Evidence of potential impacts of a nutrition-sensitive agroecology program in Andhra Pradesh, India, on dietary diversity, nutritional status, and child development.

INTRODUCTION: While a number of studies have examined the nutritional impacts of agroecological interventions, few have examined impacts on child development, maternal and child anemia, and men's dietary diversity. Moreover, there have been few such evaluations at scale. We evaluated the impact of a large-scale, multi-component food-based nutrition intervention involving homestead food production, nutrition counselling, cooking demonstrations, and crop planning exercises. METHODS: A cross-sectional assessment was conducted in 2021-2022 of 50 intervention villages where the nutrition-sensitive agroecology program had been implemented since 2018 and 79 control villages where only the agroecology program had been implemented. Data on self-reported dietary intake, caregiver-reported early child development, anthropometric measurements, and hemoglobin concentrations were collected using standardized procedures by trained Nutrition Farming Fellows, who were also responsible for implementing the program. RESULTS: A sample of 3,511 households (1,121 intervention and 2,390 control) participated in the survey. Dietary diversity scores (DDS) among women and men were mean (SD) 6.53 (±1.62) and 6.16 (±1.65), respectively, in intervention villages and 5.81 (±1.58) and 5.39 (±1.61), respectively, in control villages (p<0.01). DDS among children 6-24 months of age in intervention and control villages was 2.99 (±1.52) and 2.73 (±1.62), respectively (p<0.01). Children <2 years of age were less likely to be anemic in intervention versus control villages (59% versus 69%, p<0.01). Children 18-35 months age in intervention villages had higher child development scores than children in control villages (all p<0.05). CONCLUSION: Nutrition-sensitive agroecological programs may be effective in improving diets, nutrition, and child development in rural India.

Women's input and decision-making in agriculture are associated with diet quality in rural Tanzania.

Background: Women's empowerment is one critical pathway through which agriculture can impact women's nutrition; however, empirical evidence is still limited. We evaluated the associations of women's participation, input, and decision-making in key agricultural and household activities with women's diet quality. Methods: We analyzed data from a cross-sectional study of 870 women engaged in homestead agriculture. We used food frequency questionnaires to assess women's diets and computed women's diet quality using the Prime Diet Quality Score (PDQS) (range 0-42), which captures healthy and unhealthy foods. We evaluated women's decision-making in 8 activities, food crop farming, cash crop farming, livestock raising, non-farm economic activities, wage/salary employment, fishing, major household expenditures, and minor household expenditures. Generalized estimating equations (GEE) linear models were used to evaluate associations between (a) women's participation, (b) decision-making, (c) adequate input, (d) adequate extent of independence in decision-making in agriculture, and (e) adequate input in use of agricultural income with their PDQS. Adequate input was defined as input into some, most or all decisions compared to input into few decisions or none. Adequate extent of independence was defined as input to a medium or high extent compared to input to a small extent or none. Findings: Median PDQS was 19 (IQR: 16-21). Women's adequate input in decision-making on wage and salary employment (estimate: 4.19, 95% CI: 2.80, 5.57) and minor expenditures were associated with higher PDQS vs. inadequate input. Women with independence in decision-making on livestock production (estimate: 0.97, 95% CI: 0.05, 1.90) and minor household expenditures, and women with adequate decision-making in the use of income from wages/salaries (estimate: 3.16, 95% CI: 2.44, 3.87) had higher PDQS. Participation in agricultural activities was positively associated with PDQS. Conclusions: Women's participation and input in decision-making in wage and salary employment, livestock production, and minor household expenditures were strongly associated with the consumption of better-quality diets. Women participating in multiple farm activities were also likely to have better diet quality. This study adds to the growing evidence on the pathways through which women's empowerment may influence women's nutrition in rural Tanzania.

Women's empowerment, production choices, and crop diversity in Burkina Faso, India, Malawi, and Tanzania: a secondary analysis of cross-sectional data.

