Adherence and acceptability of multiple micronutrient supplementation during pregnancy: Study protocol for a cluster-randomized non-inferiority trial in Cambodia.

BACKGROUND: Iron and folic acid (IFA) supplements are currently provided to Cambodian women during pregnancy. However, recent research has found benefits of a multiple micronutrient supplement (MMS) over just IFA alone on several outcomes of perinatal and infant health. The Ministry of Health in Cambodia has proposed a transition from IFA to MMS but to effectively guide this transition requires implementation research on the acceptability and adherence to MMS (over IFA). METHODS: This non-inferiority trial aims to assess the adherence and acceptability of IFA (60 mg elemental iron and 400 µg folic acid) compared to MMS (standard UNIMMAP formulation including 15 micronutrients) during antenatal care in Cambodia. A prospective cohort of 1545 pregnant women will be assigned to one of three trial arms: (1) IFA for 90 days [IFA-90]; (2) MMS for 180 days with two distributions of 90-count tablet bottles [MMS-90]; or (3) MMS for 180 days with one 180-count tablet bottle [MMS-180]. Each arm will enroll 515 women across 48 health centers (clusters) in Kampong Thom Province in Cambodia. The primary outcome is the non-inferiority of adherence rates of MMS-180 compared to IFA-90, as assessed by tablet counts. Mixed-effects logistic and linear regression models will be used to estimate the difference in the adherence rate between the two groups, with an 'a priori' determined non-inferiority margin of 15%. Acceptability of MMS and IFA will be measured using a quantitative survey conducted with enrolled pregnant women at 30-day, 90-day, and 180-day time-points. DISCUSSION: Findings from this study will guide an effective and feasible MMS scale-up strategy for Cambodia. Additionally, the findings will be shared globally with other stakeholders planning to scale up MMS in other countries. TRIAL REGISTRATION: NCT05867836 ( ClinicalTrials.gov , registered May 18, 2023).

Impact of Suaahara, an integrated nutrition programme, on maternal and child nutrition at scale in Nepal.

Suaahara was an innovative, complex, multi-sectoral, large-scale, nutrition programme in Nepal to increase exposure to nutrition-related information and services, improve nutrition-related knowledge and practices among pregnant women and mothers of infants and young children, and improve their nutrition. This study evaluated the effectiveness of Suaahara to improve nutrition and nutrition-related practices by comparing changes over 10 years between intervention and comparison districts. The samples of households at baseline in 2012 and endline in 2022 were 2040 and 2480, respectively, from 120 old wards. The impact was estimated using intent-to-treat regression models in which survey year, arm and their interaction were fixed effects, accounting for district clustering, with the interaction estimating differences between arms in changes over time. The intervention, relative to comparison, reduced maternal underweight by 8.43 percentage points (p < 0.001), consistent with improved maternal and fetal condition that was manifested as the greater length of 0.761 z-scores (p = 0.004) of infants 0-5.9 months. Complementary feeding practices with children between 6 and 23.9 months of age improved more in the intervention than comparison districts: child dietary diversity by 0.294 food groups (p = 0.072) and minimum dietary diversity by 9.51 percentage points (p = 0.028), feeding sick child more (p = 0.002) and administering oral rehydration solution and zinc for diarrhoea (p = 0.057) by about 17 percentage points each, and minimum meal frequency (p = 0.004) and minimum acceptable diet (p = 0.022) by about 15 percentage points each. Substantial impacts were demonstrated despite political restructuring, earthquakes, and other major challenges that Nepal and Suaahara faced and limitations in statistical power because of the reduced number of districts that then could be included in the study. Registered at clinicaltrials.gov with identifier NCT05448287.

Model-driven survival prediction after congenital heart surgery.

