Maternal HIV-1 and HIV-2 infection and child survival in The Gambia

OBJECTIVE: To compare the survival of children born to HIV-1 or HIV-2 seropositive mothers with that of children born to HIV-seronegative mothers and to evaluate risk factors for mortality. DESIGN: Physician-blinded prospective study. METHODS: One hundred and one HIV-1-seropositive, 243 HIV-2-seropositive pregnant women, and 468 HIV-seronegative women (control group) matched by age, parity, and health centre, were followed up in a study of mother-to-child transmission of HIV. Mothers and children were seen at 2 and 6 months of age and subsequently followed at 3-monthly intervals up to 18 months of age. HIV infection in children was diagnosed by polymerase chain reaction at 2, 9 or 18 months and by antibody assays at 18 months. RESULTS: Fifteen per cent of children born to HIV-1-infected mothers died compared with 7% of children born to HIV-2-infected mothers [hazard ratio, 2.3; 95% confidence interval (CI), 1.1-4.7; P = 0.02], and 6% of HIV-seronegative mothers (hazard ratio, 2.6; 95% CI, 1.4-5.0; P = 0.003). Six of the 17 children known to be HIV-1 infected died compared with none among the eight HIV-2-infected children (P = 0.13). High proviral load in the babies, high antenatal maternal RNA plasma viral load, and maternal death increased child mortality significantly. CONCLUSIONS: More children born to HIV-1-infected mothers died in comparison with those born to HIV-2-infected mothers or to mothers from the control group. This effect was due to excess death in HIV-1-infected infants which was associated with a high viral load in the affected mother and child.     

Multiple micronutrient supplementation and dietary energy intake in pregnant women

OBJECTIVE: To compare dietary intake of women supplemented with multiple micronutrients (MM) or iron only during pregnancy. MATERIALS AND METHODS: Design: Randomized, double-blind, controlled community-based trial. Setting: One semi-urban community in Central Mexico. Subjects: Pregnant women identified before week 13 of pregnancy, willing to provide informed consent. Interventions: Women were randomly assigned to receive daily supplementation with MM or iron only from recruitment until delivery. Supplements were delivered to the participants' home and compliance observed daily. Dietary intake was assessed by repeat 24-hr recall. Data were analyzed using non-parametric tests and multiple regression analysis to determine the impact of MM supplementation on dietary intake of energy and select micronutrients. RESULTS: During the third trimester, women in the MM group consumed more energy and iron from dietary sources than women in the iron only group. After adjustment for differences between the groups at baseline, women in the MM group consumed 111.3 kcal/day more (p<0.05) energy. The difference in iron intake was not significant after adjusting for the increase in energy intake. CONCLUSIONS: Women consuming MM supplements during pregnancy increased energy intake from dietary sources without a concurrent increase in micronutrient density. Future studies should include measures of appetite and physical activity during pregnancy to determine the implications of additional energy intake for weight gain and retention.     

Effect of micronutrient supplementation on mood in nursing home residents

One third of older people in nursing and/or residential homes have significant symptoms of depression. In younger people, deficiencies in selenium, vitamin C and folate are associated with depression. This study examines the association between micronutrient status and mood before and after supplementation. The objective was to determine whether the administration of selenium, vitamin C and folate improved mood in frail elderly nursing home residents. Mood was assessed using the Hospital Anxiety and Depression rating scale (HAD), and Montgomery-Asberg Depression Rating Scale (MADRS). Micronutrient supplementation was provided for 8 weeks in a double-blinded randomised controlled trial. Significant symptoms of depression (29%) and anxiety (24%) were found at baseline. 67% of patients had low serum concentrations of vitamin C, but no-one was below the reference range for selenium. Depression was significantly associated with selenium levels, but not with folate or vitamin C levels. No individual with a HAD depression score of >or=8, had selenium levels >1.2 microM. In those patients with higher HAD depression scores, there was a significant reduction in the score and a significant increase in serum selenium levels after 8 weeks of micronutrient supplementation. Placebo group scores were unchanged. This small study concluded that depression was associated with low levels of selenium in frail older individuals. Following 8 weeks of micronutrient supplementation, there was a significant increase in selenium levels and improved symptoms of depression occurred in a subgroup.     

Problems and priorities in child survival

This work synthesizes the conclusions and recommendations of the 1985 International Workshop on Child Survival held in Teotihuacan, Mexico. Data are presented which document the extent of the problem of child survival in Latin America and the deficiencies of available data. Malnutrition, diseases preventable through vaccination, diarrheal diseases, acute respiratory infections, perinatal disorders, and shortcomings in quality of care are separately discussed following an assessment of their socioeconomic and cultural determining factors. Recent advances in the preventive component of primary health care programs are discussed. In Latin America, 900 of each 1000 live born babies survive to the 5th year of life compared to 980 in developed countries. Although the mortality rate of children under 5 in Latin America declined from 128 in 1950-55 to 63 in 1980-85, there are wide disparities between countries. Most countries of Latin America were classified as having high or very high infant and child mortality. There are serious differences in child survival between geographic regions and social groups of each country. The mortality decline in Costa Rica, Cuba, and Chile demonstrates that other countries could avoid a large proportion of deaths by ensuring that benefits of current programs have broader coverage. The severe economic crisis in Mexico and other countries threatens the progress already achieved in child survival. The recommendations of the conference are based on the premise that recent efforts to improve survival have been insufficient and a more rational use of the available resources and knowledge is required. In the area of health policy, priority should continue to be given to providing care for mothers and small children. Investments should be reoriented toward extending coverage of primary health care. The proportion of mothers attended during delivery by trained paramedical personnel or physicians should be increased, and family planning programs in rural areas should be strengthened. At least 80% of the target population should be immunized, and the use of oral rehydration therapy should be promoted. Educational programs to promote lactation through the 5th month and introduction of appropriate solids should be reinforced. Programs are needed to control acute respiratory infections by recognizing danger signs and seeking help. Excessive use of obstetrical interventions in urban areas should be curtailed. Quality of primary health care and other services should be assured and community participation in decision making and service delivery encouraged. In the area of research policy, funds for operational research should be included in primary health care budgets. Research by multidisciplinary teams should focus on improvement of service delivery systems and evaluation of quality of care and extent of coverage.     