BACKGROUND: Bolstering farm-level crop diversity is one strategy to strengthen food system resilience and achieve global food security. Women who live in rural areas play an essential role in food production; therefore, we aimed to assess the associations between women's empowerment and crop diversity. METHODS: In this secondary analysis of cross-sectional data, we used data from four cluster-randomised controlled trials done in Burkina Faso, India, Malawi, and Tanzania. We assessed women's empowerment using indicators from the Women's Empowerment in Agriculture Index. Farm-level crop diversity measures were the number of food crops grown, number of food groups grown, and if nutrient-dense crops were grown. We used a two-stage modelling approach. First, we analysed covariate-adjusted country-specific associations between women's empowerment and crop diversity indicators using multivariable generalised linear models. Second, we pooled country-specific associations using random-effects models. FINDINGS: The final analytic sample included 1735 women from Burkina Faso, 4450 women from India, 547 women from Malawi, and 574 women from Tanzania. Across all countries, compared with households in which women provided input into fewer productive decisions, households of women with greater input into productive decisions produced more food crops (mean difference 0·36 [95% CI 0·16-0·55]), a higher number of food groups (mean difference 0·16 [0·06-0·25]), and more nutrient-dense crops (percentage point difference 3 [95% CI 3-4]). Across all countries, each additional community group a woman actively participated in was associated with cultivating a higher number of food crops (mean difference 0·20 [0·04-0·35]) and a higher number of food groups (mean difference 0·11 [0·03-0·18]), but not more nutrient-dense crops. In pooled associations from Burkina Faso and India, asset ownership was associated with cultivating a higher number of food crops (mean difference 0·08 [0·04-0·12]) and a higher number of food groups (mean difference 0·05 [0·04-0·07]), but not more nutrient-dense crops. INTERPRETATION: Greater women's empowerment was associated with higher farm-level crop diversity among low-income agricultural households, suggesting that it could help enhance efforts to strengthen food system resilience. FUNDING: Bill & Melinda Gates Foundation.

Pregnancy pesticide exposure and child development in low- and middle-income countries: A prospective analysis of a birth cohort in rural Bangladesh and meta-analysis.

BACKGROUND: Despite considerable evidence on a negative association between pregnancy pesticide exposure and child development in high-income countries, evidence from low- and middle-income countries (LMICs) is limited. Therefore, we assessed associations between pregnancy pesticide exposure and child development in rural Bangladesh and summarised existing literature in a systematic review and meta-analysis. METHODS: We used data from 284 mother-child pairs participating in a birth cohort established in 2008. Eight urinary pesticide biomarkers were quantified in early pregnancy (mean gestational age 11.6±2.9 weeks) as an index of pesticide exposure. The Bayley Scales of Infant and Toddler Development, Third Edition were administered at 20-40 months of age. Associations between creatinine-adjusted urinary pesticide biomarker concentrations and child development scores were estimated using multivariable generalised linear models. We searched ten databases up to November 2021 to identify prospective studies on pregnancy pesticide exposure and child development conducted in LMICs. We used a random-effects model to pool similar studies, including our original analysis. The systematic review was pre-registered with PROSPERO: CRD42021292919. RESULTS: In the Bangladesh cohort, pregnancy 2-isopropyl-4-methyl-6-hydroxypyrimidine (IMPY) concentrations were inversely associated with motor development (-0.66 points [95% CI -1.23, -0.09]). Pregnancy 3,5,6-trichloro-2-pyridinol (TCPY) concentrations were inversely associated with cognitive development, but the association was small: -0.02 points (-0.04, 0.01). We observed no associations between 4-nitrophenol and 3-phenoxybenzoic acid (3-PBA) concentrations and child development. The systematic review included 13 studies from four LMICs. After pooling our results with one other study, we found consistent evidence that pregnancy 3-PBA concentrations were not associated with cognitive, language, or motor development. CONCLUSION: Evidence suggests that pregnancy exposure to some organophosphate pesticides is negatively associated with child development. Interventions to reduce in-utero pesticide exposure in LMICs may help protect child development.

Correction: Measurement tools and indicators for assessing nurturing care for early childhood development: A scoping review.

[This corrects the article DOI: 10.1371/journal.pgph.0000373.].

Analysis of Postdischarge Interventions for Children Treated for Moderate or Severe Wasting, Growth Faltering or Failure, or Edema: A Systematic Review.

