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1.
Pediatrics ; 146(Suppl 2): S218-S222, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33004643

RESUMO

Data from the past decade have revealed that neonatal mortality represents a growing burden of the under-5 mortality rate. To further reduce these deaths, the focus must expand to include building capacity of the workforce to provide high-quality obstetric and intrapartum care. Obstetric complications, such as hypertensive disorders and obstructed labor, are significant contributors to neonatal morbidity and mortality. A well-prepared workforce with the necessary knowledge, skills, attitudes, and motivation is required to rapidly detect and manage these complications to save both maternal and newborn lives. Traditional off-site, didactic, and lengthy training approaches have not always yielded the desired results. Helping Mothers Survive training was modeled after Helping Babies Breathe and incorporates further evidence-based methodology to deliver training on-site to the entire team of providers, who continue to practice after training with their peers. Research has revealed that significant gains in health outcomes can be reached by using this approach. In the coronavirus disease 2019 era, we must look to translate the best practices of these training programs into a flexible and sustainable model that can be delivered remotely to maintain quality services to women and their newborns.


Assuntos
Pessoal de Saúde/educação , Capacitação em Serviço/organização & administração , Assistência Perinatal/organização & administração , Fortalecimento Institucional , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Serviços de Saúde Materno-Infantil/organização & administração , Assistência Perinatal/normas , Gravidez , Complicações na Gravidez/prevenção & controle , Complicações na Gravidez/terapia
2.
Hum Resour Health ; 18(1): 75, 2020 10 07.
Artigo em Inglês | MEDLINE | ID: mdl-33028347

RESUMO

Peripartum deaths remain significantly high in low- and middle-income countries, including Kenya. The COVID-19 pandemic has disrupted essential services, which could lead to an increase in maternal and neonatal mortality and morbidity. Furthermore, the lockdowns, curfews, and increased risk for contracting COVID-19 may affect how women access health facilities. SARS-CoV-2 is a novel coronavirus that requires a community-centred response, not just hospital-based interventions. In this prolonged health crisis, pregnant women deserve a safe and humanised birth that prioritises the physical and emotional safety of the mother and the baby. There is an urgent need for innovative strategies to prevent the deterioration of maternal and child outcomes in an already strained health system. We propose strengthening community-based midwifery to avoid unnecessary movements, decrease the burden on hospitals, and minimise the risk of COVID-19 infection among women and their newborns.


Assuntos
Infecções por Coronavirus/epidemiologia , Cuidado do Lactente/organização & administração , Serviços de Saúde Materna/organização & administração , Tocologia , Pneumonia Viral/epidemiologia , Adolescente , Adulto , Betacoronavirus , Feminino , Acesso aos Serviços de Saúde , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Quênia/epidemiologia , Pandemias , Gravidez
3.
Natl Vital Stat Rep ; 69(9): 1-11, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33054916

RESUMO

Objective-This report presents 2017-2018 infant mortality rates in the United States by maternal prepregnancy body mass index, and by infant age at death, maternal age, and maternal race and Hispanic origin. Methods-Descriptive tabulations of infant deaths by maternal and infant characteristics are presented using the 2017-2018 linked period birth/infant death files; the linked period birth/infant death file is based on birth and death certificates registered in all states and the District of Columbia. The 2017 linked birth/infant death file is the first year that national data on maternal prepregnancy body mass index were available. Results-Total infant, neonatal, and postneonatal mortality rates were lowest for infants of women who were normal weight prepregnancy, and then rose with increasing prepregnancy body mass index. Total, neonatal, and postneonatal rates were higher for infants of women who were underweight prepregnancy compared with infants of women who were normal or overweight before pregnancy. Mortality rates for infants of underweight women were generally, but not exclusively, lower than those of infants born to women with obesity. Infants born to women of normal weight generally had lower mortality rates than infants born to women who had obesity prepregnancy for all maternal age and race and Hispanic-origin groups.


