The Impact of Antenatal Balanced Plate Nutrition Education for Pregnant Women on Birth Weight: A Cluster Randomised Controlled Trial in Rural Bangladesh.

Low birth weight (LBW) is a global public health problem with the highest prevalence in South Asia. It is strongly associated with maternal undernutrition. In South Asia, intra-household food distribution is inequitable, with lower dietary adequacy in women. Evidence that nutrition education improves diet during pregnancy and reduces LBW is weak. We assessed the impact of nutrition education for pregnant women on birth weight in rural Bangladesh. We conducted a parallel, two-arm, cluster-randomised controlled trial, with 36 clusters allocated equally to intervention (n = 445) or standard care (n = 448). From their first trimester until delivery, intervention participants received education about eating balanced meals to meet daily dietary requirements with diverse food groups. The primary outcome of mean birth weight was 127.5 g higher in the intervention compared to control women, and the intervention reduced the risk of LBW by 57%. Post hoc analyses showed a significantly higher birth weight and a greater reduction in LBW amongst adolescent mothers. The mean number of food groups consumed was significantly higher in the intervention from the third month of pregnancy than in the control. A community-based balanced plate nutrition education intervention effectively increased mean birth weight and reduced LBW, and improved dietary diversity in rural Bangladeshi women.

Iron and Folic Acid Supplementation in Pregnancy: Findings from the Baseline Assessment of a Maternal Nutrition Service Programme in Bangladesh.

Effective coverage of antenatal iron and folic acid (IFA) supplementation is important to prevent adverse maternal and newborn health outcomes. We interviewed 2572 women from two rural districts in Bangladesh who had a live birth in the preceding six months. We analysed the number of IFA tablets received and consumed during pregnancy and examined the factors influencing IFA consumption by multiple linear regression and user adherence-adjusted effective coverage of IFA (consuming ≥180 IFA tablets) by Poisson regression. Overall, about 80% of women consumed IFA supplements in any quantity. About 76% of women received antenatal care at least once, only 8% received ≥180 IFA tablets, and 6% had user adherence-adjusted coverage of antenatal IFA supplementation. Multivariable analysis showed a linear relationship between the number of antenatal care (ANC) visits and the number of IFA supplements consumed, which was modified by the timing of the first ANC visit. Women's education, free IFA, and advice on IFA were also associated with higher IFA consumption. Interventions targeting at least eight ANC contacts, starting early in pregnancy, providing advice on the importance of IFA, and providing IFA supplements in higher quantity at ANC contacts are likely to increase effective coverage of antenatal IFA supplementation.

Factors influencing quality nutrition service provision at antenatal care contacts: Findings from a public health facility-based observational study in 21 districts of Bangladesh.

Malnutrition during pregnancy is associated with increased maternal morbidity and mortality and has a long-term negative impact on child growth and development. Antenatal care (ANC) is the formal point of contact for pregnant women to receive preventive health and nutrition services. We assessed the quality of nutrition service delivery during ANC and examined its influencing factors related to the health facility, health care provider (HCP) and client characteristics. We conducted a cross-sectional assessment in 179 facilities, including 1,242 ANC observations and exit interviews of pregnant women from 21 districts in Bangladesh. We considered four essential nutrition services at each ANC contact including maternal weight measurement, anaemia assessment, nutrition counselling and iron-folic acid (IFA) supplement provision. We defined a composite 'quality nutrition service' outcome by counting the number of services (out of four) provided at each ANC from observation data. We explored both the supply-side and the client-level factors of quality nutrition service using multilevel Poisson regression. Overall, only 15% of clients received all four nutrition services. Performance of weight measurement (79%) was higher than IFA provision (56%), anaemia assessment (52%) and nutrition counselling (52%). The multivariable analysis showed that quality nutrition service delivery is positively associated with good logistical readiness of the facilities (aIRR: 1.23, 95% CI: 1.08-1.39), consultation by paramedics (aIRR 1.23, 95% CI: 1.06-1.42) and community health care providers (aIRR 1.32, 95% CI: 1.12-1.57), HCPs' knowledge on maternal nutrition (aIRR 1.04; 95% CI: 1.01-1.08), better HCP-client communication (aIRR 1.14; 95% CI: 1.04-1.26) and use visual aids or ANC card (aIRR 1.18; 95% CI: 1.11-1.27). We found limited associations between HCP training and external supervision with the quality of nutrition services. In conclusion, the quality of nutrition service provision during ANC is suboptimal. Public health nutrition programmers should ensure the facilities' logistical readiness, and revisit and reinforce the content and modality of training and supportive supervision of the HCPs. They should also emphasize positive HCP-client communication and the use of job aids to improve the quality of nutrition service provision during ANC.

