nationally representative data on women and children using multistage sampling. In total, 288 207 women and 195 092 children made part of the surveys in the 21 countries. Outcome measures. Five health intervention indicators were studied, related to reproductive and maternal health, along with adolescent fertility and neonatal and under-five mortality rates. Inequalities in these indicators were assessed through absolute and relative measures. Results. In most countries, subnational geographical health gradients were observed for nearly all women, child, and adolescent (WCA) indicators. Coverage of key interventions was higher in urban areas and among the richest, compared with rural areas and poorer quintiles. Analyses by woman’s age showed that coverage was lower in adolescent girls than older women for family planning indicators. Pro-urban and pro-rich inequalities were also seen for mortality in most countries. Conclusions. Regional averages hide important health inequalities between countries, but national estimates hide still greater inequalities between subgroups of women, children and adolescents. To achieve the SDG3 targets and leave no one behind, it is essential to close health inequality gaps within as well as between countries.

[RESUMO]. Objetivos. Os países da América Latina e do Caribe obtiveram avanços significativos rumo à consecução do Objetivo de Desenvolvimento Sustentável relacionado à saúde (ODS 3) no nível nacional. No entanto, enormes desigualdades em saúde persistem nos países. Apresenta-se uma linha de base das desigualdades em saúde na região, com referência à qual é possível monitorar o progresso rumo aos ODS. Contexto. Foram estudados 21 países da América Latina e do Caribe usando dados de pesquisas de demografia e saúde e pesquisas de grupos de indicadores múltiplos feitas de 2011 a 2016. Participantes. As pesquisas coletam dados nacionalmente representativos sobre mulheres e crianças, por meio de amostragem multietápica. No total, 288.207 mulheres e 195.092 crianças participaram das pesquisas nos 21 países. Medição dos resultados. Foram estudados cinco indicadores de intervenções de saúde relacionadas à saúde reprodutiva e materna, à fertilidade das adolescentes e às taxas de mortalidade neonatal e de menores de cinco anos. As desigualdades nesses indicadores foram então avaliadas, empregando medidas absolutas e relativas. Resultados. Gradientes geográficos de saúde nos níveis subnacionais foram observados na maioria dos países para quase todos os indicadores referentes às mulheres e à população infantil e adolescente. A cobertura das principais intervenções foi maior nas áreas urbanas e nos quintis mais ricos do que nas áreas rurais e nos quintis mais pobres. As análises por idade das mulheres mostraram que a cobertura das adolescentes era inferior à cobertura das mulheres adultas no que se refere aos indicadores de planejamento familiar. Além disso, foram observadas desigualdades na mortalidade que favoreciam as áreas urbanas e os ricos, na maioria dos países. Conclusões. As médias regionais mascaram desigualdades significativas na saúde entre os países, mas as estimativas nacionais mascaram desigualdades ainda maiores entre os subgrupos de mulheres, crianças e adolescentes. Para alcançar as metas do ODS 3 e não deixar ninguém para trás, é essencial abordar não apenas as lacunas da desigualdade em saúde entre os países, mas também dentro deles.

Paving the way to understanding female-headed households: Variation in household composition across 103 low- and middle-income countries.

Background: Female-headed households (FHHs) are regarded as disadvantaged. There are multiple social trajectories that can lead to women heading households. It is important to distinguish between these trajectories, as well as societal norms and contextual factors, to understand how and when are FHHs represented as a dimension of gender inequity. Our analysis defines and describes a typology of 16 FHH types (FHH16) based on demographic characteristics. Methods: This cross-sectional study used national Demographic Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) in 103 low- and middle-income countries (LMICs) to identify a typology of FHHs based on the family composition and additional household members. We performed descriptive analyses at the household level to generate median proportions of the FHH16 types and selected household characteristics. We conducted cluster analyses to explore FHH16 patterns across naturally grouped clusters of countries and described selected social and economic indicators at the ecological level. Results: The most common FHH16 types were those where the women household heads lived with children only, were alone, or lived with men, women, and children, but without a husband. In Africa and South Asia, the most common FHH was one where women heads resided with children only. In East Asia and the Pacific, the highest proportion of FHHs were those with men, women, and children. In MENA and Eastern Europe & Central Asia, households with women heads living alone were the most prevalent. Latin America had more FHHs with husbands, comparatively, and the most common FHHs were those with heads living alone or with children. Our exploratory cluster analysis generated five clusters with unique FHH16 patterns. The clusters had distinct geographic, contextual and economic characteristics. Conclusions: Our typology showed that FHHs are heterogeneous within and between countries. The ecological analysis emphasized further variation created by different societal and cultural factors. Research around their vulnerabilities and strengths needs to consider these factors and their influence on socioeconomic status and health-related outcomes within households headed by women.

