Socio-economic predictors of undernutrition and anaemia in adolescent mothers in West and Central Africa.

BACKGROUND: Adolescence is a formative period when an individual acquires physical, cognitive, emotional, and social resources that are the foundation for later life, health, and well-being [1]. However, in West and Central African region, this trajectory is curtailed by early childbearing associated with an increased risk of undernutrition and anemia. Evidence on socio-economic determinants of anemia and undernutrition in adolescent mothers is limited. This paper aims to shed some light on this issue and, more specifically, assess the socio-economic determinants of anemia among childbearing adolescents in the region. METHODS: For this observational study, we pooled data from all Demographic and Health Surveys (DHS) conducted in countries in West and Central Africa region between 1986 and 2017. Outcomes were undernutrition and anemia in adolescent mothers. Predictors were education, wealth, place of residence (rural/urban), and religion. Descriptive statistics were calculated using survey weights for individual surveys and in the pooled sample each country was additionally weighted with its population share. We estimated multiple regression models with and without primary sampling unit fixed effects for both outcomes. All regressions were linear probability models. RESULTS: Having no formal education was the strongest predictor for both anemia and undernutrition. Belonging to the richest asset quintile was also associated with lower anemia and undernutrition prevalence in some specifications. While urban location of the mother was positively associated with anemia, there was no association with undernutrition. CONCLUSIONS: Overall, having any formal education emerged as a sole strong predictor of reduced adolescent maternal undernutrition and anemia. Promotion of female education can potentially serve as a high-impact intervention to improve adolescent girls' health in the region. However, we cannot make conclusions about its causal impact based on this study alone.

Prevalence of diarrhoea, acute respiratory infections, and malaria over time (1995-2017): A regional analysis of 23 countries in West and Central Africa.

BACKGOUND: The global community recognizes the urgent need to end preventable child deaths, making it an essential part of the third Sustainable Development Goal. Pneumonia, diarrhoea, and malaria still remain the leading causes of deaths among children under five years, especially in one of the poorest geographic regions of the world - West and Central Africa. This region carries a disproportionately high share of the global burden, both in terms of morbidity and mortality. The study aims to assess levels and trends of the prevalence of these three childhood diseases in West and Central Africa to better inform ongoing and future programmes to improve child survival. METHODS: Demographic and Health Surveys and Multiple Indicator Cluster Surveys available from 1995 to 2017 for 23 countries in West and Central Africa were analysed. We estimated the prevalence of diarrhoea, acute respiratory infections (ARI), malaria, and fever as a proxy for malaria, and split the data into three time periods to assess these trends in disease prevalence over time. Further analyses were done to assess the variations by geographic location (urban and rural) and gender (boys and girls). RESULTS: In West and Central Africa, the reduction of the prevalence rates of diarrhoea, acute respiratory infections, malaria, and fever has decelerated over time (1995-2009), and little improvements occurred between 2010 and 2017. The reduction within the region has been uneven and the prevalence rates either increased or stagnated for diarrhoea (nine countries), ARI (four countries), and fever (six countries). The proportion of affected children was high in emergency or fragile settings. Disaggregated analyses of population-based data show persistent gaps between the prevalence of diseases by geographic location and gender, albeit not significant for the latter. CONCLUSIONS: Without intensified commitment to reducing the prevalence of pneumonia, malaria, and diarrhoea, many countries will not be able to meet the SDG goal to end preventable child deaths. Evidence-driven programmes that focus on improving equitable access to preventive health care information and services must be fostered, especially in complex emergency settings. This will be an opportunity to strengthen primary health care, including community health programmes, to achieve universal health coverage.

The wealth gradient in diarrhoea, acute respiratory infections, and malaria in childhood over time: A descriptive analysis using DHS and MICS from Western and Central Africa between 1995 and 2017.