Sugar-sweetened beverage consumption and overweight and obesity in adolescents in Ho Chi Minh City, Vietnam: a population-based analysis.

BACKGROUND: The aim of this research was to describe the patterns of consumption of multiple sugar-sweetened beverages (including modern and traditional ones) among adolescents in Ho Chi Minh City and to identify a possible relationship between this consumption and overweight, obesity, and other factors. METHODS: A secondary analysis from a cross-sectional study of 11-15-year-old students from 31 junior high schools across Ho Chi Minh City was used. We measured the students' anthropometric status and assessed beverage consumption using a validated Food Frequency Questionnaire. Multivariate logistic regression models were used to identify the association between the consumption of sugar-sweetened beverages, obesity and other factors. RESULTS: The sugar-sweetened beverages (SSB) ranged widely from modern soft drinks and powdered drinks to traditional sugar-added fruit and leaf juices, and milk-based drinks. These beverages were very popular among 2,660 participants with 36% consuming at least one variety daily. Factors positively associated with sugar-sweetened beverage consumption included a higher level of physical activity, higher consumption of fast foods, and daily fruit and vegetable consumption. We found a negative association between milk-based SSBs and the overweight and obesity status of the students, i.e. every kcal more of fresh milk with sugar and condensed milk can reduce an obesity odd of 0.005 (95% CI [0.002-0.008], p < 0.001) and 0.004 (95% CI [0.002-0.010], p = 0.044) consecutively. None of the other SSBs was significantly related to adolescent overweight and obesity. CONCLUSIONS: Milk-based drinks potentially protect adolescents against overweight and obesity. Further research to assess this protection is needed.

Effect of nutrition counselling with a digital job aid on child dietary diversity: Analysis of secondary outcomes from a cluster randomised controlled trial in rural Bangladesh.

Adequate dietary diversity among infants is often suboptimal in developing countries. We assessed the impact of nutrition counselling using a digital job aid on dietary diversity of children aged 6-23 months using data from a cluster randomised controlled trial in Bangladesh. The trial had five arms, each with 25 clusters. The four intervention arms provided counselling using a digital job aid and different prenatal and post-natal combinations of lipid-based supplements and the comparison arm with usual practice. We enrolled 1500 pregnant women and followed them until the children reached their second birthday. We developed a tablet-based system for intervention delivery, data collection and project supervision. We combined the four intervention arms (n = 855), in which community health workers (CHWs) provided age-appropriate complementary feeding counselling, to compare against the comparison arm (n = 403). We calculated the outcome indicators from the children's 24-h dietary recalls. Overall, the intervention increased the mean dietary diversity score by 0.09 (95% confidence interval [CI]: 0.2-0.16) and odds of minimum dietary diversity by 18% (95% CI: 0.99-1.40). However, there was a significant interaction on the effect of the intervention on dietary diversity by age. The mean dietary diversity score was 0.24 (95% CI: 0.11-0.37) higher in the intervention than in the comparison arm at 9 months and 0.14 (95% CI: 0.01-27) at 12 months of age. The intervention effect was non-significant at an older age. Overall, consumption of flesh food was 1.32 times higher in the intervention arm (odds ratio [OR] 1.32, 95% CI: 1.11-1.57) in 6-23 months of age. The intervention significantly improved child dietary diversity score in households with mild and moderate food insecurity by 0.27 (95% CI: 0.06-0.49) and 0.16 (0.05-27), respectively, but not with food-secure and severely food-insecure households. Although the study did not evaluate the impact of digital job aid alone, the findings indicate the utility of nutrition counselling by CHWs using a digital job aid to improve child feeding practices in broader programmes.

Assessing the impact of a combined nutrition counselling and cash transfer intervention on women's empowerment in rural Bangladesh: a randomised control trial protocol.

