Child survival: a narrow objective

While a community's prevailing infant mortality rate is a fairly reliable indicator of overall health status, such data are difficult to obtain on a regular basis. Maternal and neonatal mortality rates may therefore instead be used. It has been observed that deaths which occur during the prenatal or neonatal period are due to factors during pregnancy, child birth, and soon after that, while deaths which occur during the postneonatal period or later are largely due to environmental factors. The levels of infant and early child mortality have likely declined due to a variety of factors, including improvements in health care services, standards of living, and literacy levels, as well as the more broad dissemination of relevant information through the mass media. The major factors which have led to positive changes in the health sector are described. However, while parents today can reasonably believe that their young children will have a better chance of survival than they would have had they been born years before, considerable morbidity remains a concern for both mothers and children. Efforts must be made to ensure child survival as well as the best possible physical and mental development of children. Ensuring maternal health is a priority objective, for a weak mother will give birth to a weak child. To that end, the provision of comprehensive antenatal and postnatal care and other measures are suggested. The rehabilitation of physically and/or mentally handicapped children is also discussed.     

Child bearing and maternal health

The World Health Organization reported in 1985 that 63-80% of direct maternal deaths, and 88-98% of all maternal deaths could probably have been prevented with proper delivery of health care. Key requirements in preventing maternal mortality include appropriate technology, health service delivery, and research on the epidemiology of maternal deaths. Provision of technology may be inexpensive and include measurement of anemia during pregnancy and postpartum, provision of blood plasma at health centers, and appropriate tools in delivery kits for traditional birth attendants. The need is for health service research aimed at improving medical personnel training, equipment, and drugs in terms of availability, accessibility, and acceptability at the local level. The genetic advantage of women is negated by preferential treatment of males in infancy and childhood, differential provision of health services, and the biological effects of frequent childbearing with little effective maternity care and social support. Direct causes of death (hemorrhage, infection, toxemia, and obstructed labor) account for over 50% of all maternal deaths in the developing world. Illegal abortions account for an estimated 100,000-200,000 maternal deaths annually worldwide. In India, 11% of hospital deaths are due to abortions. Ectopic pregnancies may be misdiagnosed; African hospitals during the 1960s showed reports of 8-32 ectopic pregnancy admissions per 1000 deliveries. Indirect maternal causes of mortality include viral hepatitis, anemia, and cardiovascular diseases. Women can control some of the complications of pregnancy by avoiding pregnancy at very young and old ages, decreasing the number of childbirths, spacing births by 2-3 years between pregnancies, and avoiding unwanted pregnancies.     

Child survival and development

India is home to over 382.9 million children, the largest number of any country in the world. This number only shows that the country has made commendable progress in various child survival and development indicators such as infant mortality rate, education, and immunization during the last 50 years. However, according to the 1981 census, 53% of young children (0-6 years) suffered from malnutrition and about 13 million infants were being added to the child population annually. This rate of increase poses a significant problem for national development that requires immediate action. It should be understood that early childhood (0-6 years) is a very critical period for a child's physical and socio-psychological development. In view of this, the government, state and the voluntary sector implemented a large number of programs for children and nursing and expectant mothers to enable children to develop their full potential; however, these efforts were far from satisfactory. Nutritional problems of children of urban slums have increased in magnitude and there is a high prevalence of protein malnutrition among preschoolers. In addition, dietary intake of vitamin A is low among pregnant women belonging to poor communities and low-income groups. With all these problems, a tremendous task awaits the government.     

Congenital cytomegalovirus infection: predisposing maternal factors.

In a prospective study of cytomegalovirus (CMV) infection in pregnancy 69 congenitally infected infants were identified. The age, race, marital status, social class, and parity of the mothers of congenital CMV infants were compared with those of the screened population of women with non-infected infants. These factors were all individually strongly associated with the prevalence of congenital CMV. However, once age, marital status, and race were accounted for, neither social class nor parity had any additional effect. The overall congenital CMV rate was 3 per 1000 livebirths, ranging from 25/1000 for single black women under 20 to 1.6/1000 in married or cohabitating white women over 25.     

