Publications by authors named "Anthony M Costello"

18 Publications

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Participatory Women's Groups with Cash Transfers Can Increase Dietary Diversity and Micronutrient Adequacy during Pregnancy, whereas Women's Groups with Food Transfers Can Increase Equity in Intrahousehold Energy Allocation.

J Nutr 2018 09;148(9):1472-1483

Institute for Global Health.

Background: There is scarce evidence on the impacts of food transfers, cash transfers, or women's groups on food sharing, dietary intakes, or nutrition during pregnancy, when nutritional needs are elevated.

Objective: This study measured the effects of 3 pregnancy-focused nutrition interventions on intrahousehold food allocation, dietary adequacy, and maternal nutritional status in Nepal.

Methods: Interventions tested in a cluster-randomized controlled trial (ISRCTN 75964374) were "Participatory Learning and Action" (PLA) monthly women's groups, PLA with transfers of 10 kg fortified flour ("Super Cereal"), and PLA plus transfers of 750 Nepalese rupees (∼US$7.5) to pregnant women. Control clusters received usual government services. Primary outcomes were Relative Dietary Energy Adequacy Ratios (RDEARs) between pregnant women and male household heads and pregnant women and their mothers-in-law. Diets were measured by repeated 24-h dietary recalls.

Results: Relative to control, RDEARs between pregnant women and their mothers-in-law were 12% higher in the PLA plus food arm (log-RDEAR coefficient = 0.12; 95% CI: 0.02, 0.21; P = 0.014), but 10% lower in the PLA-only arm between pregnant women and male household heads (-0.11; 95% CI: -0.19, -0.02; P = 0.020). In all interventions, pregnant women's energy intakes did not improve, but odds of pregnant women consuming iron-folate supplements were 2.5-4.6 times higher, odds of pregnant women consuming more animal-source foods than the household head were 1.7-2.4 times higher, and midupper arm circumference was higher relative to control. Dietary diversity was 0.4 food groups higher in the PLA plus cash arm than in the control arm.

Conclusions: All interventions improved maternal diets and nutritional status in pregnancy. PLA women's groups with food transfers increased equity in energy allocation, whereas PLA with cash improved dietary diversity. PLA alone improved diets, but effects were mixed. Scale-up of these interventions in marginalized populations is a policy option, but researchers should find ways to increase adherence to interventions. This trial was registered at www.controlled-trials.com as ISRCTN 75964374.
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http://dx.doi.org/10.1093/jn/nxy109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6118166PMC
September 2018

Status and determinants of intra-household food allocation in rural Nepal.

Eur J Clin Nutr 2018 11 22;72(11):1524-1536. Epub 2018 Jan 22.

Institute for Global Health, University College London, London, UK.

Background/objectives: Understanding of the patterns and predictors of intra-household food allocation could enable nutrition programmes to better target nutritionally vulnerable individuals. This study aims to characterise the status and determinants of intra-household food and nutrient allocation in Nepal.

Subjects/methods: Pregnant women, their mothers-in-law and male household heads from Dhanusha and Mahottari districts in Nepal responded to 24-h dietary recalls, thrice repeated on non-consecutive days (n = 150 households; 1278 individual recalls). Intra-household inequity was measured using ratios between household members in food intakes (food shares); food-energy intake proportions ('food shares-to-energy shares', FS:ES); calorie-requirement proportions ('relative dietary energy adequacy ratios', RDEARs) and mean probability of adequacy for 11 micronutrients (MPA ratios). Hypothesised determinants were collected during the recalls, and their associations with the outcomes were tested using multivariable mixed-effects linear regression models.

Results: Women's diets (pregnant women and mothers-in-law) consisted of larger FS:ES of starchy foods, pulses, fruits and vegetables than male household heads, whereas men had larger FS:ES of animal-source foods. Pregnant women had the lowest MPA (37%) followed by their mothers-in-law (52%), and male household heads (57%). RDEARs between pregnant women and household heads were 31% higher (log-RDEAR coeff=0.27 (95% CI 0.12, 0.42), P < 0.001) when pregnant women earned more or the same as their spouse, and log-MPA ratios between pregnant women and mothers-in-law were positively associated with household-level calorie intakes (coeff=0.43 (0.23, 0.63), P < 0.001, per 1000 kcal).