BACKGROUND: While the prevalence of childhood diseases and related mortality have been decreasing over the past decades, progress has been unequally distributed. The poorest households often carry the highest disease burden. As morbidity and mortality also decline most slowly among children of the poorest households, socioeconomic status may become a more relevant risk factor for childhood diseases. METHODS: We analysed the association between socioeconomic status and highly prevalent childhood diseases, specifically diarrhoea, acute respiratory infections (ARI), and malaria, and how this association changed over time. For this observational study, we used repeated cross-sectional data, namely all available Demographic and Health Surveys as well as Multi-Indicator Cluster Surveys from Western and Central Africa between 1995 and 2017. We estimated the predicted prevalence of each disease for the entire region in three time periods. We repeated the analysis separately for each country to highlight heterogeneity between countries. RESULTS: A notable wealth gradient can be seen in the prevalence rates of diarrhoea, ARI, and malaria in Western and Central Africa. Children in the poorest quartile have a much higher morbidity than children in the richest quartile and have experienced a considerably slower decline in prevalence rates. In the period 2010-2017, predicted prevalence of diarrhoea was 17.5% for children in the poorest quartile and 12.5% for children in the richest quartile. Similarly, the predicted prevalence was 11.1% and 8.6% for ARI, and 54.1% and 24.4% for malaria in endemic countries. The pattern does not differ between boys and girls. While exact prevalence rates vary between countries, only few countries have seen a decline in the wealth gradient for childhood diseases. CONCLUSIONS: The increasing wealth gradient in health raises concerns of increasing inequality that goes beyond wealth. It suggests a need to further improve targeting of health programmes. Moreover, these programmes should be adapted to address the interlinked challenges which burden the poorest households.

Health-care seeking for childhood diseases by parental age in Western and Central Africa between 1995 and 2017: A descriptive analysis using DHS and MICS from 23 low- and middle-income countries.

BACKGROUND: Globally, health care seeking for childhood diseases seems to be on the rise. However, progress is slow and still, many cases of infectious diseases in children remain untreated, leading to preventable child mortality. A better understanding of care seeking behaviour may help to further increase the probability that a sick child is taken to a health facility for care. METHODS: We investigated whether mother's and father's age at birth of the child is associated with health care seeking behaviour for childhood diseases and how this association changed over time. For this observational study, we used repeated cross-sectional data, namely all available Demographic and Health Surveys as well as Multi-Indicator Cluster Surveys from Western and Central Africa, 1995 to 2017. We analysed care seeking behaviour for diarrhoea, acute respiratory infections (ARI), and treatment of diarrhoea with oral rehydration solution (ORS). We estimated ordinary least squares regressions, controlling for socioeconomic characteristics of the household and adding survey year- and country-fixed effects. Estimated associations are presented for the entire region and for each country separately to highlight heterogeneity. RESULTS: Overall, the likelihood that care is sought for a child suffering from diarrhoea or ARI is low in Western and Central Africa. Probability of care seeking for diarrhoea ranges between 49% for mothers above 40 years and 53% for mothers between 25 and 29 years. For ARI, the rates are 60% and 62%, respectively. Treatment of diarrhoea with ORS is even lower, ranging between 23% and 26%. The probability that parents seek health care for their child does not seem to be associated with parents' age at birth. Mother's level of education and household's wealth status seem to be more important factors. There is evidence of the relationship between parents' age and care seeking changing over time, suggesting a stronger association in the past. CONCLUSIONS: Parents' age at child birth does not seem to have a relevant association with care seeking for common childhood diseases. Identifying relevant factors may help in improving health care seeking behaviour of parents in low- and middle-income countries leading to reductions in child morbidity and mortality.

Strengthening the community health program in Liberia: Lessons learned from a health system approach to inform program design and better prepare for future shocks.

BACKGROUND: Arising from the Ebola virus disease (EVD) outbreak, the 2015-2021 Investment Plan aimed to improve the health status of the Liberian population through building a resilient health system that contributes to achieving equitable health outcomes. Recognizing the significance of community participation in overcoming the EVD outbreak, strengthening community systems emerged as one of the most important strategies for bridging the gap in accessing primary health care (PHC) services. This study reviewed the community health policy development process in order to draw lessons from the health system strengthening efforts in Liberia post-EVD crisis. METHODS: A government-led health system analysis approach was applied to assess, review and revise the community health program in Liberia. The mixed method approach combines the use of an adapted tool to assess bottlenecks and solutions during workshops, a qualitative survey (key informant interviews and focus group discussions) to assess perceptions of challenges and perspectives from different stakeholders, and an inter-agency framework - a benchmarks matrix - to jointly review program implementation gaps using the evidence compiled, and identify priorities to scale up of the community program. RESULTS: Stakeholders identified key health system challenges and proposed policy and programmatic shifts to institutionalize a standardized community health program with fit for purpose and incentivized community health assistants to provide PHC services to the targeted populations. The community health program in Liberia is currently at the phase of implementation and requires strengthened leadership, local capacities, and resources for sustainability. Lessons learned from this review included the importance of: establishing a coordination mechanism and leveraging partnership support; using a systems approach to better inform policy shifts; strengthening community engagement; and conducting evidence-based planning to inform policy-makers. CONCLUSIONS: This article contributes toward the existing body of knowledge about policy development processes and reforms on community health in Liberia, and most likely other African settings with weak health systems. Community-based systems will play an even bigger role as we move toward building resilience for future shocks and strengthening PHC, which will require that communities be viewed as actors in the health system rather than just clients of health services.