INTRODUCTION: There is growing interest in assessing the impact of health interventions, particularly when women are the focus of the intervention, on women's empowerment. Globally, research has shown that interventions targeting nutrition, health and economic development can affect women's empowerment. Evidence suggests that women's empowerment is also an underlying determinant of nutrition outcomes. Depending on the focus of the intervention, different domains of women's empowerment will be influenced, for example, an increase in nutritional knowledge, or greater control over income and access to resources. OBJECTIVE: This study evaluates the impact of the Shonjibon Cash and Counselling (SCC) Trial that combines nutrition counselling and an unconditional cash transfer, delivered on a mobile platform, on women's empowerment in rural Bangladesh. METHODS AND ANALYSIS: We will use a mixed-methods approach, combining statistical analysis of quantitative data from 2840 women in a cluster randomised controlled trial examining the impact of nutrition behaviour change communications (BCCs) and cash transfers on child undernutrition. Pregnant participants will be given a smartphone with a customised app, delivering nutrition BCC messages, and will receive nutrition counselling via a call centre and an unconditional cash transfer. This study is a component of the SCC Trial and will measure women's empowerment using a composite indicator based on the Project-Level Women's Empowerment in Agriculture Index, with quantitative data collection at baseline and endline. Thematic analysis of qualitative data, collected through longitudinal interviews with women, husbands and mothers-in-law, will elicit a local understanding of women's empowerment and the linkages between the intervention and women's empowerment outcomes. This paper describes the study protocol to evaluate women's empowerment in a nutrition-specific and sensitive intervention using internationally validated, innovative tools and will help fill the evidence gap on pathways of impact, highlighting areas to target for future programming. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the International Centre for Diarrhoeal Disease Research (Ref. PR 17106) and The University of Sydney (Ref: 2019/840). Findings from this study will be shared in Bangladesh with dissemination sessions in-country and internationally at conferences, and will be published in peer-reviewed journals.

Effect of an Integrated Package of Nutrition Behavior Change Interventions on Infant and Young Child Feeding Practices and Child Growth from Birth to 18 Months: Cohort Evaluation of the Baduta Cluster Randomized Controlled Trial in East Java, Indonesia.

The need for a multisectoral approach to tackle stunting has gained attention in recent years. Baduta project aims to address undernutrition among children during their first 1000 days of life using integrated nutrition-specific and nutrition-sensitive interventions. We undertook this cohort study to evaluate the Baduta project's effectiveness on growth among children under 2 years of age in two districts (Sidoarjo and Malang Districts) in East Java. Six subdistricts were randomly selected, in which three were from the intervention areas, and three were from the control areas. We recruited 340 pregnant women per treatment group during the third trimester of pregnancy and followed up until 18 months postpartum. The assessment of breastfeeding and complementary feeding practices used standard infant and young child feeding (IYCF) indicators in a tablet-based application. We measured weight and length at birth and every three-months after that. The enumerators met precision and accuracy criteria following an anthropometry standardization procedure. Among the breastfed children, the percentage of children who achieved the minimum dietary diversity score (DDS) and minimum acceptable diet (MAD) was higher for the intervention group than the comparison group across all age groups. The odd ratios were 3.49 (95% CI: 2.2-5.5) and 2.79 (95% CI: 1.7-4.4) for DDS and 3.49 (95% CI: 2.2-5.5) and 2.74 (95% CI: 1.8-5.2) for MAD in the 9-11 month and 16-18-month age groups, respectively. However, there was no significant improvement in growth or reduction in the prevalence of anemia. The intervention was effective in improving the feeding practices of children although it failed to show significant improvement in linear growth of children at 18 months of age.

Evaluation of a Package of Behaviour Change Interventions (Baduta Program) to Improve Maternal and Child Nutrition in East Java, Indonesia: Protocol for an Impact Study.