Importance: Children treated for acute malnutrition remain at increased risk of relapse, infection, and mortality after programmatic recovery. Global guidelines for the management of acute malnutrition currently provide no recommendations to sustain recovery following treatment discharge. Objective: To inform guideline development by evaluating the evidence on postdischarge interventions to improve outcomes within 6 months after discharge. Evidence Review: In this systematic review, 8 databases were searched from inception through December 2021 and included randomized and quasi-experimental studies investigating interventions delivered after discharge from nutritional treatment for children aged 0 to 59 months. Outcomes were relapse, deterioration to severe wasting, readmission, sustained recovery, anthropometry, all-cause mortality, and morbidity within 6 months after discharge. The risk of bias was assessed using Cochrane tools, and the certainty of the evidence was evaluated with the GRADE approach. Findings: Of 7124 records identified, 8 studies, conducted in 7 countries between 2003 and 2019 with 5965 participants, were included. The study interventions included antibiotic prophylaxis (n = 1), zinc supplementation (n = 1), food supplementation (n = 2), psychosocial stimulation (n = 3), unconditional cash transfers (n = 1), and an integrated biomedical, food supplementation, and malaria prevention package (n = 1). Risk of bias was moderate or high for half the studies. Only unconditional cash transfers were associated with reduced relapse, while the integrated package was associated with improved sustained recovery. Zinc supplementation, food supplementation, psychosocial stimulation, and unconditional cash transfers were associated with improvements in postdischarge anthropometry, while zinc supplementation was associated with reductions in multiple postdischarge morbidities. Conclusions and Relevance: In this systematic review of postdischarge interventions to reduce relapse and improve other postdischarge outcomes among children treated for acute malnutrition, evidence was limited. Biomedical, cash, and integrated interventions showed promise in improving certain postdischarge outcomes for children treated for moderate or severe acute malnutrition in single studies. Further evidence on the efficacy, effectiveness, and operational feasibility of postdischarge interventions in other contexts is needed to inform global guidance development.

Co-Benefits of Largescale Organic farming On huMan health (BLOOM): Protocol for a cluster-randomised controlled evaluation of the Andhra Pradesh Community-managed Natural Farming programme in India.

The BLOOM study (co-Benefits of Largescale Organic farming On huMan health) aims to determine if a government-implemented agroecology programme reduces pesticide exposure and improves dietary diversity in agricultural households. To achieve this aim, a community-based, cluster-randomised controlled evaluation of the Andhra Pradesh Community-managed Natural Farming (APCNF) programme will be conducted in 80 clusters (40 intervention and 40 control) across four districts of Andhra Pradesh state in south India. Approximately 34 households per cluster will be randomly selected for screening and enrolment into the evaluation at baseline. The two primary outcomes, measured 12 months post-baseline assessment, are urinary pesticide metabolites in a 15% random subsample of participants and dietary diversity in all participants. Both primary outcomes will be measured in (1) adult men ≥18 years old, (2) adult women ≥18 years old, and (3) children <38 months old at enrolment. Secondary outcomes measured in the same households include crop yields, household income, adult anthropometry, anaemia, glycaemia, kidney function, musculoskeletal pain, clinical symptoms, depressive symptoms, women's empowerment, and child growth and development. Analysis will be on an intention-to-treat basis with an a priori secondary analysis to estimate the per-protocol effect of APCNF on the outcomes. The BLOOM study will provide robust evidence of the impact of a large-scale, transformational government-implemented agroecology programme on pesticide exposure and dietary diversity in agricultural households. It will also provide the first evidence of the nutritional, developmental, and health co-benefits of adopting agroecology, inclusive of malnourishment as well as common chronic diseases. Trial registration: Study registration: ISRCTN 11819073 (https://doi.org/10.1186/ISRCTN11819073). Clinical Trial Registry of India CTRI/2021/08/035434.

Maternal and paternal employment in agriculture and early childhood development: A cross-sectional analysis of Demographic and Health Survey data.

Considerable literature from low- and lower-middle-income countries (LLMICs) links maternal employment to child nutritional status. However, less is known about the role of parental employment and occupation type in shaping child development outcomes. Additionally, little empirical work has examined the mechanisms through which parental occupation influences child outcomes. Our objective was to investigate the associations between maternal and paternal employment (comparing agricultural and non-agricultural employment) and child development and to examine childcare practices and women's empowerment as potential mechanisms. We pooled nine Demographic and Health Surveys (Benin, Burundi, Cambodia, Congo, Haiti, Rwanda, Senegal, Togo, and Uganda) with data on 8,516 children aged 36-59 months. We used generalised linear models to estimate associations between parental employment and child development, child stimulation (number of activities provided by the mother, father, and other household members), child supervision (not left alone or with older child for >1 hour), early childhood care and education programme (ECCE) attendance, and women's empowerment. In our sample, all fathers and 85% of mothers were employed. In 40% of families, both parents were employed in agriculture. After adjusting for child, parental and household confounders, we found that parental agricultural employment, relative to non-agricultural employment, was associated with poorer child development (relative risk (RR) 0.86 (95% CI 0.80, 0.92), more child stimulation provided by other household members (mean difference (MD) 0.26 (95% CI 0.09, 0.42)), less adequate child supervision (RR, 0.83 (95% 0.78, 0.80)), less ECCE attendance (RR 0.46 (95% CI 0.39, 0.54)), and lower women's empowerment (MD -1.01 (95% CI -1.18, -0.84)). Parental agricultural employment may be an important risk factor for early childhood development. More research using more comprehensive exposure and outcome measures is needed to unpack these complex relationships and to inform interventions and policies to support working parents in the agricultural sector with young children.