Galvanizing Action on Primary Health Care: Analyzing Bottlenecks and Strategies to Strengthen Community Health Systems in West and Central Africa.

INTRODUCTION: The renewed commitment to primary health care (PHC) presents an opportunity to strengthen health systems in West and Central Africa (WCA). Though evidence-based cost-effective interventions that are predicted to prevent up to one-third of maternal, newborn, and child health complications and deaths with universal coverage have been identified, more than 50% of people living in rural areas or from poor families still do not have access to these interventions in resource-constrained settings. METHODS: We conducted a multicountry systematic analysis of bottlenecks and proposed solutions to strengthen community health systems through a series of collaborative workshops in 22 countries in WCA. Countries were categorized by their under-5 mortality rate (U5MR) to assess specificities related to reported challenges. We also reviewed existing data on selected health system tracer interventions to analyze country profiles. RESULTS: The bottlenecks identified as severe or very severe were related to health financing (19 countries, 86%), essential medical technology and products (16 countries, 73%), integrated health service delivery (14 countries, 64%), and community ownership and partnerships (self-reported by 14 countries, 64%). Only the integrated service delivery was self-reported as a severe challenge by countries with high U5MR. The issue of human resources for community health was one of the least reported challenges. CONCLUSION: In WCA, strengthening community health systems as part of PHC revitalization efforts should focus on increasing health financing and innovative investments, strengthening the logistics management system, and fostering community ownership and partnerships. Countries with high U5MR should also reinforce integrated service delivery approaches through innovation. Government actions galvanized by global and regional ongoing initiatives should be sustained to ensure that no one is left behind.

Basic maternal health care coverage among adolescents in 22 sub-Saharan African countries with high adolescent birth rate.

BACKGROUND: In the sub-Saharan Africa region, the adolescent birth rate is the highest in the world, estimated at 100.5 births per 1000 women aged 15 to 19 years, and 2.4 times greater than the global average. This analysis examines coverage levels and gaps in basic maternal health care for adolescent mothers living in this region. METHODS: We used data from national Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) conducted between 2010 and 2016 in 22 of the sub-Saharan African Countdown to 2030 priority countries with adolescent birth rates above 100 in 2016. We analyzed 11 indicators of coverage of key services provided during the pre-pregnancy, pregnancy, delivery and postnatal period. We described the coverage level among adolescent girls aged 15-19 and women aged 20-49 for basic indicators in the continuum of care. We conducted a multilevel random effect logistic regression to quantify the association between the receipt of basic package of maternal care and woman's socio-demographic and socio-economic characteristics. RESULTS: The median coverage of the basic package of maternal care among adolescents was extremely low, at 9.3%. Adolescent mothers who were in the highest household wealth quintile (odds ratio OR = 2.44, 95% confidence interval (CI) = 2.23-2.68), living in an urban area (OR = 1.25, 95% CI = 1.18-1.33) and having secondary education (OR = 1.61, 95% CI = 1.50-1.73) had greater odds of receiving the basic package of maternal health care as compared to those in the lowest wealth quintile, living in rural areas, and with no education respectively. Adolescent girls aged 15-17 and 18-19 had respectively 26% (OR = 0.74, 95% CI = 0.67-0.82) and 9% (OR = 0.91, 95% CI = 0.84-0.98) lower odds of receiving the basic package compared to women 20-49 years old. Child brides had 12% (OR = 0.88, 95% CI = 0.84-0.93) lower odds of receiving the basic package compared to women who were married after the age of 18. CONCLUSION: Coverage of basic maternal health care for adolescent mothers is inadequate in the countries with the highest adolescent birth rates in the world. Addressing the reproductive and maternal health needs of adolescents in sub-Saharan Africa is of critical importance, especially given projections that this region will experience the highest increases in adolescent births in the coming decades.