BACKGROUND: Over the past decade, the prevalence of stunting has been close to 37% in children aged <5 years in Indonesia. The Baduta program, a multicomponent package of interventions developed by the Global Alliance for Improved Nutrition, aims to improve maternal and infant nutrition in Indonesia. OBJECTIVE: This study aims to assess the impact of the Baduta program, a package of health system strengthening and behavior change interventions, compared with the standard village health services on maternal and child nutrition. METHODS: The impact evaluation uses a cluster randomized controlled trial design with 2 outcome assessments. The first uses cross-sectional surveys of mothers of children aged 0-23 months and pregnant women before and after the interventions. The second is a cohort study of pregnant women followed until their child is 18 months from a subset of clusters. We will also conduct a process evaluation guided by the program impact pathway to assess coverage, fidelity, and acceptance. The study will be conducted in the Malang and Sidoarjo districts of East Java, Indonesia. The unit of randomization is the subdistricts. As random allocation of interventions to only 6 subdistricts is feasible, we will use constrained randomization to ensure balance of baseline covariates. The first intervention will be health system strengthening, including the Baby-Friendly Hospital Initiative, and training on counseling for appropriate infant and young child feeding (IYCF). The second intervention will be nutrition behavior change that includes Emo-Demos; a national television (TV) advertising campaign; local screening TV spots; a free, text message service; and promotion of low-cost water filters and hygiene practices. The primary study outcome is child stunting (low length-for-age), and secondary outcomes include length-for-age Z scores, wasting (low weight-for-length), anemia, child morbidity, IYCF indicators, and maternal and child nutrient intakes. The sample size for each cross-sectional survey is 1400 mothers and their children aged <2 years and 200 pregnant women in each treatment group. The cohort evaluation requires a sample size of 340 mother-infant pairs in each treatment group. We will seek Gatekeeper consent and written informed consent from the participants. The intention-to-treat principle will guide our data analysis, and we will apply Consolidated Standards of Reporting Trials guidelines for clustered randomized trials in the analysis. RESULTS: In February 2015, we conducted a baseline cross-sectional survey on 2435 women with children aged <2 years and 409 pregnant women. In February 2017, we conducted an end-line survey on 2740 mothers with children aged <2 years and 642 pregnant women. The cohort evaluation began in February 2015, with 729 pregnant women, and was completed in December 2016. CONCLUSIONS: The results of the program evaluation will help guide policies to support effective packages of behavior change interventions to prevent child stunting in Indonesia. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/18521.

Benefits and risks of Iron interventions in children (BRISC): protocol for a three-arm parallel-group randomised controlled field trial in Bangladesh.

INTRODUCTION: Anaemia is a major global health problem affecting about 43% of preschool children globally and 60% of 6-24-month-old children in rural Bangladesh, half of which is attributed to iron deficiency (ID). Although WHO recommends universal supplementation with iron or home fortification with iron-containing multiple micronutrient powders (MMPs) to children under 2 years, evidence for benefits of these interventions on childhood development (a key rationale for these interventions) and harms (especially infection) remains limited. This study aims to evaluate the impact of iron or MMPs supplementation compared with placebo on (a) children's development, (b) growth, (c) morbidity from infections and (d) haematological and iron indices. METHODS AND ANALYSIS: This study is a three-arm, blinded, double-dummy, parallel-group, placebo-controlled superiority trial using stratified individual block randomisation. The trial will randomise 3300 children aged 8-9 months equally to arm 1: iron syrup (12.5 mg elemental iron), placebo MMPs; arm 2: MMPs (including 12.5 mg elemental iron), placebo syrup; and arm 3: placebo syrup, placebo MNPs. Children will receive interventions for 3 months based on WHO recommendations and then be followed up for 9 months post intervention. The primary outcome is cognitive composite score measured by Bayley III. Secondary outcomes include motor and language composite score by Bayley III, behaviour rating using selected items from Wolke's rating scales and BSID-II behaviour ratings, temperament, growth, haemoglobin, anaemia and iron status, and infectious morbidity. Outcomes will be measured at baseline, at the end of 3-month intervention and after 9 months postintervention follow-up. ETHICS AND DISSEMINATION: The trial has been approved by the Ethical Review Committee of icddr,b (Dhaka, Bangladesh) and the Melbourne Health Human Research Ethics Committee (Melbourne, Australia). Results of the study will be disseminated through scientific publications, presentations at international meetings and policy briefs to key stakeholders. TRIAL REGISTRATION NUMBER: ACTRN12617000660381;Pre-results. WHO UNIVERSAL TRIAL NUMBER: U1111-1196-1125.

Risk factors for under-5 mortality: evidence from Bangladesh Demographic and Health Survey, 2004-2011.

