Infant growth patterns in the slums of Dhaka in relation to birth weight, intrauterine growth retardation, and prematurity

BACKGROUND: Relations between size and maturity at birth and infant growth have been studied inadequately in Bangladesh, where the incidence of low birth weight is high and most infants are breast-fed. OBJECTIVE: This study was conducted to describe infant growth patterns and their relations to birth weight, intrauterine growth retardation, and prematurity. DESIGN: A total of 1654 infants born in selected low-socioeconomic areas of Dhaka, Bangladesh, were enrolled at birth. Weight and length were measured at birth and at 1, 3, 6, 9, and 12 mo of age. RESULTS: The infants' mean birth weight was 2516 g, with 46.4% weighing <2500 g; 70% were small for gestational age (SGA) and 17% were premature. Among the SGA infants, 63% had adequate ponderal indexes. The mean weight of the study infants closely tracked the -2 SD curve of the World Health Organization pooled breast-fed sample. Weight differences by birth weight, SGA, or preterm categories were retained throughout infancy. Mean z scores based on the pooled breast-fed sample were -2.38, -1. 72, and -2.34 at birth, 3 mo, and 12 mo. Correlation analysis showed greater plasticity of growth in the first 3 mo of life than later in the first year. CONCLUSIONS: Infant growth rates were similar to those observed among breast-fed infants in developed countries. Most study infants experienced chronic intrauterine undernourishment. Catch-up growth was limited and weight at 12 mo was largely a function of weight at birth. Improvement of birth weight is likely to lead to significant gains in infant nutritional status in this population, although interventions in the first 3 mo are also likely to be beneficial.     

Delivery practices of traditional birth attendants in Dhaka slums, Bangladesh

This paper describes associations among delivery-location, training of birth attendants, birthing practices, and early postpartum morbidity in women in slum areas of Dhaka, Bangladesh. During November 1993-May 1995, data on delivery-location, training of birth attendants, birthing practices, delivery-related complications, and postpartum morbidity were collected through interviews with 1,506 women, 489 home-based birth attendants, and audits in 20 facilities where the women from this study gave birth. Associations among maternal characteristics, birth practices, delivery-location, and early postpartum morbidity were specifically explored. Self-reported postpartum morbidity was associated with maternal characteristics, delivery-related complications, and some birthing practices. Dais with more experience were more likely to use potentially-harmful birthing practices which increased the risk of postpartum morbidity among women with births at home. Postpartum morbidity did not differ by birth-location. Safe motherhood programmes must develop effective strategies to discourage potentially-harmful home-based delivery practices demonstrated to contribute to morbidity.     

Larger infant size at birth reduces the negative association between maternal prepregnancy body mass index and breastfeeding duration

Women who are overweight or obese prepregnancy have shorter durations of producing milk (PM) and feeding breast milk exclusively (FBM-ex) than normal-weight women. We proposed that infant size at birth may reduce the negative associations between prepregnancy BMI and the durations of PM and FBM-ex. We used data from 2798 participants in the Infant Feeding Practices Study II and characterized infant size at birth as weight-for-gestational age (WGA). To assess possible mediation of the associations between maternal BMI and the durations of PM and FBM-ex by infant size at birth, Baron and Kenny's methods, the Sobel test, and bootstrapping were used. As expected, prepregnancy BMI was negatively associated (P < 0.0001) with the durations of PM and FBM-ex; it also was positively associated (P < 0.0001) with infant size at birth. However, infant WGA was positively associated (P < 0.0003) with the durations of PM and FBM-ex after adjustment for BMI. Thus, the negative associations between BMI and the durations of PM and FBM-ex were reduced by infant WGA; i.e. the statistical removal of infant size at birth increased the magnitude of the negative associations between BMI and the durations of PM and FBM-ex. Thus, the tendency of heavier mothers to deliver heavier infants reduces the true magnitude of the association between maternal prepregnancy BMI and shortened breastfeeding duration.     

Organochlorine exposures during pregnancy and infant size at birth

BACKGROUND: Organochlorines, including polychlorinated biphenyls (PCBs) and pesticides, are environmentally persistent contaminants that concentrate in the food chain as well in human adipose tissue and readily cross the placenta. METHODS: To follow up on studies suggesting an association of organochlorine exposure with reduced birth size, we investigated the association of PCBs and organochlorine pesticides (including p,p'-dichlorodiphenyl dichloroethene [p,p'-DDE], the major degradation product of p,p'-dichlorodiphenyl trichloroethane [p,p'-DDT], and hexachlorobenzene [HCB]), with birth weight, crown-heel length, and head circumference. We evaluated a cohort of 722 infants born between 1993 and 1998 to mothers residing near a PCB-contaminated harbor and Superfund site in New Bedford, Massachusetts. RESULTS: Small negative associations were observed for PCBs and birth weight; associations were weaker for birth length and head circumference. There was evidence for effect modification by smoking during pregnancy on the association between PCBs and birth weight. No associations were found with p,p'-DDE or HCB for any measures of birth size. CONCLUSIONS: This study supports the growing literature that demonstrates at most a weak association between very low-level organochlorine exposure and birth size.     