Consensus building around nutrition lessons from the 2014-16 Ebola virus disease outbreak in Guinea and Sierra Leone.

There are important lessons learned from the 2014-16 Ebola virus disease outbreak in West Africa. However, there has not been a systematic documentation of nutrition lessons specifically. Therefore, this study sought to generate multiple stakeholder perspectives for understanding the nutrition challenges faced during the Ebola virus disease outbreak, as well as for consensus building around improved response strategies. Participatory workshops with 17 and 19 participants in Guinea and Sierra Leone, respectively, were conducted in February 2017. Workshops followed the Nominal Group Technique, which is a methodological approach for idea generation and consensus building among diverse participants. Those findings were triangulated with qualitative interview data from participants representing government, United Nations bodies, civil society, non-governmental organizations and local communities in both Guinea (n = 27) and Sierra Leone (n = 42). (1) Reduced health system access and utilization, Poor caretaking and infant and young child feeding practices, Implementation challenges during nutrition response, Household food insecurity and Changing breastfeeding practices were five nutrition challenges identified in both Guinea and Sierra Leone. (2) Between settings, 14 distinct and 11 shared organizational factors emerged as facilitators to this response. In Sierra Leone, participants identified the Use of Standard Operating Procedures and Psychosocial counselling, whereas in Guinea, Hygiene assistance was distinctly important. Political will, Increased funding, Food assistance and to a lesser extent, Enhanced coordination, were deemed 'most important' response factors. (3) The top nutrition lessons learned were diverse, reflecting those of nutrition policy, programme implementation, community activity and household behaviours. Disease outbreaks pose widespread nutrition challenges to populations in resource-constrained settings where global health security is not a guarantee. These findings should be considered for emergency nutrition preparedness and inform evidence-based priority setting in the post-Ebola virus context of Guinea and Sierra Leone.

Innovative approaches for improving maternal and newborn health--A landscape analysis.

BACKGROUND: Essential interventions can improve maternal and newborn health (MNH) outcomes in low- and middle-income countries, but their implementation has been challenging. Innovative MNH approaches have the potential to accelerate progress and to lead to better health outcomes for women and newborns, but their added value to health systems remains incompletely understood. This study's aim was to analyze the landscape of innovative MNH approaches and related published evidence. METHODS: Systematic literature review and descriptive analysis based on the MNH continuum of care framework and the World Health Organization health system building blocks, analyzing the range and nature of currently published MNH approaches that are considered innovative. We used 11 databases (MedLine, Web of Science, CINAHL, Cochrane, Popline, BLDS, ELDIS, 3ie, CAB direct, WHO Global Health Library and WHOLIS) as data source and extracted data according to our study protocol. RESULTS: Most innovative approaches in MNH are iterations of existing interventions, modified for contexts in which they had not been applied previously. Many aim at the direct organization and delivery of maternal and newborn health services or are primarily health workforce interventions. Innovative approaches also include health technologies, interventions based on community ownership and participation, and novel models of financing and policy making. Rigorous randomized trials to assess innovative MNH approaches are rare; most evaluations are smaller pilot studies. Few studies assessed intervention effects on health outcomes or focused on equity in health care delivery. CONCLUSIONS: Future implementation and evaluation efforts need to assess innovations' effects on health outcomes and provide evidence on potential for scale-up, considering cost, feasibility, appropriateness, and acceptability. Measuring equity is an important aspect to identify and target population groups at risk of service inequity. Innovative MNH interventions will need innovative implementation, evaluation and scale-up strategies for their sustainable integration into health systems.