Consumption of breast milk, formula and other non-human milk by children aged under 2 years: analysis of eighty-six low- and middle-income countries.

OBJECTIVE: To investigate the prevalence and socio-economic inequalities in breast milk, breast milk substitutes (BMS) and other non-human milk consumption, by children under 2 years in low- and middle-income countries (LMIC). DESIGN: We analysed the prevalence of continued breast-feeding at 1 and 2 years and frequency of formula and other non-human milk consumption by age in months. Indicators were estimated through 24-h dietary recall. Absolute and relative wealth indicators were used to describe within- and between-country socio-economic inequalities. SETTING: Nationally representative surveys from 2010 onwards from eighty-six LMIC. PARTICIPANTS: 394 977 children aged under 2 years. RESULTS: Breast-feeding declined sharply as children became older in all LMIC, especially in upper-middle-income countries. BMS consumption peaked at 6 months of age in low/lower-middle-income countries and at around 12 months in upper-middle-income countries. Irrespective of country, BMS consumption was higher in children from wealthier families, and breast-feeding in children from poorer families. Multilevel linear regression analysis showed that BMS consumption was positively associated with absolute income, and breast-feeding negatively associated. Findings for other non-human milk consumption were less straightforward. Unmeasured factors at country level explained a substantial proportion of overall variability in BMS consumption and breast-feeding. CONCLUSIONS: Breast-feeding falls sharply as children become older, especially in wealthier families in upper-middle-income countries; this same group also consumes more BMS at any age. Country-level factors play an important role in explaining BMS consumption by all family wealth groups, suggesting that BMS marketing at national level might be partly responsible for the observed differences.

Learning from success cases: ecological analysis of potential pathways to universal access to family planning care in low- and middle-income countries.

Background  Universal access to family planning services is a well-recognized human right and several countries and organizations are committed to this goal. Our objective was to identify countries who improved family planning coverage in the last 40 years and investigate which contexts enabled those advances.  Methods  Analyses were based on data from publicly available national health surveys carried out since 1986 in Egypt, Ethiopia, Rwanda, Afghanistan, Brazil, and Ecuador, selected based on previous evidence. We estimated demand for family planning satisfied with modern methods (mDFPS) for each country and explored inequalities in terms of wealth, women's education, and women's age. We also explored contextual differences in terms of women's empowerment, percentage of population living in extreme poverty, and share of each type of contraceptive. To better understand political and sociocultural contexts, country case studies were included, based on literature review.  Results  Patterns of mDFPS increase were distinct in the selected countries. Current level of mDFPS coverage ranged between 94% in Brazil and 38% in Afghanistan. All countries experienced important reduction in both gender inequality and extreme poverty. According to the share of each type of contraceptive, most countries presented higher use of short-acting reversible methods. Exceptions were Ecuador, where the most used method is sterilization, and Egypt, which presented higher use of long-acting reversible methods. In the first years analyzed, all countries presented huge gaps in coverage according to wealth, women's education and women's age. All countries managed to increase coverage over recent years, especially among women from the more vulnerable groups.  Conclusions  Family planning coverage increased along with reductions in poverty and gender inequality, with substantial increases in coverage among the most vulnerable in recent years. Policies involving primary health care services, provision of various methods, and high quality training of health providers are crucial to increase coverage.