Child behavior problems increased by maternal smoking during pregnancy

We investigated the effects of maternal smoking during pregnancy on behavioral problems (i.e., not mediated by low birth weight) in 3-y-old offspring. We assessed behavioral problems in 1377 2- to 3-y-old twin pairs (registered in the Netherlands Twin Register) with the Child Behavior Checklist for ages 2-3 y (CBCL/2-3) from Achenbach, Edelbrock, and Howell. Two to 3 y earlier (i.e., soon after the birth of the twins) we collected information about the smoking habits (i.e., "never," "sometimes," and "regularly") of the mother during pregnancy. We analyzed the effect of maternal smoking on the CBCL total score and on several subscale scores for first- and second-born twins separately, and we adjusted for the possible confounding effects of birth weight, socioeconomic status, maternal age, and type of feeding (i.e., breast or bottle fed). There was a significant effect of maternal smoking on so-called "externalizing" behavioral problems (e.g., oppositional, aggressive, overactive), but not on "internalizing" behavioral problems (e.g., withdrawn, depressed, anxious), in both first- and second-born twins. The enhanced "externalizing" problems were attributed predominantly to increased aggression. Although boys have higher externalizing and aggression scores than girls, the effect of maternal smoking was the same for boys and girls.     

Prenatal and adolescent blood lead levels in South Africa: Child, maternal and household risk factors in the Birth to Twenty cohort

Introduction

The risk factors for lead exposure in developing countries have not been fully described. This study looks at child, maternal and household factors associated with increased risk of lead exposure at birth and at 13 years of age in the Birth to Twenty cohort.

Methods

Mothers were recruited from antenatal clinics in the Johannesburg-Soweto metropolitan area in 1990 (n=3273). Lead levels were analysed in cord blood collected at birth (n=618) and at 13 years (n=1546). Data on selected child, maternal and household factors were collected using a structured questionnaire in the third trimester and at 13 years of age. Statistical analyses were conducted to determine the associated risk factors.

Results

The mean blood lead level at birth was 5.85 μg/dl, and at 13 years of age it was 5.66 μg/dl. The majority of children had blood lead levels above 5 μg/dl (52% at birth and 56% at 13 years). At birth, being a teenage mother and having low educational status were strong predictors for elevated cord blood lead levels. Being a male child, having an elevated cord blood level, and lack of household ownership of a phone were significant risk factors for high blood lead levels at 13 years.

Conclusion

Significant associations found in the study point to the low socio-economic status of lead-affected mothers and children. These poor circumstances frequently persist into later childhood, resulting in continued high lead levels. Thus broader measures of poverty alleviation and provision of better education may help decrease the risk of exposure.     

Child survival: should the strategy be redesigned? Experience from Bangladesh

This paper examines recent studies which focus on the effectivenessof primary health care activities and concludes that in Bangladeshthe potential for substantially improving child survival andgrowth is severely curtailed by unbalanced strategies. Morespecifically the paper argues: (1) that focusing interventionson at-risk children at about 6 months of age is more efficientand less costly in preventing malnutrition than monthly monitoringof growth; (2) that attempts to reduce deaths from diarrhoeawith vertical oral rehydration therapy (ORT) programmes willnot have a major impact unless other interventions are directedto the persistent diarrhoea-malnutrition complex; (3) that theimpact of diarrhoea on growth is transient and community effortsto control diarrhoea are unlikely to show a sustained improvementin children's nutritional status; (4) that the benefits of breast-feedingare still under-valued in view of its vital role in preventingdeaths in poor malnourished children; (5) that given the numerousconstraints on full Expanded Programme on lmmunization (EPI)implementation, tetanus toxoid and measles vaccinations formthe most cost-effective immunization strategy for child survival.     