OBJECTIVE: The aim of this study was to identify factors associated with mortality in children under 5 years of age using a nationally representative sample of singleton births for the period of 2004-2011. DESIGN, SETTING AND PARTICIPANTS: Pooled 2004, 2007 and 2011 cross-sectional data sets of the Bangladesh Demographic and Health Surveys were analysed. The surveys used a stratified two-stage cluster sample of 16,722 singleton live-born infants of the most recent birth of a mother within a 3-year period. MAIN OUTCOME MEASURES: Outcome measures were neonatal mortality (0-30 days), postneonatal mortality (1-11 months), infant mortality (0-11 months), child mortality (1-4 years) and under-5 mortality (0-4 years). RESULTS: Survival information for 16,722 singleton live-born infants and 522 deaths of children <5 years of age included: 310 neonatal deaths, 154 postneonatal deaths, 464 infant deaths, 58 child deaths and 522 under-5 deaths. Multiple variable analysis showed that, over a 7-year period, mortality reduced significantly by 48% for postneonatal deaths, 33% for infant deaths and 29% for under-5 deaths, but there was no significant reduction in neonatal deaths (adjusted OR (AOR) = 0.79, 95% CI 0.59 to 1.06) or child deaths (AOR = 1.00, 95% CI 0.51 to 1.94). The odds of neonatal, postneonatal, infant, child and under-5 deaths decreased significantly among mothers who used contraceptive and mothers who had other children aged 3 years or older. The risk of neonatal, postneonatal, infant, child and under-5 deaths was significantly higher in mothers who reported a previous death of a sibling. CONCLUSIONS: Our study suggests that family planning is needed to further reduce the overall rate of under-5 deaths in Bangladesh. To reduce childhood mortality, public health interventions that focus on child spacing and contraceptive use by mothers may be most effective.

Risk factors for postneonatal, infant, child and under-5 mortality in Nigeria: a pooled cross-sectional analysis.

OBJECTIVES: To identify common factors associated with post-neonatal, infant, child and under-5 mortality in Nigeria. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional data of three Nigeria Demographic and Health Surveys (NDHS) for the years 2003, 2008 and 2013 were used. A multistage, stratified, cluster random sampling method was used to gather information on 63,844 singleton live-born infants of the most recent birth of a mother within a 5-year period before each survey was examined using cox regression models. MAIN OUTCOME MEASURES: Postneonatal mortality (death between 1 and 11 months), infant mortality (death between birth and 11 months), child mortality (death between 12 and 59 months) and under-5 mortality (death between birth and 59 months). RESULTS: Multivariable analyses indicated that children born to mothers with no formal education was significantly associated with mortality across all four age ranges (adjusted HR=1.30, 95% CI 1.01 to 1.66 for postneonatal; HR=1.38, 95% CI 1.11 to 1.84 for infant; HR=2.13, 95% CI 1.56 to 2.89 for child; HR=1.19, 95% CI 1.02 to 1.41 for under-5). Other significant factors included living in rural areas (HR=1.48, 95% CI 1.16 to 1.89 for postneonatal; HR=1.23, 95% CI 1.03 to 1.47 for infant; HR=1.52, 95% CI 1.16 to 1.99 for child; HR=1.29, 95% CI 1.11 to 1.50 for under-5), and poor households (HR=2.47, 95% CI 1.76 to 3.47 for postneonatal; HR=1.40, 95% CI 1.10 to 1.78 for infant; HR=1.72, 95% CI 1.19 to 2.49 for child; HR=1.43, 95% CI 1.17 to 1.76 for under-5). CONCLUSIONS: This study found that no formal education, poor households and living in rural areas increased the risk of postneonatal, infant, child and under-5 mortality among Nigerian children. Community-based interventions for reducing under-5 deaths are needed and should target children born to mothers of low socioeconomic status.

Factors associated with not using antenatal iron/folic acid supplements in Indonesia: the 2002/2003 and 2007 Indonesia Demographic and Health Survey.

BACKGROUND: This analysis examined factors associated with non-use of antenatal iron/folic acid supplements in Indonesia. METHODS: Data from the 2002/2003 and 2007 Indonesia Demographic and Health Surveys (IDHS) were used, providing survival information for 26,591 most recent deliveries over the five-year period prior to each survey. The main outcome variable was non-use of iron/folic acid supplements. Using logistic regression, we examined the role of external environment, predisposing, enabling, need factors, and previous utilization of other maternal care services in non-use of antenatal iron/folic acid supplements. RESULTS: Mothers from outer Java- Bali Region and rural areas (OR=1.73, 95% CI: 1.48-2.03) had increased odds for not using antenatal iron/folic acid supplements. The likelihood for not using the supplements increased with the reduction of household wealth index and parental education. The odds increased amongst mothers with low autonomy on her own health care (OR=1.24, 95% CI: 1.04-1.49), high birth-rank infants, mothers with low knowledge of obstetric complications and low exposure to mass media. Enabling factors associated with increased odds for non-use of iron/folic acid supplements included mothers reporting money to pay health services (OR=1.28, 95% CI: 1.13- 1.44) and distance to health services (OR=1.20, 95% CI: 1.02-1.40) were major problems. Our study demonstrated the importance of antenatal care as a distribution channel of the supplements. CONCLUSIONS: Increasing community awareness, coverage and access to health services along with strengthening counselling sessions during antenatal care and community participation in health programs are necessary to improve the uptake of iron/folic acid supplements, to increase infant survival in Indonesia.