Desigualdades relacionadas con el ODS 3 en la salud de las mujeres, los niños y los adolescentes: línea de base para el monitoreo de los ODS en América Latina y el Caribe por medio de encuestas transversales nacionales / SDG3-related inequalities in women's, children's and adolescents' health: an SDG monitoring baseline for Latin America and the Caribbean using national cross-sectional surveys / Desigualdades relacionadas ao ODS 3 na saúde da mulher, da criança e do adolescente: linha de base para o monitoramento do ODS na América Latina e no Caribe por meio de pesquisas transversais nacionais

RESUMEN Objetivos. Los países de América Latina y el Caribe han realizado importantes avances hacia la consecución de las metas del Objetivo de Desarrollo Sostenible relacionado con la salud (ODS 3) a escala nacional. Sin embargo, persisten enormes desigualdades en salud en los países. Se presenta una línea de base de las desigualdades en salud en la región, contra la cual se puede monitorear el progreso hacia los ODS. Contexto. Se estudiaron 21 países de América Latina y el Caribe usando datos de encuestas de demografía y salud y encuestas de indicadores múltiples por conglomerados realizadas del 2011 al 2016. Participantes. En las encuestas se recopilan datos representativos a nivel nacional de mujeres y niños por medio del muestreo polietápico. En total, 288 207 mujeres y 195 092 niños participaron en las encuestas en los 21 países. Medición de los resultados. Se estudiaron cinco indicadores de intervenciones de salud relacionadas con la salud reproductiva y materna, la fecundidad de las adolescentes y las tasas de mortalidad neonatal y de menores de 5 años. Después se evaluaron las desigualdades en estos indicadores por medio de mediciones absolutas y relativas. Resultados. En la mayoría de los países se observaron gradientes geográficos en salud a escala subnacional en casi todos los indicadores correspondientes a las mujeres y la población infantil y adolescente. La cobertura de las principales intervenciones fue mayor en las zonas urbanas y los quintiles más ricos que en las zonas rurales y los quintiles más pobres. Los análisis por edad de la mujer mostraron que la cobertura de las adolescentes era menor que la cobertura de las mujeres adultas en lo que se refiere a los indicadores de planificación familiar. En la mayoría de los países se observaron también desigualdades en la mortalidad que favorecían a las zonas urbanas y a los ricos. Conclusiones. Los promedios regionales ocultan importantes desigualdades en salud entre los países, pero las estimaciones nacionales ocultan desigualdades incluso mayores entre subgrupos de mujeres, niños y adolescentes. Para alcanzar las metas del ODS 3 y no dejar a nadie atrás es esencial subsanar no solo las brechas de la desigualdad en salud entre los países sino también dentro de ellos.

ABSTRACT Objectives. Latin America and the Caribbean (LAC) countries have made important progress towards achieving the Sustainable Development Goal (SDG) targets related to health (SDG3) at the national level. However, vast within-country health inequalities remain. We present a baseline of health inequalities in the region, against which progress towards the SDGs can be monitored. Setting. We studied 21 countries in LAC using data from Demographic and Health Surveys and Multiple Indicator Cluster Survey carried out from 2011 to 2016. Participants. The surveys collect nationally representative data on women and children using multistage sampling. In total, 288 207 women and 195 092 children made part of the surveys in the 21 countries. Outcome measures. Five health intervention indicators were studied, related to reproductive and maternal health, along with adolescent fertility and neonatal and under-five mortality rates. Inequalities in these indicators were assessed through absolute and relative measures. Results. In most countries, subnational geographical health gradients were observed for nearly all women, child, and adolescent (WCA) indicators. Coverage of key interventions was higher in urban areas and among the richest, compared with rural areas and poorer quintiles. Analyses by woman's age showed that coverage was lower in adolescent girls than older women for family planning indicators. Pro-urban and pro-rich inequalities were also seen for mortality in most countries. Conclusions. Regional averages hide important health inequalities between countries, but national estimates hide still greater inequalities between subgroups of women, children and adolescents. To achieve the SDG3 targets and leave no one behind, it is essential to close health inequality gaps within as well as between countries.

