María Clara Restrepo-Méndez

Association between maternal age at childbirth and child and adult outcomes in the offspring: a prospective study in five low-income and middle-income countries (COHORTS collaboration)

Summary Background Both young and advanced maternal age is associated with adverse birth and child outcomes. Few studies have examined these associations in low-income and middle-income countries (LMICs) and none have studied adult outcomes in the offspring. We aimed to examine both child and adult outcomes in five LMICs. Methods In this prospective study, we pooled data from COHORTS (Consortium for Health Orientated Research in Transitioning Societies)—a collaboration of five birth cohorts from LMICs (Brazil, Guatemala, India, the Philippines, and South Africa), in which mothers were recruited before or during pregnancy, and the children followed up to adulthood. We examined associations between maternal age and offspring birthweight, gestational age at birth, height-for-age and weight-for-height Z scores in childhood, attained schooling, and adult height, body composition (body-mass index, waist circumference, fat, and lean mass), and cardiometabolic risk factors (blood pressure and fasting plasma glucose concentration), along with binary variables derived from these. Analyses were unadjusted and adjusted for maternal socioeconomic status, height and parity, and breastfeeding duration. Findings We obtained data for 22 188 mothers from the five cohorts, enrolment into which took place at various times between 1969 and 1989. Data for maternal age and at least one outcome were available for 19 403 offspring (87%). In unadjusted analyses, younger (≤19 years) and older (≥35 years) maternal age were associated with lower birthweight, gestational age, child nutritional status, and schooling. After adjustment, associations with younger maternal age remained for low birthweight (odds ratio [OR] 1·18 (95% CI 1·02–1·36)], preterm birth (1·26 [1·03–1·53]), 2-year stunting (1·46 [1·25–1·70]), and failure to complete secondary schooling (1·38 [1·18–1·62]) compared with mothers aged 20–24 years. After adjustment, older maternal age remained associated with increased risk of preterm birth (OR 1·33 [95% CI 1·05–1·67]), but children of older mothers had less 2-year stunting (0·64 [0·54–0·77]) and failure to complete secondary schooling (0·59 [0·48–0·71]) than did those with mothers aged 20–24 years. Offspring of both younger and older mothers had higher adult fasting glucose concentrations (roughly 0·05 mmol/L). Interpretation Children of young mothers in LMICs are disadvantaged at birth and in childhood nutrition and schooling. Efforts to prevent early childbearing should be strengthened. After adjustment for confounders, children of older mothers have advantages in nutritional status and schooling. Extremes of maternal age could be associated with disturbed offspring glucose metabolism. Funding Wellcome Trust and the Bill & Melinda Gates Foundation.

Life-course evidence of birth weight effects on bone mass: systematic review and meta-analysis

A systematic review of the literature was performed in July 2011. Original papers based on longitudinal studies measuring spine, femoral neck, or total body bone mass by DXA were included (n = 17). Birth weight was positively associated with bone mass among children. The association was unclear among adolescents and weak among adults. This study aims to evaluate the association between birth weight and bone mass in future ages through a systematic review of literature and meta-analysis. A systematic review of the literature was performed in July 2011 in Medline, Web of Science and LILACS bases using key terms: (“birth size” OR “birth weight” OR birthweight OR prematurity OR premature OR “gestational age”) AND (osteoporosis OR “bone mass” OR “bone density” OR “bone mineral density” OR “bone mineral content” OR “bone area”) AND (longitudinal OR cohort). Original papers based on longitudinal studies measuring lumbar spine, femoral neck or total body bone mass by dual-emission X-ray absorptiometry (DXA) were included. A meta-analysis was performed using birth weight and bone mass density and/or content as continuous variables and adjusted for current height and/or weight. A total of 218 articles were retrieved from which 17 were selected and grouped into three categories according to age: studies with children; with adolescents and young adults, and studies with adults (older than 25). Five papers were included in the meta-analysis. Positive association between birth weight and bone mass was clear among children, unclear among adolescents, and weak among adults. The effect on bone mass content was stronger than those on body mass density regardless of age. Birth weight influences positively bone health in later life. Preventive health policies dealing with early-life modifiable risk factors, as birth weight, should be encouraged to attain an optimal peak bone mass as an strategy to decrease osteoporosis in the elderly.

Scaling up maternal nutrition programs to improve birth outcomes: a review of implementation issues.

