Relationship of Antenatal Iron-folic Acid (IFA) Supplementation and Birth Size: Evidence from Nepal.

Objectives: To determine the effect of antenatal IFA supplementation on maternal perceived birth size in Nepal using pooled data from 3 Nepal Demographic and Health Survey (DHS) 2001, 2006 and 2011. Methods: We used survival information from 13,111 most recent live-born infants. Primary outcome was maternal perceived birth size and the main exposure variable was the antenatal IFA supplementation. Birth weight was reported in 19% of live births. Perceived birth size was considered as surrogate for birth weight. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Analyses used multivariate logistic regression adjusted for 18 potential confounders. Results: Maternal use of IFA supplementation during pregnancy significantly reduced the risk of less than average birth size by 15% (aOR: 0.85 p=0.01) compared to no IFA use after adjustment for other confounders. The protective effect of IFA supplementation on less than average birth size remained there whether other antenatal services used or not (aOR: 0.81, p=0.001) compared to no IFA supplementation and no antenatal services. A slightly greater magnitude of protective effect was observed when mother used ≥90 supplements in their pregnancy (aOR: 0.84, p=0.03) than those mothers who never used any IFA supplements after adjustment for other confounding factors. Conclusions: Maternal use of IFA supplements during pregnancy significantly reduces the risk of less than average birth size in Nepal. The magnitude of protective effect on the risk of having less than average birth size was greater in infants whose mothers used ≥90 supplements in their pregnancy.

Antenatal Iron-folic Acid Supplementation Reduces Risk of Low Birth Weight in Pakistan.

Objectives: To examine the effect of iron-folic acid (IFA) supplementation on perceived birth size and birth weight using Pakistan Demographic and Health Survey (PDHS) 2006-07. Methods: Information from 5,692 most recent live-born infants within 5 years prior to survey was used. The primary outcomes were maternal perception of birth size and birth weight and the main exposure was any use of antenatal IFA supplements. Birth weight was reported for only 10% of live births in PDHS 2006-07. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Analyses used multivariate logistic regression adjusted for 14 potential confounders. Results: The risk of having less than average birth size babies was significantly reduced by 18% (aOR: 0.82, 95% CI 0.71, 0.96) for mothers who used any IFA supplements compared to no IFA use. A similar (18%), but non-significant reduction in the risk of low birth weight babies was found with maternal use of IFA supplements. Mothers who started IFA in the first trimester of pregnancy, significantly reduced the risk of having less than average birth size babies by 19%. Population attributable risk estimates showed 11% of ‘less than average birth size’ were attributed to non-use of antenatal IFA supplementation and universal coverage of IFA supplementation could prevent 112,000 newborns to have ‘less than average birth size’ each year in Pakistan. Conclusions: Antenatal IFA supplementation significantly reduces the risk of less than average birth size and low birth weight babies in Pakistan. Universal coverage of supplementation improves birth size.

Enhanced Iron-folic Acid (IFA) Supplementation Program Reduces Risk of Under 5 Mortality in Nepal.

Objectives: To investigate the impact of a decade-long program to improve coverage of antenatal IFA supplementation on child survival in Nepal over a 15 year period from 1996 to 2011. Methods: We used pooled data of 3 Nepal Demographic and Health Survey (DHS) 2001, 2006 and 2011 with survival information from 13,106 most recent live-born infants. Primary outcomes were mortality indicators in children <5 years and the main exposure variable was the implementation of an improved IFA supplementation program. The improved program was implemented in 70 out of 75 districts in a phased manner at district level starting in 2003-04 and continuing till 2011. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Analyses used multivariate Cox proportional hazards regression adjusted for 22 potential confounders. Results: After the phased implementation of the program to improve coverage of IFA supplementation, the risk of mortality on day 0 (first day of life) and early neonatal mortality (0-7 days) significantly reduced by 56% and 55% respectively compared to before the implementation of program after the adjustment of other confounders. The protective effect of implementation of improved IFA supplementation program was also observed in infant (aHR: 0.53, p=0.011) and under five mortality (aHR: 0.64, p=0.046) compared to before the program started. Conclusions: An enhanced IFA supplementation program significantly reduces the deaths on first day of life and in early neonatal period in Nepal. The protective effect of the program was also seen in infants and in children <5 years of age.

Antenatal Iron-folic Acid (IFA) Supplementation Reduces Mortality in Children Less than 5 years of Age in Nepal.