Maternal cigarette smoking during pregnancy and child aggressive behavior

This study's objective was to examine the association between maternal smoking during pregnancy and childhood aggressive behavior in African-American and Puerto Rican children, as well as the relationship between maternal unconventional behavior, low maternal affection, and offspring aggression. Participants consisted of African-American and Puerto Rican children (N = 203; mean age = 8.6, SD = 0.87) and their mothers living in an inner city community. An interview consisting of a structured questionnaire was administered to the mothers and their children. Scales with adequate psychometric properties were adapted from previous validated measures. They included maternal smoking during pregnancy, maternal education, unconventionality, and warmth. Controlling for demographic factors, maternal unconventional behavior, and low maternal warmth, maternal smoking during pregnancy was associated with having offspring who were aggressive. Maternal unconventionality and warmth were independently related to childhood aggression. Although causal limitations are noted, it may be that a decrease in smoking during pregnancy is associated with a reduction in aggression in the offspring.     

Maternal and child health in Brazil: progress and challenges

In the past three decades, Brazil has undergone rapid changes in major social determinants of health and in the organisation of health services. In this report, we examine how these changes have affected indicators of maternal health, child health, and child nutrition. We use data from vital statistics, population censuses, demographic and health surveys, and published reports. In the past three decades, infant mortality rates have reduced substantially, decreasing by 5·5% a year in the 1980s and 1990s, and by 4·4% a year since 2000 to reach 20 deaths per 1000 livebirths in 2008. Neonatal deaths account for 68% of infant deaths. Stunting prevalence among children younger than 5 years decreased from 37% in 1974-75 to 7% in 2006-07. Regional differences in stunting and child mortality also decreased. Access to most maternal-health and child-health interventions increased sharply to almost universal coverage, and regional and socioeconomic inequalities in access to such interventions were notably reduced. The median duration of breastfeeding increased from 2·5 months in the 1970s to 14 months by 2006-07. Official statistics show stable maternal mortality ratios during the past 10 years, but modelled data indicate a yearly decrease of 4%, a trend which might not have been noticeable in official reports because of improvements in death registration and the increased number of investigations into deaths of women of reproductive age. The reasons behind Brazil's progress include: socioeconomic and demographic changes (economic growth, reduction in income disparities between the poorest and wealthiest populations, urbanisation, improved education of women, and decreased fertility rates), interventions outside the health sector (a conditional cash transfer programme and improvements in water and sanitation), vertical health programmes in the 1980s (promotion of breastfeeding, oral rehydration, and immunisations), creation of a tax-funded national health service in 1988 (coverage of which expanded to reach the poorest areas of the country through the Family Health Program in the mid-1990s); and implementation of many national and state-wide programmes to improve child health and child nutrition and, to a lesser extent, to promote women's health. Nevertheless, substantial challenges remain, including overmedicalisation of childbirth (nearly 50% of babies are delivered by caesarean section), maternal deaths caused by illegal abortions, and a high frequency of preterm deliveries.     

Biological and socioeconomic determinants of child survival

This document describes advances in a conceptual framework under development since 1984 for research on child survival in developing countries. The framework links variables explaining biologically determined disease processes to social determinants in the family and community. The major addition is the extension of previous models of proximate determinants to include fertility-child survival interactions, as well as the interaction between child growth and child survival. The role of health policies within the framework of proximate determinants is also explored. A strategy oriented toward specific diseases will not prove successful in developing countries, where most infant and child deaths are not due to a single cause but rather are the final product of a series of episodes of infection combined with malnutrition. Health policies must therefore identify the risk factors that reduce probabilities of survival as well as the pathologies that actually cause death. Risk factors can be classified as proximate determinants, the basic biological mechanisms that directly influence risks of morbidity and mortality, and underlying determinants, all the other social and environmental determinants that operate indirectly through the proximate determinants to influence infant survival. The 1st step in applying the focus on proximate determinants is to achieve a clear understanding of some measurable biological indicators of health and child survival or of their opposites, illness and death. Abnormal growth has been found to be a sensitive and nonspecific indicator of morbidity in children. Measurement of height and weight could serve as the social science counterpart of mortality measurement for a demographer. Mortality and permanent growth stunting are both indicators reflecting different points of chronic and irreversible physical deterioration on the continuum that ranges from good health to death. The proposed conceptual framework integrates Bongaarts' proximate fertility determinants with the proximate child survival determinants proposed in an earlier work by Mosley and Chen. 9 specific determinants are divided into 4 categories of factors that influence both child survival and fertility: factors regulating exposure to conception (sexual union, coital frequency), lactation, ecological risk (dietary deficiency, environmental contamination, accidents), and direct interventions (personal preventive measures, curative measures, and intentionally inflicted lesions). 5 groups of underlying determinants operate through the proximate determinants: individual factors, family factors, cultural factors, institutional factors, and environmental factors.