An infant feeding update program at healthcare centers and its impact on breastfeeding and morbidity

This study evaluated the impact of an infant feeding update program on exclusive breastfeeding and the incidence of diarrhea and respiratory illness in infants. A randomized cluster field study was conducted in the city of Porto Alegre, Rio Grande do Sul State, Brazil, with 20 healthcare centers. Health professionals received information on the Ten Steps to Healthy Feeding for Children up to Two Years of Age. We evaluated 619 infants 6-9 months of age. The results showed longer duration of exclusive breastfeeding (p = 0.02) in the intervention group but no significant differences in the incidence of diarrhea or respiratory symptoms. Complementary analyses showed that exclusive breastfeeding was longer in the group of children without the occurrence of diarrhea (p = 0.001) or respiratory symptoms (p = 0.03). The data suggest that the training was insufficient to affect incidence of illness, but that it was effective in extending exclusive breastfeeding.     

Birth weight and the effects of birth spacing and breastfeeding on infant mortality

Analyses previously reported, based on data from the World Fertility Survey (WFS), are replicated here with data from the Malaysian Family Life Survey. Comparison of results, when data limitations inherent in the World Fertility Surveys are reproduced or relaxed, suggests that these limitations cause little distortion, and thus bolsters confidence in the validity of results based on WFS data in which these limitations are inescapable. Generalizations based on the present investigation and on the body of previous work that it tends to validate are presented. Most significantly, these include the greater importance of both breastfeeding and birth spacing under generally unfavorable conditions, the variability of durations to which some benefit of continued breastfeeding persists, and the observation that the great majority of birth-spacing effects operate through some mechanism other than the association of breastfeeding with birth interval lengths.     

Causes of neonatal and maternal deaths in Dhaka slums: Implications for service delivery

Background  

Bangladesh has about 5.7 million people living in urban slums that are characterized by adverse living conditions, poor access to healthcare services and health outcomes. In an attempt to ensure safe maternal, neonatal and child health services in the slums BRAC started a programme, MANOSHI, in 2007. This paper reports the causes of maternal and neonatal deaths in slums and discusses the implications of those deaths for Maternal Neonatal and Child Health service delivery.     

Determinants of childhood mortality in slums of Karachi,Pakistan

Pakistan has an infant mortality rate (IMR) of 90.5/1000 live births, and the country's child mortality level of 117.5 is worse than in other South Asian countries. Rapid population growth combined with rural-to-urban migration has led to the creation of urban slums in which morbidity levels are usually higher than in rural populations. A study was conducted in January 1993 in 6 slums of Karachi where the Aga Khan University has operated primary health care programs since 1985. Researchers recorded the deaths of 347 children under age 5 years old due to diarrhea and acute respiratory infections (ARI) during 1989-93. 235 mothers of these children were interviewed. The following are discussed as risk factors for under-5 child mortality: the use of traditional healers, poor nutritional status, incomplete or no immunization, the quick change of healers, inappropriate child care arrangements, mother's literacy, who decides about outside treatment, short birth interval, bottle feeding, and nuclear family structure. Maternal autonomy, appropriate health-seeking behavior, and child-rearing processes identified in the study point to the need for intervention strategies which go beyond the usual primary health care initiatives and involve communities in developing social support systems for mothers.     

A study on sex ratio at birth in suburban slums of Mumbai

A cross sectional study was conducted in four selected suburban slums of Mumbai to determine the sex ratio at birth and to assess the various factors related to it. Information were collected on the sex of new born babies and other socio demographic characteristics of selected couples, including number of births, history of spontaneous and induced abortions and the preferred sex of siblings. Data were collected from a total of 302 families using a pre-tested interview schedule. There were 698 births of which 351(50.3%) were males and 347 females. The sex ratio at birth was 988 females for 1000 males. There were 84 abortions of which 60(71.4%) were induced and 24 (28.6%) were spontaneous. The reason stated for induced abortions was related to sex of the child in 31(51.7%) of the cases and in 26(83.9%) of these, the abortions were induced to prevent the birth of a female child. There was a preference for male children in the study families. Gender bias and its implications are discussed.     

