A simulation study to improve calcium intake through wheat flour fortification.

OBJECTIVE: to simulate the impact on calcium intake- effectiveness and safety- of fortifying wheat flour with 200, 400 and 500 mg of calcium per 100 g of flour. DESIGN: secondary analysis of cross-sectional data collected through repeated 24-hour dietary recalls using IOWA the Intake Modelling, Assessment and Planning Program. SETTING: urban cities in the National Health and Nutrition Survey of Argentina (ENNyS 2018 - 2019). PARTICIPANTS: 21358 participants, including children, adolescents, and adults. RESULTS: Most individuals in all age groups reported consuming wheat flour. The prevalence of low calcium intake was above 80% in individuals older than 9 years. Simulating the fortification of 500 mg of calcium per 100 g of wheat flour showed that the prevalence of low calcium intake could be reduced by more than 40 percentage points in girls and women aged 19 to less than 51 and boys and men aged 4 to less than 71, while it remained above 65% in older ages. The percentages above the upper intake level remained below 1.5% in all age groups. CONCLUSIONS: Calcium flour fortification could be further explored to improve calcium intake. Subnational simulations could be performed to identify groups that might not be reached by this strategy that could be explored in Argentina. This analysis could be used to advocate for a strategy to fortify wheat flour.

Calcium supplementation for people with overweight or obesity.

BACKGROUND: Obesity is a major health problem worldwide as it can lead to high blood pressure, heart disease, stroke, diabetes, and insulin resistance. The prevalence of overweight and obesity is increasing worldwide across different age groups. There is evidence of an inverse relationship between calcium intake and body weight. The clinical relevance of a small reduction in body weight has been questioned. However, at a population level, a small effect could mitigate the observed global trends. OBJECTIVES: To assess the effects of calcium supplementation on weight loss in individuals living with overweight or obesity. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, LILACS (Latin American and Caribbean Health Science Information database), and two clinical trials registries. The date of the last search of all databases (except Embase) was 10 May 2023. No language restrictions were applied. SELECTION CRITERIA: We included randomised controlled trials evaluating the effect of calcium in participants with overweight or obesity of any age or gender. We excluded studies in participants with absorption problems. We included studies of any dose with a minimum duration of two months. We included the following comparisons: calcium supplementation versus placebo, calcium-fortified food or beverage versus placebo, or calcium-fortified food or beverage versus non-calcium-fortified food or beverage. We excluded studies that evaluated the effect of calcium and vitamin D or mixed minerals compared to placebo. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcomes were body weight, health-related quality of life, and adverse events. Our secondary outcomes were anthropometric measures other than body weight, all-cause mortality, and morbidity. MAIN RESULTS: We found 18 studies that evaluated the effect of calcium compared to placebo or control, with a total of 1873 randomised participants (950 participants in the calcium supplementation groups and 923 in the control groups). All included studies gave oral calcium supplementation as the intervention. We did not find any studies evaluating calcium-fortified foods. We excluded 38 studies, identified four ongoing studies, and listed one study as 'awaiting classification'. Sixteen studies compared calcium supplementation to placebo; two studies compared different doses of calcium supplementation. Doses ranged from very low (0.162 g of calcium/day) to high (1.5 g of calcium/day). Most studies were performed in the USA and Iran, lasted less than six months, and included only women. Low-certainty evidence suggests that calcium supplementation compared to placebo or control may result in little to no difference in body weight (mean difference (MD) -0.15 kg, 95% confidence interval (CI) -0.55 to 0.24; P = 0.45, I2 = 46%; 17 studies, 1317 participants; low-certainty evidence). We downgraded the certainty of the evidence by two levels for risk of bias and heterogeneity. None of the included studies reported health-related quality of life, all-cause mortality, or morbidity/complications as outcomes. Only five studies assessed or reported adverse events. Low-certainty evidence suggests a low frequency of adverse events, with no clear difference between intervention and control groups. Moderate-certainty evidence shows that calcium supplementation compared to placebo or control probably results in a small reduction in body mass index (BMI) (MD -0.18 kg/m2,95% CI -0.22 to -0.13; P < 0.001, I2 = 0%; 9 studies, 731 participants) and waist circumference (MD -0.51 cm, 95% CI -0.72 to -0.29; P < 0.001, I2 = 0%; 6 studies, 273 participants). Low-certainty evidence suggests that calcium supplementation compared to placebo or control may result in a small reduction in body fat mass (MD -0.34 kg, 95% CI -0.73 to 0.05; P < 0.001, I2 = 97%; 12 studies, 812 participants). AUTHORS' CONCLUSIONS: Calcium supplementation for eight weeks to 24 months may result in little to no difference in body weight in people with overweight or obesity. The current evidence is of low certainty, due to concerns regarding risk of bias and statistical heterogeneity. We found that the degree of heterogeneity might be partly explained by calcium dosage, the presence or absence of a co-intervention, and whether an intention-to-treat analysis was pursued. While our analyses suggest that calcium supplementation may result in a small reduction in BMI, waist circumference, and fat mass, this evidence is of low to moderate certainty. Future studies could investigate the effect of calcium supplementation on lean body mass to explore if there is a change in body composition.