The effect of solid fuel use on childhood mortality in Nigeria: evidence from the 2013 cross-sectional household survey.

BACKGROUND: In Nigeria, approximately 69% of households use solid fuels as their primary source of domestic energy for cooking. These fuels produce high levels of indoor air pollution. This study aimed to determine whether Nigerian children residing in households using solid fuels at <5 years of age were at higher risk of death. METHODS: The 2013 Nigeria Demographic and Health Survey data were analysed in Cox regression analyses to examine the effects of solid fuel use on deaths of children aged 0-28 days (neonatal), 1-11 months (post-neonatal), and 12-59 months (child). RESULTS: The results indicated that approximately 0.8% of neonatal deaths, 42.9% of post-neonatal deaths, and 36.3% of child deaths could be attributed to use of solid fuels. The multivariable analyses found that use of solid fuel was associated with post-neonatal mortality (hazard ratio [HR] =1.92, 95% confidence interval [CI]: 1.42-2.58) and child mortality (HR = 1.63, CI: 1.09-2.42), but was not associated with neonatal mortality (HR = 1.01, CI: 0.73-1.26). Living in rural areas and poor households were associated with an increased risk of death during the three mortality periods. CONCLUSION: Living in a rural area and poor households were strongly associated with an increased risk of a child > 1 to < 60 months dying due to use of solid fuels. The health effects of household use of solid fuels are a major public health threat that requires increased research and policy development efforts. Research should focus on populations in rural areas and low socioeconomic households so that child survival in Nigeria can be improved.

Determinants of neonatal mortality in Nigeria: evidence from the 2008 demographic and health survey.

BACKGROUND: Nigeria continues to have one of the highest rates of neonatal deaths in Africa. This study aimed to identify risk factors associated with neonatal death in Nigeria using the 2008 Nigeria Demographic and Health Survey (NDHS). METHODS: Neonatal deaths of all singleton live-born infants between 2003 and 2008 were extracted from the 2008 NDHS. The 2008 NDHS was a multi-stage cluster sample survey of 36,298 households. Of these households, survival information of 27,147 singleton live-borns was obtained, including 996 cases of neonatal mortality. The risk of death was adjusted for confounders relating to individual, household, and community level factors using Cox regression. RESULTS: Multivariable analyses indicated that a higher birth order of newborns with a short birth interval ≤ 2 years (hazard ratio [HR] = 2.19, confidence interval [CI]: 1.68-2.84) and newborns with a higher birth order with a longer birth interval > 2 years (HR = 1.36, CI: 1.05-1.78) were significantly associated with neonatal mortality. Other significant factors that affected neonatal deaths included neonates born to mothers younger than 20 years (HR = 4.07, CI: 2.83-5.86), neonates born to mothers residing in rural areas compared with urban residents (HR = 1.26, CI: 1.03-1.55), male neonates (HR = 1.30, CI: 1.12-1.53), mothers who perceived their neonate's body size to be smaller than the average size (HR = 2.10, CI: 1.77-2.50), and mothers who delivered their neonates by caesarean section (HR = 2.80, CI: 1.84-4.25). CONCLUSIONS: Our study suggests that the Nigerian government needs to invest more in the healthcare system to ensure quality care for women and newborns. Community-based intervention is also required and should focus on child spacing, childbearing at a younger age, and poverty eradication programs, particularly in rural areas, to reduce avoidable neonatal deaths in Nigeria.

Antenatal iron/folic acid supplements, but not postnatal care, prevents neonatal deaths in Indonesia: analysis of Indonesia Demographic and Health Surveys 2002/2003-2007 (a retrospective cohort study).