Pesticide exposure and child growth in low- and middle-income countries: A systematic review.

BACKGROUND: In low- and middle-income countries (LMICs), pesticides are widely used in agricultural and residential settings. Little is known about how pesticides affect child growth. OBJECTIVES: To systematically review and synthesise the evidence on the associations between pesticide exposure and adverse birth outcomes and/or impaired postnatal growth in children up to 5 years of age in LMICs. METHODS: We searched 10 databases from inception through November 2021. We included cohort and cross-sectional studies investigating associations between self-reported or measured prenatal or postnatal pesticide exposure and child growth (postnatal child linear/ponderal growth, and/or birth outcomes). Two researchers screened studies, extracted data, and assessed certainty using GRADE. The protocol was preregistered with PROSPERO (CRD42021292919). RESULTS: Of 939 records retrieved, 31 studies met inclusion criteria (11 cohort, 20 cross-sectional). All studies assessed prenatal exposure. Twenty-four studies reported on birth weight. Four found positive associations with organochlorines (0.01-0.25 standardised mean difference (SMD)) and two found negative associations (-0.009 SMD to -55 g). Negative associations with organophosphates (-170 g, n = 1) and pyrethroids (-97 to -233 g, n = 2) were also documented. Two (out of 15) studies reporting on birth length found positive associations with organochlorines (0.21-0.25 SMD) and one found negative associations (-0.25 to -0.32 SMD). Organophosphate exposure was negatively associated with birth length (-0.37 cm, n = 1). Organophosphate exposure was also associated with higher risk/prevalence of low birth weight (2 out of nine studies) and preterm birth (2 out of six studies). Certainty of the evidence was "very low" for all outcomes. CONCLUSION: The limited literature from LMICs shows inconclusive associations between prenatal pesticide exposure, child growth, and birth outcomes. Studies with accurate quantitative data on exposure to commonly used pesticides in LMICs using consistent methodologies in comparable populations are needed to better understand how pesticides influence child growth.

Investigating the direct and indirect associations between birth intervals and child growth and development: A cross-sectional analysis of 13 Demographic and Health Surveys.

There is considerable literature on the associations of short birth intervals with adverse perinatal outcomes. However, less is known about the associations with child growth and development. In this study, we investigated the associations between birth intervals and child growth and development and examined child illness, child diet, and maternal stimulation as potential mechanisms. We pooled Demographic and Health Survey data on 8300 children aged 36-59 months from 13 countries (Benin, Burundi, Cambodia, Cameroon, Chad, Congo, Haiti, Honduras, Rwanda, Senegal, Timor-Leste, Togo, and Uganda). Longer birth interval was defined as a preceding birth interval ≥33 months. Child growth was assessed using height-for-age Z-score (HAZ). Child cognitive and socio-emotional development were measured using the Early Childhood Development Index. Child morbidity was defined as any illness in the past two weeks. Child diet was assessed using dietary diversity score and maternal stimulation by the number of stimulation activities. We used generalised linear models to estimate associations between longer birth intervals and child growth and development. Structural equation modelling was used to assess direct and indirect effects. In our sample, 44% of children had a preceding birth interval ≥33 months, 42% were stunted, 25% were cognitively off-track, and 33% socio-emotionally off-track. Longer birth intervals were associated with higher HAZ (mean difference 0.23 (95% CI 0.14, 0.32)) and socio-emotional development (relative risk (RR) 1.04 (95% CI 1.00, 1.09), but not cognitive development (RR 1.02 (95% CI 0.98, 1.06). We observed no significant indirect effects via child illness, child dietary diversity, or maternal stimulation. Although longer birth intervals were beneficial for child growth and socio-emotional development, we found no empirical support for the biological and behavioural mechanisms we explored. Additional research is needed to investigate alternative mechanisms to elucidate underlying processes and inform future interventions.