Antenatal corticosteroids for management of preterm birth: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: Preterm birth complications are the leading cause of deaths for children under five years. Antenatal corticosteroids (ACS) are effective at reducing mortality and serious morbidity amongst infants born at <34 weeks gestation. WHO guidelines strongly recommend use of ACS for women at risk of imminent preterm birth where gestational age, imminent preterm birth, and risk of maternal infection can be assessed, and appropriate maternal/newborn care provided. However, coverage remains low in high-burden countries for reasons not previously systematically investigated. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for ACS. RESULTS: Eleven out of twelve countries provided data in response to the ACS questionnaire. Health system building blocks most frequently reported as having significant or very major bottlenecks were health information systems (11 countries), essential medical products and technologies (9 out of 11 countries) and health service delivery (9 out of 11 countries). Bottlenecks included absence of coverage data, poor gestational age metrics, lack of national essential medicines listing, discrepancies between prescribing authority and provider cadres managing care, delays due to referral, and lack of supervision, mentoring and quality improvement systems. CONCLUSIONS: Analysis centred on health system building blocks in which 9 or more countries (>75%) reported very major or significant bottlenecks. Health information systems should include improved gestational age assessment and track ACS coverage, use and outcomes. Better health service delivery requires clarified policy assigning roles by level of care and cadre of provider, dependent on capability to assess gestational age and risk of preterm birth, and the implementation of guidelines with adequate supervision, mentoring and quality improvement systems, including audit and feedback. National essential medicines lists should include dexamethasone for antenatal use, and dexamethasone should be integrated into supply logistics.

Basic newborn care and neonatal resuscitation: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: An estimated two-thirds of the world's 2.7 million newborn deaths could be prevented with quality care at birth and during the postnatal period. Basic Newborn Care (BNC) is part of the solution and includes hygienic birth and newborn care practices including cord care, thermal care, and early and exclusive breastfeeding. Timely provision of resuscitation if needed is also critical to newborn survival. This paper describes health system barriers to BNC and neonatal resuscitation and proposes solutions to scale up evidence-based strategies. METHODS: The maternal and newborn bottleneck analysis tool was applied by 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" that hinder the scale up of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for BNC and neonatal resuscitation. RESULTS: Eleven of the 12 countries provided grading data. Overall, bottlenecks were graded more severely for resuscitation. The most severely graded bottlenecks for BNC were health workforce (8 of 11 countries), health financing (9 out of 11) and service delivery (7 out of 9); and for neonatal resuscitation, workforce (9 out of 10), essential commodities (9 out of 10) and service delivery (8 out of 10). Country teams from Africa graded bottlenecks overall more severely. Improving workforce performance, availability of essential commodities, and well-integrated health service delivery were the key solutions proposed. CONCLUSIONS: BNC was perceived to have the least health system challenges among the seven maternal and newborn intervention packages assessed. Although neonatal resuscitation bottlenecks were graded more severe than for BNC, similarities particularly in the workforce and service delivery building blocks highlight the inextricable link between the two interventions and the need to equip birth attendants with requisite skills and commodities to assess and care for every newborn. Solutions highlighted by country teams include ensuring more investment to improve workforce performance and distribution, especially numbers of skilled birth attendants, incentives for placement in challenging settings, and skills-based training particularly for neonatal resuscitation.

Treatment of neonatal infections: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: Around one-third of the world's 2.8 million neonatal deaths are caused by infections. Most of these deaths are preventable, but occur due to delays in care-seeking, and access to effective antibiotic treatment with supportive care. Understanding variation in health system bottlenecks to scale-up of case management of neonatal infections and identifying solutions is essential to reduce mortality, and also morbidity. METHODS: A standardised bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the development of the Every Newborn Action Plan. Country workshops involved technical experts to complete a survey tool, to grade health system "bottlenecks" hindering scale up of maternal-newborn intervention packages. Quantitative and qualitative methods were used to analyse the data, combined with literature review, to present priority bottlenecks and synthesise actions to improve case management of newborn infections. RESULTS: For neonatal infections, the health system building blocks most frequently graded as major or significant bottlenecks, irrespective of mortality context and geographical region, were health workforce (11 out of 12 countries), and community ownership and partnership (11 out of 12 countries). Lack of data to inform decision making, and limited funding to increase access to quality neonatal care were also major challenges. CONCLUSIONS: Rapid recognition of possible serious bacterial infection and access to care is essential. Inpatient hospital care remains the first line of treatment for neonatal infections. In situations where referral is not possible, the use of simplified antibiotic regimens for outpatient management for non-critically ill young infants has recently been reported in large clinical trials; WHO is developing a guideline to treat this group of young infants. Improving quality of care through more investment in the health workforce at all levels of care is critical, in addition to ensuring development and dissemination of national guidelines. Improved information systems are needed to track coverage and adequately manage drug supply logistics for improved health outcomes. It is important to increase community ownership and partnership, for example through involvement of community groups.

