Katarina Ekholm Selling

Intergenerational effects of preterm birth and reduced intrauterine growth: a population‐based study of Swedish mother–offspring pairs

Objective  To estimate the intergenerational effects of preterm birth and reduced intrauterine growth.

Targeted Interventions for Improved Equity in Maternal and Child Health in Low- and Middle-Income Settings: A Systematic Review and Meta-Analysis

Background Targeted interventions to improve maternal and child health is suggested as a feasible and sometimes even necessary strategy to reduce inequity. The objective of this systematic review was to gather the evidence of the effectiveness of targeted interventions to improve equity in MDG 4 and 5 outcomes. Methods and Findings We identified primary studies in all languages by searching nine health and social databases, including grey literature and dissertations. Studies evaluating the effect of an intervention tailored to address a structural determinant of inequity in maternal and child health were included. Thus general interventions targeting disadvantaged populations were excluded. Outcome measures were limited to indicators proposed for Millennium Development Goals 4 and 5. We identified 18 articles, whereof 15 evaluated various incentive programs, two evaluated a targeted policy intervention, and only one study evaluated an intervention addressing a cultural custom. Meta-analyses of the effectiveness of incentives programs showed a pooled effect size of RR 1.66 (95% CI 1.43–1.93) for antenatal care attendance (four studies with 2,476 participants) and RR 2.37 (95% CI 1.38–4.07) for health facility delivery (five studies with 25,625 participants). Meta-analyses were not performed for any of the other outcomes due to scarcity of studies. Conclusions The targeted interventions aiming to improve maternal and child health are mainly limited to addressing economic disparities through various incentive schemes like conditional cash transfers and voucher schemes. This is a feasible strategy to reduce inequity based on income. More innovative action-oriented research is needed to speed up progress in maternal and child survival among the most disadvantaged populations through interventions targeting the underlying structural determinants of inequity.

Hospitalizations in adolescence and early adulthood among Swedish men and women born preterm or small for gestational age.

Background: Preterm birth and reduced intrauterine growth appear to be related to morbidity in childhood and later adulthood. We studied whether the risk of all-cause hospitalization in adolescence and early adulthood differed between individuals who were born preterm or small for gestational age (SGA) compared with those born at term and appropriate for gestational age. Methods: Using Swedish registries, we followed 304,275 men and women born in 1973–1975 for any hospitalizations occurring in 1987–1996. Preterm birth was defined as <37 weeks of gestation and SGA as babies smaller than 2 standard deviations below the mean weight for gestational length, according to Swedish standards. We created 3 mutually exclusive categories: “preterm” (<37 weeks and not SGA), “SGA” (SGA and not preterm), and “both preterm and SGA.” The comparison group was all term births not SGA. Childhood socioeconomic characteristics were accounted for in the analyses. Results: The overall risk of hospitalization was higher for men and women born SGA (adjusted odds ratio = 1.16; 95% confidence interval = 1.12–1.21), for those born preterm (1.06; 1.02–1.10), and for those born both preterm and SGA (1.42; 1.26–1.59). In addition to higher risks for previously reported adverse health outcomes, such as neurodevelopment sequelae and congenital anomalies, men and women born SGA or preterm were more likely to be hospitalized due to unspecified symptoms. SGA also appeared to be associated with genitourinary diseases and drug use. Conclusions: Men and women born SGA or preterm were at higher risk for hospitalization during adolescence and early adulthood, with men and women born SGA more at risk than those born preterm.

Effect of facilitation of local maternal-and-newborn stakeholder groups on neonatal mortality: a cluster randomised trial

Background Facilitation of local women’s groups may reportedly reduce neonatal mortality. It is not known whether facilitation of groups composed by local healthcare staff and politicians can improve perinatal outcomes. We hypothesized that facilitation of local stakeholder groups would reduce neonatal mortality (primary outcome) and improve maternal, delivery and newborn care indicators (secondary outcomes) in Quang Ninh province, Vietnam. Trial registration: Current Controlled Trials ISRCTN44599712.