Burden and risk factors for relapse following successful treatment of uncomplicated severe acute malnutrition in young children: Secondary analysis from a randomised trial in Niger.

This study aimed to quantify the burden of relapse following successful treatment for uncomplicated severe acute malnutrition (SAM) and to identify associated risk factors in rural Niger. We used data from 1490 children aged 6-59 months discharged as recovered from an outpatient nutritional programme for SAM and followed for up to 12 weeks after admission. Postdischarge SAM relapse was defined as weight-for-height Z-score <-3, mid-upper arm circumference (MUAC) <115 mm or bipedal oedema after having been discharged as recovered. Postdischarge hospitalisation was defined as admission to inpatient SAM treatment or hospitalisation for any cause after having been discharged as recovered. We used multivariate log-binomial models to identify independent risk factors. After programmatic discharge, 114 (8%) children relapsed to SAM and 89 (6%) were hospitalised. Factors associated with SAM relapse were discharge during the lean season (relative risk [RR] = 1.80 [95% confidence interval [CI] = 1.22-2.67]) and larger household size (RR = 1.56 [95% CI = 1.01-2.41]), whereas older child age (RR = 0.94 [95% CI = 0.88-1.00]), higher child MUAC at discharge (RR = 0.93 [95% CI = 0.87-1.00]) and maternal literacy (RR = 0.54 [95% CI = 0.29-0.98]) were protective factors. Discharge during the lean season (RR = 2.27 [95% CI = 1.46-3.51]) was independently associated with postdischarge hospitalisation. Future nutritional programmes in the context of Niger may consider modification of anthropometric discharge criteria or the provision of additional home support or follow-up during the lean season as potential interventions to prevent relapse. More research including postdischarge follow-up is needed to better understand the sustainability of treatment outcomes after discharge and the type of intervention that may best sustain recovery over time. Clinical Trial Registration: ClinicalTrials.gov number, NCT01613547.

Evaluation of multiple micronutrient supplementation and medium-quantity lipid-based nutrient supplementation in pregnancy on child development in rural Niger: A secondary analysis of a cluster randomized controlled trial.

BACKGROUND: It is estimated that over 250 million children under 5 years of age in low- and middle-income countries (LMICs) do not reach their full developmental potential. Poor maternal diet, anemia, and micronutrient deficiencies during pregnancy are associated with suboptimal neurodevelopmental outcomes in children. However, the effect of prenatal macronutrient and micronutrient supplementation on child development in LMIC settings remains unclear due to limited evidence from randomized trials. METHODS AND FINDINGS: We conducted a 3-arm cluster-randomized trial (n = 53 clusters) that evaluated the efficacy of (1) prenatal multiple micronutrient supplementation (MMS; n = 18 clusters) and (2) lipid-based nutrient supplementation (LNS; n = 18 clusters) as compared to (3) routine iron-folic acid (IFA) supplementation (n = 17 clusters) among pregnant women in the rural district of Madarounfa, Niger, from March 2015 to August 2019 (ClinicalTrials.gov identifier NCT02145000). Children were followed until 2 years of age, and the Bayley Scales of Infant and Toddler Development III (BSID-III) were administered to children every 3 months from 6 to 24 months of age. Maternal report of WHO gross motor milestone achievement was assessed monthly from 3 to 24 months of age. An intention-to-treat analysis was followed. Child BSID-III data were available for 559, 492, and 581 singleton children in the MMS, LNS, and IFA groups, respectively. Child WHO motor milestone data were available for 691, 781, and 753 singleton children in the MMS, LNS, and IFA groups, respectively. Prenatal MMS had no effect on child BSID-III cognitive (standardized mean difference [SMD]: 0.21; 95% CI: -0.20, 0.62; p = 0.32), language (SMD: 0.16; 95% CI: -0.30, 0.61; p = 0.50) or motor scores (SMD: 0.18; 95% CI: -0.39, 0.74; p = 0.54) or on time to achievement of the WHO gross motor milestones as compared to IFA. Prenatal LNS had no effect on child BSID-III cognitive (SMD: 0.17; 95% CI: -0.15, 0.49; p = 0.29), language (SMD: 0.11; 95% CI: -0.22, 0.44; p = 0.53) or motor scores (SMD: -0.04; 95% CI: -0.46, 0.37; p = 0.85) at the 24-month endline visit as compared to IFA. However, the trajectory of BSID-III cognitive scores during the first 2 years of life differed between the groups with children in the LNS group having higher cognitive scores at 18 and 21 months (approximately 0.35 SD) as compared to the IFA group (p-value for difference in trajectory <0.001). Children whose mothers received LNS also had earlier achievement of sitting alone (hazard ratio [HR]: 1.57; 95% CI: 1.10 to 2.24; p = 0.01) and walking alone (1.52; 95% CI: 1.14 to 2.03; p = 0.004) as compared to IFA, but there was no effect on time to achievement of other motor milestones. A limitation of our study is that we assessed child development up to 2 years of age, and, therefore, we may have not captured effects that are easier to detect or emerge at older ages. CONCLUSIONS: There was no benefit of prenatal MMS on child development outcomes up to 2 years of age as compared to IFA. There was evidence of an apparent positive effect of prenatal LNS on cognitive development trajectory and time to achievement of selected gross motor milestones. TRIAL REGISTRATION: ClinicalTrials.gov NCT02145000.