Scaling up quality care for mothers and newborns around the time of birth: an overview of methods and analyses of intervention-specific bottlenecks and solutions.

BACKGROUND: The Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality targets cannot be achieved without high quality, equitable coverage of interventions at and around the time of birth. This paper provides an overview of the methodology and findings of a nine paper series of in-depth analyses which focus on the specific challenges to scaling up high-impact interventions and improving quality of care for mothers and newborns around the time of birth, including babies born small and sick. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the ENAP process. Country workshops engaged technical experts to complete a tool designed to synthesise "bottlenecks" hindering the scale up of maternal-newborn intervention packages across seven health system building blocks. We used quantitative and qualitative methods and literature review to analyse the data and present priority actions relevant to different health system building blocks for skilled birth attendance, emergency obstetric care, antenatal corticosteroids (ACS), basic newborn care, kangaroo mother care (KMC), treatment of neonatal infections and inpatient care of small and sick newborns. RESULTS: The 12 countries included in our analysis account for the majority of global maternal (48%) and newborn (58%) deaths and stillbirths (57%). Our findings confirm previously published results that the interventions with the most perceived bottlenecks are facility-based where rapid emergency care is needed, notably inpatient care of small and sick newborns, ACS, treatment of neonatal infections and KMC. Health systems building blocks with the highest rated bottlenecks varied for different interventions. Attention needs to be paid to the context specific bottlenecks for each intervention to scale up quality care. Crosscutting findings on health information gaps inform two final papers on a roadmap for improvement of coverage data for newborns and indicate the need for leadership for effective audit systems. CONCLUSIONS: Achieving the Sustainable Development Goal targets for ending preventable mortality and provision of universal health coverage will require large-scale approaches to improving quality of care. These analyses inform the development of systematic, targeted approaches to strengthening of health systems, with a focus on overcoming specific bottlenecks for the highest impact interventions.

Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: Good outcomes during pregnancy and childbirth are related to availability, utilisation and effective implementation of essential interventions for labour and childbirth. The majority of the estimated 289,000 maternal deaths, 2.8 million neonatal deaths and 2.6 million stillbirths every year could be prevented by improving access to and scaling up quality care during labour and birth. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for skilled birth attendance and basic and comprehensive emergency obstetric care. RESULTS: Across 12 countries the most critical bottlenecks identified by workshop participants for skilled birth attendance were health financing (10 out of 12 countries) and health workforce (9 out of 12 countries). Health service delivery bottlenecks were found to be the most critical for both basic and comprehensive emergency obstetric care (9 out of 12 countries); health financing was identified as having critical bottlenecks for comprehensive emergency obstetric care (9 out of 12 countries). Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, proposed solutions included improving quality of care and establishing public private partnerships. CONCLUSIONS: Progress towards the 2030 targets for ending preventable maternal and newborn deaths is dependent on improving quality of care during birth and the immediate postnatal period. Strengthening national health systems to improve maternal and newborn health, as a cornerstone of universal health coverage, will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery.

Inpatient care of small and sick newborns: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: Preterm birth is the leading cause of child death worldwide. Small and sick newborns require timely, high-quality inpatient care to survive. This includes provision of warmth, feeding support, safe oxygen therapy and effective phototherapy with prevention and treatment of infections. Inpatient care for newborns requires dedicated ward space, staffed by health workers with specialist training and skills. Many of the estimated 2.8 million newborns that die every year do not have access to such specialised care. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" (or factors that hinder the scale up) of maternal-newborn intervention packages. For this paper, we used quantitative and qualitative methods to analyse the bottleneck data, and combined these with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for inpatient care of small and sick newborns. RESULTS: Inpatient care of small and sick newborns is an intervention package highlighted by all country workshop participants as having critical health system challenges. Health system building blocks with the highest graded (significant or major) bottlenecks were health workforce (10 out of 12 countries) and health financing (10 out of 12 countries), followed by community ownership and partnership (9 out of 12 countries). Priority actions based on solution themes for these bottlenecks are discussed. CONCLUSIONS: Whilst major bottlenecks to the scale-up of quality inpatient newborn care are present, effective solutions exist. For all countries included, there is a critical need for a neonatal nursing cadre. Small and sick newborns require increased, sustained funding with specific insurance schemes to cover inpatient care and avoid catastrophic out-of-pocket payments. Core competencies, by level of care, should be defined for monitoring of newborn inpatient care, as with emergency obstetric care. Rather than fatalism that small and sick newborns will die, community interventions need to create demand for accessible, high-quality, family-centred inpatient care, including kangaroo mother care, so that every newborn can survive and thrive.