Polygyny,maternal HIV status and child survival: Rakai,Uganda

The objective of this research was to assess the association of child mortality with polygyny and maternal HIV status through a prospective community-based study in Rakai district, Uganda. We sought to test whether there was an indirect evidence that polygynous households in an HIV prevalent area may divert resources away from the children of HIV-infected mothers in favor of children with better survival prospects. We test this theory using data from a follow-up study which collected detailed behavioral and medical information at 10-month intervals on a cohort of over 4000 pregnant women and their infants (5300 person years of observation). Cox proportional hazards models estimated the mortality hazard (RR) associated with polygyny for children of HIV-negative and HIV-positive mothers. HIV prevalence in the full cohort of mothers was 11.9%, and 23% of mothers lived in polygynous households. Multivariate analysis showed an increased hazard of child mortality if the mother was HIV-positive (RR = 1.75, p<0.001). Maternal education reduced mortality, whereas low birth weight increased mortality risk. Polygyny was associated with an increase in the hazard of child mortality in the full sample (RR = 1.36, p<0.001) and in mothers who were HIV-positive (RR = 2.17, p<0.001), but not in HIV-negative mothers. Being born to an HIV-positive mother increased mortality risk and polygyny accentuated a child's risk of death. Polygyny had no significant effect on the survival of children with HIV-negative mothers. Polygynous households, where not all wives may have HIV, could be diverting resources away from the children of the infected wives.     

The impact of maternal health improvement on perinatal survival: cost-effective alternatives

Each year, an estimated half million women die from complications related to child birth either during pregnancy, delivery or within 42 days afterwards. When pregnant women have complications, their infants are at greater risk of becoming ill, permanently disabled or dying. For every maternal death, there are at least 20 infant deaths: stillbirths, neonatal or postneonatal deaths. Altogether, an estimated 7 million infants each year die perinatally (stillborn or deaths within the first week of life). Low cost, feasible, and effective intervention strategies include: a) improved family planning and abortion services; b) obstetric care at delivery; and, c) prenatal services. Two hypothetical populations of one million (a low mortality and a high mortality country) are used to illustrate maternal and perinatal program strategies and priorities. In countries with high fertility, major reductions in maternal and infant deaths result both from reductions in the number of pregnancies through family planning and from improved obstetric care. Where fertility is already low, reductions result almost entirely from improved obstetric and prenatal care. The investments required are relatively low, while the potential gains are great. The cost to avert each death in a high mortality population is estimated between $800 and $1,500 or as low as $0.50 per capita per year. The priorities for programs targeting maternal and perinatal health depend on demographic, ecologic and economic factors, and should include the promotion of good health, not merely the avoidance of death. More operational research is required on various aspects of maternal and perinatal health; in particular, on the cost-effectiveness of different service components.     

The contribution of prenatal maternal factors to maternal gestational weight gain

Data from 807 mothers in Iran delivering a singleton live infant and their offspring—during the last 2 years up to August 2014—were collected from eight public health care centers and analyzed. Of the women, 46.2% gained weight within the recommended range, 29.4% had inadequate gestational weight gain (GWG), and 24.4% had excessive GWG. Excessive GWG was more common among overweight and obese women, whereas inadequate GWG was prevalent among 50% of under and normal weight women. A significant correlation was found between maternal anthropometric characteristics, folic acid intake during pregnancy, and birth order with GWG. Maternal GWG was positively correlated with neonates' weight and height.     

The association of grandmaternal and maternal factors with maternal adult stature

BACKGROUND: Stature is an important determinant of several reproductive and non-reproductive health problems. Documentation of secular trends in stature has been based primarily on cross-sectional studies of special populations, primarily of men. The objective of this study is to determine how growth and socio-economic status (SES) factors relate to stature changes among lineal female relatives, maternal grandmothers to mothers. METHODS: The study base was derived from a population-based intergenerational cohort which linked several statewide databases to data from the mothers' own birth certificates: the Washington State Intergenerational Cohort. Mothers in these ethnic groups were separately studied: non-Hispanic Whites, African Americans, Native Americans, Hispanics. We generated simple, partial, and multiple correlation coefficients to investigate the association between stature and other growth and SES factors. RESULTS: A mother's stature is determined partly by her own mother's stature and partly by her birthweight. These two measures are individually stronger predictors of stature than are several available SES factors considered in combination-grandmother's age, parity, marital status, and mother's age. The maximal multiple correlation models yielded R2 values from 18% to 28%. CONCLUSIONS: Growth measures are stronger predictors of intergenerational changes in stature than are the several available socio-economic factors. However, socio-economic factors are partly responsible for the level of achieved prenatal and postnatal growth. Since grandmother's stature is a determinant of mother's birthweight, which in turn is a determinant of infant birthweight, some environmentally influenced determinants of some birth outcomes are already established before a prospective mother is conceived or born.     