Background Maternal nutrition interventions are efficacious in improving birth outcomes. It is important to demonstrate that if delivered in field conditions they produce improvements in health and nutrition. Objective Analyses of scaling-up of five program implemented in several countries. These include micronutrient supplementation, food fortification, food supplements, nutrition education and counseling, and conditional cash transfers (as a platform for delivering interventions). Evidence on impact and cost-effectiveness is assessed, especially on achieving high, equitable, and sustained coverage, and reasons for success or failure Methods Systematic review of articles on large-scale programs in several databases. Two separate reviewers carried out independent searches. A separate review of the gray literature was carried out including websites of the most important organizations leading with these programs. With Google Scholar a detailed review of the 100 most frequently cited references on each of the five above topics was conducted. Results Food fortification programs: iron and folic acid fortification were less successful than salt iodization initiatives, as the latter attracted more advocacy. Micronutrient supplementation programs: Nicaragua and Nepal achieved good coverage. Key elements of success are antenatal care coverage, ensuring availability of tablets, and improving compliance. Integrated nutrition programs in India, Bangladesh, and Madagascar with food supplementation and/or behavioral change interventions report improved coverage and behaviors, but achievements are below targets. The Mexican conditional cash transfer program provides a good example of use of this platform to deliver maternal nutritional interventions. Conclusions Programs differ in complexity, and key elements for success vary with the type of program and the context in which they operate. Special attention must be given to equity, as even with improved overall coverage and impact inequalities may even be increased. Finally, much greater investments are needed in independent monitoring and evaluation.

Childbearing during adolescence and offspring mortality: findings from three population-based cohorts in southern Brazil

BackgroundThe role of young maternal age as a determinant of adverse child health outcomes is controversial, with existing studies providing conflicting results. This work assessed the association between adolescent childbearing and early offspring mortality in three birth cohort studies from the city of Pelotas in Southern Brazil.MethodsAll hospital births from 1982 (6,011), 1993 (5,304), and 2004 (4,287) were identified and these infants were followed up. Deaths were monitored through vital registration, visits to hospitals and cemeteries. The analyses were restricted to women younger than 30 years who delivered singletons (72%, 70% and 67% of the original cohorts, respectively). Maternal age was categorized into three groups (< 16, 16-19, and 20-29 years). Further analyses compared mothers aged 12-19 and 20-29 years. The outcome variables included fetal, perinatal, neonatal, postneonatal and infant mortality. Crude and adjusted odds ratios (ORs) were estimated with logistic regression models.ResultsThere were no interactions between maternal age and cohort year. After adjustment for confounding, pooled ORs for mothers aged 12-19 years were 0.6 (95% CI = 0.4; 1.0) for fetal death, 0.9 (0.6; 1.3) for perinatal death, 1.0 (0.7; 1.6) for early neonatal death, 1.6 (0.7; 3.4) for late neonatal death, 1.8 (1.1; 2.9) for postneonatal death, and 1.6 (1.2; 2.1) for infant death, when compared to mothers aged 20-29 years. Further adjustment for mediating variables led to the disappearance of the excess of postneonatal mortality. The number of mothers younger than 16 years was not sufficient for most analyses.ConclusionThe slightly increased odds of postneonatal mortality among children of adolescent mothers suggest that social and environmental factors may be more important than maternal biologic immaturity.

Child health and nutrition in Peru within an antipoverty political agenda: a Countdown to 2015 country case study

