David Osrin

Biomass fuel use and the exposure of children to particulate air pollution in southern Nepal.

The exposure of children to air pollution in low resource settings is believed to be high because of the common use of biomass fuels for cooking. We used microenvironment sampling to estimate the respirable fraction of air pollution (particles with median diameter less than 4 μm) to which 7–9 year old children in southern Nepal were exposed. Sampling was conducted for a total 2649 h in 55 households, 8 schools and 8 outdoor locations of rural Dhanusha. We conducted gravimetric and photometric sampling in a subsample of the children in our study in the locations in which they usually resided (bedroom/living room, kitchen, veranda, in school and outdoors), repeated three times over one year. Using time activity information, a 24-hour time weighted average was modeled for all the children in the study. Approximately two-thirds of homes used biomass fuels, with the remainder mostly using gas. The exposure of children to air pollution was very high. The 24-hour time weighted average over the whole year was 168 μg/m3. The non-kitchen related samples tended to show approximately double the concentration in winter than spring/autumn, and four times that of the monsoon season. There was no difference between the exposure of boys and girls. Air pollution in rural households was much higher than the World Health Organization and the National Ambient Air Quality Standards for Nepal recommendations for particulate exposure.

Barriers to and incentives for achieving partograph use in obstetric practice in low- and middle-income countries: a systematic review.

BackgroundThe partograph is a graphic display of the progress of labour, recommended by the World Health Organization, but often underused in practice in low- and middle-income countries. We were interested in going beyond demonstration of potential efficacy – on which the existing literature concentrates - through a systematic review to identify barriers to and incentives for achieving partograph use.MethodsWe searched Ovid MEDLINE, Ovid Maternity and Infant Care, POPLINE, Web of Science, and Scopus, from 1st January 1994 to 30th September 2013, using the term ‘partogra*’ to include ‘partograph’, ‘partogram’, or ‘partogramme’. The selection criteria were for primary or secondary research describing barriers to and incentives for partograph use in low- and middle-income countries, in English, reported in peer-reviewed publications since 1994. Thematic analysis of text on partograph use was applied to a commonly used framework for change in clinical practice, with levels describing the innovation, the individual professional, the woman, and social, organisational, economic and political contexts.ResultsReported barriers to and incentives for partograph use related to the partograph itself, professional skills and practice, clinical leadership and quality assurance, and the organisational environment within the wider provision of obstetric care. Neither the evidence base for its effectiveness, nor its credibility, was reported as a barrier to use.ConclusionIdentifying and addressing local barriers and incentives in low- and middle-income countries, based on those in published research, could inform strategies to improve partograph use. Emerging technologies could be used to address some barriers. The thresholds for essential maternity care at which the partograph adds value should be further evaluated.

Sweat, Skepticism, and Uncharted Territory: A Qualitative Study of Opinions on Data Sharing Among Public Health Researchers and Research Participants in Mumbai, India

Efforts to internalize data sharing in research practice have been driven largely by developing international norms that have not incorporated opinions from researchers in low- and middle-income countries. We sought to identify the issues around ethical data sharing in the context of research involving women and children in urban India. We interviewed researchers, managers, and research participants associated with a Mumbai non-governmental organization, as well as researchers from other organizations and members of ethics committees. We conducted 22 individual semi-structured interviews and involved 44 research participants in focus group discussions. We used framework analysis to examine ideas about data and data sharing in general; its potential benefits or harms, barriers, obligations, and governance; and the requirements for consent. Both researchers and participants were generally in favor of data sharing, although limited experience amplified their reservations. We identified three themes: concerns that the work of data producers may not receive appropriate acknowledgment, skepticism about the process of sharing, and the fact that the terrain of data sharing was essentially uncharted and confusing. To increase data sharing in India, we need to provide guidelines, protocols, and examples of good practice in terms of consent, data preparation, screening of applications, and what individuals and organizations can expect in terms of validation, acknowledgment, and authorship.

Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries

BACKGROUND Micronutrient deficiencies are common among women in low-income and middle-income countries. Data from randomised trials suggest that maternal multiple micronutrient supplementation decreases the risk of low birthweight and potentially improves other infant health outcomes. However, heterogeneity across studies suggests influence from effect modifiers. We aimed to identify individual-level modifiers of the effect of multiple micronutrient supplements on stillbirth, birth outcomes, and infant mortality in low-income and middle-income countries. METHODS This two-stage meta-analysis of individual patient included data from 17 randomised controlled trials done in 14 low-income and middle-income countries, which compared multiple micronutrient supplements containing iron-folic acid versus iron-folic acid alone in 112 953 pregnant women. We generated study-specific estimates and pooled subgroup estimates using fixed-effects models and assessed heterogeneity between subgroups with the χ2 test for heterogeneity. We did sensitivity analyses using random-effects models, stratifying by iron-folic acid dose, and exploring individual study effect. FINDINGS Multiple micronutrient supplements containing iron-folic acid provided significantly greater reductions in neonatal mortality for female neonates compared with male neonates than did iron-folic acid supplementation alone (RR 0·85, 95% CI 0·75-0·96 vs 1·06, 0·95-1·17; p value for interaction 0·007). Multiple micronutrient supplements resulted in greater reductions in low birthweight (RR 0·81, 95% CI 0·74-0·89; p value for interaction 0·049), small-for-gestational-age births (0·92, 0·87-0·97; p=0·03), and 6-month mortality (0·71, 0·60-0·86; p=0·04) in anaemic pregnant women (haemoglobin <110g/L) as compared with non-anaemic pregnant women. Multiple micronutrient supplements also had a greater effect on preterm births among underweight pregnant women (BMI <18·5 kg/m2; RR 0·84, 95% CI 0·78-0·91; p=0·01). Initiation of multiple micronutrient supplements before 20 weeks gestation provided greater reductions in preterm birth (RR 0·89, 95% CI 0·85-0·93; p=0·03). Generally, the survival and birth outcome effects of multiple micronutrient supplementation were greater with high adherence (≥95%) to supplementation. Multiple micronutrient supplements did not significantly increase the risk of stillbirth or neonatal, 6-month, or infant mortality, neither overall or in any of the 26 examined subgroups. INTERPRETATION Antenatal multiple micronutrient supplements improved survival for female neonates and provided greater birth-outcome benefits for infants born to undernourished and anaemic pregnant women. Early initiation in pregnancy and high adherence to multiple micronutrient supplements also provided greater overall benefits. Studies should now aim to elucidate the mechanisms accounting for differences in the effect of antenatal multiple micronutrient supplements on infant health by maternal nutrition status and sex. FUNDING None.

Malnutrition and infant and young child feeding in informal settlements in Mumbai, India: findings from a census

Childhood malnutrition remains common in India. We visited families in 40 urban informal settlement areas in Mumbai to document stunting, wasting, and overweight in children under five, and to examine infant and young child feeding (IYCF) in children under 2 years. We administered questions on eight core WHO IYCF indicators and on sugary and savory snack foods, and measured weight and height of children under five. Stunting was seen in 45% of 7450 children, rising from 15% in the first year to 56% in the fifth. About 16% of children were wasted and 4% overweight. 46% of infants were breastfed within the first hour, 63% were described as exclusively breastfed under 6 months, and breastfeeding continued for 12 months in 74%. The indicator for introduction of solids was met for 41% of infants. Only 13% of children satisfied the indicator for minimum dietary diversity, 43% achieved minimum meal frequency, and 5% had a minimally acceptable diet. About 63% of infants had had sugary snacks in the preceding 24 h, rising to 78% in the second year. Fried and salted snack foods had been eaten by 34% of infants and 66% of children under two. Stunting and wasting remain unacceptably common in informal settlements in Mumbai, and IYCF appears problematic, particularly in terms of dietary diversity. The ubiquity of sugary, fried, and salted snack foods is a serious concern: substantial consumption begins in infancy and exceeds that of all other food groups except grains, roots, and tubers.

