National, regional, and global estimates of low birthweight in 2020, with trends from 2000: a systematic analysis.

BACKGROUND: Low birthweight (LBW; <2500 g) is an important predictor of health outcomes throughout the life course. We aimed to update country, regional, and global estimates of LBW prevalence for 2020, with trends from 2000, to assess progress towards global targets to reduce LBW by 30% by 2030. METHODS: For this systematic analysis, we searched population-based, nationally representative data on LBW from Jan 1, 2000, to Dec 31, 2020. Using 2042 administrative and survey datapoints from 158 countries and areas, we developed a Bayesian hierarchical regression model incorporating country-specific intercepts, time-varying covariates, non-linear time trends, and bias adjustments based on data quality. We also provided novel estimates by birthweight subgroups. FINDINGS: An estimated 19·8 million (95% credible interval 18·4-21·7 million) or 14·7% (13·7-16·1) of liveborn newborns were LBW worldwide in 2020, compared with 22·1 million (20·7-23·9 million) and 16·6% (15·5-17·9) in 2000-an absolute reduction of 1·9 percentage points between 2000 and 2020. Using 2012 as the baseline, as this is when the Global Nutrition Target began, the estimated average annual rate of reduction from 2012 to 2020 was 0·3% worldwide, 0·85% in southern Asia, and 0·59% in sub-Saharan Africa. Nearly three-quarters of LBW births in 2020 occurred in these two regions: of 19 833 900 estimated LBW births worldwide, 8 817 000 (44·5%) were in southern Asia and 5 381 300 (27·1%) were in sub-Saharan Africa. Of 945 300 estimated LBW births in northern America, Australia and New Zealand, central Asia, and Europe, approximately 35·0% (323 700) weighed less than 2000 g: 5·8% (95% CI 5·2-6·4; 54 800 [95% CI 49 400-60 800]) weighed less than 1000 g, 9·0% (8·7-9·4; 85 400 [82 000-88 900]) weighed between 1000 g and 1499 g, and 19·4% (19·0-19·8; 183 500 [180 000-187 000]) weighed between 1500 g and 1999 g. INTERPRETATION: Insufficient progress has occurred over the past two decades to meet the Global Nutrition Target of a 30% reduction in LBW between 2012 and 2030. Accelerating progress requires investments throughout the lifecycle focused on primary prevention, especially for adolescent girls and women living in the most affected countries. With increasing numbers of births in facilities and advancing electronic information systems, improvements in the quality and availability of administrative LBW data are also achievable. FUNDING: The Children's Investment Fund Foundation; the UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction; and the Bill & Melinda Gates Foundation.

A Comparative Analysis of Maternal Nutrition Decision-Making Autonomy During Pregnancy-An Application of the Food Choice Process Model in Burkina Faso and Madagascar.

BACKGROUND: Adequate nutrition has been cited as one of the most critical components for optimal health outcomes during pregnancy. Women in Burkina Faso and Madagascar experience high rates of undernutrition due to lack of knowledge, finances, cultural norms, and autonomy. Therefore, this study aimed (1) to describe typical maternal diets during pregnancy in Burkina Faso and Madagascar, (2) to understand the multilevel factors that influence women's nutrition decision-making, and (3) to explore the extent to which women have nutrition decision-making autonomy during pregnancy. METHODS: This study was conducted between October 2020 and February 2021 in Burkina Faso and Madagascar. Semi-structured interviews, focus group interviews, and free lists were conducted among women of reproductive age and pregnant and lactating women. Textual data from interviews were recorded and translated verbatim from local languages into French. The Food Choice Process Model guided textual content analysis using Dedoose software. Free list data were analyzed using cultural domain analysis approaches. RESULTS: In Burkina Faso and Madagascar, women primarily consumed staple foods such as rice and tô during pregnancy. Participants cited eating fruits and vegetables when available, while the animal source foods were rarely consumed. Across both contexts, nutrition during pregnancy was influenced by factors that impact food choices, such as social factors, resources, ideals, and personal factors. While women and men in Madagascar had more shared decision-making on critical domains such as finances, men were the primary decision-makers in most areas of inquiry (eg, finances) in Burkina Faso. CONCLUSIONS: The lack of adequate diverse diet consumed during pregnancy is primarily due to important factors including social factors and resources. Understanding the ability for women to consume optimal diets during pregnancy is needed to target behavioral change in maternal nutrition programming.