Consumo de alimentos ultraprocesados en niños entre 6 y 23 meses según la Segunda Encuesta Nacional de Nutrición y Salud de Argentina / Consumption of ultra-processed foods among children aged 6 to 23 months as per the Second National Survey on Nutrition and Health of Argentina

Introducción. Contar con los datos del consumo de alimentos ultraprocesados en los niños resulta importante para planificar políticas públicas. Objetivos. Describir la prevalencia de consumo de alimentos ultraprocesados en menores de 2 años e identificar factores asociados. Describir la proporción que los alimentos ultraprocesados representan del número total de los alimentos consumidos en el día. Métodos. Análisis secundario de los datos de niños entre 6 y 23 meses de edad con al menos un recordatorio de 24 horas de consumo de alimentos de la Segunda Encuesta Nacional de Nutrición y Salud de Argentina del año 2018. Se estudiaron como variables principales: "consumo de alimentos ultraprocesados" (según el sistema NOVA) categorizada en sí/no y la "proporción de ultraprocesados del total de alimentos consumidos". Los factores asociados explorados fueron lactancia materna, sexo, edad y el número de alimentos no ultraprocesados consumidos. Se realizó un modelo de regresión logística multivariable y se aplicó un factor de expansión para ponderar los datos. Resultados. Se incluyeron 4224 niños (ponderado 908 104). La prevalencia de consumo de ultraprocesados fue del 90,8 % (IC95%: 89,5-92) y fue asociado con mayor edad (OR 3,21; IC95% 2,28-4,52) y con el número de alimentos no ultraprocesados consumidos (OR 1,17; IC95% 1,13-1,23). Los ultraprocesados representaron una mediana del 20 % (RIC: 12,5-28,6 %) del total de alimentos consumidos en el día. Conclusiones. Este estudio señala la alta penetración de los alimentos ultraprocesados en la alimentación complementaria.

Introduction. The availability of data on the consumption of ultra-processed foods among children is important for planning public policies. Objectives. To describe the prevalence of consumption of ultra-processed foods in children under 2 years of age and identify associated factors. To describe the proportion that ultra-processed foods represent out of the total number of foods consumed in a day. Methods. Secondary analysis of data from children aged 6­23 months with at least a 24-hour recall of food consumption based on the Second National Survey on Nutrition and Health of Argentina (2018). The following primary variables were studied: "consumption of ultra-processed foods" (according to the NOVA system) categorized into yes/no and "proportion of ultra-processed out of total foods consumed." The following associated factors were studied: breastfeeding, sex, age, and number of non-ultra-processed foods consumed. A multivariate logistic regression model was developed and an expansion factor was applied to weight the data. Results. A total of 4224 children were included (weighed: 908 104). The prevalence of ultra-processed food consumption was 90.8% (95% CI: 89.5­92) and was associated with an older age (OR: 3.21, 95% CI: 2.28­4.52) and the number of non-ultra-processed foods consumed (OR: 1.17, 95% CI: 1.13­1.23). Ultra-processed foods accounted for a median 20% (IQR: 12.5­28.6%) of all foods consumed in a day. Conclusions. This study highlights the high penetration of ultra-processed foods in complementary feeding.