RESUMO Objetivos. Os países da América Latina e do Caribe obtiveram avanços significativos rumo à consecução do Objetivo de Desenvolvimento Sustentável relacionado à saúde (ODS 3) no nível nacional. No entanto, enormes desigualdades em saúde persistem nos países. Apresenta-se uma linha de base das desigualdades em saúde na região, com referência à qual é possível monitorar o progresso rumo aos ODS. Contexto. Foram estudados 21 países da América Latina e do Caribe usando dados de pesquisas de demografia e saúde e pesquisas de grupos de indicadores múltiplos feitas de 2011 a 2016. Participantes. As pesquisas coletam dados nacionalmente representativos sobre mulheres e crianças, por meio de amostragem multietápica. No total, 288.207 mulheres e 195.092 crianças participaram das pesquisas nos 21 países. Medição dos resultados. Foram estudados cinco indicadores de intervenções de saúde relacionadas à saúde reprodutiva e materna, à fertilidade das adolescentes e às taxas de mortalidade neonatal e de menores de cinco anos. As desigualdades nesses indicadores foram então avaliadas, empregando medidas absolutas e relativas. Resultados. Gradientes geográficos de saúde nos níveis subnacionais foram observados na maioria dos países para quase todos os indicadores referentes às mulheres e à população infantil e adolescente. A cobertura das principais intervenções foi maior nas áreas urbanas e nos quintis mais ricos do que nas áreas rurais e nos quintis mais pobres. As análises por idade das mulheres mostraram que a cobertura das adolescentes era inferior à cobertura das mulheres adultas no que se refere aos indicadores de planejamento familiar. Além disso, foram observadas desigualdades na mortalidade que favoreciam as áreas urbanas e os ricos, na maioria dos países. Conclusões. As médias regionais mascaram desigualdades significativas na saúde entre os países, mas as estimativas nacionais mascaram desigualdades ainda maiores entre os subgrupos de mulheres, crianças e adolescentes. Para alcançar as metas do ODS 3 e não deixar ninguém para trás, é essencial abordar não apenas as lacunas da desigualdade em saúde entre os países, mas também dentro deles.

Time-dependent decay of detectable antibodies against SARS-CoV-2: A comparison of ELISA with two batches of a lateral-flow test.

BACKGROUND: Large-scale epidemiological studies of seroprevalence of antibodies against SARS-CoV-2 often rely on point-of-care tests that provide immediate results to participants. Yet, little is known on how long rapid tests remain positive after the COVID-19 episode, or how much variability exists across different brands and even among batches of the same test. METHODS: In November 2020, we assessed the sensitivity of three tests applied to 133 individuals with a previous positive PCR result between April and October. All subjects provided finger prick blood samples for two batches (A and B) of the Wondfo lateral-flow IgG/IgM test, and dried blood spot samples for the S-UFRJ ELISA test. RESULTS: Overall sensitivity levels were 92.5% (95% CI 86.6-96.3), 63.2% (95% CI 54.4-71.4) and 33.8% (95% CI 25.9-42.5) for the S-UFRJ test, Wondfo A and Wondfo B tests, respectively. There was no evidence of a decline in the positivity of S-UFRJ with time since the diagnosis, but the two Wondfo batches showed sharp reductions to as low as 41.9% and 19.4%, respectively, for subjects with a positive PCR in June or earlier. Positive results for batch B of the rapid test were 35% to 54% lower than for batch A at any given month of diagnosis. INTERPRETATION: Whereas the ELISA test showed high sensitivity and stability of results over the five months of the study, both batches of the rapid test showed substantial declines, with one of the batches consistently showing lower sensitivity levels than the other. ELISA tests based on dried-blood spots are an inexpensive alternative to rapid lateral-flow tests in large-scale epidemiological studies. FUNDING: The study was funded by the "Todos Pela Saúde" initiative, Instituto Serrapilheira, Brazilian Ministry of Health, Brazilian Collective Health Association (ABRASCO) and the JBS S.A. initiative 'Fazer o Bem Faz Bem'.

SDG3-related inequalities in women's, children's and adolescents' health: an SDG monitoring baseline for Latin America and the Caribbean using national cross-sectional surveys.