Plain language titleA comparison of How Pregnant Women Make Decisions About What to Eat in Burkina Faso and Madagascar Using a Model Called the Food Choice Process ModelPlain language summaryHaving a proper diet is very important for the health of pregnant women. In Burkina Faso and Madagascar, many women do not get enough nutritious food due to lack of knowledge on what to eat, lack of money, cultural traditions, and not having control over their own choices. This study wants to find out (1) what women eat during pregnancy in Burkina Faso and Madagascar, (2) what influences the decisions women make about what to eat during pregnancy, and (3) explore how women had decision-making autonomy during pregnancy. The study took place in Burkina Faso and Madagascar. The researchers talked to women who could have babies and women who were already pregnant or breastfeeding. They used different methods like focus group discussions and semi-structured interviews to gather information. They recorded and translated everything that was said from the local languages to French. They used special software to analyze the information from the interviews. They also used a free list to understand the things women mentioned most often when talking about food. In Burkina Faso and Madagascar, women mostly ate basic foods like rice and tô during pregnancy. Sometimes they ate fruits and vegetables when they were available, but they did not eat much meat or other foods from animals. In both places, the women's food choices during pregnancy were influenced by different things like what their friends and family thought, how much money they had, their personal preferences, and other factors. In Madagascar, men and women made decisions together about important things like money, but in Burkina Faso, men were usually the ones making the decisions. The lack of a proper diverse diet during pregnancy in Burkina Faso and Madagascar is primarily caused by social factors and resources. To help women make better food choices during pregnancy, it's important to understand what affects their ability to have a healthy diet. This can help programs that aim to improve the nutrition of pregnant women by encouraging them to change their behavior.

Small vulnerable newborns-big potential for impact.

Despite major achievements in child survival, the burden of neonatal mortality has remained high and even increased in some countries since 1990. Currently, most neonatal deaths are attributable to being born preterm, small for gestational age (SGA), or with low birthweight (LBW). Besides neonatal mortality, these conditions are associated with stillbirth and multiple morbidities, with short-term and long-term adverse consequences for the newborn, their families, and society, resulting in a major loss of human capital. Prevention of preterm birth, SGA, and LBW is thus critical for global child health and broader societal development. Progress has, however, been slow, largely because of the global community's failure to agree on the definition and magnitude of newborn vulnerability and best ways to address it, to frame the problem attractively, and to build a broad coalition of actors and a suitable governance structure to implement a change. We propose a new definition and a conceptual framework, bringing preterm birth, SGA, and LBW together under a broader umbrella term of the small vulnerable newborn (SVN). Adoption of the framework and the unified definition can facilitate improved problem definition and improved programming for SVN prevention. Interventions aiming at SVN prevention would result in a healthier start for live-born infants, while also reducing the number of stillbirths, improving maternal health, and contributing to a positive economic and social development in the society.

Study protocol for UNICEF and WHO estimates of global, regional, and national low birthweight prevalence for 2000 to 2020.