Assuntos
Índice de Massa Corporal , Mortalidade Infantil/tendências , Adulto , Grupos de Populações Continentais/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Lactente , Mortalidade Infantil/etnologia , Idade Materna , Estados Unidos/epidemiologia
4.
BMC Infect Dis ; 20(1): 725, 2020 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-33008316

RESUMO

BACKGROUND: Commencing lifelong antiretroviral therapy (ART) immediately following HIV diagnosis (Option B+), has greatly improved maternal-infant health. Thus, large and increasing numbers of HIV-infected women are on ART during pregnancy, a situation concurrently increasing numbers of HIV-exposed-uninfected (HEU) infants. Compared to their HIV-unexposed-uninfected (HUU) counterparts, HEU infants show higher rates of adverse birth outcomes, mortality, infectious/non-communicable diseases including impaired growth and neurocognitive development. There is an urgent need to understand the impact of HIV and early life ART exposures, immune-metabolic dysregulation, comorbidities and environmental confounders on adverse paediatric outcomes. METHODS: Six hundred (600) HIV-infected and 600 HIV-uninfected pregnant women ≥20 weeks of gestation will be enrolled from four primary health centres in high density residential areas of Harare. Participants will be followed up as mother-infant-pairs at delivery, week(s) 1, 6, 10, 14, 24, 36, 48, 72 and 96 after birth. Clinical, socio-economic, nutritional and environmental data will be assessed for adverse birth outcomes, impaired growth, immune/neurodevelopment, vertical transmission of HIV, hepatitis-B/C viruses, cytomegalovirus and syphilis. Maternal urine, stool, plasma, cord blood, amniotic fluid, placenta and milk including infant plasma, dried blood spot and stool will be collected at enrolment and follow-up visits. The composite primary endpoint is stillbirth and infant mortality within the first two years of life in HEU versus HUU infants. Maternal mortality in HIV-infected versus -uninfected women is another primary outcome. Secondary endpoints include a range of maternal and infant outcomes. Sub-studies will address maternal stress and malnutrition, maternal-infant latent tuberculosis, Helicobacter pylori infections, immune-metabolomic dysregulation including gut, breast milk and amniotic fluid dysbiosis. DISCUSSION: The University of Zimbabwe-College of Health-Sciences-Birth-Cohort study will provide a comprehensive assessment of risk factors and biomarkers for HEU infants' adverse outcomes. This will ultimately help developing strategies to mitigate effects of maternal HIV, early-life ART exposures and comorbidities on infants' mortality and morbidity. TRIAL REGISTRATION: ClinicalTrial.gov Identifier: NCT04087239 . Registered 12 September 2019.


Assuntos
Transmissão Vertical de Doença Infecciosa , Estudos de Coortes , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por Helicobacter/complicações , Helicobacter pylori , Hepatite B/complicações , Humanos , Lactente , Mortalidade Infantil , Leite Humano , Morbidade , Parto , Gravidez , Complicações Infecciosas na Gravidez/virologia , Fatores de Risco , Natimorto , Sífilis/complicações , Universidades , Zimbábue
5.
Artigo em Espanhol | PAHO-IRIS | ID: phr-52915

RESUMO

[RESUMEN]. Objetivo. Estimar la tendencia de la mortalidad infantil, de la desigualdad entre jurisdicciones y de la desigualdad asociada a las condiciones sociales en Argentina entre 1980 y 2017. Métodos. Estudio ecológico y de serie temporal de la mortalidad infantil y de su desigualdad. Se obtuvieron los datos oficiales de mortalidad infantil, de nacimientos y de necesidades básicas insatisfechas; se calculó la tasa de mortalidad infantil, el índice de Gini y el índice de concentración. También se analizó la tendencia con un modelo de regresión lineal y se calculó el coeficiente de regresión y su significación estadística. Resultados. La mortalidad infantil se redujo 71,2% (de 32,41 a 9,34 por 1 000 nacidos vivos). La desigualdad por jurisdicción también se redujo y el índice de Gini pasó de 0,163 a 0,09. La desigualdad asociada a las condiciones sociales también mostró una reducción, y el índice de concentración disminuyó de -0,153 a -0,079. Si bien la mortalidad infantil se redujo en todo el período, este descenso no siempre se acompañó de una reducción del índice de Gini y del índice de concentración. Conclusiones. La tendencia de la tasa de mortalidad infantil fue al descenso mientras que la desigualdad en su distribución por jurisdicción y la desigualdad asociada a las condiciones sociales no siempre acompañaron esa reducción.


[ABSTRACT]. Objective. To estimate the trend in infant mortality, inequality between jurisdictions and inequality associated with social conditions in Argentina between 1980 and 2017. Methods. Ecological and time series study of infant mortality and its inequality. Official data on infant mortality, births and unmet basic needs were obtained; the infant mortality rate, the Gini index and the concentration index were calculated. The trend was also analyzed with a linear regression model and the regression coefficient and its statistical significance were calculated. Results. Infant mortality was reduced by 71.2% (from 32.41 to 9.34 per 1 000 live births). Inequality by jurisdiction also decreased, and the Gini index fell from 0,163 to 0,09. Inequality associated with social conditions also showed a reduction, and the concentration index was reduced from -0.153 to -0.079. Although infant mortality declined throughout the period, this decline was not always accompanied by a reduction in the Gini index and the concentration index. Conclusions. The trend in the infant mortality rate decreased while the inequality in its distribution by jurisdiction and the inequality associated with social conditions did not always accompany this reduction.