BACKGROUND Peru is an upper-middle-income country with wide social and regional disparities. In recent years, sustained multisectoral antipoverty programmes involving governments, political parties, and civil society have included explicit health and nutrition goals and spending increased sharply. We did a country case study with the aim of documenting Perus progress in reproductive, maternal, neonatal, and child health from 2000-13, and explored the potential determinants. METHODS We examined the outcomes of health interventions coverage, under-5 mortality, neonatal mortality, and prevalence of under-5 stunting. We obtained data from interviews with key informants, a literature review of published and unpublished data, national censuses, and governmental reports. We obtained information on social determinants of health, including economic growth, poverty, unmet basic needs, urbanisation, womens education, water supply, fertility rates, and child nutrition from the annual national households surveys and the Peruvian Demographic and Health Surveys. We obtained national mortality data from the Interagency Group for Child Mortality Estimation, and calculated subnational rates from 11 surveys. Analyses were stratified by region, wealth quintiles, and urban or rural residence. We calculated coverage indicators for the years 2000-13, and we used the Lives Saved Tool (LiST) to estimate the effect of changes in intervention coverage and in nutritional status on mortality. FINDINGS From 2000 to 2013, under-5 mortality fell by 58% from 39·8 deaths per 1000 livebirths to 16·7. LiST, which was used to predict the decline in mortality arising from changes in fertility rates, water and sanitation, undernutrition, and coverage of indicators of reproductive, maternal, neonatal, and child health predicted that the under-5 mortality rate would fall from 39·8 to 28·4 per 1000 livebirths, accounting for 49·2% of the reported reduction. Neonatal mortality fell by 51% from 16·2 deaths per 1000 livebirths to 8·0. Stunting prevalence remained stable at around 30% until 2007, decreasing to 17·5% by 2013, and the composite coverage index for essential health interventions increased from 75·1% to 82·6%, with faster increases among the poor, in rural areas, and in the Andean region. Socioeconomic, urban-rural, and regional inequalities in coverage, mortality, and stunting were substantially reduced. The proportion of the population living below the poverty line reduced from 47·8% to 23·9%, women with fewer than 4 years of schooling reduced from 11·5% to 6·9%, urbanisation increased from 68·1% to 75·6%, and the total fertility rate decreased from 3·0 children per woman to 2·4. We interviewed 175 key informants and they raised the following issues: economic growth, improvement of social determinants, civil society empowerment and advocacy, out-of-health and within-health-sector changes, and sustained implementation of evidence-based, pro-poor reproductive, maternal, neonatal, and child health interventions. INTERPRETATION Peru has made substantial progress in reducing neonatal and under-5 mortality, and child stunting. This country is a good example of how a combination of political will, economic growth, broad societal participation, strategies focused on poor people, and increased spending in health and related sectors can achieve significant progress in reproductive, maternal, neonatal, and child health. The remaining challenges include continuing to address inequalities in wealth distribution, poverty, and access to basic services, especially in the Amazon and Andean rural areas. FUNDING Bill & Melinda Gates Foundation.

The association of maternal age with birthweight and gestational age: A cross-cohort comparison

Background We examined the associations of maternal age with low birthweight (LBW) and preterm birth in four cohorts from a middle- and a high-income country, where the patterning of maternal age by socio-economic position (SEP) is likely to differ. Methods Population-based birth cohort studies were carried out in the city of Pelotas, Brazil in 1982, 1993, and 2004, and in Avon, UK in 1991 [Avon Longitudinal Study of Parents and Children (ALSPAC)]. Adjustment for multiple indicators of SEP were applied. Results Low SEP was associated with younger age at childbearing in all cohorts, but the magnitudes of these associations were stronger in ALSPAC. Inverse associations of SEP with LBW and preterm birth were observed in all cohorts. U-shaped associations were observed between maternal age and odds of LBW in all cohorts. After adjustment for SEP, increased odds of LBW for young mothers (<20 years) attenuated to the null but remained or increased for older mothers (≥35 years). Very young (<16 years) maternal age was also associated with both outcomes even after full SEP adjustment. SEP adjusted odds ratio of having a LBW infant in women <16 years and ≥35 years, compared with 25–29 years, were 1.48 [95% confidence interval (CI) 1.00, 2.20] and 1.66 [95% CI 1.36, 2.02], respectively. The corresponding results for preterm birth were 1.80 [95% CI 1.23, 2.64)] and 1.38 [95% CI 1.15, 1.67], respectively. Conclusion Confounding by SEP explains much of the excess risk of LBW and preterm among babies born to teenage mothers as a whole, but not for mothers aged <16 or ≥35 years. Given that the proportion of women becoming pregnant at <16 years is smaller than for those ≥35 years, the population burden is greater for older age.

Time trends in socio-economic inequalities in stunting prevalence: Analyses of repeated national surveys

OBJECTIVE Much is known about national trends in child undernutrition, but there is little information on how socio-economic inequalities are evolving over time. We aimed to assess socio-economic inequalities in stunting prevalence over time. DESIGN We selected nationally representative surveys carried out since the mid-1990s for which information was available on asset indices and on child anthropometry. We identified twenty-five countries that had at least two surveys over an interval of 10 years or more, totalling eighty-seven surveys. Stunting prevalence was calculated according to wealth quintiles. Absolute and relative inequalities were calculated and time trends were obtained by regression. Setting Nationally representative household surveys from twenty-five low- and middle-income countries. SUBJECTS Children <5 years of age. RESULTS National prevalence declined significantly in twenty-two of the twenty-five countries. In eighteen out of twenty-five countries, relative reductions were higher among the rich than among the poor. Overall, there was no indication that inequalities improved. Striking examples are Nepal, with a 17·0 percentage points decline in stunting per decade, but where inequalities increased sharply; and Brazil, where stunting fell by 6·7 percentage points and inequalities were all but eliminated. CONCLUSIONS Global progress in reducing stunting has not been accompanied by improved equity, but countries varied markedly in how successful they were in reducing prevalence among the poorest children. It is important to document how some countries were able to reduce inequalities, so that these lessons can be used to foster global progress, particularly in light of the increased importance of within-country inequalities in the post-2015 agenda.