OBJECTIVES: Latin America and the Caribbean (LAC) countries have made important progress towards achieving the Sustainable Development Goal (SDG) targets related to health (SDG3) at the national level. However, vast within-country health inequalities remain. We present a baseline of health inequalities in the region, against which progress towards the SDGs can be monitored. SETTING: We studied 21 countries in LAC using data from Demographic and Health Surveys and Multiple Indicator Cluster Survey carried out from 2011 to 2016 PARTICIPANTS: The surveys collect nationally representative data on women and children using multistage sampling. In total, 288 207 women and 195 092 children made part of the surveys in the 21 countries. OUTCOME MEASURES: Five health intervention indicators were studied, related to reproductive and maternal health, along with adolescent fertility and neonatal and under-five mortality rates. Inequalities in these indicators were assessed through absolute and relative measures. RESULTS: In most countries, subnational geographical health gradients were observed for nearly all women, child, and adolescent (WCA) indicators. Coverage of key interventions was higher in urban areas and among the richest, compared with rural areas and poorer quintiles. Analyses by woman's age showed that coverage was lower in adolescent girls than older women for family planning indicators. Pro-urban and pro-rich inequalities were also seen for mortality in most countries. CONCLUSIONS: Regional averages hide important health inequalities between countries, but national estimates hide still greater inequalities between subgroups of women, children and adolescents. To achieve the SDG3 targets and leave no one behind, it is essential to close health inequality gaps within as well as between countries.

Is women's empowerment associated with coverage of RMNCH interventions in low- and middle-income countries? An analysis using a survey-based empowerment indicator, the SWPER.

BACKGROUND: Women's empowerment has a strong potential to promote sustainable development. We evaluate the association between women's empowerment and the Composite Coverage Index (CCI), a weighted average of coverage of eight interventions in reproductive, maternal, newborn and child health (RMNCH). We also assess whether these effects are modified by wealth. METHODS: We used Demographic and Health Survey data from 62 low- and middle-income countries. Women's empowerment was measured using the three domains (attitude to violence, social independence and decision making) of the survey-based indicator of women's empowerment (SWPER). Analyses followed an ecological design. Meta-regression models were used to account for within-country uncertainty in the CCI. We also carried out meta-regression with wealth quintiles of households as the units of analyses and tested for interaction between wealth and each empowerment domain. RESULTS: We found positive associations between the three domains of SWPER and CCI at the country level. One standard deviation change in empowerment increased the CCI by 14.2 percentage points (attitude to violence), 15.3 percentage points (decision-making), and 16.3 percentage points (social independence). The association between social independence and CCI was modified by wealth: each additional standard deviation was associated with 21.8 (95% confidence interval (CI) = 14.0-29.6) and 8.7 (95% CI = 5.4-12.0) percentage points increase in the CCI among the poorest and the richest quintiles, respectively. CONCLUSIONS: Our findings suggest that efforts toward the achievement of SDG5 (Achieve gender equality and empower all women and girls) may support improvements in RMNCH in low- and middle-income countries, especially among the poorest women and children.

Influence of maternal pre-pregnancy nutritional status on offspring anthropometric measurements and body composition in three Brazilian Birth Cohorts.

OBJECTIVE: We aimed at evaluating the association of maternal pre-pregnancy nutritional status with offspring anthropometry and body composition. We also evaluated whether these associations were modified by gender, diet and physical activity and mediated by birth weight. DESIGN: Birth cohort study. SETTING: Waist circumference was measured with an inextensible tape, and fat and lean mass were measured using dual-energy X-ray absorptiometry. Multiple linear regression was used to adjust for possible confounders and allele score of BMI. We carried out mediation analysis using G-formula. PARTICIPANTS: In 1982, 1993 and 2004, all maternity hospitals in Pelotas (South Brazil) were visited daily and all live births whose families lived in the urban area of the city were evaluated. These subjects have been followed up at different ages. RESULTS: Offspring of obese mothers had on average higher BMI, waist circumference and fat mass index than those of normal weight mothers, and these differences were higher among daughters. The magnitudes of the association were similar in the cohorts, except for height, where the association pattern was not clear. In the 1982 cohort, further adjustment for a BMI allele score had no material influence on the magnitude of the associations. Mediation analyses showed that birth weight captured part of this association. CONCLUSIONS: Our findings suggest that maternal pre-pregnancy nutritional status is positively associated with offspring BMI and adiposity in offspring. And this association is higher among daughters whose mother was overweight or obese and, birth weight explains part of this association.