Assuntos
Mortalidade Infantil , Saúde da Criança , Equidade em Saúde , Iniquidade Social , Estudos Ecológicos , Argentina , Mortalidade Infantil , Saúde da Criança , Equidade em Saúde , Iniquidade Social , Estudos Ecológicos
6.
PLoS Med ; 17(9): e1003285, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32931496

RESUMO

BACKGROUND: Biannual azithromycin distribution has been shown to reduce child mortality as well as increase antimicrobial resistance. Targeting distributions to vulnerable subgroups such as malnourished children is one approach to reaching those at the highest risk of mortality while limiting selection for resistance. The objective of this analysis was to assess whether the effect of azithromycin on mortality differs by nutritional status. METHODS AND FINDINGS: A large simple trial randomized communities in Niger to receive biannual distributions of azithromycin or placebo to children 1-59 months old over a 2-year timeframe. In exploratory subgroup analyses, the effect of azithromycin distribution on child mortality was assessed for underweight subgroups using weight-for-age Z-score (WAZ) thresholds of -2 and -3. Modification of the effect of azithromycin on mortality by underweight status was examined on the additive and multiplicative scale. Between December 2014 and August 2017, 27,222 children 1-11 months of age from 593 communities had weight measured at their first study visit. Overall, the average age among included children was 4.7 months (interquartile range [IQR] 3-6), 49.5% were female, 23% had a WAZ < -2, and 10% had a WAZ < -3. This analysis included 523 deaths in communities assigned to azithromycin and 661 deaths in communities assigned to placebo. The mortality rate was lower in communities assigned to azithromycin than placebo overall, with larger reductions among children with lower WAZ: -12.6 deaths per 1,000 person-years (95% CI -18.5 to -6.9, P < 0.001) overall, -17.0 (95% CI -28.0 to -7.0, P = 0.001) among children with WAZ < -2, and -25.6 (95% CI -42.6 to -9.6, P = 0.003) among children with WAZ < -3. No statistically significant evidence of effect modification was demonstrated by WAZ subgroup on either the additive or multiplicative scale (WAZ < -2, additive: 95% CI -6.4 to 16.8, P = 0.34; WAZ < -2, multiplicative: 95% CI 0.8 to 1.4, P = 0.50, WAZ < -3, additive: 95% CI -2.2 to 31.1, P = 0.14; WAZ < -3, multiplicative: 95% CI 0.9 to 1.7, P = 0.26). The estimated number of deaths averted with azithromycin was 388 (95% CI 214 to 574) overall, 116 (95% CI 48 to 192) among children with WAZ < -2, and 76 (95% CI 27 to 127) among children with WAZ < -3. Limitations include the availability of a single weight measurement on only the youngest children and the lack of power to detect small effect sizes with this rare outcome. Despite the trial's large size, formal tests for effect modification did not reach statistical significance at the 95% confidence level. CONCLUSIONS: Although mortality rates were higher in the underweight subgroups, this study was unable to demonstrate that nutritional status modified the effect of biannual azithromycin distribution on mortality. Even if the effect were greater among underweight children, a nontargeted intervention would result in the greatest absolute number of deaths averted. TRIAL REGISTRATION: The MORDOR trial is registered at clinicaltrials.gov NCT02047981.


Assuntos
Azitromicina/uso terapêutico , Transtornos da Nutrição Infantil/tratamento farmacológico , Transtornos da Nutrição Infantil/mortalidade , Antibacterianos/uso terapêutico , Peso Corporal , Mortalidade da Criança/tendências , Pré-Escolar , Feminino , Humanos , Lactente , Mortalidade Infantil/tendências , Malária/tratamento farmacológico , Masculino , Administração Massiva de Medicamentos/métodos , Administração Massiva de Medicamentos/mortalidade , Níger/epidemiologia , Estado Nutricional , Magreza
7.
S Afr Med J ; 110(6): 497-501, 2020 May 29.
Artigo em Inglês | MEDLINE | ID: mdl-32880561