Are home gardening programs a sustainable way to improve nutrition? Lessons from a cluster-randomized controlled trial in Rufiji, Tanzania.

Homestead food production (HFP) programs may improve diet and nutrition outcomes by increasing availability of nutrient dense foods such as vegetables and supporting livelihoods. We conducted a pair-matched cluster-randomized controlled trial to investigate whether vegetable home gardens could improve women's dietary diversity, household food security, maternal and child iron status, and the probability of women consuming nutrient-rich food groups. We enrolled 1,006 women of reproductive age (18-49 years) in ten villages in Pwani Region, Eastern Tanzania, matched the villages into pairs according to village characteristics, and randomly allocated villages to intervention or control. Households in the intervention villages received agricultural training, inputs to promote home production of nutritious crops, and nutrition and health education. Data were collected in 2016, 2017, and 2019 and analyzed using linear regression models with propensity score weighting adjusting for individual-level confounders, differential loss to follow-up, and fixed effects for village pairs to accommodate the pair-matched design. Results after one year of the intervention (previously published) found significant improvements in dietary diversity. However, three years after the start of the intervention the difference in dietary diversity disappeared, even though the number of women who grew at least one crop was significantly higher (75 percentage points, 95% CI: 72, 81) in treatment households compared to controls. Barriers to maintaining a home garden, including lack of irrigation opportunities and fencing materials, and social disruption may have precluded sustained impacts from home gardening in this context. Future home garden programs should carefully consider mechanisms and investments needed for sustained impact over time.

Four-Year Effects of a 2-Year Nutrition and Gender Sensitive Agricultural Program on Women's Nutritional Status, Knowledge, and Empowerment in Rural Burkina Faso.

BACKGROUND: Little is known about the sustained effects of nutrition- and gender-sensitive agricultural programs (NSAPs) after they end. OBJECTIVES: To examine the 4-year effects (2010-2014) of a 2-year NSAP (2010-2012) on women's outcomes in rural Burkina Faso. METHODS: We used baseline (2010) and endline (2012) data from a cluster-randomized controlled trial of Helen Keller International's Enhanced Homestead Food Production (EHFP) program and baseline (2014) data from a new program. We included 134 women: 82 who participated in the 2-year EHFP program (treatment) and 52 who did not (control). We examined program (2010-2012), post-program (2012-2014), and overall 4-year effects (2010-2014) using difference-in-difference analysis (DID). RESULTS: We found significant positive program effects (2010-2012) on women's underweight prevalence (DID: 16.44 percentage points [pp]; P = .09) and on women's knowledge about appropriate age to introduce liquids (DID: 28.40 pp; P = .01). Although there were no significant postprogram effects (2012-2014), differences found in 2012 between the treatment and control group were sustained resulting in an overall 4-year (2010-2014) reduction in women's underweight prevalence (DID: 18.26 pp; P = .02) and an improvement in women's knowledge about appropriate age to introduce liquids (DID: 31.29 pp; P = .02). We observed no postprogram or overall 4-year effects on women's knowledge of child feeding and handwashing practices or women's empowerment. CONCLUSIONS: Nutrition- and gender-sensitive agricultural programs demonstrate potential for sustained improvements in women's nutritional status and nutritional knowledge. Postprogram assessments of NSAPs should be embedded in program evaluations to help further understand the potential of NSAPs to generate sustainable impacts on women's outcomes.