影响哺乳期产妇母乳喂养适应性的预测因素研究

目的：探讨哺乳期产妇母乳喂养适应性的影响因素。方法采用简单抽样的方法,抽取2014年12月至2015年6月在西安医学院第二附属医院自然分娩后1～6个月的哺乳期产妇181名进行问卷调查,并对数据进行描述性统计、方差分析、相关分析和多元线性分析。结果①哺乳期产妇母乳喂养适应性平均值为3．89±0．45;对家庭收入主观感受平均值为2．87±0．73;婚姻满意度平均值为3．88±0．70;育儿压力平均值为2．83±0．49;②影响母乳喂养适应性的主要因素及出现的顺位依次为育儿压力（β＝－0．28,P＜0．05）、婚姻满意度（β＝0．25,P＜0．05）、目前母乳喂养问题（β＝－0．24,P＜0．05）。结论减轻哺乳期产妇的育儿压力、解决母乳喂养中存在的问题、提高对婚姻的满意程度是提高哺乳期产妇母乳喂养适应性的主要影响因素。     

Parasite and maternal risk factors for malnutrition in preschool-age children in Belen, Peru using the new WHO Child Growth Standards

Child malnutrition, including wasting, underweight and stunting, is associated with infections, poor nutrient intake, and environmental and socio-demographic factors. Preschool-age children are especially vulnerable due to their high growth requirements. To target interventions for preschool-age children in a community of extreme poverty in Peru, we conducted a household survey between October 2005 and January 2006 to determine the prevalence of malnutrition and its risk factors. Of 252 children < 5 years old, the prevalence of wasting, underweight and stunting was 26.6, 28.6 and 32.1 %, respectively, based on the new WHO Child Growth Standards. Risk factors for wasting were: (1) moderate-high intensity Trichuris infection (OR 2.50; 95 % CI 1.06, 5.93); (2) hookworm infection (OR 6.67; 95 % CI 1.08, 41.05); (3) age (OR6-month 1.27; 95 % CI 1.11, 1.46); (4) maternal education (secondary incomplete) (OR 5.77; 95 % CI 2.38, 13.99); and (5) decreasing maternal BMI (OR1 kg/m2 1.12; 95 % CI 1.02, 1.23). Risk factors for underweight were: (1) moderate-high intensity Trichuris infection (OR 4.74; 95 % CI 1.99, 11.32); (2) age (OR6-month 1.22; 95 % CI 1.07, 1.38); (3) maternal education (secondary incomplete) (OR 2.92; 95 % CI 1.40, 6.12); and (4) decreasing maternal BMI (OR1 kg/m2 1.11; 95 % CI 1.02, 1.21). Risk factors for stunting were: (1) age (OR6-month 1.14; 95 % CI 1.02, 1.27) and (2) decreasing maternal height (OR1 cm 1.12; 95 % CI 1.06, 1.20). Overall, risk factors for malnutrition included both child and maternal determinants. Based on these data, locally appropriate and cost-effective dietary, de-worming and educational programmes should be targeted to mothers and preschool-age children.     