Consumption of ultra-processed foods among children aged 6 to 23 months as per the Second National Survey on Nutrition and Health of Argentina. / Consumo de alimentos ultraprocesados en niños entre 6 y 23 meses según la Segunda Encuesta Nacional de Nutrición y Salud de Argentina.

Introduction. The availability of data on the consumption of ultra-processed foods among children is important for planning public policies. Objectives. To describe the prevalence of consumption of ultra-processed foods in children under 2 years of age and identify associated factors. To describe the proportion that ultra-processed foods represent out of the total number of foods consumed in a day. Methods. Secondary analysis of data from children aged 6-23 months with at least a 24-hour recall of food consumption based on the Second National Survey on Nutrition and Health of Argentina (2018). The following primary variables were studied: "consumption of ultra-processed foods" (according to the NOVA system) categorized into yes/no and "proportion of ultra-processed out of total foods consumed." The following associated factors were studied: breastfeeding, sex, age, and number of non-ultra-processed foods consumed. A multivariate logistic regression model was developed and an expansion factor was applied to weight the data. Results. A total of 4224 children were included (weighed: 908 104). The prevalence of ultra-processed food consumption was 90.8% (95% CI: 89.5-92) and was associated with an older age (OR: 3.21, 95% CI: 2.28-4.52) and the number of non-ultra-processed foods consumed (OR: 1.17, 95% CI: 1.13-1.23). Ultra-processed foods accounted for a median 20% (IQR: 12.5-28.6%) of all foods consumed in a day. Conclusions. This study highlights the high penetration of ultra-processed foods in complementary feeding.

Introducción. Contar con los datos del consumo de alimentos ultraprocesados en los niños resulta importante para planificar políticas públicas. Objetivos. Describir la prevalencia de consumo de alimentos ultraprocesados en menores de 2 años e identificar factores asociados. Describir la proporción que los alimentos ultraprocesados representan del número total de los alimentos consumidos en el día. Métodos. Análisis secundario de los datos de niños entre 6 y 23 meses de edad con al menos un recordatorio de 24 horas de consumo de alimentos de la Segunda Encuesta Nacional de Nutrición y Salud de Argentina del año 2018. Se estudiaron como variables principales: "consumo de alimentos ultraprocesados" (según el sistema NOVA) categorizada en sí/no y la "proporción de ultraprocesados del total de alimentos consumidos". Los factores asociados explorados fueron lactancia materna, sexo, edad y el número de alimentos no ultraprocesados consumidos. Se realizó un modelo de regresión logística multivariable y se aplicó un factor de expansión para ponderar los datos. Resultados. Se incluyeron 4224 niños (ponderado 908 104). La prevalencia de consumo de ultraprocesados fue del 90,8 % (IC95%: 89,5-92) y fue asociado con mayor edad (OR 3,21; IC95% 2,28-4,52) y con el número de alimentos no ultraprocesados consumidos (OR 1,17; IC95% 1,13-1,23). Los ultraprocesados representaron una mediana del 20 % (RIC: 12,5-28,6 %) del total de alimentos consumidos en el día. Conclusiones. Este estudio señala la alta penetración de los alimentos ultraprocesados en la alimentación complementaria.

Factors affecting the implementation of calcium supplementation strategies during pregnancy to prevent pre-eclampsia: a mixed-methods systematic review.