RESUMO

BACKGROUND: The burden of neonatal surgical conditions is not well documented in low- to middle-income countries (LMICs). These conditions are thought to be relatively common, with a considerable proportion of neonates admitted to the neonatal intensive care unit (NICU) requiring surgical intervention. OBJECTIVES: To review neonates with surgical conditions admitted to the NICU in our hospital setting. METHODS: This was a retrospective, descriptive study of neonates with surgical conditions admitted to the NICU at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), South Africa, between 1 January 2013 and 31 December 2015. The characteristics and survival of these neonates were described using univariate analysis. The NICU at CMJAH is combined with a paediatric intensive care unit, to a total of 15 beds, and serves as a referral unit. RESULTS: Of 923 neonates admitted to the NICU, 319 (34.6%) had primarily surgical conditions. Of these 319 neonates, 205 survived (64.3%). There were 125/319 neonates (39.2%) with necrotising enterocolitis (NEC), 55 of whom survived (55/125; 44.0%), making the presence of NEC significantly associated with poor outcome (p<0.001). Other significant predictors of poor outcome were the patient being outborn (p=0.029); the presence of late-onset sepsis (p<0.001), with Gram-negative organisms (p=0.005); and lesser gestational age (p=0.001) and lower birth weight (p<0.001). Major birth defects were present in 166/319 neonates (52.0%). The abdomen was the most prevalent site of surgery, with 216/258 procedures (83.7%) being abdominal, resulting in a mortality rate of 76/216 (35.2%). CONCLUSIONS: Neonates with major surgical conditions accounted for one-third of NICU admissions in the present study. The study highlights the considerable burden placed on paediatric surgical services at a large referral hospital in SA. Paediatric surgical services, with early referral and improvement of neonatal transport systems, must be a priority in planned healthcare interventions to reduce neonatal mortality in LMICs.


Assuntos
Mortalidade Infantil , Doenças do Recém-Nascido/mortalidade , Doenças do Recém-Nascido/cirurgia , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , África do Sul/epidemiologia , Taxa de Sobrevida
8.
Am J Perinatol ; 37(S 02): S5-S9, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32898875

RESUMO

Despite continued advances and developments in neonatal medicine, neonatal sepsis is the third leading cause of neonatal mortality and a major public health problem, especially in developing countries. Sepsis accounts for mortality for almost 50% of global children under 5 years of age.Over the past 50 years, there have been many advances in the diagnosis, prevention, and treatment of neonatal infections. The diagnostic advances include better culture techniques that permit more rapid confirmation of the diagnosis, advent of polymerase chain reaction (PCR) to rapidly diagnose viral infections, use of biologic markers indicating evidence of infection, and a better understanding of immunoglobulin markers of infection. From a therapeutic stand point, there have been a variety of antibiotics, antifungals, and antiviral agents, better approaches to prevent sepsis, specific immunotherapy, for example, respiratory syncytial virus (RSV); bundled approach to prevention of deep-line infection and better antibiotic stewardship, leading to earlier discontinuation of antibiotic therapy.Hand hygiene remains the benchmark and gold standard for late-onset sepsis prevention. The challenge has been that each decade, newer resistant bacteria dominate as the cause of sepsis and newer viruses emerge, for example, human immunodeficiency virus, zika virus, and novel coronavirus disease 2019.Future treatment options might include stem cell therapy, other antimicrobial protein and peptides, and targeting of pattern recognition receptors in an effort to prevent and/or treat sepsis in this vulnerable population. Also, the microbiome of premature infants has a smaller proportion of beneficial bacteria and higher numbers of pathogenic bacteria compared with term infants, likely owing to higher frequencies of cesarean sections, antibiotic use, exposure to the hospital environment, and feeding nonhuman milk products. Modifying the microbiome with more mother's milk and shorter duration of antibiotics in noninfected babies should be a goal. KEY POINTS: · Neonatal sepsis remains a leading cause of mortality.. · Challenges include bacterial resistance and newer viruses.. · Future treatments may include newer antibiotics/antivirals and stem cell therapy..