OBJECTIVE: This study aimed to assess the contribution of postnatal services to the risk of neonatal mortality, and the relative contributions of antenatal iron/folic acid supplements and postnatal care in preventing neonatal mortality in Indonesia. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Data used in this study were the 2002-2007 Indonesia Demographic and Health Surveys, nationally representative surveys. The pooled data provided survival information of 26 591 most recent live-born infants within the 5-years prior to each interview. PRIMARY OUTCOMES: Primary outcomes were early neonatal mortality, that is, deaths in the first week, and all neonatal mortality, that is, deaths in the first month of life. Exposures were antenatal iron/folic acid supplementation and postnatal care from days 1 to 7. Potential confounders were community, socio-economic status and birthing characteristics and perinatal healthcare. Cox regression was used to assess the association between study factors and neonatal mortality. RESULTS: Postnatal care services were not associated with newborn survival. Postnatal care on days 1-7 after birth did not reduce neonatal death (HR=1.00, 95% CI 0.55 to 1.83, p=1.00) and early postnatal care on day 1 was associated with an increased risk of early neonatal death (HR=1.27, 95% CI 0.69 to 2.32, p=0.44) possibly reflecting referral of ill newborns. Early postnatal care on day 1 was not protective for neonatal deaths on days 2-7 whether provided by doctors (HR 3.61, 95% CI 1.54 to 8.45, p<0.01), or by midwives or nurses (HR 1.38, 95% CI 0.53 to 3.57, p=0.512). In mothers who took iron/folic acid supplements during pregnancy, the risk of early neonatal death was reduced by 51% (HR=0.49, 95% CI 0.30 to 0.79, p<0.01). CONCLUSIONS: We found no protective effect of postnatal care against neonatal deaths in Indonesia. However, important reductions in the risk of neonatal death were found for women who reported use of antenatal iron/folic acid supplements during pregnancy.

Effect of a school-based peer education intervention on physical activity and sedentary behaviour in Chinese adolescents: a pilot study.

OBJECTIVE: To evaluate the effect on physical activity and sedentary behaviour of a pilot school-based peer education programme in urban Beijing, China. DESIGN: 4 junior high schools were matched by school size and randomised to intervention (n=346) and control group (n=336). INTERVENTION: Trained peer leaders from grade 7 by research staff delivered weekly 40-min lessons to their classmates over four consecutive weeks. Students in control schools received no intervention. OUTCOME MEASURES: A validated 7-day youth physical activity questionnaire was used to evaluate physical activity and sedentary behaviours at baseline (September 2010), 3 months (December 2010) and 7 months (May 2011). Generalised linear mixed models were applied to evaluate the effect. RESULTS: There was a significant decrease in time in sedentary behaviour on weekdays, 20 min/day at 7 months (p=0.020) reported by students in the intervention schools compared with control schools. This reduction was mainly due to a reduction of 14 min/day in computer usage on weekdays (p=0.0009). There were no significant differences in time on other sedentary behaviours, including television and DVD, video game, extracurricular reading, writing, drawing and listening to music, passive commuting and sitting to talk. There was also no significant difference in time in moderate-to-vigorous physical activity between intervention and control group. CONCLUSIONS: Peer education appears to be a promising intervention in reducing sedentary behaviours in adolescents in China. These results need confirmation in a larger study. CLINICAL TRIAL REGISTRATION NUMBER: ACTRN12612000417886 at http://ANZCTR.org.au.

Cohort profile: Ho Chi Minh City Youth Cohort--changes in diet, physical activity, sedentary behaviour and relationship with overweight/obesity in adolescents.

OBJECTIVES: The Ho Chi Minh Youth cohort study aimed to assess the change in nutritional status; indicators of adiposity; diet; physical activity and sedentary behaviours; home, neighbourhood and school microenvironments and their complex relationships in adolescents in urban areas of Ho Chi Minh City. DESIGN: Prospective 5-year cohort. SETTING: Systematic random sampling was used to select 18 schools in urban districts. PARTICIPANTS: Children were followed up over 5 years with an assessment in each year. Consent, from both adolescents and their parents, was required. At baseline, 759 students were recruited into the cohort, and of these students, 740 remained in the cohort for the first round, 712 for the second round, 630 for the third round and 585 for the last round of follow-up. PRIMARY AND SECONDARY OUTCOME MEASURES: Anthropometric measurements were taken using established guidelines. Six main groups of exposure factors including dietary intake and behaviours, physical activity and sedentary behaviours, family social and physical environment, school environment, socioeconomic status and parental characteristics were measured. RESULTS: Retention rate was high (77%). Within 5-year period, the prevalence of combined overweight and obesity using International Obesity Task Force cut-off values increased from 14.2% to 21.8%. Time spent on physical activity decreased significantly in the 5-year period from 87 to 50 min/day. Time spent on sedentary behaviours increased in the 5-year period from 512 to 600 min/day. CONCLUSIONS: The complete data analysis of this cohort study will allow a full exploration of the role of environmental and lifestyle behaviours on adolescent overweight and obesity and also identify the factors most strongly associated with excess weight gain and the appearance of overweight and obesity in different age groups of adolescents from this large city in Vietnam.