Time-dependent decay of detectable antibodies against SARS-CoV-2: A comparison of ELISA with two batches of a lateral-flow test

ABSTRACT Background: Large-scale epidemiological studies of seroprevalence of antibodies against SARS-CoV-2 often rely on point-of-care tests that provide immediate results to participants. Yet, little is known on how long rapid tests remain positive after the COVID-19 episode, or how much variability exists across different brands and even among batches of the same test. Methods: In November 2020, we assessed the sensitivity of three tests applied to 133 individuals with a previous positive PCR result between April and October. All subjects provided finger prick blood samples for two batches (A and B) of the Wondfo lateral-flow IgG/IgM test, and dried blood spot samples for the S-UFRJ ELISA test. Results: Overall sensitivity levels were 92.5% (95% CI 86.6-96.3), 63.2% (95% CI 54.4-71.4) and 33.8% (95% CI 25.9-42.5) for the S-UFRJ test, Wondfo A and Wondfo B tests, respectively. There was no evidence of a decline in the positivity of S-UFRJ with time since the diagnosis, but the two Wondfo batches showed sharp reductions to as low as 41.9% and 19.4%, respectively, for subjects with a positive PCR in June or earlier. Positive results for batch B of the rapid test were 35% to 54% lower than for batch A at any given month of diagnosis. Interpretation: Whereas the ELISA test showed high sensitivity and stability of results over the five months of the study, both batches of the rapid test showed substantial declines, with one of the batches consistently showing lower sensitivity levels than the other. ELISA tests based on dried-blood spots are an inexpensive alternative to rapid lateral-flow tests in large-scale epidemiological studies.

SWPER Global: A survey-based women's empowerment index expanded from Africa to all low- and middle-income countries.

Background In 2017, a survey-based women's empowerment index (SWPER) was proposed for African countries, including three domains: social independence, decision making and attitude to violence. External validity and predictive value of the SWPER has been demonstrated in terms of coverage of maternal and child interventions and use of modern contraception. To determine its value for global monitoring, we explored the applicability of the SWPER in national health surveys from low- and middle- income countries (LMICs) in other world regions. METHODS: We used data from the latest Demographic and Health Survey for 62 LMICs since 2000. 14 pre-selected questions (items) were considered during the validation process. Content adaptations included the exclusion of women's working status and recategorization of the decision-making related items. We compared the loading patterns obtained from principal components analysis performed for each country separately with those obtained in a pooled data set with all countries combined. Country rankings based on the score of each SWPER domain were correlated with their rankings in the Gender Development Index (GDI) and the Gender Inequality Index (GII) for external validation. RESULTS: Consistency regarding item loadings for the three SWPER empowerment domains was observed for most countries. Correlations between the scores generated for each country and global score obtained from the combined data were 0.89 or higher for all countries. Correlations between the country rankings according to SWPER and GDI were, respectively, 0.74, 0.72 and 0.67 for social independence, decision-making, and attitude to violence domains. The correlations were equal to 0.81, 0.67, and 0.44, respectively, with GII. CONCLUSIONS: The indicator we propose, named SWPER Global, is a suitable common measure of women's empowerment for LMICs, addressing the need for a single consistent survey-based indicator of women´s empowerment that allows for tracking of progress over time and across countries at the individual and country levels.

The impact of women's empowerment on their children's early development in 26 African countries.