Effects of COVID-19 on child health services utilization and delivery in rural Mozambique: a qualitative study.

Little is known about the COVID-19 pandemic-related disruptions in health services and the resilience of the health system response in rural low-resource settings. We conducted a phenomenological qualitative study (October-November 2020) to understand COVID-19-related influences on the utilization and delivery of child health services in Monapo district, rural Mozambique. We interviewed 36 caregivers with children <2.5 years, 21 health providers and 4 district health services staff using in-person in-depth interviews. Data were analysed using inductive thematic content analysis. Our findings showed that caregivers, providers and district health services staff unanimously reported a decrease in child consultations at the start of the pandemic. Administrative data from health facilities confirmed persisting declines in monthly consultations. Respondents explained reductions due to miscommunication about health facility operations, fear of COVID-19, reduced consultation schedules and reduced household incomes. Providers reported several challenges in delivering services including lack of caregiver compliance with risk mitigation measures, caregivers' fear of risk mitigation measures, perceived lack of caregiver knowledge about COVID-19 and lack of supplies and protective equipment. All respondents described how COVID-19 had increased food insecurity and food prices and reduced incomes and livelihoods. These negative economic consequences were perceived as the main reason for reported increases in cases of child malnutrition. Despite reductions, child health service utilization and delivery have largely continued throughout the COVID-19 pandemic, indicating an adaptive and resilient primary health system response in Monapo district. Our findings highlighted the persistent difficulties providers and caregivers face adhering to COVID-19 prevention and risk mitigation measures. A coordinated multi-sectoral response is needed to address the persistent negative economic impacts of the pandemic for young children and their families in rural areas.

Birth weight and adult earnings: a systematic review and meta-analysis.

While substantial evidence has identified low birth weight (LBW; <2500 g) as a risk factor for early life morbidity, mortality and poor childhood development, relatively little is known on the links between birth weight and economic outcomes in adulthood. The objective of this study was to systematically review the economics (EconLit) and biomedical literature (Medline) and estimate the pooled association between birth weight and adult earnings. A total of 15 studies from mostly high-income countries were included. On average, each standard deviation increase in birth weight was associated with a 2.75% increase in annual earnings [(95% CI: 1.44 to 4.07); 9 estimates]. A negative, but not statistically significant, association was found between being born LBW and earnings, compared to individuals not born LBW [mean difference: -3.41% (95% CI: -7.55 to 0.73); 7 estimates]. No studies from low-income countries were identified and all studies were observational. Overall, birth weight was consistently associated with adult earnings, and therefore, interventions that improve birth weight may provide beneficial effects on adult economic outcomes.

Prenatal supplementation with multiple micronutrient supplements or medium-quantity lipid-based nutrient supplements has limited effects on child growth up to 24 months in rural Niger: a secondary analysis of a cluster randomized trial.

BACKGROUND: Prenatal multiple micronutrient supplementation (MMS) and lipid-based nutrient supplementation (LNS) can improve birth outcomes relative to iron-folic acid supplementation (IFA); however, effects on child postnatal growth remain unclear. OBJECTIVES: The aim was to compare the effect of prenatal MMS, medium-quantity LNS (MQ-LNS), and IFA on child growth up to 2 y of age. METHODS: We conducted a cluster randomized controlled trial of prenatal nutritional supplementation in Madarounfa, Niger. Villages were randomly assigned for pregnant women to receive IFA (17 villages, 1105 women), MMS (18 villages, 1083 women) or MQ-LNS (18 villages, 1144 women). Pregnant women received nutritional supplements weekly until delivery, and children were followed up monthly from 6-8 wk to 24 mo of age. We assessed the effect of prenatal MMS and MQ-LNS compared with IFA and the effect of prenatal MMS compared with MQ-LNS on child length-for-age z scores (LAZ), weight-for-age z scores (WAZ), and weight-for-length z scores (WLZ) at 24 mo of age using generalized linear models. In secondary analyses, we used mixed-effects models to assess the trajectories of anthropometric z scores longitudinally from 6-8 wk to 24 mo. RESULTS: Compared with IFA, MMS and MQ-LNS had no effect on child LAZ, WAZ, or WLZ at 24 mo of age (P > 0.05). Children in the MQ-LNS arm had significantly higher mid-upper arm circumference at 24 mo than children in the MMS arm: mean difference 0.50 cm (95% CI 0.10, 0.91 cm). WAZ and WLZ trajectories were more negative in the MQ-LNS arm compared with IFA and MMS, with lower z scores from 14 to 20 mo of age. However, WAZ and WLZ trajectories converged after 20 mo of age, and there were no differences by 24 mo of age. CONCLUSIONS: Prenatal MMS and MQ-LNS had limited effect on anthropometric measures of child growth up to 24 mo of age as compared with IFA in rural Niger.