OBJECTIVES: Daily calcium supplements are recommended for pregnant women from 20 weeks' gestation to prevent pre-eclampsia in populations with low dietary calcium intake. We aimed to improve understanding of barriers and facilitators for calcium supplement intake during pregnancy to prevent pre-eclampsia. DESIGN: Mixed-method systematic review, with confidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations-Confidence in the Evidence from Reviews of Qualitative research approach. DATA SOURCES: MEDLINE and EMBASE (via Ovid), CINAHL and Global Health (via EBSCO) and grey literature databases were searched up to 17 September 2022. ELIGIBILITY CRITERIA: We included primary qualitative, quantitative and mixed-methods studies reporting implementation or use of calcium supplements during pregnancy, excluding calcium fortification and non-primary studies. No restrictions were imposed on settings, language or publication date. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data and assessed risk of bias. We analysed the qualitative data using thematic synthesis, and quantitative findings were thematically mapped to qualitative findings. We then mapped the results to behavioural change frameworks to identify barriers and facilitators. RESULTS: Eighteen reports from nine studies were included in this review. Women reported barriers to consuming calcium supplements included limited knowledge about calcium supplements and pre-eclampsia, fears and experiences of side effects, varying preferences for tablets, dosing, working schedules, being away from home and taking other supplements. Receiving information regarding pre-eclampsia and safety of calcium supplement use from reliable sources, alternative dosing options, supplement reminders, early antenatal care, free supplements and support from families and communities were reported as facilitators. Healthcare providers felt that consistent messaging about benefits and risks of calcium, training, and ensuring adequate staffing and calcium supply is available would be able to help them in promoting calcium. CONCLUSION: Relevant stakeholders should consider the identified barriers and facilitators when formulating interventions and policies on calcium supplement use. These review findings can inform implementation to ensure effective and equitable provision and scale-up of calcium interventions. PROSPERO REGISTRATION NUMBER: CRD42021239143.

Stillbirths: Contribution of preterm birth and size-for-gestational age for 125.4 million total births from nationwide records in 13 countries, 2000-2020.

OBJECTIVE: To examine the contribution of preterm birth and size-for-gestational age in stillbirths using six 'newborn types'. DESIGN: Population-based multi-country analyses. SETTING: Births collected through routine data systems in 13 countries. SAMPLE: 125 419 255 total births from 22+0 to 44+6 weeks' gestation identified from 2000 to 2020. METHODS: We included 635 107 stillbirths from 22+0 weeks' gestation from 13 countries. We classified all births, including stillbirths, into six 'newborn types' based on gestational age information (preterm, PT, <37+0 weeks versus term, T, ≥37+0 weeks) and size-for-gestational age defined as small (SGA, <10th centile), appropriate (AGA, 10th-90th centiles) or large (LGA, >90th centile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH-21st standards. MAIN OUTCOME MEASURES: Distribution of stillbirths, stillbirth rates and rate ratios according to six newborn types. RESULTS: 635 107 (0.5%) of the 125 419 255 total births resulted in stillbirth after 22+0 weeks. Most stillbirths (74.3%) were preterm. Around 21.2% were SGA types (PT + SGA [16.2%], PT + AGA [48.3%], T + SGA [5.0%]) and 14.1% were LGA types (PT + LGA [9.9%], T + LGA [4.2%]). The median rate ratio (RR) for stillbirth was highest in PT + SGA babies (RR 81.1, interquartile range [IQR], 68.8-118.8) followed by PT + AGA (RR 25.0, IQR, 20.0-34.3), PT + LGA (RR 25.9, IQR, 13.8-28.7) and T + SGA (RR 5.6, IQR, 5.1-6.0) compared with T + AGA. Stillbirth rate ratios were similar for T + LGA versus T + AGA (RR 0.7, IQR, 0.7-1.1). At the population level, 25% of stillbirths were attributable to small-for-gestational-age. CONCLUSIONS: In these high-quality data from high/middle income countries, almost three-quarters of stillbirths were born preterm and a fifth small-for-gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation-specific risk in these populations, as well as patterns in lower-income contexts, especially those with higher rates of intrapartum stillbirth and SGA.

Including calcium-fortified water or flour in modeled diets based on local foods could improve calcium intake for women, adolescent girls, and young children in Bangladesh, Uganda, and Guatemala.

Adequate calcium intake is essential for health, especially for infants, children, adolescents, and women, yet is difficult to achieve with local foods in many low- and middle-income countries. Previous analysis found it was not always possible to identify food-based recommendations (FBRs) that reached the calcium population recommended intake (PRI) for these groups in Bangladesh, Guatemala, and Uganda. We have modeled the potential contribution of calcium-fortified drinking water or wheat flour to FBR sets, to fill the remaining intake gaps. Optimized diets containing fortified products, with calcium-rich local foods, achieved the calcium PRI for all target groups. Combining fortified water or flour with FBRs met dietary intake targets for adolescent girls in all geographies and allowed a reduction from 3-4 to the more feasible 1-2 FBRs. Water with a calcium concentration of 100 mg/L with FBRs was sufficient to meet calcium targets in Uganda, but higher concentrations (400-500 mg/L) were mostly required in Guatemala and Bangladesh. Combining calcium-fortified wheat flour at 400 mg/100 g of flour and the FBR for small fish resulted in diets meeting the calcium PRI in Bangladesh. Calcium-fortified water or flour could improve calcium intake for vulnerable populations, especially when combined with FBRs based on locally available foods.