Assuntos
Antibacterianos/uso terapêutico , Unidades de Terapia Intensiva Neonatal , Sepse Neonatal/mortalidade , Sepse Neonatal/prevenção & controle , Antivirais/uso terapêutico , Farmacorresistência Bacteriana , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Recém-Nascido Prematuro , Doenças do Prematuro/mortalidade , Doenças do Prematuro/prevenção & controle , Sepse Neonatal/tratamento farmacológico
9.
PLoS One ; 15(8): e0237656, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32866167

RESUMO

OBJECTIVE: Preterm birth is the primary driver of neonatal mortality worldwide, but it is defined by gestational age (GA) which is challenging to accurately assess in low-resource settings. In a commitment to reducing preterm birth while reinforcing and strengthening facility data sources, the East Africa Preterm Birth Initiative (PTBi-EA) chose eligibility criteria that combined GA and birth weight. This analysis evaluated the quality of the GA data as recorded in maternity registers in PTBi-EA study facilities and the strength of the PTBi-EA eligibility criteria. METHODS: We conducted a retrospective analysis of maternity register data from March-September 2016. GA data from 23 study facilities in Migori, Kenya and the Busoga Region of Uganda were evaluated for completeness (variable present), consistency (recorded versus calculated GA), and plausibility (falling within the 3rd and 97th birth weight percentiles for GA of the INTERGROWTH-21st Newborn Birth Weight Standards). Preterm birth rates were calculated using: 1) recorded GA <37 weeks, 2) recorded GA <37 weeks, excluding implausible GAs, 3) birth weight <2500g, and 4) PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks. RESULTS: In both countries, GA was the least recorded variable in the maternity register (77.6%). Recorded and calculated GA (Kenya only) were consistent in 29.5% of births. Implausible GAs accounted for 11.7% of births. The four preterm birth rates were 1) 14.5%, 2) 10.6%, 3) 9.6%, 4) 13.4%. CONCLUSIONS: Maternity register GA data presented quality concerns in PTBi-EA study sites. The PTBi-EA eligibility criteria of <2500g and between 2500g and 3000g if the recorded GA is <37 weeks accommodated these concerns by using both birth weight and GA, balancing issues of accuracy and completeness with practical applicability.


Assuntos
Coleta de Dados/normas , Idade Gestacional , Serviços de Saúde Materna/organização & administração , Nascimento Prematuro/epidemiologia , Sistema de Registros/estatística & dados numéricos , Peso ao Nascer , Coleta de Dados/estatística & dados numéricos , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido de Peso Extremamente Baixo ao Nascer , Lactente Extremamente Prematuro , Recém-Nascido , Quênia/epidemiologia , Serviços de Saúde Materna/estatística & dados numéricos , Gravidez , Nascimento Prematuro/prevenção & controle , Melhoria de Qualidade , Sistema de Registros/normas , Reprodutibilidade dos Testes , Estudos Retrospectivos , Uganda/epidemiologia
13.
Rev Assoc Med Bras (1992) ; 66(7): 931-936, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32844925

RESUMO

BACKGROUND To determine the magnitude and temporal trends of deaths due to congenital heart disease (CHD) in Pernambuco between 1996 and 2016. METHODS This was an ecological, time-series study, involving all cases of deaths from congenital cardiovascular malformations in the state of Pernambuco, from 1996 to 2016, using data from DATASUS, SINASC and SIM. RESULTS There were 3,584 deaths from congenital cardiovascular malformations amongst individuals aged 0 to 14 years, of which 81.94% were concentrated in children aged under one year. The infant mortality rate (IMR) presented a linear growth trend of 0.4645 per year (p <0.01). The cause-of-death code Q24 (other congenital malformations of the heart) was present in 72.54% of the death records and 48.17% of the deaths occurred in infants aged between 28 and 364 days of life. The highest occurrence of deaths was identified in children with low birth weight (500 and 1,499g), male, premature, children of mothers without schooling, in deliveries at home (p <0.05). CONCLUSIONS Congenital heart disease still represents a public health problem as a cause of death, particularly in the first year of life, with IMR in a linear growth trend. Deaths from CHD were more prevalent in male children, born prematurely, with low birth weight, born to mothers with low schooling and deliveries without medical care.


Assuntos
Cardiopatias Congênitas , Nascimento Prematuro , Adolescente , Brasil/epidemiologia , Causas de Morte , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/mortalidade , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido de Baixo Peso , Recém-Nascido , Masculino , Gravidez
14.
PLoS One ; 15(8): e0237314, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32780762