Objectives: To examine the effect of antenatal iron-folic acid (IFA) supplements on the risk of childhood mortality in Nepal using pooled data from 3 Nepal Demographic and Health Survey (DHS) 2001, 2006 and 2011. Methods: Survival information was used from 13,009 singleton most recent live-born infants. Primary outcomes were mortality indicators in children <5 years and the main exposure variable was any use of IFA supplements. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Analyses used multivariate Cox proportional hazards regression adjusted for 24 potential confounders based on Mosley and Chen framework for childhood survival in developing countries. Results: Any use of IFA supplements significantly reduced risk of early neonatal deaths by 45% (aHR: 0.55, 95% CI: 0.38, 0.79), and total neonatal deaths by 42% (aHR: 0.58, 95% CI: 0.39, 0.85). Similarly, the risk of infant and under-5 mortality was significantly reduced by 32% and 48%, respectively. For mothers who started ≤4 months of pregnancy and used ≥150 supplements under- 5 mortality was significantly reduced by 57% (aHR: 0.43, 95% CI: 0.23, 0.78). Population attributable risk estimates found 15% of under-5 deaths were attributed to non-use of IFA, and 29,000 under-5 deaths could be prevented in the next 5 years with universal IFA coverage. Conclusions: Antenatal IFA supplementation significantly reduces the risk of neonatal and under- 5 deaths in Nepal. The greatest impact on child survival was found in women who started early in pregnancy and took ≥150 supplements. Universal IFA coverage could improve childhood survival.

Perceptions of Antenatal Iron-folic Acid Supplements in Urban and Rural Pakistan: A Qualitative Study.

Objectives: To understand women and healthcare providers’ perceptions, and to investigate the cultural and behavioural factors influencing the use of antenatal IFA supplements in rural and urban settings of Pakistan. Methods: Focus group discussions and in-depth interviews with mothers, currently pregnant women, community health workers and doctors were conducted in rural and urban areas of two districts of Pakistan. Data was collected between August and November 2012. Results: The majority of women were aware of the perceived benefits of antenatal IFA supplements. The facilitating factors for the women’s use of supplements were: they had knowledge of benefits; they had trust in the healthcare providers; the supplements were available; they had the financial capacity to buy them; they felt better after taking these supplements; and they received support from family members. The barriers to the women’s use of supplements were: they forgot to take them; the non-availability of supplements; their limited financial capacity to buy them; the lack of antenatal care services; family members not allowing use of the supplements; not knowing about the benefits or no education; fear or experience of side effects; considering them as contraceptives; and felt better thus stopped. Conclusions: The coverage of antenatal IFA supplementation can be improved by reducing the barriers related to the use of antenatal IFA supplementation in Pakistan. Interventions focused on providing adequate awareness, good quality counselling, reminder messages, availability of free supplements throughout pregnancy and reducing the side effects should be developed and implemented.

Factors Associated with Non-use of Antenatal Iron and Folic Acid Supplements among Pakistani Women: A Cross Sectional Household Survey.

Objectives: To determine the prevalence of use of antenatal iron-folic acid (IFA) supplements, and to identify socio-demographic risk factors for non-use of antenatal IFA supplements. Methods: A cross sectional household cluster sample survey was conducted in 14 districts in Pakistan. Trained female fieldworkers conducted interviews with married women of reproductive age from December 2011 to March 2012. Women with live births in the preceding five years of the survey were selected for this study. Data was analysed by using STATA 13 and adjusted for the cluster sampling design. Multivariate logistic regression models were constructed to identify the independent factors for non-use of antenatal IFA supplements. Results: Out of 6,266, 2,400 (38.3%, 95% CI: 36.6%, 40.1%) women took antenatal IFA supplements during their last pregnancy. Common sources of supplements were doctors (49.4%) and community health workers (40.3%). The mean (±SD) month of pregnancy at initiation of supplementation was 5.3 (±1.7) months. Living in Dera Ghazi Khan district (Adj OR=1.72), maternal age ≥45 years (Adj OR=2.01), no maternal education (Adj OR=2.33), no paternal education (Adj OR=1.58), belonging to the lowest household wealth index quartile (Adj OR=1.47), and no antenatal care services used (Adj OR=13.44) were risk factors for non-use of antenatal IFA supplements. Conclusions: The coverage of antenatal IFA supplements is low in the surveyed districts of Pakistan, and the lack of parental education, older aged women, belonging to poorest households, residence in Dera Ghazi Khan district and no antenatal care services used were risk factors for non-use of IFA supplements.

Antenatal care procedures and information reported by women in three rural areas of Vietnam.

The objective was to identify factors related to antenatal care (ANC) procedures and information reported by women in Long An, Ben Tre, and Quang Ngai Provinces. Cross-sectional surveys were conducted. Women who had ANC during a previous pregnancy were asked if they had received any of 13 procedures and information. The Donabedian quality of health model was used to select potential related factors. Data from 857 women were available for analyses. Only 24% of the women reported ten items or more. The mean number of items reported was seven. Factors related to reporting fewer items were living in Quang Ngai (OR = 0.3, 95% Cl = 0.2-0.6), having ANC at private facilities (OR = 0.4, 95% Cl = 0.2-0.7), having ANC delivered by nurses or assistant doctors (OR = 0.6, 95% Cl = 0.3-0.9), and unplanned pregnancy (OR = 0.5, 95% Cl = 0.3-0.9). Factors related to reporting more items were being housewives (OR = 1.7, 95% Cl = 1.0-2.8), consumption of iron/folate tablets (OR = 4.2, 95% Cl = 2.2-8.2), more use of ANC services (OR = 2.1, 95% Cl = 1.4-3.2 for sufficient utilization and OR = 3.8, 95% Cl = 2.1-7.0 for sufficient plus), more perceived helpfulness of ANC (OR = 3.0, 95% Cl = 1.9-4.8) and high satisfaction with ANC received (OR = 1.6, 95% Cl = 1.0-2.6). The most effective interventions would be to improve the quality of health facilities and of ANC providers, and to educate women to make sufficient number of ANC visits and to seek ANC from qualified ANC providers.