BACKGROUND: Every year more than 200 million children under-five years fail to achieve their full developmental potential in low- and middle-income countries (LMICs). Although women´s empowerment has been associated with improved child health and development outcomes, this is a topic little studied in LMICs. We investigated the associations between women´s empowerment and early childhood development among a sample population of 84537 children aged 36-59 months from national health surveys of 26 African countries. METHODS: We used data from Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) ranging from 2010 to 2018. Four developmental domains were assessed among children using the Early Childhood Development Index: literacy-numeracy, physical, learning and socioemotional. Women's empowerment in attitude to violence, social independence and decision-making was evaluated using the SWPER global, a validated survey-based index. We reported effect sizes for each country and a combined estimate of the association. The study covers all countries with surveys in the region and uses a novel approach for measuring women's empowerment, the SWPER. RESULTS: Across all countries, 15.1% of the children were on track in the literacy-numeracy domain, 92.3% in physical, 81.3% in learning and 67.8% in socio-emotional. The odds of a child being on track in literacy-numeracy increased by 34% (odds ratio (OR) = 1.34; 95% confidence interval (CI) = 1.31-1.37), 88% (OR = 1.88; 95% CI = 1.85-1.91) and 34% (OR = 1.34; 95% CI = 1.29-1.39), with a one standard deviation increase in the scores of attitudes to violence, social independence and decision-making domains of empowerment, respectively. No effect of empowerment was observed for the other domains of child development. CONCLUSIONS: Our results show a consistent positive effect of empowerment on the literacy-numeracy domain of child development cross-nationally in Africa and this was particularly evident for the social independence domain of the SWPER. Programs and interventions may also consider addressing the reduction of gender inequalities to improve child development.

Early childhood suspected developmental delay in 63 low- and middle-income countries: Large within- and between-country inequalities documented using national health surveys.

2Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil. BACKGROUND: The Sustainable Development Goals call for inclusive, equitable and quality learning opportunities for all. This is especially important for children, to ensure they all develop to their full potential. We studied the prevalence and inequalities of suspected delay in child development in 63 low- and middle-income countries. METHODS: We used the early child development module from national health surveys, which covers four developmental domains (physical, social-emotional, learning, literacy-numeracy) and provides a combined indicator (early child development index, ECDI) of whether children are on track. We calculated the age-adjusted prevalence of suspected delay at the country level and stratifying by wealth, urban/rural residence, sex of the child and maternal education. We also calculated measures of absolute and relative inequality. RESULTS: We studied 330 613 children from 63 countries. Prevalence of suspected delay for the ECDI ranged from 3% in Barbados to 67% in Chad. For all countries together, 25% of the children were suspected of developmental delay. At regional level, prevalence of delay ranged from 10% in Europe and Central Asia to 42% in West and Central Africa. The literacy-numeracy domain was by far the most challenging, with the highest proportions of delay. We observed very large inequalities, and most markedly for the literacy-numeracy domain. CONCLUSIONS: To date, our study presents the most comprehensive analysis of child development using an instrument especially developed for national health surveys. With a quarter of the children globally suspected of developmental delay, we face an immense challenge. The multifactorial aspect of early child development and the large gaps we found only add to the challenge of not leaving these children behind.

Time trends in demand for family planning satisfied: analysis of 73 countries using national health surveys over a 24-year period.

BACKGROUND: Universal access to family planning is key to extend its health and economic benefits worldwide. Our aim was to track progress in demand for family planning satisfied with modern methods (mDFPS) and its inequalities in low- and middle-income countries (LMICs). METHODS: Analyses were based on Demographic and Health Surveys and Multiple Indicator Cluster Surveys carried out between 1993 and 2017 in 73 LMICs, using data for married women aged 15-49 years. We estimated trends in mDFPS coverage by country and world region and evaluated trends in wealth-based inequalities. The analyses pooling all countries together were stratified by wealth quintiles, area of residence and woman's age. mDFPS coverage in 2030 for each country was predicted using a linear model. RESULTS: Overall, mDFPS increased and poor-rich gaps narrowed. Eastern & Southern Africa showed an average increase of 1.5 percentage points (p.p.) a year, being the region with the fastest progress. West & Central Africa had an increase in mDFPS of 1 p.p. a year but current coverage is still below 40%. Generally, inequalities were reduced, except for West & Central Africa and Europe & Central Asia where almost no change was observed. The country with the fastest progress in mDFPS was Rwanda, with an increase of 5 p.p./y, while Timor Leste had the fastest reduction in absolute inequality, less 3.8 p.p./y. Inequalities by area of residence were reduced, but large gaps remain. A similar trend was observed for different age groups. If the current trend is not accelerated, 44 countries will not achieve universal coverage in mDFPS by 2030. CONCLUSIONS: Generally, mDFPS is increasing and inequalities are decreasing. However, progress is slow in some regions, especially West & Central Africa, where low coverage is combined with high levels of inequalities. Efforts to increase family planning coverage must be prioritized in countries where progress is slow or inexistent.