OBJECTIVES: The objective of the study was to improve postoperative risk assessment in congenital heart surgery by developing a machine-learning model based on readily available peri- and postoperative parameters. METHODS: Our bicentric retrospective data analysis from January 2014 to December 2019 of established risk parameters for dismal outcome was used to train and test a model to predict postoperative survival within the first 30 days. The Freiburg training data consisted of 780 procedures; the Heidelberg test data comprised 985 procedures. STAT mortality score, age, aortic cross-clamp time and postoperative lactate values over 24 h were considered. RESULTS: Our model showed an area under the curve (AUC) of 94.86%, specificity of 89.48% and sensitivity of 85.00%, resulting in 3 false negatives and 99 false positives.The STAT mortality score and the aortic cross-clamp time each showed a statistically highly significant impact on postoperative mortality. Interestingly, a child's age was barely statistically significant. Postoperative lactate values indicated an increased mortality risk if they were either constantly at a high level or low during the first 8 h postoperatively with an increase afterwards.When considering parameters available before, at the end of and 24 h after surgery, the predictive power of the complete model achieved the highest AUC. This, compared to the already high predictive power alone (AUC 88.9%) of the STAT mortality score, translates to an error reduction of 53.5%. CONCLUSIONS: Our model predicts postoperative survival after congenital heart surgery with great accuracy. Compared with preoperative risk assessments, our postoperative risk assessment reduces prediction error by half. Heightened awareness of high-risk patients should improve preventive measures and thus patient safety.

Outcomes of a food voucher program and factors associated with the recovery rate of children with moderate acute malnutrition in Far North Cameroon.

BACKGROUND: Research on moderate acute malnutrition (MAM) is limited, despite its high prevalence. This study examined outcomes of bi-weekly locally available foods provided via a food voucher program (FVP) on nutritional recovery [mid-upper arm circumference (MUAC) ≥ 125 mm] from MAM (defined as MUAC between 115 and 124 mm) and identified the factors associated with recovery rate in Kaélé health district, Far North Region of Cameroon. METHODS: This was a prospective study with 474 MAM children aged 6-59 months. Food voucher distribution and MUAC screening were conducted at 6 bi-weekly visits or until the child was recovered. Time to recovery was evaluated with multivariate Cox proportional regression hazard models with associations quantified using adjusted hazard ratio (aHR). The trend for MUAC, including its determinants, was examined with multivariate linear mixed effect models. RESULTS: The recovery rate was 78.3% by 6 weeks after the first food basket; 3.4% remained MAM, and 5.9% were transferred for treatment for severe acute malnutrition (SAM defined as MUAC < 115 mm). Boys were 34% more likely to recover from MAM than girls [aHR = 1.34, 95%CI (1.09, 1.67)]. Children aged 24-53 months were 30% more likely to recover than those aged 6-11 months [aHR = 1.30, 95%CI (0.99, 1.70)]. A one unit increase in weight-for-height Z-score (WHZ) was associated with 1.89-fold greater likelihood of recovery [aHR = 1.89, 95%CI (1.66, 2.14)]. Male children had on average 1.82 mm greater increase in MUAC than female children (p < 0.001). One unit increase in WHZ was associated with 3.42 mm increase in MUAC (p = 0.025). Children aged 12-23 and 24-53 months had 1.03 mm and 2.44 mm, respectively, greater increase in MUAC over the program than children aged 6-11 months (all p < 0.01). CONCLUSION: The recovery rate of MAM children treated with the FVP met the Sphere standards for targeted supplementary feeding programs (> 75%). Child's WHZ, gender and age were significant factors associated with MUAC increase and recovery from MAM in the FVP. These findings indicate the FVP approach shows promise as an effective alternative treatment for MAM with consideration of associated factors and merits further evaluation.

Engaging men in maternal, infant and young child nutrition in rural Tanzania: Outcomes from a cluster randomized control trial and qualitative study.