Conclusions: Pregnant women receive inequitably lower shares of food and nutrients, but this could be improved by increasing pregnant women's cash earnings and household food security.
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http://dx.doi.org/10.1038/s41430-017-0063-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5924867PMC
November 2018

Global application of therapeutic hypothermia to treat perinatal asphyxial encephalopathy.

Int Health 2010 Jun;2(2):79-81

UCL Institute for Women's Health, University College London, 86-96 Chenies Mews, London, WC1E 6HX, United Kingdom.

Therapeutic hypothermia improves neurodevelopmental outcome following perinatal asphyxial encephalopathy and has now become 'standard of care' in industrialised countries. However, none of the cooling trials so far have been conducted in developing countries, where approximately one million asphyxial deaths occur every year. Use of therapeutic hypothermia in such settings raises several clinical, pragmatic and ethical issues. We suggest that rigorous clinical trials of cooling are required to ensure that a safe and effective neuroprotective therapy demonstrated in high resource settings does not become an unsafe and ineffective practice in low resource settings.
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http://dx.doi.org/10.1016/j.inhe.2010.03.003DOI Listing
June 2010

Ethical challenges in cluster randomized controlled trials: experiences from public health interventions in Africa and Asia.

Bull World Health Organ 2009 Oct;87(10):772-9

University College London, Institute of Child Health, London, England.

Public health interventions usually operate at the level of groups rather than individuals, and cluster randomized controlled trials (RCTs) are one means of evaluating their effectiveness. Using examples from six such trials in Bangladesh, India, Malawi and Nepal, we discuss our experience of the ethical issues that arise in their conduct. We set cluster RCTs in the broader context of public health research, highlighting debates about the need to reconcile individual autonomy with the common good and about the ethics of public health research in low-income settings in general. After a brief introduction to cluster RCTs, we discuss particular challenges we have faced. These include the nature of - and responsibility for - group consent, and the need for consent by individuals within groups to intervention and data collection. We discuss the timing of consent in relation to the implementation of public health strategies, and the problem of securing ethical review and approval in a complex domain. Finally, we consider the debate about benefits to control groups and the standard of care that they should receive, and the issue of post-trial adoption of the intervention under test.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2755306PMC
http://dx.doi.org/10.2471/blt.08.051060DOI Listing
October 2009

Estimation of potential effects of improved community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model.

Lancet 2009 Oct 23;374(9699):1441-8. Epub 2009 Sep 23.

Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK.

Background: Maternal mortality in Africa has changed little since 1990. We developed a mathematical model with the aim to assess whether improved community-based access to life-saving drugs, to augment a core programme of health-facility strengthening, could reduce maternal mortality due to post-partum haemorrhage or sepsis.

Methods: We developed a mathematical model by considering the key events leading to maternal death from post-partum haemorrhage or sepsis after delivery. With parameter estimates from published work of occurrence of post-partum haemorrhage and sepsis, case fatality, and the effectiveness of drugs, we used this model to estimate the effect of three potential packages of interventions: 1) health-facility strengthening; 2) health-facility strengthening combined with improved drug provision via antenatal-care appointments and community health workers; and 3) all interventions in package two combined with improved community-based drug provision via female volunteers in villages. The model was applied to Malawi and sub-Saharan Africa.

Findings: In the implementation of the model, the lowest risk deliveries were those in health facilities. With the model we estimated that of 2860 maternal deaths from post-partum haemorrhage or sepsis per year in Malawi, intervention package one could prevent 210 (7%) deaths, package two 720 (25%) deaths, and package three 1020 (36%) deaths. In sub-Saharan Africa, we estimated that of 182 000 of such maternal deaths per year, these three packages could prevent 21 300 (12%), 43 800 (24%), and 59 000 (32%) deaths, respectively. The estimated effect of community-based drug provision was greatest for the poorest women.

Interpretation: Community provision of misoprostol and antibiotics to reduce maternal deaths from post-partum haemorrhage and sepsis could be a highly effective addition to health-facility strengthening in Africa. Investigation of such interventions is urgently needed to establish the risks, benefits, and challenges of widespread implementation.