Child diet and mother-child interactions mediate intervention effects on child growth and development.

This study examined whether child diet and mother-child interactions mediated the effects of a responsive stimulation and nutrition intervention delivered from 2009 to 2012 to 1324 children aged 0-24 months living in rural Pakistan. Results showed that the intervention improved children's cognitive, language and motor development through child diet and mother-child interactions. Although the intervention did not improve child growth or socio-emotional development, we observed positive indirect effects on child growth via child diet and on socio-emotional development via both child diet and mother-child interactions. In addition, child diet emerged as a shared mechanism to improve both child growth and development, whereas mother-child interactions emerged as a distinct mechanism to improve child development. Nevertheless, our results suggest the two mechanisms were mutually reinforcing and that interventions leveraging both mechanisms are likely to be more effective at improving child outcomes than interventions leveraging only one of these mechanisms.

Diet and development among children aged 36-59 months in low-income countries.

OBJECTIVE: To assess the associations between diet, stimulation and development among children 36-59 months of age in low-income and middle-income countries (LMICs). DESIGN: We pooled Demographic and Health Survey data on 12 126 children aged 36-59 months from 15 LMICs. Child diet indicators included dietary diversity score (DDS, range 0-7), minimum dietary diversity (MDD, defined as DDS ≥4) and animal source foods (ASFs) consumption. Child development was assessed using the Early Childhood Development Index and stimulation by the number of stimulation activities (range 0-6). Associations were assessed using generalised linear models. RESULTS: In our sample, 18% of children met MDD and 50% received ≥4 stimulation activities. The prevalence of suboptimal cognitive, socioemotional, literacy-numeracy and physical development was 24%, 32%, 87% and 11%, respectively. Higher DDS, meeting MDD and consuming ASFs were associated with 8%-13% more stimulation activities. Children who met MDD were slightly less likely to have suboptimal literacy-numeracy development compared with children who did not meet MDD: relative risk 0.97 (95% CI 0.95 to 1.00). DDS, meeting MDD and ASFs consumption were not associated with cognitive, socioemotional or physical development. However, there was evidence of positive associations between MDD and cognitive and literacy-numeracy development among subgroups of children, including those who received ≥4 stimulation activities or attended an early childhood care and education programme. CONCLUSIONS: Child diet was associated with more stimulation activities. However, independent of stimulation, socioeconomic status and other factors, child diet appeared to be a prominent determinant only of literacy-numeracy development among children 36-59 months of age.

A pilot to promote early child development within health systems in Mozambique: a qualitative evaluation.

Health systems offer unique opportunities for integrating services to promote early child development (ECD). However, there is limited knowledge about the implementation experiences of using health services to target nurturing care and ECD, especially in sub-Saharan Africa. We conducted a qualitative implementation evaluation to assess the delivery, acceptability, perceived changes, and barriers and facilitators associated with a pilot strategy that integrated developmental monitoring, nutritional screening, and early learning and nutrition counseling into the existing health facility, and community-based services for young children in rural Mozambique. We completed individual interviews with caregivers (N = 36), providers (N = 27), and district stakeholders (N = 10), and nine facility observational visits at three primary health facilities in October-November 2020. We analyzed data using thematic content analysis. Results supported fidelity to the intended pilot model and acceptability of nurturing care services. Respondents expressed various program benefits, including strengthened health system capacity and improved knowledge, attitudes, and practices regarding nurturing care and ECD. Government leadership and supportive supervision were key facilitators, whereas health system resource constraints were key barriers. We conclude that health systems are promising platforms for supporting ECD and discuss several programmatic recommendations for enhancing service delivery and maximizing potential impacts on nurturing care and ECD outcomes.