The social construction of 'dowry deaths'

The classification of cause of death is real in its consequences: for the reputation of the deceased, for her family, for those who may be implicated, and for epidemiological and social research and policies and practices that may follow from it. The study reported here refers specifically to the processes involved in classifying deaths of women from burns in India. In particular, it examines the determination of ‘dowry death’, a class used in India, but not in other jurisdictions. Classification of death is situated within a framework of special legal provisions intended to protect vulnerable women from dowry-related violence and abuse. The findings are based on 33 case studies tracked in hospital in real time, and interviews with 14 physicians and 14 police officers with experience of dealing with burns cases. The formal class into which any given death is allocated is shown to result from motivated accounting processes representing the interests and resources available to the doctors, victims, victim families, the victim’s husband and his family, and ultimately, the police. These processes may lead to biases in research and to injustice in the treatment of victims and alleged offenders. Suggestions are made for methods of ameliorating the risks.

A probabilistic method to estimate the burden of maternal morbidity in resource-poor settings: preliminary development and evaluation

BackgroundMaternal morbidity is more common than maternal death, and population-based estimates of the burden of maternal morbidity could provide important indicators for monitoring trends, priority setting and evaluating the health impact of interventions. Methods based on lay reporting of obstetric events have been shown to lack specificity and there is a need for new approaches to measure the population burden of maternal morbidity. A computer-based probabilistic tool was developed to estimate the likelihood of maternal morbidity and its causes based on self-reported symptoms and pregnancy/delivery experiences. Development involved the use of training datasets of signs, symptoms and causes of morbidity from 1734 facility-based deliveries in Benin and Burkina Faso, as well as expert review. Preliminary evaluation of the method compared the burden of maternal morbidity and specific causes from the probabilistic tool with clinical classifications of 489 recently-delivered women from Benin, Bangladesh and India.ResultsUsing training datasets, it was possible to create a probabilistic tool that handled uncertainty of women’s self reports of pregnancy and delivery experiences in a unique way to estimate population-level burdens of maternal morbidity and specific causes that compared well with clinical classifications of the same data. When applied to test datasets, the method overestimated the burden of morbidity compared with clinical review, although possible conceptual and methodological reasons for this were identified.ConclusionThe probabilistic method shows promise and may offer opportunities for standardised measurement of maternal morbidity that allows for the uncertainty of women’s self-reported symptoms in retrospective interviews. However, important discrepancies with clinical classifications were observed and the method requires further development, refinement and evaluation in a range of settings.

A qualitative study of the background and in-hospital medicolegal response to female burn injuries in India

BackgroundMost burns happen in low- and middle-income countries. In India, deaths related to burns are more common in women than in men and occur against a complex background in which the cause – accidental or non-accidental, suicidal or homicidal – is often unclear. Our study aimed to understand the antecedents to burns and the problem of ascribing cause, the sequence of medicolegal events after a woman was admitted to hospital, and potential opportunities for improvement.MethodsWe conducted semi-structured interviews with 33 women admitted to two major burns units, their families, and 26 key informant doctors, nurses, and police officers. We used framework analysis to examine the context in which burns occurred and the sequence of medicolegal action after admission to hospital.ResultsInterviewees described accidents, attempted suicide, and attempted homicide. Distinguishing between these was difficult because the underlying combination of poverty and cultural precedent was common to all and action was contingent on potentially conflicting narratives. Space constraint, problems with cooking equipment, and inflammable clothing increased the risk of accidental burns, but coexisted with household conflict, gender-based violence, and alcohol use. Most burns were initially ascribed to accidents. Clinicians adhered to medicolegal procedures, the police carried out their investigative requirements relatively rapidly, but both groups felt vulnerable in the face of the legal process. Women’s understandable reticence to describe burns as non-accidental, the contested nature of statements, their perceived history of changeability, the limited quality and validity of forensic evidence, and the requirement for resilience on the part of clients underlay a general pessimism.ConclusionsThe similarities between accident and intention cluster so tightly as to make them challenging to distinguish, especially given women’s understandable reticence to describe burns as non-accidental. The contested status of forensic evidence and a reliance on testimony means that only a minority of cases lead to conviction. The emphasis should be on improving documentation, communication between service providers, and public understanding of the risks of burns.