Trends and social differentials in child mortality in Rwanda 1990–2010: results from three demographic and health surveys

Background Rwanda has embarked on ambitious programmes to provide equitable health services and reduce mortality in childhood. Evidence from other countries indicates that advances in child survival often have come at the expense of increasing inequity. Our aims were to analyse trends and social differentials in mortality before the age of 5 years in Rwanda from 1990 to 2010. Methods We performed secondary analyses of data from three Demographic and Health Surveys conducted in 2000, 2005 and 2010 in Rwanda. These surveys included 34 790 children born between 1990 and 2010 to women aged 15–49 years. The main outcome measures were neonatal mortality rates (NMR) and under-5 mortality rates (U5MR) over time, and in relation to mothers educational level, urban or rural residence and household wealth. Generalised linear mixed effects models and a mixed effects Cox model (frailty model) were used, with adjustments for confounders and cluster sampling method. Results Mortality rates in Rwanda peaked in 1994 at the time of the genocide (NMR 60/1000 live births, 95% CI 51 to 65; U5MR 238/1000 live births, 95% CI 226 to 251). The 1990s and the first half of the 2000s were characterised by a marked rural/urban divide and inequity in child survival between maternal groups with different levels of education. Towards the end of the study period (2005–2010) NMR had been reduced to 26/1000 (95% CI 23 to 29) and U5MR to 65/1000 (95% CI 61 to 70), with little or no difference between urban and rural areas, and household wealth groups, while children of women with no education still had significantly higher U5MR. Conclusions Recent reductions in child mortality in Rwanda have concurred with improved social equity in child survival. Current challenges include the prevention of newborn deaths.

Diagnostic testing of pediatric fevers: meta-analysis of 13 national surveys assessing influences of malaria endemicity and source of care on test uptake for febrile children under five years.

Background In 2010, the World Health Organization revised guidelines to recommend diagnosis of all suspected malaria cases prior to treatment. There has been no systematic assessment of malaria test uptake for pediatric fevers at the population level as countries start implementing guidelines. We examined test use for pediatric fevers in relation to malaria endemicity and treatment-seeking behavior in multiple sub-Saharan African countries in initial years of implementation. Methods and Findings We compiled data from national population-based surveys reporting fever prevalence, care-seeking and diagnostic use for children under five years in 13 sub-Saharan African countries in 2009–2011/12 (n = 105,791). Mixed-effects logistic regression models quantified the influence of source of care and malaria endemicity on test use after adjusting for socioeconomic covariates. Results were stratified by malaria endemicity categories: low (PfPR2–10<5%), moderate (PfPR2–10 5–40%), high (PfPR2–10>40%). Among febrile under-fives surveyed, 16.9% (95% CI: 11.8%–21.9%) were tested. Compared to hospitals, febrile children attending non-hospital sources (OR: 0.62, 95% CI: 0.56–0.69) and community health workers (OR: 0.31, 95% CI: 0.23–0.43) were less often tested. Febrile children in high-risk areas had reduced odds of testing compared to low-risk settings (OR: 0.51, 95% CI: 0.42–0.62). Febrile children in least poor households were more often tested than in poorest (OR: 1.63, 95% CI: 1.39–1.91), as were children with better-educated mothers compared to least educated (OR: 1.33, 95% CI: 1.16–1.54). Conclusions Diagnostic testing of pediatric fevers was low and inequitable at the outset of new guidelines. Greater testing is needed at lower or less formal sources where pediatric fevers are commonly managed, particularly to reach the poorest. Lower test uptake in high-risk settings merits further investigation given potential implications for diagnostic scale-up in these areas. Findings could inform continued implementation of new guidelines to improve access to and equity in point-of-care diagnostics use for pediatric fevers.

Effect of diagnostic testing on medicines used by febrile children less than five years in 12 malaria-endemic African countries: a mixed-methods study

BackgroundIn 2010, WHO revised guidelines to recommend testing all suspected malaria cases prior to treatment. Yet, evidence to assess programmes is largely derived from limited facility settings in a limited number of countries. National surveys from 12 sub-Saharan African countries were used to examine the effect of diagnostic testing on medicines used by febrile children under five years at the population level, including stratification by malaria risk, transmission season, source of care, symptoms, and age.MethodsData were compiled from 12 Demographic and Health Surveys in 2010–2012 that reported fever prevalence, diagnostic test and medicine use, and socio-economic covariates (n = 16,323 febrile under-fives taken to care). Mixed-effects logistic regression models quantified the influence of diagnostic testing on three outcomes (artemisinin combination therapy (ACT), any anti-malarial or any antibiotic use) after adjusting for data clustering and confounding covariates. For each outcome, interactions between diagnostic testing and the following covariates were separately tested: malaria risk, season, source of care, symptoms, and age. A multiple case study design was used to understand varying results across selected countries and sub-national groups, which drew on programme documents, published research and expert consultations. A descriptive typology of plausible explanations for quantitative results was derived from a cross-case synthesis.ResultsSignificant variability was found in the effect of diagnostic testing on ACT use across countries (e.g., Uganda OR: 0.84, 95% CI: 0.66-1.06; Mozambique OR: 3.54, 95% CI: 2.33-5.39). Four main themes emerged to explain results: available diagnostics and medicines; quality of care; care-seeking behaviour; and, malaria epidemiology.ConclusionsSignificant country variation was found in the effect of diagnostic testing on paediatric fever treatment at the population level, and qualitative results suggest the impact of diagnostic scale-up on treatment practices may not be straightforward in routine conditions given contextual factors (e.g., access to care, treatment-seeking behaviour or supply stock-outs). Despite limitations, quantitative results could help identify countries (e.g., Mozambique) or issues (e.g., malaria risk) where facility-based research or programme attention may be warranted. The mixed-methods approach triangulates different evidence to potentially provide a standard framework to assess routine programmes across countries or over time to fill critical evidence gaps.