There is growing recognition that engaging men in maternal, infant and young child nutrition (MIYCN) interventions can benefit child health and disrupt harmful gender norms. We conducted a cluster-randomized controlled trial in Tanzania, which engaged men and women in behaviour change via mobile messaging (short message service [SMS]) and traditional interpersonal communication (IPC), separately and in combination. Here, we evaluate intervention effects on individual-level men's MIYCN knowledge and discuss barriers to male engagement. Eligible clusters were dispensary catchment areas with >3000 residents. Forty clusters were stratified by population size and randomly allocated to the four study arms, with 10 clusters per arm. Data on knowledge and intervention exposure were collected from 1394 men through baseline and endline surveys (March-April 2018 and July-September 2019). A process evaluation conducted partway through the 15-18-month intervention period included focus group discussions and interviews. Data were analysed for key trends and themes using Stata and ATLAS.ti software. Male participants in the short message service + interpersonal communication (SMS + IPC) group reported higher exposure to IPC discussions than IPC-only men (43.8% and 21.9%, respectively). Knowledge scores increased significantly across all three intervention groups, with the greatest impact in the SMS + IPC group. Qualitative findings indicated that the main barriers to male participation were a lack of interest in health/nutrition and perceptions that these topics were a woman's responsibility. Other challenges included meeting logistics, prioritizing income-earning activities and insufficient efforts to engage men. The use of a combined approach fusing IPC with SMS is promising, yet countering gender norms and encouraging stronger male engagement may require additional strategies.

Between the city and the farm: food environments in artisanal mining communities in Upper Guinea.

OBJECTIVE: Artisanal and small-scale mining (ASM) is a widespread livelihood in low- and middle-income countries; however, many in ASM communities face high levels of poverty and malnutrition. The food environments in ASM communities have non-agricultural rural characteristics that differ from those in urban and agricultural rural areas examined in much existing food environment literature. DESIGN: We examine these complex external and personal food environments in ASM communities via a study using qualitative and quantitative methods. Market surveys and a cross-sectional household survey, plus qualitative mining site non-participant observations and in-depth structured interviews, were conducted in three waves. SETTING: Eighteen study sites in ASM communities in northern Guinea. PARTICIPANTS: Surveys covered mothers in mining households with young children (n 613); in-depth interviews engaged caregivers of young children (n 45), food vendors (n 40) and young single miners (n 15); observations focused on mothers of young children (n 25). RESULTS: The external food environment in these ASM communities combines widespread availability of commercially processed and staple-heavy foods with lower availability and higher prices for more nutritious, non-staple foods. Within the personal food environment, miners are constrained in their food choices by considerable variability in daily cash income and limited time for acquisition and preparation. CONCLUSIONS: We demonstrate that ASM communities have characteristics of both urban and rural populations and argue for greater nuance and appreciation of complexity in food environment research and resultant policy and programming.

Season of Data Collection of Child Dietary Diversity Indicators May Affect Conclusions About Longer-Term Trends in Peru, Senegal, and Nepal.

BACKGROUND: The WHO-UNICEF minimum dietary diversity (MDD) indicator for children aged 6-23 mo is a global monitoring indicator used to track multi-year population-level changes in dietary quality, but the influence of seasonality on MDD estimates remains unclear. OBJECTIVES: To examine how seasonality of data collection may influence population-level MDD estimates and inferences about MDD changes over multiple survey years. METHODS: We selected countries with 3 or more consecutive years of MDD data collection, including continuous national Demographic Health Surveys in Senegal (2012-2017; n = 12,183) and Peru (2005-2016; n = 35,272) and the Policy and Science for Health, Agriculture, and Nutrition sentinel site seasonal surveys (covering 3 seasons/y) in Nepal (2013-2016; n  = 1309). The MDD prevalence (≥5 of 8 food groups) and an 8-item continuous Food Group Score (FGS) and 95% CIs were estimated by month and compared for lean and non-lean seasons using ordinary least squares regression with dummy variables for year. RESULTS: The national prevalence of MDD was higher in Peru (75.4%) than in Nepal (39.1%) or in Senegal (15.7%). Children in Peru were 1.8% (coefficient, -0.0179; 95% CI, -0.033 to -0.002) less likely to achieve MDD during the lean season. Similar seasonal magnitudes were observed in Senegal (coefficient, -0.0347; 95% CI, -0.058 to -0.011) and Nepal (coefficient, -0.0133; 95% CI, -0.107 to 0.081). The FGS was about 0.1 item lower during the lean season in all 3 countries. In comparison, MDD increased by an average rate of only 4.2 and 4.4 percentage points per 5 y in Peru and Senegal, respectively. Intakes of specific food groups were stable across months in all countries, with the provitamin A-rich food group exhibiting the most seasonality. CONCLUSIONS: The magnitude of seasonal variation in MDD prevalence was smaller than expected but large relative to longer-term changes. If large-scale surveys are not conducted in the same season, biased conclusions about trends are possible.