Funding: Institute of Child Health and Faculty of Mathematical and Physical Sciences, University College London, and a donation from John and Ann-Margaret Walton.
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http://dx.doi.org/10.1016/S0140-6736(09)61566-XDOI Listing
October 2009

The experiences of districts in implementing a national incentive programme to promote safe delivery in Nepal.

BMC Health Serv Res 2009 Jun 9;9:97. Epub 2009 Jun 9.

Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.

Background: Nepal's Safe Delivery Incentive Programme (SDIP) was introduced nationwide in 2005 with the intention of increasing utilisation of professional care at childbirth. It provided cash to women giving birth in a health facility and an incentive to the health provider for each delivery attended, either at home or in the facility. We explored early implementation of the programme at the district-level to understand the factors that have contributed to its low uptake.

Methods: We conducted in ten study districts a series of key informant interviews and focus group discussions with staff from health facilities and the district health office and other stakeholders involved in implementation. Manual content analysis was used to categorise data under emerging themes.

Results: Problems at the central level imposed severe constraints on the ability of district-level actors to implement the programme. These included bureaucratic delays in the disbursement of funds, difficulties in communicating the policy, both to implementers and the wider public and the complexity of the programme's design. However, some district implementers were able to cope with these problems, providing reasons for why uptake of the programme varied considerably between districts. Actions appeared to be influenced by the pressure to meet local needs, as well individual perceptions and acceptance of the programme. The experience also sheds light on some of the adverse effects of the programme on the wider health system.

Conclusion: The success of conditional cash transfer programmes in Latin America has led to a wave of enthusiasm for their adoption in other parts of the world. However, context matters and proponents of similar programmes in south Asia should give due attention to the challenges to implementation when capacity is weak and health services inadequate.
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http://dx.doi.org/10.1186/1472-6963-9-97DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700798PMC
June 2009

Effects of antenatal multiple micronutrient supplementation on children's weight and size at 2 years of age in Nepal: follow-up of a double-blind randomised controlled trial.

Lancet 2008 Feb;371(9611):492-9

Mother and Infant Research Activities (MIRA), Kathmandu, Nepal.

Background: The negative effects of low birthweight on the later health of children in developing countries have been well studied. However, undertaking programmes to address this issue can be difficult since there is no simple correlation between increasing birthweight and improving child health. In 2005, we published results of a randomised controlled trial in Nepal, in which 1200 women received either iron and folic acid or a supplement that provided the recommended daily allowance of 15 vitamins and minerals, over the second and third trimesters of pregnancy. Here, we report on 2-3 years' follow-up of children born during the trial.

Methods: We visited children at home and obtained data for the primary outcomes of weight and height, for childhood illnesses, and maternal blood haemoglobin. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN88625934.

Findings: Between December, 2005, and December, 2006, we assessed 917 children (455 controls, 462 intervention) at a mean age of 2.5 years. Mean birthweight had been 77 g (95% CI 24-130) greater in the micronutrient group than in controls. At 2.5 years old, controls weighed a mean of 10.7 kg (SD 1.38), and those in the intervention group 10.9 kg (SD 1.54). Children of women who had taken multiple micronutrient supplements during pregnancy were a mean 204 g (95% CI 27-381) heavier than controls. They also had greater measurements than controls in the circumference of the head (2.4 mm [95% CI 0.6-4.3]), chest (3.2 mm [0.4-6.0]), and mid-upper arm (2.4 mm [1.1-3.7]), and in triceps skinfold thickness (2.0 mm [0.0-0.4]). Systolic blood pressure was slightly lower in the intervention group (2.5 mm Hg [0.5-4.6]).

Interpretation: In a poor population, the effects of maternal multiple micronutrient supplementation on the fetus persisted into childhood, with increases in both weight and body size. These increases were small, however, since those exposed to micronutrients had an average of 2% higher weight than controls. The public-health implications of changes in weight and blood pressure need to be clarified through further follow-up.
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http://dx.doi.org/10.1016/S0140-6736(08)60172-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2241662PMC
February 2008

Problems of developing molecular diagnostic tests for opportunistic pathogens: the example of Pneumocystis jirovecii.

J Eukaryot Microbiol 2006 ;53 Suppl 1:S85-6

Centre for Infectious Diseases & International Health, University College London, London, United Kingdom.

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http://dx.doi.org/10.1111/j.1550-7408.2006.00182.xDOI Listing
October 2007

Effect of multiple micronutrient supplementation during pregnancy on inflammatory markers in Nepalese women.