RESUMO

BACKGROUND: Compared to other racial/ethnic groups, infant mortality rates (IMR) are persistently highestamong Black infants in the United States, yet there is considerable regional variation. We examined state and county-level contextual factors that may explain regional differences in Black IMR and identified potential strategies for improvement. METHODS AND FINDINGS: Black infant mortality data are from the Linked Birth/Infant Death files for 2009-2011. State and county contextual factors within social, economic, environmental, and health domains were compiled from various Census databases, the Food Environment Atlas, and the Area Health Resource File. Region was defined by the nine Census Divisions. We examined contextual associations with Black IMR using aggregated county-level Poisson regression with standard errors adjusted for clustering by state. Overall, Black IMR varied 1.5-fold across regions, ranging from 8.78 per 1,000 in New England to 13.77 per 1,000 in the Midwest. In adjusted models, the following factors were protective for Black IMR: higher state-level Black-White marriage rate (rate ratio (RR) per standard deviation (SD) increase = 0.81, 95% confidence interval (CI):0.70-0.95), higher state maternal and child health budget per capita (RR per SD = 0.96, 95% CI:0.92-0.99), and higher county-level Black index of concentration at the extremes (RR per SD = 0.85, 95% CI:0.81-0.90). Modeled variables accounted for 35% of the regional variation in Black IMR. CONCLUSIONS: These findings are broadly supportive of ongoing public policy efforts to enhance social integration across races, support health and social welfare program spending, and improve economic prosperity. Although contextual factors accounted for about a third of regional variation, further research is needed to more fully understand regional variation in Black IMR disparities.


Assuntos
Afro-Americanos/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Mortalidade Infantil/etnologia , Feminino , Geografia , Humanos , Lactente , Recém-Nascido , Fatores Socioeconômicos , Estados Unidos/epidemiologia
15.
Proc Natl Acad Sci U S A ; 117(34): 20511-20519, 2020 08 25.
Artigo em Inglês | MEDLINE | ID: mdl-32788353

RESUMO

Examining linkages among multiple sustainable development outcomes is key for understanding sustainability transitions. Yet rigorous evidence on social and environmental outcomes of sustainable development policies remains scarce. We conduct a national-level analysis of Brazil's flagship social protection program, Zero Hunger (ZH), which aims to reduce food insecurity and poverty. Using data from rural municipalities across Brazil and quasi-experimental causal inference techniques, we assess relationships between social protection investment and outcomes related to sustainable development goals (SDGs): "no poverty" (SDG 1), "zero hunger" (SDG 2), and "health and well being" (SDG 3). We also assess potential perverse outcomes arising from agricultural development impacting "climate action" (SDG 13) and "life on land" (SDG 15) via clearance of natural vegetation. Despite increasing daily per capita protein and kilocalorie production, summed ZH investment did not alleviate child malnutrition or infant mortality and negligibly influenced multidimensional poverty. Higher investment increased natural vegetation cover in some biomes but increased losses in the Cerrado and especially the Pampa. Effects varied substantially across subprograms. Conditional cash transfer (Bolsa Familia [BF]) was mainly associated with nonbeneficial impacts but increased protein production and improved educational participation in some states. The National Program to Strengthen Family Farming (PRONAF) was typically associated with increased food production (protein and calories), multidimensional poverty alleviation, and changes in natural vegetation. Our results inform policy development by highlighting successful elements of Brazil's ZH program, variable outcomes across divergent food security dimensions, and synergies and trade-offs between sustainable development goals, including environmental protection.


Assuntos
Abastecimento de Alimentos , Política Pública , Desenvolvimento Sustentável , Brasil , Transtornos da Nutrição Infantil/prevenção & controle , Pré-Escolar , Humanos , Lactente , Mortalidade Infantil , Pobreza , Floresta Úmida
16.
Pediatrics ; 146(3)2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32778541

RESUMO

CONTEXT: Helping Babies Breathe (HBB) is a well-established neonatal resuscitation program designed to reduce newborn mortality in low-resource settings. OBJECTIVES: In this literature review, we aim to identify challenges, knowledge gaps, and successes associated with each stage of HBB programming. DATA SOURCES: Databases used in the systematic search included Medline, POPLINE, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, African Index Medicus, Cochrane, and Index Medicus. STUDY SELECTION: All articles related to HBB, in any language, were included. Article quality was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation framework. DATA EXTRACTION: Data were extracted if related to HBB, including its implementation, acquisition and retention of HBB knowledge and skills, changes in provider behavior and clinical care, or the impact on newborn outcomes. RESULTS: Ninety-four articles met inclusion criteria. Barriers to HBB implementation include staff turnover and limited time or focus on training and practice. Researchers of several studies found HBB cost-effective. Posttraining decline in knowledge and skills can be prevented with low-dose high-frequency refresher trainings, on-the-job practice, or similar interventions. Impact of HBB training on provider clinical practices varies. Although not universal, researchers in multiple studies have shown a significant association of decreased perinatal mortality with HBB implementation. LIMITATIONS: In addition to not conducting a gray literature search, articles relating only to Essential Care for Every Baby or Essential Care for Small Babies were not included in this review. CONCLUSIONS: Key challenges and requirements for success associated with each stage of HBB programming were identified. Despite challenges in obtaining neonatal mortality data, the program is widely believed to improve neonatal outcomes in resource-limited settings.