The Risk Factors for Child Anemia Are Consistent across 3 National Surveys in Nepal.

BACKGROUND: Anemia is an etiologically heterogeneous condition affecting over half of preschool-aged children in South Asia. An urgent need exists to elucidate context-specific causes of anemia to effectively address this issue. OBJECTIVES: This study investigated national trends and stability in the prevalence of child anemia and associated risk factors from 2013 to 2016 in Nepal. METHODS: Same-season national surveys were administered in 2013, 2014, and 2016 in 63 sites across 21 districts, selected using multistage random sampling, representing the mountains, hills, and Tarai (plains). Among consenting households with children aged 6-59 mo, a random sample of capillary blood was selected each year for anemia assessment using an Hb 201+ hemoglobinometer, with n = 835, 807, and 881 children assessed, respectively. Prevalence of child anemia, defined as hemoglobin <11.0 g/dL with adjustment for altitude, was estimated each year and disaggregated by region and child age. Prevalence ratios were estimated using log-binomial regression models with robust SE or robust Poisson regression when models failed to converge. Interaction terms between each risk factor and year were created to test for consistencies in associations over time. RESULTS: The national prevalence of child anemia decreased from 63.3% (95% CI: 59.0%, 67.5%) in 2013 to 51.9% (95% CI: 46.5%, 57.2%) in 2014 and increased to 59.3% (95% CI: 54.7%, 63.8%) in 2016. Across years, prevalence was highest in the Tarai (58.4-70.2%), followed by the mountains (53.0-61.1%) and hills (37.5-51.4%). Nationally and across time, child age and maternal anemia were significantly associated with child anemia. Child diarrhea and stunting, maternal thinness, and poor water and sanitation conditions also showed consistent trends toward higher anemia prevalence. CONCLUSIONS: Anemia affects more than half of Nepalese children aged 6-59 mo. Although prevalence varies year to year, the stability of observed risk factors suggests the need to focus on reducing gastrointestinal infection, promoting adequate household sanitation, and improving maternal and child health.

"If you don't find anything, you can't eat" - Mining livelihoods and income, gender roles, and food choices in northern Guinea.

Artisanal and small-scale mining (ASM) continues to grow as a viable economic activity in sub-Saharan Africa. The health and environmental impacts of the industry, notably linked to the use of potentially toxic chemicals, has been well documented. What has not been explored to the same extent is how pressures associated with ASM affect food choices of individuals and families living in mining camps. This paper presents research conducted in 18 mining sites in northern Guinea exploring food choices and the various factors affecting food decision-making practices. Two of the most influential factors to emerge from this study are income variability and gender roles. Results from this study suggest that through artisanal mining, women have the opportunity to earn a larger income that would otherwise be unavailable through agriculture. However, this benefit of potentially earning a larger income is often reduced or constrained by existing gender roles both at the mines and in the home, such as disparity in pay between men and women and increased pressures on women's time. This limits the potential benefit to household food decision-making that could have been gained from higher income. These results do not seek to establish one livelihood as superior; rather, they demonstrate that even when presented with opportunities to earn higher incomes, women still face many of the same barriers and challenges that they would in other economic activities. Additionally, while work and time demands on women change upon arrival in the mining camps, existing gender roles and expectations do not, further restricting women's decision-making capacity.

A longitudinal impact evaluation of a comprehensive nutrition program for reducing stunting among children aged 6-23 months in rural Malawi.