Am J Clin Nutr 2006 Nov;84(5):1086-92

Institute of Child Health, London, United Kingdom.

Background: Multiple micronutrient supplementation of Nepalese women during pregnancy is associated with a significant increase in birth weight.

Objective: We tested the hypothesis that improved birth weight in infants of mothers supplemented with micronutrients is associated with a decrease in inflammatory responses and an increase in the production of T helper 1 cells and T helper 2 cells.

Design: The study was embedded in a randomized controlled trial of 15 micronutrients, compared with iron-folate supplementation (control), given during pregnancy with the aim of increasing birth weight. Blood samples were collected at 32 wk of gestation, 12-20 wk after supplementation began, for the measurement of inflammatory markers. Breast-milk samples were collected 1 mo after delivery for the measurement of the ratio of milk sodium to potassium (milk Na:K). In an opportunistically selected subgroup of 70 women, mitogen-stimulated cytokine production was measured ex vivo in whole blood.

Results: Blood eosinophils; plasma concentrations of the acute phase reactants C-reactive protein, alpha(1)-acid glycoprotein (AGP), neopterin, and ferritin; milk Na:K; and the production of interleukin (IL) 10, IL-4, interferon gamma, and tumor necrosis factor alpha in whole blood did not differ significantly between the supplemented and control groups. Plasma C-reactive protein and AGP were higher in women who had a preterm delivery, and AGP was higher in women who delivered a low-birth-weight term infant than in women who delivered a normal-birth-weight term infant.

Conclusions: The results indicate an association between systemic inflammation in late pregnancy and compromised delivery outcome in Nepalese women but do not support the hypothesis that multiple micronutrient supplementation changes cytokine production or inflammatory markers.
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http://dx.doi.org/10.1093/ajcn/84.5.1086DOI Listing
November 2006

Women's groups' perceptions of maternal health issues in rural Malawi.

Lancet 2006 Sep;368(9542):1180-8

Centre for International Health and Development, Institute of Child Health, University College London, UK.

Background: Improvements in preventive and care-seeking behaviours to reduce maternal mortality in rural Africa depend on the knowledge and attitudes of women and communities. Surveys have indicated a poor awareness of maternal health problems by individual women. We report the perceptions of women's groups to such issues in the rural Mchinji district of Malawi.

Methods: Participatory women's groups in the Mchinji district identified maternal health problems (172 groups, 3171 women) and prioritised problems they considered most important (171 groups, 2833 women). In-depth qualitative data was obtained through six focus-group discussions with the women's groups, three with women's group facilitators, and four interviews with facilitator supervisors.

Findings: The maternal health problems most commonly identified by more than half the groups were anaemia (87%), malaria (80%), retained placenta (77%), obstructed labour (76%), malpresentation (71%), antepartum and postpartum haemorrhage (70% each), and pre-eclampsia (56%). The five problems prioritised as most important were anaemia (sum of rank score 304), malpresentation (295), retained placenta (277), obstructed labour (276). and postpartum haemorrhage (275). HIV/AIDS and sepsis were identified or prioritised much less because complexity and contextual factors hindered their consideration.

Interpretation: Rural Malawian women meeting in participatory groups showed a developed awareness of maternal health problems and the concern and motivation to address them. Community mobilisation strategies, such as women's groups, might be effective at reducing maternal mortality because they can draw on the collective capacity in communities to solve problems and make women's voices heard by decision-makers.
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http://dx.doi.org/10.1016/S0140-6736(06)69475-0DOI Listing
September 2006

Behaviour change in perinatal care practices among rural women exposed to a women's group intervention in Nepal [ISRCTN31137309].

BMC Pregnancy Childbirth 2006 Jun 15;6:20. Epub 2006 Jun 15.

Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College London, 30 Guilford Street London WC1N 1EH, UK.

Background: A randomised controlled trial of participatory women's groups in rural Nepal previously showed reductions in maternal and newborn mortality. In addition to the outcome data we also collected previously unreported information from the subgroup of women who had been pregnant prior to study commencement and conceived during the trial period. To determine the mechanisms via which the intervention worked we here examine the changes in perinatal care of these women. In particular we use the information to study factors affecting positive behaviour change in pregnancy, childbirth and newborn care.