Validity and reproducibility of a semi-quantitative food frequency questionnaire for use among pregnant women in rural China.

A longitudinal study was conducted to validate a 68-item semi-quantitative food-frequency questionnaire (FFQ) for assessing nutrient intake among pregnant women in rural China. The interview administrated FFQs were conducted at the start of the third trimester (FFQ1) and repeated three months later prior to delivery (FFQ2), and compared with six repeated 24-hour recalls collected between the FFQs. From June to September 2004, 125 women at 23 to 26 weeks of gestation were recruited into the study in two rural counties in Shaanxi province, China. Pearson correlation coefficients for crude nutrients assessed by FFQ1 and FFQ2 had a mean of 0.46, and ranged from 0.31 for thiamin to 0.61 for fat. Pearson correlation coefficients estimated by FFQ2 and 24-hour recalls had a mean of 0.62 for all nutrients, and ranged from 0.53 for cholesterol and carotene to 0.70 for alpha-vitamin E and potassium. De-attenuated coefficients had a mean of 0.69 for all nutrients, and ranged from 0.58 for cholesterol to 0.77 for alpha- vitamin E. Bland-Altman plots revealed significant relationships between the difference and the average of the two methods with larger differences at higher average intakes. On average, 74% of participants were classified into the same or adjacent nutrient intake quintiles, while 1% were grossly misclassified to opposite quintiles. In conclusion, this FFQ has adequate reproducibility and validity for most nutrients but would benefit from the addition of wheat porridge to ensure it is suitable for assessing dietary intake in pregnant women in rural China.

Antenatal care procedures and information reported by women in three rural areas of Vietnam.

The objective was to identify factors related to antenatal care (ANC) procedures and information reported by women in Long An, Ben Tre, and Quang Ngai Provinces. Cross-sectional surveys were conducted. Women who had ANC during a previous pregnancy were asked if they had received any of 13 procedures and information. The Donabedian quality of health model was used to select potential related factors. Data from 857 women were available for analyses. Only 24% of the women reported ten items or more. The mean number of items reported was seven. Factors related to reporting fewer items were living in Quang Ngai (OR = 0.3, 95% Cl = 0.2-0.6), having ANC at private facilities (OR = 0.4, 95% Cl = 0.2-0.7), having ANC delivered by nurses or assistant doctors (OR = 0.6, 95% Cl = 0.3-0.9), and unplanned pregnancy (OR = 0.5, 95% Cl = 0.3-0.9). Factors related to reporting more items were being housewives (OR = 1.7, 95% Cl = 1.0-2.8), consumption of iron/folate tablets (OR = 4.2, 95% Cl = 2.2-8.2), more use of ANC services (OR = 2.1, 95% Cl = 1.4-3.2 for sufficient utilization and OR = 3.8, 95% Cl = 2.1-7.0 for sufficient plus), more perceived helpfulness of ANC (OR = 3.0, 95% Cl = 1.9-4.8) and high satisfaction with ANC received (OR = 1.6, 95% Cl = 1.0-2.6). The most effective interventions would be to improve the quality of health facilities and of ANC providers, and to educate women to make sufficient number of ANC visits and to seek ANC from qualified ANC providers.

Determinants of antenatal care utilization in three rural areas of Vietnam.

OBJECTIVE: To identify factors associated with any use of antenatal care (ANC), gestational age at entry to ANC, number of visits, and overall ANC utilization in the three provinces of Long an, Ben tre, and Quang ngai. DATA: The Vietnam-Australia Primary Health Care Project conducted cross-sectional surveys in 1998-1999. Data from 1,335 eligible women were available for analysis. METHODS: Explanatory variables were selected using the Andersen Health Seeking Behavior Model and analyzed using multivariate regression techniques. RESULTS: External environment, predisposing characteristics, and need, which existed before contact with ANC providers, were most related to using any ANC and gestational age at entry to ANC. However, ANC services provided to women and personal health care during pregnancy, which could have resulted from initial contact with ANC providers, were most related to continuation of ANC visits and overall ANC utilization. Significant variability in the use of ANC existed between provinces and between subsets of women in each province. CONCLUSION: To have more women who attend ANC and attend early, promotion should be targeted at high-risk groups of women. However, to improve the number of ANC visits and overall utilization, the quality of ANC services should be improved.