Prevalence of exclusive breastfeeding in Bangladesh and its association with diarrhoea and acute respiratory infection: results of the multiple indicator cluster survey 2003.

The objective of this study was to investigate the association between the prevalence of exclusive breastfeeding and morbidity (diarrhoeal diseases and acute respiratory infection) in infants aged 0-3 month(s) using the Multiple Indicator Cluster Survey (MICS) 2003 data from Bangladesh. The study population included 1633 infants aged 0-3 month(s). The prevalence of diarrhoea and acute respiratory infection was compared using the chi-square tests between infants aged 0-3 month(s) who were exclusively breastfed and infants who were not exclusively breastfed. Logistic regression was used to adjust for confounders and for calculating adjusted odds ratios. To adjust for cluster sampling and reduced variability, the adjusted chi-square value was divided by the design effect, and a re-estimated p value was calculated. The prevalence of diarrhoea and acute respiratory infection in this sample of 0-3-month old infants in Bangladesh was 14.3% and 31.2% respectively. The prevalence of both illnesses was significantly associated with lack of exclusive breastfeeding. The adjusted odds ratio for diarrhoea was 0.69 (95% confidence interval [CI] 0.49-0.98, p = 0.039), and the adjusted odds ratio for acute respiratory infection was also 0.69 (95% CI 0.54-0.88, p = 0.003). Only 192 infants (11.7% of total sample) were exclusively breastfed at the time of interview, and 823 infants (50.3%) were never exclusively breastfed. The prevalence of prelacteal feeding was 66.6%. The results confirmed a protective effect of exclusive breastfeeding against infectious diseases-related morbidity in infancy and showed that frequently-collected cross-sectional datasets could be used for estimating effects. The low prevalence of exclusive breastfeeding in Bangladesh needs to be improved to decrease child morbidity.

A tool for rapid socioeconomic assessment.

OBJECTIVE: To validate a simple wealth index scale (WIS) based assessment of socioeconomic status and compare it with existing kuppuswamy(KUP) scale. METHODS: Families of 300 children aged 6 to 59 months of acute diarrhoea enrolled in a cross-sectional study were interviewed for socio economic status using both 8 item ownership scale (WIS) and Kuppuswamy (KUP) scale, validated against a reference standard Income Scale (IS). RESULTS: Out of 111 people classified as low based on Income scale (IS), 17% were identified by WIS, and 21% by KUP. In the upper low, 69.4% were identified by WIS and 84.3 % by KUP. Amongst the low middle group the WIS identified 27.6% while KUP identified 10.6% and amongst upper middle patients 30% were identified by WIS and 15 % by KUP. There were none in the upper income of WIS or KUP category. The WIS performed well in all income categories whereas the KUP was better for upper low and low income categories. The agreement between WI and KUP was 55.56%. CONCLUSION: KUP scale is lengthy and difficult to administer by pediatric students and biased towards professional qualifications and education, rather than actual standard of living. It can be replaced by a simple 8 item ownership scale (WI) which is robust for all income groups and also shows good agreement with KUP.

Factors affecting utilization of health care services by mothers of children ill with diarrhea in rural Vietnam.

To examine the use of health services for the treatment of childhood diarrhea in three southern provinces of Vietnam, and identified household, maternal, child and health service characteristics associated with this use, a cross-sectional household survey was conducted between November 1998 and January 1999. Women with a pre-school aged child living at home were the primary respondents for the survey questionnaires. Respondents were asked to recall diarrheal disease events experienced by their child during the two weeks prior to interview, and their responses to these events. Prevalence ratios (PR) were used to identify associations between maternal age, education, occupation, ethnicity, knowledge about diarrhea, feeding practises during diarrhea, household residence and economic status, disease severity, use of oral rehydration solution (ORS), time to nearest health care facility and overall satisfaction with local medical services, and the use of health care services for children ill with diarrhea. The two-week period prevalence of childhood diarrhea was 10% and varied by the province and ethnicity of the child's mother. Forty-three percent of mothers reported using ORS during diarrheal episodes. Seventy percent of mothers sought advice or treatment when their child became ill with diarrhea. After controlling for potential confounders in regression models, maternal ethnicity, maternal high school education (in comparison to no education or incomplete primary education), more severe disease and the use of ORS were factors associated with increased utilization of health care services. There was a low level of the utilization of ORS to treat children with diarrhea, especially by ethnic minority mothers. A high percentage of mothers reported low levels of satisfaction with medical services, especially those from ethnic minorities. Mothers from ethnic minorities and those with lower levels of education were less likely to seek advice or treatment. These findings suggest the need for programs to promote the use of ORS and use of appropriate services for the treatment of childhood diarrheal disease. Interventions are needed to improve the access of ethnic minority children to child health care services for the treatment of diarrhea.