Size at birth and abdominal adiposity in adults: a systematic review and meta‐analysis

We performed a systematic literature review on the associations between birth size and abdominal adiposity in adults, while also investigating the role of the adjustment for adult body mass index (BMI). MEDLINE, Scopus, Web of Science, LILACS and SciELO databases were searched for articles published up to February 2013. Only prospective studies were included. After screening 2,570 titles, we selected 31 publications for the narrative synthesis, of which 13 were considered to be of high methodological quality. Six main indicators of birth size were identified, and birth weight (BW) was the most extensively studied. Most studies relied on anthropometric measurements as proxies for abdominal fatness or as indicators of body fat distribution. Few studies assessed abdominal adiposity through imaging methods, generally with small sample sizes. Eleven articles could be included in the meta‐analyses. BW was found to be positively associated with waist circumference in adulthood, but the association disappeared after adjustment for adult BMI. In contrast, there was no association between BW and waist‐to‐hip ratio, whereas a strong negative association became evident after controlling for adult BMI. In conclusion, BW seems to be associated with larger adult size in general, including both waist and hip circumferences. The marked change in coefficients after adjustment for adult BMI suggests that post‐natal growth strongly affects relative central adiposity, whereas BW per se does not play a role. Given the potential impact of post‐natal growth, further research is needed to identify different growth trajectories that lead to abdominal adiposity, as well as studies on interactions of foetal and post‐natal growth patterns.

Patterns and determinants of antenatal care utilization: analysis of national survey data in seven countdown countries

Background Antenatal care (ANC) is critical for improving maternal and newborn health. WHO recommends that pregnant women complete at least four ANC visits. Countdown and other global monitoring efforts track the proportions of women who receive one or more visits by a skilled provider (ANC1+) and four or more visits by any provider (ANC4+). This study investigates patterns of drop–off in use between ANC1+ and ANC4+, and explores inequalities in women’s use of ANC services. It also identifies determinants of utilization and describes countries’ ANC–related policies, and programs. Methods We performed secondary analyses using Demographic Health Survey (DHS) data from seven Countdown countries: Bangladesh, Cambodia, Cameroon, Nepal, Peru, Senegal and Uganda. The descriptive analysis illustrates country variations in the frequency of visits by provider type, content, and by household wealth, women’s education and type of residence. We conducted a multivariable analysis using a conceptual framework to identify determinants of ANC utilization. We collected contextual information from countries through a standard questionnaire completed by country–based informants. Results Each country had a unique pattern of ANC utilization in terms of coverage, inequality and the extent to which predictors affected the frequency of visits. Nevertheless, common patterns arise. Women having four or more visits usually saw a skilled provider at least once, and received more evidence–based content interventions than women reporting fewer than four visits. A considerable proportion of women reporting four or more visits did not report receiving the essential interventions. Large disparities exist in ANC use by household wealth, women’s education and residence area; and are wider for a larger number of visits. The multivariable analyses of two models in each country showed that determinants had different effects on the dependent variable in each model. Overall, strong predictors of ANC initiation and having a higher frequency (4+) of visits were woman’s education and household wealth. Gestational age at first visit, birth rank and preceding birth interval were generally negatively associated with initiating visits and with having four or more visits. Information on country policies and programs were somewhat informative in understanding the utilization patterns across the countries, although timing of adoption and actual implementation make direct linkages impossible to verify. Conclusion Secondary analyses provided a more detailed picture of ANC utilization patterns in the seven countries. While coverage levels differ by country and sub–groups, all countries can benefit from specific in–country assessments to properly identify the underserved women and the reasons behind low coverage and missed interventions. Overall, emphasis needs to be put on assessing the quality of care offered and identifying women’s perception to the care as well as the barriers hindering utilization. Country policies and programs need to be reviewed, evaluated and/or implemented properly to ensure that women receive the recommended number of ANC visits with appropriate content, especially, poor and less educated women residing in rural areas.

Inequalities in full immunization coverage: trends in low- and middle-income countries.

Abstract Objective To investigate disparities in full immunization coverage across and within 86 low- and middle-income countries. Methods In May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we investigated inequalities in full immunization coverage – i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine – in 86 low- or middle-income countries. We then investigated temporal trends in the level and inequality of such coverage in eight of the countries. Findings In each of the World Health Organization’s regions, it appeared that about 56–69% of eligible children in the low- and middle-income countries had received full immunization. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. We detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which we investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunization coverage over the last two decades, particularly among the poorest quintiles of their populations. Conclusion Most low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunization coverage that are not apparent when only national mean values of such coverage are reported.