Could local foods achieve recommended calcium intakes for nutritionally vulnerable populations in Uganda, Guatemala, and Bangladesh?

Globally, dietary intake of calcium is often insufficient, and it is unclear if adequacy could be achieved by promoting calcium-rich local foods. This study used linear programming and household consumption data from Uganda, Bangladesh, and Guatemala to assess whether local foods could meet calcium population reference intakes (Ca PRIs). The most promising food-based approaches to promote dietary calcium adequacy were identified for 12- to 23-month-old breastfed children, 4- to 6-year-old children, 10- to 14-year-old girls, and nonpregnant and nonbreastfeeding (NPNB) women of reproductive age living in two regions of each country. Calcium-optimized diets achieved 75-253% of the Ca PRI, depending on the population, and were <100% for 4- to 6-year-olds in one region of each country and 10- to 14-year-old girls in Sylhet, Bangladesh. The best food sources of calcium were green leafy vegetables and milk, across geographic locations, and species of small fish, nixtamalized (lime-treated) maize products, sesame seeds, and bean varieties, where consumed. Food-based recommendations (FBRs) achieving the minimum calcium threshold were identified for 12- to 23-month-olds and NPNB women across geographic locations, and for 4- to 6-year-olds and 10-to 14-year-old girls in Uganda. However, for 4- to 6-year-olds and 10- to 14-year-old girls in Bangladesh and Guatemala, calcium-adequate FBRs could not be identified, indicating a need for alternative calcium sources or increased access to and consumption of local calcium-rich foods.

Calcium supplementation to prevent pre-eclampsia: protocol for an individual participant data meta-analysis, network meta-analysis and health economic evaluation.

INTRODUCTION: Low dietary calcium intake is a risk factor for pre-eclampsia, a major contributor to maternal and perinatal mortality and morbidity worldwide. Calcium supplementation can prevent pre-eclampsia in women with low dietary calcium. However, the optimal dose and timing of calcium supplementation are not known. We plan to undertake an individual participant data (IPD) meta-analysis of randomised trials to determine the effects of various calcium supplementation regimens in preventing pre-eclampsia and its complications and rank these by effectiveness. We also aim to evaluate the cost-effectiveness of calcium supplementation to prevent pre-eclampsia. METHODS AND ANALYSIS: We will identify randomised trials on calcium supplementation before and during pregnancy by searching major electronic databases including Embase, CINAHL, MEDLINE, CENTRAL, PubMed, Scopus, AMED, LILACS, POPLINE, AIM, IMSEAR, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform, without language restrictions, from inception to February 2022. Primary researchers of the identified trials will be invited to join the International Calcium in Pregnancy Collaborative Network and share their IPD. We will check each study's IPD for consistency with the original authors before standardising and harmonising the data. We will perform a series of one-stage and two-stage IPD random-effect meta-analyses to obtain the summary intervention effects on pre-eclampsia with 95% CIs and summary treatment-covariate interactions (maternal risk status, dietary intake, timing of intervention, daily dose of calcium prescribed and total intake of calcium). Heterogeneity will be summarised using tau2, I2 and 95% prediction intervals for effect in a new study. Sensitivity analysis to explore robustness of statistical and clinical assumptions will be carried out. Minor study effects (potential publication bias) will be investigated using funnel plots. A decision analytical model for use in low-income and middle-income countries will assess the cost-effectiveness of calcium supplementation to prevent pre-eclampsia. ETHICS AND DISSEMINATION: No ethical approvals are required. We will store the data in a secure repository in an anonymised format. The results will be published in peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42021231276.

Global inequities in cesarean section deliveries and required resources persist.