Health system context and implementation of evidence-based practices—development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings

BackgroundThe gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose.MethodsThe development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries.ResultsThe tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge.ConclusionsAspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.

Stunted at 10 Years. Linear Growth Trajectories and Stunting from Birth to Pre-Adolescence in a Rural Bangladeshi Cohort

Background Few studies in low-income settings analyse linear growth trajectories from foetal life to pre-adolescence. The aim of this study is to describe linear growth and stunting from birth to 10 years in rural Bangladesh and to analyse whether maternal and environmental determinants at conception are associated with linear growth throughout childhood and stunting at 10 years. Methods and Findings Pregnant women participating in the MINIMat trial were identified in early pregnancy and a birth cohort (n = 1054) was followed with 19 growth measurements from birth to 10 years. Analyses of baseline predictors and mean height-for-age Z-scores (HAZ) over time were modelled using GLMM. Logistic regression analysis was used to investigate the associations between baseline predictors and stunting (HAZ<-2) at 10 years. HAZ decreased to 2 years, followed by an increase up to 10 years, while the average height-for-age difference in cm (HAD) to the WHO reference median continued to increase up to 10 years. Prevalence of stunting was highest at 2 years (50%) decreasing to 29% at 10 years. Maternal height, maternal educational level and season of conception were all independent predictors of HAZ from birth to pre-adolescence (p<0.001) and stunting at 10 years. The highest probability to be stunted at 10 years was for children born by short mothers (<147.5 cm) (ORadj 2.93, 95% CI: 2.06–4.20), mothers with no education (ORadj 1.74, 95% CI 1.17–2.81) or those conceived in the pre-monsoon season (ORadj 1.94, 95% CI 1.37–2.77). Conclusions Height growth trajectories and prevalence of stunting in pre-adolescence showed strong intergenerational associations, social differentials, and environmental influence from foetal life. Targeting women before and during pregnancy is needed for the prevention of impaired child growth.

Effects of prenatal micronutrient and early food supplementation on metabolic status of the offspring at 4.5 years of age. The MINIMat randomized trial in rural Bangladesh

Background: Fetal nutritional insults may alter the later metabolic phenotype. We hypothesized that early timing of prenatal food supplementation and multiple micronutrient supplementation (MMS) would favourably influence childhood metabolic phenotype. Methods: Pregnant women recruited 1 January to 31 December 2002 in Matlab, Bangladesh, were randomized into supplementation with capsules of either 30 mg of iron and 400 μg of folic acid, 60 mg of iron and 400 μg of folic acid, or MMS containing a daily allowance of 15 micronutrients, and randomized to food supplementation (608 kcal) either with early invitation (9 weeks’ gestation) or usual invitation (at 20 weeks). Their children (n = 1667) were followed up at 4.5 years with assessment of biomarkers of lipid and glucose metabolism, inflammation and oxidative stress. Results: Children in the group with early timing of food supplementation had lower cholesterol (difference -0.079 mmol/l, 95% confidence interval (CI) -0.156; -0.003), low-density lipoprotein (LDL) (difference -0.068 mmol/l, 95% CI -0.126; -0.011) and ApoB levels (difference -0.017 g/l, 95% CL -0.033; -0.001). MMS supplementation resulted in lower high-density lipoprotein (HDL) (difference -0.028 mmol/l, 95% CL -0.053; -0.002), lower glucose (difference -0.099 mmol/l, 95% CL -0.179; -0.019) and lower insulin-like growth factor 1 (IGF-1) (difference on log scale -0.141 µg/l, 95% CL -0.254; -0.028) than 60 mg iron and 400 μg folic acid. There were no effects on markers of inflammation or oxidative stress. Conclusions: Findings suggest that in a population where malnutrition is prevalent, nutrition interventions during pregnancy may modify the metabolic phenotype in the young child that could have consequences for later chronic disease risks.