Prognostic factors in survival after cancer: epidemiological model

Résumé L'étude de la survie des patients a pour principal objectif l'évaluation de la qualité de leur prise en charge. Lorsque le calcul se base sur les cas hospitalisés (survie clinique), il vise essentiellement à établir les effets de la thérapeutique, en général après prise en compte des caractéristiques diagnostiques de la lésion (stades, etc.). Lorsque la survie est calculée dans le cadre d'une population démographiquement définie (survie épidémiologique), le calcul rend compte de la qualité des soins mais aussi des modalités de recours au système de soins. Or, celles-ci varient en fonction de caractéristiques individuelles et socio-culturelles. Les variables pronostiques les plus intéressantes de la survie épidémiologique peuvent être celles qui délimitent les groupes de cas en fonction du stade de diagnostic et des filières de soins. Dans un registre du cancer, les indicateurs thérapeutiques apparaissent ainsi autant comme des variables à expliquer que comme des variables explicatives. Cette problématique est illustrée par l'exemple du cancer du sein, à Genève. L'analyse repose sur la régression multiple selon Cox.

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Prognostic factors for cancer: the epidemiologic model

Summary Quality of care assessment is one of the principal issues considered when studying the survival of cancer patients. Survival rates based on hospital series («clinical survival») essentially aim at evaluating the impact of therapy, taking into account the stage of the tumor. When, on the other hand, survival rates refer to a demographically defined population («epidemiologic survival») they depend not only on quality of therapy but also on differentials in access to health services which in turn condition partly the stage at time of diagnosis and therapy selection. Since these patterns of access can vary according to socio-cultural characteristics, the epidemiologist is tempted to focus the prognostic analysis of survival on these caracteristics. In a cancer registry setting, clinical indicators (stage of the lesions, type of health care institution and therapy) must not be neglected. Rather, these must be analyzed both as co-factors of survival and as phenomena to be explained in their own right. Issues relating to this topic are discussed using the example of breast cancer in Geneva.

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Variablen, die mit der Letalität der Krebspatienten im Zusammenhang stehen: das epidemiologische Modell

Zusammenfassung Untersuchungen über die Überlebenschance von Krebspatienten haben als erstes Ziel, die Evaluation der Qualität der medizinischen Versorgung. Bezieht sich die Analyse auf hospitalisierte Patienten (klinische Letalität), so richtet sie sich vor allem auf die Beurteilung der Wirksamkeit der Behandlungsmethoden, wobei in der Regel diagnostische Kriterien, wie das Tumorstadium, berücksichtigt werden. Wird die Letalität hingegen auf alle Patienten in einer Bevölkerung bezogen (epidemiologisches Modell), so erfasst die Analyse neben der Wirksamkeit der Behandlungsmethoden auch den Zugang der Bevölkerung zum medizinischen Angebot. Dieses wird durch die soziokulturelle Situation und durch die Einstellung des Einzelnen mitbestimmt. Unter den Variablen aus dem epidemiologischen Modell sind jene am interessantesten, die unter Berücksichtigung der Art der medizinischen Versorgung und des Tumorstadiums, Gruppen unterschiedlicher Prognose abgrenzen. In einem Krebsregister aufgeführte Angaben zur Therapie müssen im epidemiologischen Modell darum oft als abhängige und als unabhängige Variablen einbezogen werden. Diese Problematik wird am Beispiel der Daten des Genfer Registers über die Brustkrebspatientinnen erläutert.

     

Health systems factors influencing maternal health services: a four-country comparison

It is widely understood that maternal health care relies on the entire health system. However, little empirical, country-specific, research has been done to trace out the ways in which health system elements can shape maternal health outcomes. This study seeks to redress this situation, by providing an example of how a health systems approach can benefit the understanding of maternal health services. A comparative analysis was conducted based on extensive case studies of maternal health and health systems in Bangladesh, Russia, South Africa, and Uganda. A number of cross-cutting health system characteristics affecting maternal health were identified by comparing these diverse settings. The most important common systems issues underlying maternal health care were found to be the human resource structures, the public-private mix of service provision, and the changes involved with health sector reforms. Specific country contexts can further determine many factors influencing maternal health outcomes and service performance. Systems issues were found to influence the access to and utilization of services, quality of care provided, and ultimately maternal health outcomes. This paper provides a first step in tracing out how such broad systems issues actually work to influence maternal health.