BACKGROUND: Growth failure in sub-Saharan Africa leads to a high prevalence of child stunting starting in infancy, and is attributed to dietary inadequacy, poor hygiene, and morbidity. OBJECTIVES: To evaluate the impact of a program in Malawi providing a lipid-based nutrient supplement to infants from 6-23 months of age, accompanied by a social and behavior change communication intervention to optimize caregiver feeding and handwashing practices. METHODS: This impact evaluation was a quasi-experimental, longitudinal study with 1 program and 1 comparison district. Infants were enrolled at 6-7 months of age. Anthropometry, child morbidity, and caregiver feeding and handwashing practices were assessed at enrollment and at 6, 12, and 18 month follow-ups (ages 6, 12, 18, and 24 months, respectively). Changes in the length-for-age z-score (LAZ), weight-for-length z-score (WLZ), and midupper arm circumference (MUAC) were compared using mixed-effects models. Program impacts on child stunting (LAZ < -2), wasting (WLZ < -2), morbidity, and feeding and handwashing practices were estimated using difference-in-differences. RESULTS: We enrolled 367 infants across the program (n = 176) and comparison (n = 191) districts. The combined prevalences of stunting and wasting at enrollment were 42.1% and 1.4%, respectively, and did not differ by district. At enrollment, the prevalence of severe stunting (LAZ < -3) was higher in the program (15.5%) versus comparison (7.6%) district (P = 0.02), with corresponding lower LAZ scores (-1.9 vs. -1.7, respectively; P = 0.12). Growth velocities favored program children, such that LAZ, WLZ, and MUAC measurements increased by +0.12/y (P = 0.06), +0.12/y (P = 0.04), and +0.24 cm/y (P < 0.001), respectively, leading to comparable LAZ distributions across districts by 24 months of age. Program exposure was associated with 19.8 percentage point (pp) and 13.8 pp reductions in the prevalences of malaria (P = 0.001) and fever (P = 0.02), respectively, at the 18-month follow-up. Improvements of 20 pp (P < 0.01) in minimum dietary diversity and minimum acceptable diet were seen in the program versus comparison district at 18 months of follow-up. CONCLUSIONS: The program improved child growth patterns, with benefits to health and diet apparent after 18 months of exposure. This trial was registered at clinicaltrials.gov as NCT02985359.

Assessing the challenges to women's access and implementation of text messages for nutrition behaviour change in rural Tanzania.

OBJECTIVE: This process evaluation aimed to understand factors affecting the implementation of a government-sponsored short message service (SMS) programme for delivering nutrition information to rural populations, including message access, acceptability and putting messages into action. DESIGN: The study was nested within a larger randomised controlled trial. Cross-sectional data collection included structured surveys and in-depth interviews. Data were analysed for key trends and themes using Stata and ATLAS.ti software. SETTING: The study took place in Tanzania's Mtwara region. PARTICIPANTS: Surveys were conducted with 205 women and 93 men already enrolled in the randomised controlled trial. A sub-set of 30 women and 14 men participated in the in-depth interviews. RESULTS: Among women relying on a spouse's phone, sharing arrangements impeded regular SMS access; men were commonly away from home, forgot to share SMS or did not share them in women's preferred way. Phone-owning women faced challenges related to charging their phones and defective handsets. Once SMS were delivered, most participants viewed them as trustworthy and comprehensible. However, economic conditions limited the feasibility of applying certain recommendations, such as feeding meat to toddlers. A sub-set of participants concurrently enrolled in an interpersonal counselling (IPC) intervention indicated that the SMS provided reminders of lessons learned during the IPC; yet, the SMS did not help participants contextualise information and overcome the challenges of putting that information into practice. CONCLUSIONS: The challenges to accessing and implementing SMS services highlighted here suggest that such platforms may work well as one component of a comprehensive nutrition intervention, yet not as an isolated effort.

Letter to the Editor of the Journal of Artificial Organs: The flaws in the detail of describing methods, comparing patient cohorts and interpreting results.

We read with great interest the article written by Murphy et al. (J Artif Organs 22:286-293, 2019). We acknowledge the authors contribution. However, the results presented may be difficult to interpret due to several missing information and therefore may not support the conclusions. Therefore, the results of this publication should be viewed very critically.

Impact Evaluation of a Comprehensive Nutrition Program for Reducing Stunting in Children Aged 6-23 Months in Rural Malawi.