OBJECTIVE: The purpose of this study was to estimate the global distribution and financial cost associated with the inequities present in the use of cesarean sections (CS) worldwide. STUDY DESIGN: We used the latest estimates on CS rates published by WHO and we adopted 10-15 % as the range of CS rates that are considered optimal for adequate use. We calculated the cost (in USD) to achieve CS rates of 10-15 % for countries that reported rates below 10 %. We also calculated the cost of CS rates in excess (>15 % and > 20 %) by estimating how much it would cost to reduce the rates to 10-15 % for each of those countries. RESULTS: 137 countries are included in this analysis with updated data on CS rates between the years 2010 and 2018. Our analysis found that 36 countries reported CS rates < 10 %, whereas 91 countries reported CS rates > 15 % (a majority of which were > 20 %); only 10 countries reported CS rates between 10 and 15 %. The cost of CS exceeding a rate of 15 % is estimated to be $9,586,952,466 including inflation and exceeding 20 % is $7.169.248.033 (USD). The cost of achieving "needed" CS among countries with CS rates < 10 % is $612,609,418 (USD). The cost of cesarean sections exceeding 15 % has increased by 313 % between 2008 and more recent years, accruing $7 billion (USD) more in surplus since 2008. The reallocation of CS funding would save the global economy $9 billion (USD). CONCLUSION: Global inequities in CS performed and associated costs have increased since 2008, resulting in a disproportionate number of resources allocated.

Calcium concentration of drinking water to improve calcium intake: A simulation study.

The risk of inadequate calcium intake is a worldwide problem. We performed a simulation exercise on the impact, effectiveness, and safety of increasing calcium levels in drinking water using the 2019 Health and Nutrition National Survey of Argentina, which provides water intake and water sources data at the individual level. We simulated the distribution of calcium intake assuming a calcium concentration of 100 mg of calcium per liter of tap water and 400 mg of calcium per liter of bottled water. After the simulation, all population groups had a slightly improved calcium intake. Higher impacts were observed in adults, as reported water intake was higher in adults 19-51 years old. In young adult women, the estimated calcium intake inadequacy decreased from 91.0% to 79.7% when calcium was increased in tap water and to 72.2% when calcium was increased in tap and bottled water. The impact was lower in adolescents and older adults who have higher calcium recommendations and reported lower water intake. Increased calcium concentration of water could improve calcium intake in Argentina, especially in adults as their reported water intake is higher. Combining more than one strategy to improve calcium intake might be required for countries like Argentina with low calcium intake.

Calculation of the contribution of water to calcium intake in low- and middle-income countries.

Dietary calcium intake is low in many countries, particularly in low- and middle-income countries (LMICs). Water is often overlooked as a source of dietary calcium despite it being universally consumed and providing good calcium bioavailability. Our objective was to assess water distribution systems in LMICs and to develop a formula to simulate the contribution of different water sources to calcium availability. We calculated the contribution of drinking water considering different calcium concentration levels to estimate total calcium availability. We consider a country's households' access to drinking water sources and the distribution of the country's population by age and gender. Calcium availability could be increased by an average of 49 mg of calcium per person per day in the 62 countries assessed if calcium in drinking water was considered. In 22 (31%) of the countries studied, 80% of households are supplied by water sources that could increase calcium availability. Improving calcium concentration in water could be considered as a strategy in LMICs to slightly improve calcium availability.

Tendencia de cesáreas en entidades privadas de la provincia de Buenos Aires, Argentina (2017-2021) / Cesarean section trends in private entities in the province of Buenos Aires, Argentina (2017-2021)

Resumen OBJETIVO: Evaluar las tasas de cesárea en la finalización de embarazos registrados en el sector privado de la Obra Social de la provincia de Buenos Aires (Instituto de Obra Médico Asistencial) entre los años 2017 a 2021. MATERIALES Y MÉTODOS: Estudio analítico y descriptivo de cesáreas registradas en el Sistema de Modulación Centro Único de Auditoría y Fiscalización IOMA (CUAFI) de las 13 regiones sanitarias de la provincia de Buenos Aires. Se describen los porcentajes de cesárea por año y por región sanitaria. RESULTADOS: Se registraron 75,244 partos únicos. En el año 2017 el porcentaje de cesáreas se incrementó de 69.0% (12,600 cesáreas de 18,258 partos) a 73.6% (8,232 cesáreas de 11,180 partos) en 2021. Los mayores porcentajes de cesárea se registraron en la Región IV (83.6%), la Región XIV (81.7%) y Región X (78.9%). CONCLUSIÓN: El alto porcentaje de cesáreas registrado y el incremento en los últimos años muestra la necesidad de diseñar intervenciones para reducir su tasa. Será importante contar con información de sus indicaciones y explorar intervenciones destinadas al personal de salud y a las mujeres para reducir su práctica.