Methods: Women's groups focusing on perinatal care were introduced into 12 of 24 study clusters(average cluster population 7000). A total of 5400 women of reproductive age enrolled in the trial had previously been pregnant and conceived during the trial period. For each of four outcomes (attendance at antenatal care; use of a boiled blade to cut the cord; appropriate dressing of the cord; not discarding colostrum) each of these women was classified as BETTER, GOOD, BAD or WORSE to describe whether and how she changed her pre-trial practice. Multilevel multinomial models were used to identify women most responsive to intervention.

Results: Among those not initially following good practice, women in intervention areas were significantly more likely to do so later for all four outcomes (OR 1.92 to 3.13). Within intervention clusters, women who attended groups were more likely to show a positive change than non-group members with regard to antenatal care utilisation and not discarding colostrum, but non-group members also benefited.

Conclusion: Women's groups promoted significant behaviour change for perinatal care amongst women not previously following good practice. Positive changes attributable to intervention were not restricted to specific demographic subgroups.
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http://dx.doi.org/10.1186/1471-2393-6-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513253PMC
June 2006

Economic assessment of a women's group intervention to improve birth outcomes in rural Nepal.

Lancet 2005 Nov;366(9500):1882-4

Infectious Disease and Epidemiology Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.

We did a cost-effectiveness analysis alongside a cluster-randomised controlled trial of a participatory intervention with women's groups to improve birth outcomes in rural Nepal. The average provider cost of the women's group intervention was US0.75 dollars per person per year (0.90 dollars with health-service strengthening) in a population of 86,704. The incremental cost per life-year saved (LYS) was 211 dollars (251 dollars), and expansion could rationalise on start-up costs and technical assistance, reducing the cost per LYS to 138 dollars (179 dollars). Sensitivity analysis showed a variation from 83 dollars to 263 dollars per LYS for most variables. This intervention could provide a cost-effective way of reducing neonatal deaths.
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http://dx.doi.org/10.1016/S0140-6736(05)67758-6DOI Listing
November 2005

Effects of antenatal multiple micronutrient supplementation on birthweight and gestational duration in Nepal: double-blind, randomised controlled trial.

Lancet 2005 Mar 12-18;365(9463):955-62

International Perinatal Care Unit, Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK.

Background: Neonatal mortality is the biggest contributor to global mortality of children younger than 5 years, and low birthweight is a crucial underlying factor. We tested the hypotheses that antenatal multiple micronutrient supplementation would increase infant birthweight and gestational duration.

Methods: We did a double-blind, randomised controlled trial in Dhanusha district, Nepal. Women attending for antenatal care with singleton pregnancies at up to 20 weeks' gestation were invited to participate. Participants were randomly allocated either routine iron and folic acid supplements (control; n=600) or a multiple micronutrient supplement providing a recommended daily allowance of 15 vitamins and minerals (intervention; n=600). Supplementation began at a minimum of 12 weeks' gestation and continued until delivery. Primary outcome measures were birthweight and gestational duration. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN88625934.

Findings: Birthweight was available for 523/600 infants in the control group and 529/600 in the intervention group. Mean birthweight was 2733 g (SD 422) in the control group and 2810 g (453) in the intervention group, representing a mean difference of 77 g (95% CI 24-130; p=0.004) and a relative fall in the proportion of low birthweight by 25%. No difference was recorded in the duration of gestation (0.2 weeks [-0.1 to 0.4]; p=0.12), infant length (0.3 cm [-0.1 to 0.6]; p=0.16), or head circumference (0.2 cm [-0.1 to 0.4]; p=0.18).

Interpretation: In a poor community in Nepal, consumption of a daily supplement containing a recommended daily allowance of 15 micronutrients in the second and third trimesters of pregnancy was associated with increased birthweight when compared with a standard iron and folic acid preparation. The effects on perinatal morbidity and mortality need further comparisons between studies. Published online March 3, 2005 http://image.thelancet.com/extras/04art11045web.pdf.
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http://dx.doi.org/10.1016/S0140-6736(05)71084-9DOI Listing
April 2005

Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial.

Lancet 2004 Sep 11-17;364(9438):970-9

Mother and Infant Research Activities (MIRA), PO Box 921, Kathmandu, Nepal.