Background Reducing low birthweight (LBW, weight at birth less than 2,500g) prevalence by at least 30% between 2012 and 2025 is a target endorsed by the World Health Assembly that can contribute to achieving Sustainable Development Goal 2 (Zero Hunger) by 2030. The 2019 LBW estimates indicated a global prevalence of 14.6% (20.5 million newborns) in 2015. We aim to develop updated LBW estimates at global, regional, and national levels for up to 202 countries for the period of 2000 to 2020. Methods Two types of sources for LBW data will be sought: national administrative data and population-based surveys. Administrative data will be searched for countries with a facility birth rate ≥80% and included when birthweight data account for ≥80% of UN estimated live births for that country and year. Surveys with birthweight data published since release of the 2019 edition of the LBW estimates will be adjusted using the standard methodology applied for the previous estimates. Risk of bias assessments will be undertaken. Covariates will be selected based on a conceptual framework of plausible associations with LBW, covariate time-series data quality, collinearity between covariates and correlations with LBW. National LBW prevalence will be estimated using a Bayesian multilevel-mixed regression model, then aggregated to derive regional and global estimates through population-weighted averages. Conclusion Whilst availability of LBW data has increased, especially with more facility births, gaps remain in the quantity and quality of data, particularly in low-and middle-income countries. Challenges include high percentages of missing data, lack of adherence to reporting standards, inaccurate measurement, and data heaping. Updated LBW estimates are important to highlight the global burden of LBW, track progress towards nutrition targets, and inform investments in programmes. Reliable, nationally representative data are key, alongside investments to improve the measurement and recording of an accurate birthweight for every baby.

Setting research priorities on multiple micronutrient supplementation in pregnancy.

Prenatal micronutrient deficiencies are associated with negative maternal and birth outcomes. Multiple micronutrient supplementation (MMS) during pregnancy is a cost-effective intervention to reduce these adverse outcomes. However, important knowledge gaps remain in the implementation of MMS interventions. The Child Health and Nutrition Research Initiative (CHNRI) methodology was applied to inform the direction of research and investments needed to support the implementation of MMS interventions for pregnant women in low- and middle-income countries (LMIC). Following CHNRI methodology guidelines, a group of international experts in nutrition and maternal health provided and ranked the research questions that most urgently need to be resolved for prenatal MMS interventions to be successfully implemented. Seventy-three research questions were received, analyzed, and reorganized, resulting in 35 consolidated research questions. These were scored against four criteria, yielding a priority ranking where the top 10 research options focused on strategies to increase antenatal care attendance and MMS adherence, methods needed to identify populations more likely to benefit from MMS interventions and some discovery issues (e.g., potential benefit of extending MMS through lactation). This exercise prioritized 35 discrete research questions that merit serious consideration for the potential of MMS during pregnancy to be optimized in LMIC.

A Changing Landscape for Vitamin A Programs: Implications for Optimal Intervention Packages, Program Monitoring, and Safety.

BACKGROUND: Vitamin A deficiency (VAD) remains a widespread public health problem in the developing world, despite changes in under-5 mortality rates, morbidity patterns, and intervention options. OBJECTIVE: This article considers the implications of a changing epidemiologic and programmatic landscape for vitamin A (VA) programs. METHODS: We review progress to prevent VAD and its health consequences, assess gaps in VA status and intervention coverage data, and assess data needed to guide decisions regarding the optimal mix, targeting, and dose of VA interventions to maximize benefit and minimize risk. RESULTS: Vitamin A supplementation programs have contributed to the reduction in under-5 mortality rates, but alone, do not address the underlying problem of inadequate dietary VA intakes and VAD among preschool-aged children in the developing world. A combination of VA interventions (eg, supplementation, fortified foods, multiple micronutrient powders, and lipid-based nutrient supplements) will be required to achieve VA adequacy in most settings. Current efforts to measure the coverage of multiple VA interventions, as well as whether and how much VA children are receiving, are few and fragmented. CONCLUSIONS: Where intervention overlap exists, further effort is needed to monitor VA intakes, ensuring that targeted groups are consuming adequate amounts but not exceeding the tolerable upper intake level. Vitamin A status data will also be critical for navigating the changing landscape of VA programs. Data from these monitoring efforts will help to guide decisions on the optimal mix, targeting, and exposure to VA interventions to maximize public health benefit while minimizing any potential risk.

The Role of Child Health Days in the Attainment of Global Deworming Coverage Targets among Preschool-Age Children.