Assuntos
Asfixia Neonatal/mortalidade , Asfixia Neonatal/terapia , Competência Clínica , Mortalidade Infantil , Ressuscitação/educação , Ressuscitação/métodos , Asfixia Neonatal/diagnóstico , Humanos , Lactente , Mortalidade Infantil/tendências , Recém-Nascido
17.
Pediatrics ; 146(3)2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32817396

RESUMO

BACKGROUND: Severe maternal morbidity (SMM) comprises an array of conditions and procedures denoting an acutely life-threatening pregnancy-related condition. SMM may further compromise fetal well-being. Empirical data are lacking about the relation between SMM and infant mortality. METHODS: This population-based cohort study included 1 892 857 singleton births between 2002 and 2017 in Ontario, Canada, within a universal health care system. The exposure was SMM as an overall construct arising from 23 weeks' gestation up to 42 days after the index delivery. The primary outcome was infant mortality from birth to 365 days. Multivariable modified Poisson regression generated relative risks and 95% confidence intervals (CIs), adjusted for maternal age, income, rurality, world region of origin, diabetes mellitus, and chronic hypertension. RESULTS: Infant mortality occurred among 174 of 19 587 live births with SMM (8.9 per 1000) vs 5289 of 1 865 791 live births without SMM (2.8 per 1000) (an adjusted relative risk of 2.93 [95% CI 2.51-3.41]). Of 19 587 pregnancies with SMM, 4523 (23.1%) had sepsis. Relative to births without SMM, the adjusted odds ratio for infant death from sepsis was 1.95 (95% CI 1.10-3.45) if SMM occurred without maternal sepsis and 6.36 (95% CI 3.50-11.55) if SMM included sepsis. CONCLUSIONS: SMM confers a higher risk of infant death. There is also coupling tendency (concurrent event of interest) between SMM with sepsis and infant death from sepsis. Identification of preventable SMM indicators, as well as the development of strategies to limit their onset or progression, may reduce infant mortality.


Assuntos
Mortalidade Infantil/tendências , Saúde Materna/tendências , Complicações na Gravidez/epidemiologia , Índice de Gravidade de Doença , Adolescente , Adulto , Estudos de Coortes , Feminino , Humanos , Lactente , Recém-Nascido , Pessoa de Meia-Idade , Morbidade , Ontário/epidemiologia , Gravidez , Complicações na Gravidez/diagnóstico , Adulto Jovem
18.
PLoS One ; 15(8): e0236355, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32833993

RESUMO

INTRODUCTION: Neonatal infections are a common cause of death in India, but many families cannot access appropriate hospitals for its treatment due to various reasons. We implemented the World Health Organization PSBI management guideline when referral is not feasible within the public health system in Pune, India to evaluate feasibility, barriers and facilitators for its implementation. METHODS: A national-level consultative meeting between government officials and study partners resulted in a consensus on adaptation and implementation in four demonstration sites in selected states in India. At the state and district levels, similar meetings to plan the implementation strategy and roles were held between KEM Hospital Research Centre (KEMHRC) Pune and the public health system Pune, Maharashtra. The public health system was responsible for implementation of the intervention at eight tribal primary health centres (PHC) in Pune district, India, including delivering the intervention and ensuring supplies of all commodities while KEMHRC was responsible for technical support including training of health workers, assistance in PSBI identification and management, data collection and documentation of the implementation strategy. RESULTS: A total of 175 young infants with PSBI were identified and managed. Of these, 34 had critical illness (CI), 46 had clinical severe infection (CSI) and 10 were infants aged 0-6 days with fast breathing (FB) while 85 infants aged 7-59 days had fast breathing. Assuming a 10% incidence of PSBI among all live births, with 3071 live births recorded, the actual incidence of PSBI found in the study was 5.7%, resulting in an actual coverage was of 57%. Among the 90 infants with CI, CSI and FB in 0-6 days, who were advised referral to government tertiary care centre as per the PSBI guideline algorithm, 81 (90%) accepted referral while 9 (10%) refused and were offered treatment at primary health centres (PHC) with a seven-day course of injectable gentamicin and oral amoxicillin. All infants with FB in 7-59 days were offered treatment at PHCs as per the PSBI guideline algorithm with a seven-day course of oral amoxicillin. All except six infants who died and one with FB in 7-59 days, who was lost to follow-up, were successfully cured. Of the six who died, five had CSI and one had CI. Among the 81 infants with CI, CSI and FB in 0-6 days who accepted referral; 48(53%) were successfully referred to government tertiary facility while 33 (36.6%) preferred to visit a private tertiary health facility. The implementation strategy demonstrated a relatively high fidelity, acceptance and intervention penetration. Lack of training and confidence of the public health staff were major challenges faced, which were resolved to a large extent through supportive supervision and re-trainings. CONCLUSION: Management of PSBI is feasible to implement in out-patient facilities in the public health system, but technical support to the health system is required to jump-start the process. Fast breathing in 7-59 days old infants can be managed with oral amoxicillin without referral. A sustainable adoption of this intervention by the health system can lead to decrease in neonatal mortality and morbidity.