BACKGROUND: The prevalence of stunting in central rural Malawi is ∼50%, which prompted a multipronged nutrition program in 1 district from 2014 to 2016. The program distributed a daily, fortified, small-quantity lipid-based nutritional supplement, providing 110 kcal and 2.6 g of protein to children aged 6-23 mo, and behavior change messages around optimal infant and young child feeding (IYCF) and water, sanitation, and hygiene. OBJECTIVES: Our objective was to perform an impact evaluation of the program using a neighboring district as comparison. METHODS: Using a quasi-experimental study design, with cross-sectional baseline (January-March, 2014; n = 2404) and endline (January-March, 2017; n = 2453) surveys, we evaluated the program's impact using a neighboring district as comparison. Impact on stunting was estimated using propensity score weighted difference-in-differences regression analyses to account for baseline differences between districts. RESULTS: No differences in mean length-for-age z-score or prevalence of stunting were found at endline. However, mean weight, weight-for-length z-score, and mid-upper arm circumference were higher at endline by 150 g, 0.22, and 0.19 cm, respectively, in the program compared with the comparison district (all P < 0.05). Weekly reports of high fever and malaria were also lower by 6.4 and 4.7 percentage points, respectively, in the program compared with the comparison district (both P < 0.05). There was no impact on anemia. Children's dietary diversity score improved by 0.17, and caregivers' infant and young child feeding and hand-washing practices improved by 8-11% in the program compared with the comparison district (all P < 0.05). CONCLUSIONS: An impact evaluation of a comprehensive nutrition program in rural Malawi demonstrated benefit for child ponderal growth and health, improved maternal IYCF and hand-washing practices, but a reduction in stunting prevalence was not observed.

Refocusing vitamin A supplementation programmes to reach the most vulnerable.

WHO recommends vitamin A supplementation (VAS) programmes for children 6-59 months where vitamin A deficiency is a public health problem. However, resources for VAS are falling short of current needs and programme coverage is suffering. The authors present the case for considering the options for shifting efforts and resources from a generalised approach, to prioritising resources to reach populations with continued high child mortality rates and high vitamin A deficiency prevalence to maximise child survival benefits . This includes evaluating where child mortality and/or vitamin A deficiency has dropped, as well as using under 5 mortality rates as a proxy for vitamin A deficiency, in the absence of recent data. The analysis supports that fewer countries may now need to prioritise VAS than in the year 2000, but that there are still a large number of countries that do. The authors also outline next steps for analysing options for improved targeting and cost-effectiveness of programmes. Focusing VAS resources to reach the most vulnerable is an efficient use of resources and will continue to promote young child survival.

Preschool Child Nutritional Status in Nepal in 2016: A National Profile and 40-Year Comparative Trend.

BACKGROUND: Preschool child anthropometric status has been assessed nationally in Nepal since 1975, with semi-decadal surveys since 1996, plus several recent, short-interval surveys to track progress toward achieving a World Health Assembly (WHA) goal to reduce stunting to 24% by 2025. OBJECTIVE: We report prevalence of preschool child stunting and wasting from a national survey in 2016 and place findings into the context of national trends and alignment for Nepal to attain its WHA 2025 goal. METHODS: A representative, midyear Policy and Science for Health, Agriculture and Nutrition (PoSHAN) survey was conducted in 2016 on 5479 children <60 months in 4051 households in 21 village development committees. Child weight and height were measured, and sociodemographic factors were assessed. Data from previous surveys (Nepal Demographic Health Surveys, PoSHAN) were also acquired, and rates of stunting (<-2 height-for-age z score) and wasting (<-2 weight-for-height z score) were compared to current World Health Organization standards. Trends were expressed as average annual rates of reduction (AARR). RESULTS: Nationally, in 2016, 34.1% of preschoolers were stunted and 13.7% wasted. Stunting was highest in the Mountains (40.6%) and wasting highest in the Tarai (18.9%). Trend analysis revealed a steady decline (3.8% AARR) in stunting from 2001 to 2013, with virtually no decline from 2013 to 2016. Wasting has been continually high and variable, at ≥8%, since 1975. CONCLUSIONS: Following a steady decline in prevalence, preschool child stunting has plateaued at ∼35% in Nepal, while wasting has changed little over time, offering the opportunity to inform, reassess, and adjust, as needed, efforts to reach WHA 2025 goals.