BACKGROUND: Global deworming programs aim to reach 75% of at-risk preschool-age children (pre-SAC) by 2020. The 2013 global pre-SAC deworming coverage initially published by the World Health Organization (WHO) was 23.9%, but this estimate inadequately captured deworming delivered through Child Health Day (CHD) platforms. OBJECTIVE: To update global and regional coverage estimates of pre-SAC deworming in 2013 by supplementing data from the WHO Preventive Chemotherapy and Transmission Control (PCT) databank with national CHD data. METHODS: UNICEF country offices (n = 82) were mailed a questionnaire in July 2014 to report on official national biannual CHD deworming coverage as part of the global vitamin A supplementation coverage reporting mechanism. Coverage data obtained were validated and considered for inclusion in the PCT databank in a collaboration between UNICEF and WHO. Descriptive statistical analyses were conducted to update the number of pre-SAC reached and the number of treatments delivered. RESULTS: Of the 47 countries that responded to the UNICEF pre-SAC deworming questionnaire, 73 data points from 39 countries were considered for inclusion into the WHO PCT databank. Of these, 21 new data points were from 12 countries were newly integrated into the WHO database. With this integration, deworming coverage among pre-SAC increased to 49.1%, representing an increase in the number of children reached and treatments administered from 63.7 million to 130.7 million and 94.7 million to 234.8 million, respectively. The updated databank comprised 98 mass deworming activities conducted in 55 countries, in which 80.4% of the global pre-SAC population requiring deworming reside. In all, 57 countries requiring deworming were not yet represented in the database. CONCLUSIONS: With the inclusion of CHD data, global deworming programs are on track to achieving global pre-SAC coverage targets. However, further efforts are needed to improve pre-SAC coverage reporting as well as to sustain and expand deworming delivery through CHDs and other platforms.

Evolution of the child health day strategy for the integrated delivery of child health and nutrition services.

BACKGROUND: In efforts to meet the Millennium Development Goal for mortality among children under 5 years of age, countries require strategies for covering hard-to-reach and older children who are often missed by routine, fixed-site health services. OBJECTIVE: To document the evolution of Child Health Days (CHDs), designed as regular events for the delivery of health and nutrition services to children under the age of five. METHODS: We extracted information on service delivery strategies and codelivered interventions for the period 1999 to 2010from global monitoring databases for vitamin A and immunization. RESULTS: Our data illustrate a dramatic rise in CHDs over the decade: only two countries held CHDs in 1999; in 2010, 96 CHDs were conducted in 51 countries. Reliance on CHDs has been particularly marked in sub-Saharan Africa, where they are increasingly used to deliver five or more_services per event. Whereas early CHDs were largely defined by codelivery of vitamin A, immunizations, and deworming, they have since evolved into diverse packages including services such as water purification tablets and screening for severe malnutrition. CONCLUSIONS: The scale-up of CHDs is helping countries to achieve high and equitable coverage of essential health and nutrition services. Future research should consider whether the increasingly diverse services delivered via CHDs are guided by epidemiologic considerations, and whether the rising number of codelivered interventions is affecting coverage performance or service quality. Guidance is also needed to ensure that CHDs are implemented as part of systematic efforts to improve health systems.

Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition.

Implementation of innovative strategies to improve coverage of evidence-based interventions, especially in the most marginalised populations, is a key focus of policy makers and planners aiming to improve child survival, health, and nutrition. We present a three-step approach to improvement of the effective coverage of essential interventions. First, we identify four different intervention delivery channels--ie, clinical or curative, outreach, community-based preventive or promotional, and legislative or mass media. Second, we classify which interventions' deliveries can be improved or changed within their channel or by switching to another channel. Finally, we do a meta-review of both published and unpublished reviews to examine the evidence for a range of strategies designed to overcome supply and demand bottlenecks to effective coverage of interventions that improve child survival, health, and nutrition. Although knowledge gaps exist, several strategies show promise for improving coverage of effective interventions-and, in some cases, health outcomes in children-including expanded roles for lay health workers, task shifting, reduction of financial barriers, increases in human-resource availability and geographical access, and use of the private sector. Policy makers and planners should be informed of this evidence as they choose strategies in which to invest their scarce resources.