Background: Neonatal deaths in developing countries make the largest contribution to global mortality in children younger than 5 years. 90% of deliveries in the poorest quintile of households happen at home. We postulated that a community-based participatory intervention could significantly reduce neonatal mortality rates.

Methods: We pair-matched 42 geopolitical clusters in Makwanpur district, Nepal, selected 12 pairs randomly, and randomly assigned one of each pair to intervention or control. In each intervention cluster (average population 7000), a female facilitator convened nine women's group meetings every month. The facilitator supported groups through an action-learning cycle in which they identified local perinatal problems and formulated strategies to address them. We monitored birth outcomes in a cohort of 28?931 women, of whom 8% joined the groups. The primary outcome was neonatal mortality rate. Other outcomes included stillbirths and maternal deaths, uptake of antenatal and delivery services, home care practices, infant morbidity, and health-care seeking. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN31137309.

Findings: From 2001 to 2003, the neonatal mortality rate was 26.2 per 1000 (76 deaths per 2899 livebirths) in intervention clusters compared with 36.9 per 1000 (119 deaths per 3226 livebirths) in controls (adjusted odds ratio 0.70 [95% CI 0.53-0.94]). Stillbirth rates were similar in both groups. The maternal mortality ratio was 69 per 100000 (two deaths per 2899 livebirths) in intervention clusters compared with 341 per 100000 (11 deaths per 3226 livebirths) in control clusters (0.22 [0.05-0.90]). Women in intervention clusters were more likely to have antenatal care, institutional delivery, trained birth attendance, and hygienic care than were controls.

Interpretation: Birth outcomes in a poor rural population improved greatly through a low cost, potentially sustainable and scalable, participatory intervention with women's groups.
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http://dx.doi.org/10.1016/S0140-6736(04)17021-9DOI Listing
September 2004

Care for perinatal illness in rural Nepal: a descriptive study with cross-sectional and qualitative components.

BMC Int Health Hum Rights 2003 Aug 21;3(1). Epub 2003 Aug 21.

International Perinatal Care Unit, Institute of Child Health, University College, London, UK.

BACKGROUND: Maternal, perinatal and neonatal mortality rates remain high in rural areas of developing countries. Most deliveries take place at home and care-seeking behaviour is often delayed. We report on a combined quantitative and qualitative study of care seeking obstacles and practices relating to perinatal illness in rural Makwanpur district, Nepal, with particular emphasis on consultation strategies. METHODS: The analysis included a survey of 8798 women who reported a birth in the previous two years [of whom 3557 reported illness in their pregnancy], on 30 case studies of perinatal morbidity and mortality, and on 43 focus group discussions with mothers, other family members and health workers. RESULTS: Early pregnancy was often concealed, preparation for birth was minimal and trained attendance at birth was uncommon. Family members were favoured attendants, particularly mothers-in-law. The most common recalled maternal complications were prolonged labour, postpartum haemorrhage and retained placenta. Neonatal death, though less definable, was often associated with cessation of suckling and shortness of breath. Many home-based care practices for maternal and neonatal illness were described. Self-medication was common.There were delays in recognising and acting on danger signs, and in seeking care beyond the household, in which the cultural requirement for maternal seclusion, and the perceived expense of care, played a part. Of the 760 women who sought care at a government facility, 70% took more than 12 hours from the decision to seek help to actual consultation. Consultation was primarily with traditional healers, who were key actors in the ascription of causation. Use of the government primary health care system was limited: the most common source of allopathic care was the district hospital. CONCLUSIONS: Major obstacles to seeking care were: a limited capacity to recognise danger signs; the need to watch and wait; and an overwhelming preference to treat illness within the community. Safer motherhood and newborn care programmes in rural communities, must address both community and health facility care to have an impact on morbidity and mortality. The roles of community actors such as mothers-in-law, husbands, local healers and pharmacies, and increased access to properly trained birth attendants need to be addressed if delays in reaching health facilities are to be shortened.
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http://dx.doi.org/10.1186/1472-698X-3-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC194728PMC
August 2003

Implementing a community-based participatory intervention to improve essential newborn care in rural Nepal.

Trans R Soc Trop Med Hyg 2003 Jan-Feb;97(1):18-21

Centre for International Child Health, Institute of Child Health, London, WC1N 1EH, UK.