Food Security in Artisanal Mining Communities: An Exploration of Rural Markets in Northern Guinea.

The number of people engaged in artisanal and small-scale mining (ASM) has grown rapidly in the past twenty years, but they continue to be an understudied population experiencing high rates of malnutrition, poverty, and food insecurity. This paper explores how characteristics of markets that serve ASM populations facilitate and pose challenges to acquiring a nutritious and sustainable diet. The study sites included eight markets across four mining districts in the Kankan Region in the Republic of Guinea. Market descriptions to capture the structure of village markets, as well as twenty in-depth structured interviews with food vendors at mining site markets were conducted. We identified three forms of market organization based on location and distance from mining sites. Markets located close to mining sites offered fewer fruit and vegetable options, as well as a higher ratio of prepared food options as compared with markets located close to village centers. Vendors were highly responsive to customer needs. Food accessibility and utilization, rather than availability, are critical for food security in non-agricultural rural areas such as mining sites. Future market-based nutrition interventions need to consider the diverse market settings serving ASM communities and leverage the high vendor responsiveness to customer needs.

Thinness and fecundability: Time to pregnancy after adolescent marriage in rural Bangladesh.

Undernutrition may affect fecundability, but few studies have quantified this relationship. In rural Bangladesh, where newlywed couples face strong pressures to become pregnant, we assessed fecundability, estimated by time to pregnancy (TTP), and its association with preconceptional thinness among nulligravid, newlywed female adolescents. During 2001-2002, 5,516 newlywed women aged 12-19 years participated in a home-based, 5-weekly surveillance system for 5-6 years to enrol pregnant women into an antenatal vitamin A or ß-carotene supplementation trial. Thinness was defined as a left mid-upper arm circumference (MUAC) ≤21.5 versus >21.5 cm. At each visit, staff obtained a monthly history of menstruation. Report of amenorrhea prompted a human chorionic gonadotropin urine test to confirm pregnancy. We derived hazard ratios (with 95% confidence intervals [CI]) for pregnancy and Kaplan-Meier curves for TTP. Ages of women at marriage and pregnancy detection (mean ± standard deviation) were 15.3 ± 1.9 and 17.0 ± 1.9 years, respectively. A total of 82.7% of thinner and 87.3% of better nourished women became pregnant. The unadjusted and multivariable relative hazard of ever becoming pregnant was 0.84 (95% CI [0.78, 0.89]) and 0.86 (95% CI [0.81, 0.92]), respectively, and TTP was 12 weeks longer (median [95% CI]: 63 [58-68] vs. 51 [49-54]) in women whose MUAC was ≤21.5 versus >21.5 cm. In rural Bangladesh, thin adolescent newlywed girls have a lower probability of becoming pregnant and experience a longer time to pregnancy.

Maternal nutritional status mediates the linkage between household food insecurity and mid-infancy size in rural Bangladesh.

Household food insecurity (HFI) is a major concern in South Asia. The pathways by which HFI may reduce child growth remain inadequately understood. In a cohort study of 12 693 maternal-infant dyads in rural Bangladesh, we examined association and likely explanatory pathways linking HFI, assessed using a validated nine-item perception-based index, to infant size at 6 months. Mothers were assessed early in pregnancy for anthropometric status, dietary diversity and socio-economic status. Infants were assessed for weight, length, and arm, chest and head circumferences and breast and complementary feeding status at birth and 6 months of age. Extent of HFI shared a negative, dose-response association with all measures of infant size at 6 months and odds of wasting and stunting; 57-89 % of variances in the unadjusted models were explained by prenatal factors (maternal nutritional status and dietary diversity), and birth size adjusted for gestational age. Postnatal infant breast and complementary feeding and morbidity exposures explained the remaining fraction of the significant association between HFI and differences in infant arm and chest circumferences and odds of underweight. Contextual (i.e. socio-economic) factors finally brought remaining non-significant fractions of the food insecurity-related mid-infancy growth deficit to practically zero. Improving food security prior to pregnancy and during gestation would likely improve infant growth the most in rural Bangladesh.