The use and interpretation of serum retinol distributions in evaluating the public health impact of vitamin A programmes.

OBJECTIVE: Developing countries have adopted universal, high-potency vitamin A (VA) supplementation and food fortification as major strategies to control deficiency, prevent nutritional blindness and reduce child mortality. Yet questions persist regarding how best to measure impact and when to phase out supplementation. The present paper provides guidance on the use and interpretation of serum retinol (SROL) distributions as indicators of both programme impact and adequate VA intake in a population. DESIGN: We reviewed extant data on SROL's response to high-potency VA supplementation and VA-fortified foods in children. RESULTS: Supplementation virtually eliminates xerophthalmia and reduces child mortality; however, it shifts the SROL distribution only transiently (<2 months). Regular consumption of VA-fortified foods prevents xerophthalmia, lowers mortality and sustainably improves SROL distributions, from which both compliance and public health impact can be inferred. CONCLUSIONS: Given SROL's limited responsiveness to high-potency VA supplementation, target population coverage remains the preferred performance indicator. However, periodic SROL surveys do reflect underlying dietary risk and can guide programming: low or marginal SROL distributions in areas with high supplementation coverage do not signify programme failure, but rather suggest the need to continue supplementation while working to effectively raise dietary VA intakes. We propose that a sustained rise in the SROL distribution, defined as ≤5 % prevalence of SROL < 0·70 µmol/l among vulnerable population groups in at least two consecutive surveys (≥1 year apart), be used as an indicator of stable and adequate dietary VA intake and status in a population, at which point programmes may re-evaluate the need for continued universal supplementation.

Long-term intermittent multiple micronutrient supplementation enhances hemoglobin and micronutrient status more than iron + folic acid supplementation in Bangladeshi rural adolescent girls with nutritional anemia.

Previous short-term supplementation studies showed no additional hematologic benefit of multiple micronutrients (MMN) compared with iron + folic acid (IFA) in adolescent girls. This study examines whether long-term once- or twice-weekly supplementation of MMN can improve hemoglobin (Hb) and micronutrient status more than twice-weekly IFA supplementation in anemic adolescent girls in Bangladesh. Anemic girls (n = 324) aged 11-17 y attending rural schools were given once- or twice-weekly MMN or twice-weekly IFA, containing 60 mg iron/dose in both supplements, for 52 wk in a randomized double-blind trial. Blood samples were collected at baseline and 26 and 52 wk. Intent to treat analysis showed no significant difference in the Hb concentration between treatments at either 26 or 52 wk. However, after excluding girls with hemoglobinopathy and adjustment for baseline Hb, a greater increase in Hb was observed with twice-weekly MMN at 26 wk (P = 0.045). Although all 3 treatments effectively reduced iron deficiency, once-weekly MMN produced significantly lower serum ferritin concentrations than the other treatments at both 26 and 52 wk. Both once- and twice-weekly MMN significantly improved riboflavin, vitamin A, and vitamin C status compared with IFA. Overall, once-weekly MMN was less efficacious than twice-weekly MMN in improving iron, riboflavin, RBC folic acid, and vitamin A levels. Micronutrient supplementation beyond 26 wk was likely important in sustaining improved micronutrient status. These findings highlight the potential usefulness of MMN intervention in this population and have implications for programming.

Multiple micronutrient supplementation during pregnancy in developing-country settings: policy and program implications of the results of a meta-analysis.