Impact of smoking on the quantity and quality of antibodies induced by human papillomavirus type 16 and 18 AS04-adjuvanted virus-like-particle vaccine - a pilot study.

BACKGROUND: The AS04-adjuvanted bivalent L1 virus-like-particle (VLP) vaccine (Cervarix™) against infection with human papillomavirus (HPV) types 16/18 holds great promise to prevent HPV16/18 infections and associated neoplasias, but it is important to rule out significant co-factors of the neoplasias like smoking. METHODS: We conducted a pilot study to compare the quantity and quality of HPV16/18 antibody response at baseline and 7 months post vaccination in 104 non-smoking and 112 smoking female participants vaccinated at 0, 1 and 6 months with Cervarix™ (55 and 48 study participants) or with Hepatitis A vaccine (HAVRIX™) (48 and 64 participants, respectively). These 216 women were a sub-sample of 4808 baseline 16- to 17-year old Finnish women initially enrolled in the double-blind, randomized controlled phase III PATRICIA trial. Following end-of-study unblinding in 2009 they were randomly chosen out of all the participants of the three major Finnish PATRICIA study sites in the Helsinki metropolitan area (University of Helsinki, N = 535, and Family Federation Finland, N = 432) and Tampere (University of Tampere, N = 428). Following enrolment, serum samples were collected at month 0 and month 7 post 1st vaccination shot, and were analysed for levels and avidity of IgG antibodies to HPV16 and HPV18 using standard and modified (4 M urea elution) VLP ELISAs. RESULTS: We found that at month 7 post vaccination women who smoked (cotinine level > 20 ng/ml) had levels of anti-HPV16/18 antibodies comparable to those of non-smoking women. Low-avidity HPV16/18 IgG antibodies were observed in 16% of the vaccinated women, and active smoking conferred a three-fold increased risk (95% CI 1.0-9.3) of having the low-avidity antibodies. CONCLUSION: Our data suggest that while smoking does not interfere with the quantity of vaccine-induced peak IgG levels, it may affect the avidity of IgG induced by HPV16/18 vaccination.

Every Newborn: health-systems bottlenecks and strategies to accelerate scale-up in countries.

Universal coverage of essential interventions would reduce neonatal deaths by an estimated 71%, benefit women and children after the first month, and reduce stillbirths. However, the packages with the greatest effect (care around birth, care of small and ill newborn babies), have low and inequitable coverage and are the most sensitive markers of health system function. In eight of the 13 countries with the most neonatal deaths (55% worldwide), we undertook a systematic assessment of bottlenecks to essential maternal and newborn health care, involving more than 600 experts. Of 2465 bottlenecks identified, common constraints were found in all high-burden countries, notably regarding the health workforce, financing, and service delivery. However, bottlenecks for specific interventions might differ across similar health systems. For example, the implementation of kangaroo mother care was noted as challenging in the four Asian country workshops, but was regarded as a feasible aspect of preterm care by respondents in the four African countries. If all high-burden countries achieved the neonatal mortality rates of their region's fastest progressing countries, then the mortality goal of ten or fewer per 1000 livebirths by 2035 recommended in this Series and the Every Newborn Action Plan would be exceeded. We therefore examined fast progressing countries to identify strategies to reduce neonatal mortality. We identified several key factors: (1) workforce planning to increase numbers and upgrade specific skills for care at birth and of small and ill newborn babies, task sharing, incentives for rural health workers; (2) financial protection measures, such as expansion of health insurance, conditional cash transfers, and performance-based financing; and (3) dynamic leadership including innovation and community empowerment. Adapting from the 2005 Lancet Series on neonatal survival and drawing on this Every Newborn Series, we propose a country-led, data-driven process to sharpen national health plans, seize opportunities to address the quality gap for care at birth and care of small and ill newborn babies, and systematically scale up care to reach every mother and newborn baby, particularly the poorest.

The importance of parental beliefs and support for physical activity and body weights of children: a population-based analysis.