Chlorhexidine cord cleansing to reduce neonatal mortality

The rising proportional contribution of neonatal mortality to deaths in childhood has featured in international health policy discussions for more than a decade. Low-income and middle-income countries bear the burden of 99% of global neonatal deaths.1 Many infants—perhaps 60 million every year—are born at home.2 Infections account for an estimated 30% of neonatal deaths,1 and the umbilical cord is recognised as a potential entry point for infection, especially in the first few days of life. WHO and UNICEF recommend that newborn babies are visited at home in the first week of life to ensure healthy neonatal care practices, including hygienic cord care.3 Research evidence on topical cord care is, however, scarce: most studies included in a 2004 Cochrane review4 were from high-income countries, and the review could not address the effect of topical care on systemic infections or mortality. The investigators called for trials in low-income settings, suggesting that “where the risk of bacterial infection appears high it might be prudent to use topical antiseptics”. The choice of antiseptic and regimen of application was unclear: “it would seem sensible, in situations where packages of care around improving umbilical cord sepsis are introduced, to conduct randomized comparisons to identify the best agents and regimens”.4 Two large trials5,6 in The Lancet—both of which record encouraging reductions in neonatal mortality after application of a topical antiseptic, chlorhexidine, to the umbilicus—now improve the knowledge base. The trials build on the findings of a cluster-randomised controlled trial in Nepal, which compared chlorhexidine application with education on dry cord care and showed an apparent effect on neonatal mortality of chlorhexidine application in a subgroup enrolled within 24 h of birth (relative risk 0·66; 95% CI 0·46–0·95).7 In Shams El Arifeen and colleagues’ randomised controlled trial5 in 133 clusters in Sylhet, Bangladesh, education on dry cord care was compared with two regimens: a single application of 4% chlorhexidine solution as soon after birth as possible, and the same initial application followed by daily application for 7 days. In an analysis of about 10 000 livebirths per allocation group, signs of local infection were reduced (albeit statistically significantly in only two of eight comparisons), and risk of neonatal death was lower in the single application group (relative risk 0·80; 95% CI 0·65–0·98), but not in the multiple application group (0·94; 0·78–1·14). In Sajid Soofi and colleagues’ cluster-randomised trial6 in the rural Sindh province, Pakistan, families in 187 clusters were given clean home delivery kits and educational messages by traditional birth attendants. With a factorial design, two interventions were compared with advice on dry cord care. One was the provision of 4% chlorhexidine solution—the solution was applied to the umbilical cord by the traditional birth attendant at delivery, and advice was given to caregivers to repeat the application daily for 14 days. The other intervention was the provision of soap and handwashing advice. In an analysis of about 2350 livebirths per allocation group, risks of signs of local infection (risk ratio 0·58; 95% CI 0·41–0·82) and of neonatal mortality (0·62; 0·45–0·85) were lower in the chlorhexidine groups. Findings for the frequency of chlorhexidine application in the Bangladesh trial—a reduction in mortality with a single application, but not when additional applications were given—are counterintuitive. We tend to agree with the investigators’ suggestion that the latter might be a chance finding, especially because the trial in Pakistan showed a benefit from repeated applications. On balance, we think that sufficient evidence has accrued to claim proof-of-principle that application of 4% chlorhexidine to the cord stump can prevent omphalitis and neonatal mortality in high-mortality settings. Three cluster-randomised trials have now shown some effect of chlorhexidine application on mortality,5–7 and have suggested no adverse effects. The Nepal results suggest that early application is important;7 the results from Bangladesh suggest that a single application might be sufficient,5 and the results from Pakistan show a mortality effect even though families continued to apply other substances to the cord.6 We could argue that more research is needed—questions certainly exist about the duration and timing of application and about external validity. Evidence from high-mortality populations in Africa would be useful. Nevertheless, to demand more evidence of effectiveness might be to repeat an old public health debate: if the need is clear, the possibilities attractive, and the risk low, how much evidence is necessary before we act on plausible findings? The next question is about evidence for the potential effectiveness of delivering cord antisepsis at scale. The trials should be seen in the context of the population health truism that the effect of an intervention is likely to diminish when it is rolled out. The Bangladesh and Pakistan trials both achieved impressive coverage, but neither worked within the confines of a government health system, which raises questions about feasibility and sustainability of delivery at scale. In Bangladesh, the intervention was delivered by specially recruited female village health workers, each covering a population of 1000 people and supervised by a community health worker. A large proportion of women were reached on the day of delivery, which could be difficult to replicate in some settings. The delivery model ran parallel to the government system, and could attract the criticism that it might not be scalable. There is, however, a precedent, in that huge areas of Bangladesh receive health services from non-governmental organisations and private-sector initiatives. In Pakistan, the intervention was delivered by traditional birth attendants who received their delivery kits from community health workers specifically recruited for the trial. Project workers were necessary because their government counterparts (lady health workers) did not link formally with traditional birth attendants, although this might change as a result of a trial published last year, which showed that reduced neonatal mortality was associated with changes to lady health workers’ activities and stronger links with traditional attendants.8 Working with traditional birth attendants acknowledges existing community structures, but might not be effective in settings where home deliveries are mainly done by family members, or where governments are reluctant to engage with traditional birth attendants. An alternative delivery strategy might be in families themselves. A desire to apply something (eg, ash, oil, or dung) to the umbilical cord is common.9–12 If we think of topical chlorhexidine as a technology, and of its adoption by families as needing diffusion of innovation, progress could be rapid, either after its inclusion in clean delivery kits or through independent access.