The persistence of high perinatal and neonatal mortality rates in many developing countries make efforts to improve perinatal care in the home and at local health facilities important public health concerns. We describe a study which aims to evaluate a community-level participatory intervention in rural Nepal. The effectiveness of community-based action research interventions with mothers and other key members of the community in improving perinatal health outcomes is being examined using a cluster randomized, controlled trial covering a population of 28,000 married women of reproductive age. The unit of randomization was the village development committee (VDC): 12 VDCs receive the intervention while 12 serve as controls. The key elements of the intervention are the activities of female facilitators, each of whom works in one VDC facilitating the activities of women's groups in addressing problems in pregnancy, childbirth and the newborn period. Each group moves through a participatory planning cycle of assessment, sharing experiences, planning, action and reassessment, with the aim of improving essential maternal and newborn care. Outcomes assessed are neonatal and perinatal mortality rates, changes in patterns of home care, health care seeking and referral. The study also aims to generate programmatic information on the process of implementation in communities.
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http://dx.doi.org/10.1016/s0035-9203(03)90008-3DOI Listing
September 2003

Micronutrient status during pregnancy and outcomes for newborn infants in developing countries.

J Nutr 2003 05;133(5 Suppl 2):1757S-1764S

International Perinatal Care Unit, Institute of Child Health, University College London, London WC1N 1EH.

More than 9 million neonatal deaths occur each year, 98% of them in developing countries. Neonatal deaths account for two-thirds of deaths in infancy and 40% of deaths before age 5 y. The major direct causes of neonatal death are infections, preterm delivery and asphyxia. Important indirect causes include low birth weight and hypothermia. The present body of work on multiple micronutrient interventions is not sufficient for us to draw conclusions on their effects on neonatal well-being. Because studies have generally concentrated on single micronutrients and a range of outcomes, this paper reviews the findings for individual nutrients and then summarizes the situation. The evidence for the contribution of micronutrient deficiencies to perinatal mortality and duration of gestation is limited, and the evidence base for individual micronutrient effects on neonatal mortality and morbidity is patchy. To translate knowledge into policy, community evaluations of effect and an expanded evidence base that includes affordability, acceptability and scalability are also required. A balance between supply-side and demand-side interventions must be struck, with an emphasis on effect and sustainability. Among the key requirements are randomized, controlled community effectiveness trials of the effect of micronutrient supplementation in pregnancy on perinatal mortality and neurodevelopment, studies on improving adherence and studies on the relation between micronutrient deficiencies and sepsis and neonatal encephalopathy. It would also be helpful to look at mechanisms for bringing the periconceptional period within the ambit of trials.
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http://dx.doi.org/10.1093/jn/133.5.1757SDOI Listing
May 2003

Cross sectional, community based study of care of newborn infants in Nepal.

BMJ 2002 Nov;325(7372):1063

International Perinatal Care Unit, Institute of Child Health, University College London, London WC1N 1EH.

Objective: To determine home based newborn care practices in rural Nepal in order to inform strategies to improve neonatal outcome.

Design: Cross sectional, retrospective study using structured interviews.

Setting: Makwanpur district, Nepal.

Participants: 5411 married women aged 15 to 49 years who had given birth to a live baby in the past year.

Main Outcomes Measures: Attendance at delivery, hygiene, thermal care, and early feeding practices.

Results: 4893 (90%) women gave birth at home. Attendance at delivery by skilled government health workers was low (334, 6%), as was attendance by traditional birth attendants (267, 5%). Only 461 (8%) women had used a clean home delivery kit, and about half of attendants had washed their hands. Only 3482 (64%) newborn infants had been wrapped within half an hour of birth, and 4992 (92%) had been bathed within the first hour. 99% (5362) of babies were breast fed, 91% (4939) within six hours of birth. Practices with respect to colostrum and prelacteals were not a cause for anxiety.

Conclusions: Health promotion interventions most likely to improve newborn health in this setting include increasing attendance at delivery by skilled service providers, improving information for families about basic perinatal care, promotion of clean delivery practices, early cord cutting and wrapping of the baby, and avoidance of early bathing.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC131178PMC
http://dx.doi.org/10.1136/bmj.325.7372.1063DOI Listing
November 2002