Determinants of infant feeding practices in a low socio-economic area: identifying environmental barriers to breastfeeding

OBJECTIVE: To identify environmental barriers to breastfeeding. METHOD: Focus groups were conducted with young women, parents-to-be, mothers, fathers and grandmothers in 1996 in northern Adelaide, South Australia (a low socio-economic area). RESULTS: Seven focus groups (4-8 participants per group) were conducted. Breastfeeding was seen as being embarrassing to do in public, and not possible to combine with paid employment. While fathers were not supportive of their partners breastfeeding in public, health professionals were seen as strong advocates of breastfeeding. Bottle feeding was perceived to be more convenient for the mother, more acceptable in public but not as good as breastfeeding for the baby. CONCLUSION: An environmental that enables women to breastfeed is far from being achieved in this low socio-economic area, particularly in relation to breastfeeding in public. IMPLICATIONS: Breastfeeding promotion should have a public health focus, concentrating on creating a supportive breastfeeding environment through a multi strategy approach aimed not just at mothers but also at the community.     

Milk consumption during pregnancy is associated with increased infant size at birth: prospective cohort study

BACKGROUND: Cow milk contains many potentially growth-promoting factors. OBJECTIVE: The objective was to examine whether milk consumption during pregnancy is associated with greater infant size at birth. DESIGN: During 1996-2002, the Danish National Birth Cohort collected data on midpregnancy diet through questionnaires and on covariates through telephone interviews and ascertained birth outcomes through registry linkages. Findings were adjusted for mother's parity, age, height, prepregnant BMI, gestational weight gain, smoking status, and total energy intake; father's height; and family's socioeconomic status The analyses included data from 50,117 mother-infant pairs. RESULTS: Mean (+/-SD) consumption of milk was 3.1 +/- 2.0 glasses/d. Milk consumption was inversely associated with the risk of small-for gestational age (SGA) birth and directly with both large-for-gestational age (LGA) birth and mean birth weight (P for trend < 0.001). In a comparison of women drinking >or=6 glasses/d with those drinking 0 glasses/d, the odds ratio for SGA was 0.51 (95% CI: 0.39, 0.65) and for LGA was 1.59 (1.16, 2.16); the increment in mean birth weight was 108 g (74, 143 g). We also found graded relations (P < 0.001) for abdominal circumference (0.52 cm; 0.35, 0.69 cm), placental weight (26 g; 15, 38 g), birth length (increment: 0.31 cm; 0.15, 0.46 cm), and head circumference (0.13 cm; 0.04, 0.25 cm). Birth weight was related to intake of protein, but not of fat, derived from milk. CONCLUSION: Milk intake in pregnancy was associated with higher birth weight for gestational age, lower risk of SGA, and higher risk of LGA.     

Impact of dropout of female volunteer community health workers: an exploration in Dhaka urban slums

ABSTRACT: BACKGROUND: Volunteer Community Health Workers (CHWs) are a common approach to serving the poor communities in developing countries. BRAC, a large NGO in Bangladesh, is a pioneer in this area, uses female CHWs as core workers in its community-based health programs since 1977. After 25 years of implementing of the CHW model in rural areas, BRAC has begun using female CHWs in urban slums through a community-based maternal health intervention. However, BRAC experiences high dropout rates among CHWs suggesting a need to better understand the impact of their dropout which will help to reduce dropout and increase program sustainability. The main objective of the study is to estimate impact of dropout of volunteer CHWs from both BRAC and community perspectives. Also, it estimates cost of possible strategies to reduce dropout and compares whether they are more or less than the cost borne by BRAC and the community. METHODS: The study uses 'ingredient approach' to estimate the cost of recruiting and training of CHWs and so-called 'friction cost approach' to estimate the cost of replacement of CHWs after adapting. Finally, forgone services in the community due to CHW dropout are estimated applying the concept of friction period. RESULTS: In 2009, average cost per regular CHW was US$ 59.28 which was US$ 60.04 for an ad-hoc CHW if a CHW participated, a three-week basic training, a one-day refresher training, one incentive day and worked for a month in the community after recruitment. One month absence of a CHW with standard average performance in the community means substantial forgone health services like health education, antenatal visits, deliveries, referrals of complicated cases, and distribution of drugs and health commodities. However, with an additional investment of US$ 121 yearly per CHW BRAC can save another US$ 60 invested for ad-hoc CHWs plus forgone services in the community. CONCLUSION: Although CHWs work as volunteers in Dhaka urban slums impact of their dropout is immense both in financial term and forgone services. High cost of dropout makes the program less sustainable. However, simple and financially competitive strategies could improve the sustainability of the program.     