OBJECTIVE: To determine whether parental beliefs and support for physical activity (PA) are associated with normal-weight and overweight children's self-reported PA and body weight using a population-based approach. METHODS: We analyzed cross-sectional survey data from 6,585 students and their parents in Alberta, Canada, collected in 2008 and 2010. Parental beliefs and support were collected through questions on "care about staying fit", "encourage PA" and "engage in PA with their child". Children's PA was self-reported. Body mass index was calculated from measured height and weight. We applied random effects models to assess: 1) the association of parental beliefs and support with children's PA; 2) differences in the associations for normal-weight and overweight children; 3) the association of parental beliefs and support with overweight. RESULTS: Parental care, encouragement, and engagement in PA were independently and positively associated with PA among both normal-weight and overweight children. Relative to children whose parents encouraged them "quite a lot", those whose parents encouraged them "very much" were 22% less likely to be overweight (OR=0.78, 95% CI: 0.68-0.89). CONCLUSION: Health promotion strategies that target parents to encourage and engage in PA with their children may increase activity levels and reduce overweight among children.

Do improvements in outreach, clinical, and family and community-based services predict improvements in child survival? An analysis of serial cross-sectional national surveys.

BACKGROUND: There are three main service delivery channels: clinical services, outreach, and family and community. To determine which delivery channels are associated with the greatest reductions in under-5 mortality rates (U5MR), we used data from sequential population-based surveys to examine the correlation between changes in coverage of clinical, outreach, and family and community services and in U5MR for 27 high-burden countries. METHODS: Household survey data were abstracted from serial surveys in 27 countries. Average annual changes (AAC) between the most recent and penultimate survey were calculated for under-five mortality rates and for 22 variables in the domains of clinical, outreach, and family- and community-based services. For all 27 countries and a subset of 19 African countries, we conducted principal component analysis to reduce the variables into a few components in each domain and applied linear regression to assess the correlation between changes in the principal components and changes in under-five mortality rates after controlling for multiple potential confounding factors. RESULTS: AAC in under 5-mortality varied from 6.6% in Nepal to -0.9% in Kenya, with six of the 19 African countries all experiencing less than a 1% decline in mortality. The strongest correlation with reductions in U5MR was observed for access to clinical services (all countries: p = 0.02, r² = 0.58; 19 African countries p < 0.001, r² = 0.67). For outreach activities, AAC U5MR was significantly correlated with antenatal care and family planning services, while AAC in immunization services showed no association. In the family- and community services domain, improvements in breastfeeding were associated with significant changes in mortality in the 30 countries but not in the African subset; while in the African countries, nutritional status improvements were associated with a significant decline in mortality. CONCLUSIONS: Our findings support the importance of increasing access to clinical services, certain outreach services and breastfeeding and, in Africa, of improving nutritional status. Integrated programs that emphasize these services may lead to substantial mortality declines.

Should public health interventions aimed at reducing childhood overweight and obesity be gender-focused?

BACKGROUND: Overweight in childhood is a major public health concern that calls for immediate preventative action. An increasing number of reports suggest that gender specific approaches to prevention may be more effective. However, there is a paucity of information to guide gender-sensitive health promotion and population health interventions for the prevention of overweight in childhood. In the present study, we sought to determine gender-differentials in overweight and underlying behaviors, nutrition and physical activity, among pre-adolescents in Alberta, Canada, to inform the discussion on gender-focused interventions for chronic disease prevention. METHODS: In 2008, we surveyed 3421 grade five students and their parents of 148 randomly selected schools. Students completed the Harvard food frequency questionnaire, questions on physical activities, and had their height and weight measured. Parents completed questions on socio-economic background and child's lifestyle. We applied multilevel regression methods to assess gender differentials in overweight, nutrition and physical activity. RESULTS: Overall, the prevalence of overweight was slightly higher among boys (29.1%) than girls (27.9%) with more pronounced differences in towns and urban geographies. Boys reported to be much more physically active relative to girls (OR = 2.12, 95% CI: 1.73-2.60). Diets of boys, relative to those of girls, reportedly constituted more fat and were less likely to meet the recommendation of 6 daily servings of vegetables and fruits (OR = 0.81, 95% CI: 0.71-0.93). CONCLUSION: Our findings confirm the existence of gender differences in physical activity and nutrition, and support gender-focused health promotion whereby priority is given to physical activity among girls and to healthy eating among boys.