BACKGROUND: An independent Systematic Review Team performed a meta-analysis of 12 randomized, controlled trials comparing multiple micronutrients with daily iron-folic acid supplementation during pregnancy. OBJECTIVE: To provide an independent interpretation of the policy and program implications of the results of the meta-analysis. METHODS: A group of policy and program experts performed an independent review of the meta-analysis results, analyzing internal and external validity and drawing conclusions on the program implications. RESULTS: Although iron content was often lower in the multiple micronutrient supplement than in the iron-folic acid supplement, both supplements were equally effective in tackling anemia. Community-based supplementation ensured high adherence, but some mothers still remained anemic, indicating the need to concomitantly treat infections. The small, significant increase in mean birthweight among infants of mothers receiving multiple micronutrients compared with infants of mothers receiving iron-folic acid is of similar magnitude to that produced by food supplementation during pregnancy. Larger micronutrient doses seem to produce greater impact. Meaningful improvements have also been observed in height and cognitive development of the children by 2 years of age. There were no significant differences in the rates of stillbirth, early neonatal death, or neonatal death between the supplemented groups. The nonsignificant trend toward increased early neonatal mortality observed in the groups receiving multiple micronutrients may be related to differences across trials in the rate of adolescent pregnancies, continuing iron deficiency, and/or adequacy of postpartum health care and merits further investigation. CONCLUSIONS: Replacing iron-folic acid supplements with multiple micronutrient supplements in the package of health and nutrition interventions delivered to mothers during pregnancy will improve the impact of supplementation on birthweight and on child growth and development.

Micronutrient deficiencies and gender: social and economic costs.

Vitamin and mineral deficiencies adversely affect a third of the world's people. Consequently, a series of global goals and a serious amount of donor and national resources have been directed at such micronutrient deficiencies. Drawing on the extensive experience of the authors in a variety of institutional settings, the article used a computer search of the published scientific literature of the topic, supplemented by reports and published and unpublished work from the various agencies. In examining the effect of sex on the economic and social costs of micronutrient deficiencies, the paper found that: (1) micronutrient deficiencies affect global health outcomes; (2) micronutrient deficiencies incur substantial economic costs; (3) health and nutrition outcomes are affected by sex; (4) micronutrient deficiencies are affected by sex, but this is often culturally specific; and finally, (5) the social and economic costs of micronutrient deficiencies, with particular reference to women and female adolescents and children, are likely to be considerable but are not well quantified. Given the potential impact on reducing infant and child mortality, reducing maternal mortality, and enhancing neuro-intellectual development and growth, the right of women and children to adequate food and nutrition should more explicitly reflect their special requirements in terms of micronutrients. The positive impact of alleviating micronutrient malnutrition on physical activity, education and productivity, and hence on national economies suggests that there is also an urgent need for increased effort to demonstrate the cost of these deficiencies, as well as the benefits of addressing them, especially compared with other health and nutrition interventions.

Combating hidden hunger: the role of international agencies.

The importance of micronutrient deficiencies or "hidden hunger" was clearly emphasized by the inclusion of specific goals on iron, vitamin A, and iodine deficiency at the 1990 World Summit for Children and other major international nutrition conferences. Significant progress has since been made toward eliminating vitamin A and iodine deficiencies, with less progress made toward reducing the burden of iron-deficiency anemia. The role of international agencies, such as the World Health Organization, United Nations Children's Fund, Food and Agricultural Organization, and World Bank in assisting countries to make progress toward the World Summit for Children goals has been very important. International agencies have played a critical role in advocating for and raising awareness of these issues at the international, regional, and national levels among policymakers and the general population. Using a rights-based approach, UNICEF and other agencies have been instrumental in elevating to the highest political level the discussion of every child's right to adequate nutrition. International agencies have also been very supportive at the national level in providing technical guidance for programs, including monitoring and evaluation. These agencies have played a critical role in engaging the cooperation of other partners, including bilateral donors, non-governmental organizations, and the private sector for micronutrient programs. Furthermore, international agencies provide financial and material support for micronutrient programs. In the future, such agencies must continue to be heavily involved in programs to achieve the newly confirmed goals for 2010. The present paper focuses on the role of international agencies in combating micronutrient deficiencies, drawing on the lessons learned over the last decade. The first section of the paper summarizes the progress achieved since 1990, and the second section describes the specific role of international agencies in contributing to that progress.