Determinants of breastfeeding in the Philippines: a survival analysis

This study examines modern and traditional factors that may lengthen or shorten the duration of breastfeeding. Specifically, health sector, socio-economic, demographic, and supplementary food variables are analysed among a large representative sample of women in the Philippines. It is proposed that while modernisation can lead to the adoption of western behaviours, traditional cultural values can also prevail, resulting in the rejection of certain aspects of modernity. The Cox Proportional Hazards model is employed for the analysis of breastfeeding. The results show that traditional factors associated with breastfeeding (use of solid foods such as porridge and applesauce, and prenatal care by a traditional nurse/midwife) do not play a significant role in the mother's decision to continue breastfeeding. Factors associated with modernity are significant in explaining early termination of breastfeeding (respondent's education, prenatal care by a medical doctor, delivery in a hospital and use of infant formula). The findings of this study suggest that health institutions and medical professionals can play a significant role in promoting breastfeeding in the Philippines; and educational campaigns that stress the benefits of lactation are important strategies for encouraging mothers to breastfeed longer.     

Determinants of the exclusive breastfeeding abandonment: psychosocial factors

OBJECTIVE

To assess the determinants of exclusive breastfeeding abandonment.

METHODS

Longitudinal study based on a birth cohort in Viçosa, MG, Southeastern Brazil. In 2011/2012, 168 new mothers accessing the public health network were followed. Three interviews, at 30, 60, and 120 days postpartum, with the new mothers were conducted. Exclusive breastfeeding abandonment was analyzed in the first, second, and fourth months after childbirth. The Edinburgh Postnatal Depression Scale was applied to identify depressive symptoms in the first and second meetings, with a score of ≥ 12 considered as the cutoff point. Socioeconomic, demographic, and obstetric variables were investigated, along with emotional conditions and the new mothers’ social network during pregnancy and the postpartum period.

RESULTS

The prevalence of exclusive breastfeeding abandonment at 30, 60, and 120 days postpartum was 53.6% (n = 90), 47.6% (n = 80), and 69.6% (n = 117), respectively, and its incidence in the fourth month compared with the first was 48.7%. Depressive symptoms and traumatic delivery were associated with exclusive breastfeeding abandonment in the second month after childbirth. In the fourth month, the following variables were significant: lower maternal education levels, lack of homeownership, returning to work, not receiving guidance on breastfeeding in the postpartum period, mother’s negative reaction to the news of pregnancy, and not receiving assistance from their partners for infant care.

CONCLUSIONS

Psychosocial and sociodemographic factors were strong predictors of early exclusive breastfeeding abandonment. Therefore, it is necessary to identify and provide early treatment to nursing mothers with depressive symptoms, decreasing the associated morbidity and promoting greater duration of exclusive breastfeeding. Support from health professionals, as well as that received at home and at work, can assist in this process.     

Size at birth, infant, early and later childhood growth and adult body composition: a prospective study in a stunted population

BACKGROUND: Pre-natal and post-natal growth are associated with adult body composition, but the relative importance of growth in different periods of childhood is still unclear, particularly in stunted populations. METHODS: We studied 358 women and 352 men measured as children in 1969-77 in four villages in Guatemala, and re-measured as adults in 2002-04 (mean age 32.7 years). We determined the associations of body mass index (BMI) and length at birth, and changes in BMI and length during infancy (0-1.0 year) and early (1.0-3.0 years) and later (3.0-7.0 years) childhood, with adult BMI ((a)BMI), percentage of body fat ((a)PBF), abdominal circumference ((a)AC) and fat-free mass ((a)FFM). RESULTS: Prevalence of stunting was high (64% at 3 years; HAZ < -2SD). Obesity (WHZ > 2SD) prevalence in childhood was <2%, while overweight prevalence in adulthood was 52%. BMI at birth was positively associated with (a)BMI and (a)FFM while length at birth was positively associated with (a)AC and (a)FFM. Increased BMI in infancy and later childhood were positively associated with all four adult body composition measures; associations in later childhood with fatness and abdominal fatness were stronger than those with (a)FFM. Change in length during infancy and early childhood was positively associated with all four adult body composition outcomes; the associations with (a)FFM were stronger than those with fat mass. CONCLUSIONS: Increases in BMI between 3.0 and 7.0 years had stronger associations with adult fat mass and abdominal fat than with (a)FFM; increases in length prior to age 3.0 years were most strongly associated with increases in (a)FFM.