Community resource centres to improve the health of women and children in informal settlements in Mumbai: a cluster-randomised, controlled trial

Summary Background Around 105 million people in India will be living in informal settlements by 2017. We investigated the effects of local resource centres delivering integrated activities to improve womens and childrens health in urban informal settlements. Methods In a cluster-randomised controlled trial in 40 clusters, each containing around 600 households, 20 were randomly allocated to have a resource centre (intervention group) and 20 no centre (control group). Community organisers in the intervention centres addressed maternal and neonatal health, child health and nutrition, reproductive health, and prevention of violence against women and children through home visits, group meetings, day care, community events, service provision, and liaison. The primary endpoints were met need for family planning in women aged 15–49 years, proportion of children aged 12–23 months fully immunised, and proportion of children younger than 5 years with anthropometric wasting. Census interviews with women aged 15–49 years were done before and 2 years after the intervention was implemented. The primary intention-to-treat analysis compared cluster allocation groups after the intervention. We also analysed the per-protocol population (all women with data from both censuses) and assessed cluster-level changes. This study is registered with ISRCTN, number ISRCTN56183183, and Clinical Trials Registry of India, number CTRI/2012/09/003004. Findings 12 614 households were allocated to the intervention and 12 239 to control. Postintervention data were available for 8271 women and 5371 children younger than 5 years in the intervention group, and 7965 women and 5180 children in the control group. Met need for family planning was greater in the intervention clusters than in the control clusters (odds ratio [OR] 1·31, 95% CI 1·11–1·53). The proportions of fully immunised children were similar in the intervention and control groups in the intention-to-treat analysis (OR 1·30, 95% CI 0·84–2·01), but were greater in the intervention group when assessed per protocol (1·73, 1·05–2·86). Childhood wasting did not differ between groups (OR 0·92, 95% CI 0·75–1·12), although improvement was seen at the cluster level in the intervention group (p=0·020). Interpretation This community resource model seems feasible and replicable and may be protocolised for expansion. Funding Wellcome Trust, CRY, Cipla.