Assuntos
Amoxicilina/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Mortalidade Infantil , Infecções Bacterianas/epidemiologia , Infecções Bacterianas/microbiologia , Estudos de Viabilidade , Feminino , Gentamicinas/uso terapêutico , Humanos , Índia/epidemiologia , Lactente , Recém-Nascido , Masculino , Grupos Populacionais , Organização Mundial da Saúde
20.
Lancet Glob Health ; 8(10): e1273-e1281, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32791117

RESUMO

BACKGROUND: The COVID-19 pandemic response is affecting maternal and neonatal health services all over the world. We aimed to assess the number of institutional births, their outcomes (institutional stillbirth and neonatal mortality rate), and quality of intrapartum care before and during the national COVID-19 lockdown in Nepal. METHODS: In this prospective observational study, we collected participant-level data for pregnant women enrolled in the SUSTAIN and REFINE studies between Jan 1 and May 30, 2020, from nine hospitals in Nepal. This period included 12·5 weeks before the national lockdown and 9·5 weeks during the lockdown. Women were eligible for inclusion if they had a gestational age of 22 weeks or more, a fetal heart sound at time of admission, and consented to inclusion. Women who had multiple births and their babies were excluded. We collected information on demographic and obstetric characteristics via extraction from case notes and health worker performance via direct observation by independent clinical researchers. We used regression analyses to assess changes in the number of institutional births, quality of care, and mortality before lockdown versus during lockdown. FINDINGS: Of 22 907 eligible women, 21 763 women were enrolled and 20 354 gave birth, and health worker performance was recorded for 10 543 births. From the beginning to the end of the study period, the mean weekly number of births decreased from 1261·1 births (SE 66·1) before lockdown to 651·4 births (49·9) during lockdown-a reduction of 52·4%. The institutional stillbirth rate increased from 14 per 1000 total births before lockdown to 21 per 1000 total births during lockdown (p=0·0002), and institutional neonatal mortality increased from 13 per 1000 livebirths to 40 per 1000 livebirths (p=0·0022). In terms of quality of care, intrapartum fetal heart rate monitoring decreased by 13·4% (-15·4 to -11·3; p<0·0001), and breastfeeding within 1 h of birth decreased by 3·5% (-4·6 to -2·6; p=0·0032). The immediate newborn care practice of placing the baby skin-to-skin with their mother increased by 13·2% (12·1 to 14·5; p<0·0001), and health workers' hand hygiene practices during childbirth increased by 12·9% (11·8 to 13·9) during lockdown (p<0·0001). INTERPRETATION: Institutional childbirth reduced by more than half during lockdown, with increases in institutional stillbirth rate and neonatal mortality, and decreases in quality of care. Some behaviours improved, notably hand hygiene and keeping the baby skin-to-skin with their mother. An urgent need exists to protect access to high quality intrapartum care and prevent excess deaths for the most vulnerable health system users during this pandemic period. FUNDING: Grand Challenges Canada.


Assuntos
Infecções por Coronavirus/prevenção & controle , Parto Obstétrico , Mortalidade Infantil/tendências , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Natimorto/epidemiologia , Infecções por Coronavirus/epidemiologia , Feminino , Humanos , Lactente , Recém-Nascido , Nepal/epidemiologia , Pneumonia Viral/epidemiologia , Gravidez , Estudos Prospectivos
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