Abstract OBJECTIVE: To evaluate the rates of caesarean section in the termination of pregnancies registered in the private sector of the Obra Social of the province of Buenos Aires (Instituto de Obra Médico Asistencial) between 2017 and 2021. MATERIALS AND METHODS: Analytical and descriptive study of caesarean sections registered in the Modulation System of the IOMA Single Audit and Control Centre (CUAFI) of the 13 health regions of the province of Buenos Aires. The percentages of caesarean sections per year and per health region are described. RESULTS: 75,244 singleton deliveries were registered in the private sector of the Instituto de Obra Médico Asistencial. In 2017, the percentage of caesarean sections increased from 69.0% (12,600 caesarean sections out of 18,258 deliveries) to 73.6% (8,232 caesarean sections out of 11,180 deliveries) in 2021. The highest caesarean section rates were recorded in Region IV (83.6%), Region XIV (81.7%) and Region X (78.9%). CONCLUSION: The high percentage of caesarean sections recorded and the increase in recent years shows the need to design interventions to decrease the rate. It is important to have information on the indications for caesarean section and to explore interventions aimed at health personnel and women to reduce the rate.

Calcium for pre-eclampsia prevention: A systematic review and network meta-analysis to guide personalised antenatal care.

BACKGROUND: Calcium supplementation reduces the risk of pre-eclampsia, but questions remain about the dosage to prescribe and who would benefit most. OBJECTIVES: To evaluate the effectiveness of high (≥1 g/day) and low (<1 g/day) calcium dosing for pre-eclampsia prevention, according to baseline dietary calcium, pre-eclampsia risk and co-interventions, and intervention timing. SEARCH STRATEGY: CENTRAL, PubMed, Global Index Medicus and CINAHL, from inception to 2 February 2021, clinical trial registries, reference lists and expert input (CRD42018111239). SELECTION CRITERIA: Randomised controlled trials of calcium supplementation for pre-eclampsia prevention, for women before or during pregnancy. Network meta-analysis (NMA) also included trials of different calcium doses. DATA COLLECTION AND ANALYSIS: Two independent reviewers extracted published data. The meta-analysis employed random-effects models and the NMA, a Bayesian random-effects model, to obtain direct and indirect effect estimates. MAIN RESULTS: The meta-analysis included 30 trials (N = 20 445 women), and the NMA to evaluate calcium dosage included 25 trials (N = 15 038). Calcium supplementation prevented pre-eclampsia similarly with a high dose (RR 0.49, 95% CI 0.36-0.66) or a low dose (RR 0.49, 95% CI 0.36-0.65). By NMA, high-dose (vs low-dose) calcium did not differ in effect (RR 0.79, 95% CI 0.43-1.40). Calcium was similarly effective regardless of baseline pre-eclampsia risk, vitamin D co-administration or timing of calcium initiation, but calcium was ineffective among women with adequate average baseline calcium intake. CONCLUSIONS: Low- and high-dose calcium supplementation are effective for pre-eclampsia prevention in women with low calcium intake. This has implications for population-level implementation where dietary calcium is low, and targeted implementation where average intake is adequate. TWEETABLE ABSTRACT: A network meta-analysis of 25 trials found that low-dose calcium supplementation (<1 g/day) is as effective as high-dose calcium supplementation (≥1 g/day) in halving the risk of pre-eclampsia when baseline calcium intake is low.

Calcium deficiency worldwide: prevalence of inadequate intakes and associated health outcomes.

Dietary calcium deficiency is considered to be widespread globally, with published estimates suggesting that approximately half of the world's population has inadequate access to dietary calcium. Calcium is essential for bone health, but inadequate intakes have also been linked to other health outcomes, including pregnancy complications, cancers, and cardiovascular disease. Populations in low- and middle-income countries (LMICs) are at greatest risk of low calcium intakes, although many individuals in high-income countries (HICs) also do not meet recommendations. Paradoxically, many LMICs with lower calcium intakes show lower rates of osteoporotic fracture as compared with HICs, though data are sparse. Calcium intake recommendations vary across agencies and may need to be customized based on other dietary factors, health-related behaviors, or the risk of calcium-related health outcomes. The lack of standard methods to assess the calcium status of an individual or population has challenged efforts to estimate the prevalence of calcium deficiency and the global burden of related adverse health consequences. This paper aims to consolidate available evidence related to the global prevalence of inadequate calcium intakes and associated health outcomes, with the goal of providing a foundation for developing policies and population-level interventions to safely improve calcium intake and status where necessary.

Fortification of staple foods with calcium: a novel costing tool to inform decision making.

Low calcium intake and its impact on maternal and child health are a major concern in low- and middle-income countries. Given the low calcium in diet, as well as the low adherence and acceptability of calcium pills in those settings, the discussion about policies to increase calcium intake has moved toward staple food fortification strategies. Nevertheless, there is scarce information on the economic feasibility of implementing these strategies. We aimed to design and propose a novel costing tool to estimate the cost of the flour fortification with calcium by carrying out a literature review about costing studies for staple food fortification programs and costing tools previously developed. A deliberative meeting with stakeholders was held to discuss and face-validate the conceptual framework proposed. We showed the costing tool application for the case of Costa Rica (a country with a population with low calcium intake), including the absolute cost of the staple food fortification production process, the incremental cost of fortification according to the public/private sector, and the incremental cost by target population. This open-source and publicly available costing tool can be useful to inform policymaking in countries considering the implementation of staple food fortification programs.

The peripartum period involvement in the development of post-partum depression. A prospective cohort study.

PURPOSE: This study explores postpartum depression (PPD) in women who screened negative in mid-pregnancy to assess the impact of the peripartum period on the development of depressive symptoms. METHODS: A prospective cohort study was carried out in two facilities in Argentina. The Edinburgh postnatal depression scale (EPDS) scale was applied to pregnant women between weeks 20-24 gestation, and those screening negative (<10) were included in the cohort. Participants were followed up until the 4th week postpartum, when the EPDS was repeated. If positive, a semi-structured clinical interview was applied (MINI) to define the diagnosis. RESULTS: A total of 112 pregnant women were eligible for the follow-up. At the 4th week postpartum, 14 women (12.5%, CI 95% 7.0; 20.1) screened positive using a cutoff point of 10 or more in the EPDS. Of those screened positive in the EPDS, two participants (1.8%, CI 95% 0.2-6.3) had a Major Depressive Disorder. Newborn admission to the Intensive Care Unit, hospitalization of the newborn after discharge, abuse during childbirth, and lack of company during labor were identified as peripartum risk factors. CONCLUSIONS: This study reinforces the relevance of women and newborn mental health care during the hospitalization process surrounding peripartum. The women and newborn hospitalization process should be better explored to understand the contribution to PPD and design and test strategies to alleviate the impact of maternal depression.

Interventions to improve calcium intake through foods in populations with low intake.

Calcium intake remains inadequate in many low- and middle-income countries, especially in Africa and South Asia, where average intakes can be below 400 mg/day. Given the vital role of calcium in bone health, metabolism, and cell signaling, countries with low calcium intake may want to consider food-based approaches to improve calcium consumption and bioavailability within their population. This is especially true for those with low calcium intake who would benefit the most, including pregnant women (by reducing the risk of preeclampsia) and children (by reducing calcium-deficiency rickets). Specifically, some animal-source foods that are naturally high in bioavailable calcium and plant foods that can contribute to calcium intake could be promoted either through policies or educational materials. Some food processing techniques can improve the calcium content in food or increase calcium bioavailability. Staple-food fortification with calcium can also be a cost-effective method to increase intake with minimal behavior change required. Lastly, biofortification is currently being investigated to improve calcium content, either through genetic screening and breeding of high-calcium varieties or through the application of calcium-rich fertilizers. These mechanisms can be used alone or in combination based on the local context to improve calcium intake within a population.