Summary Conceived in 2003 and born in 2005 with the launch of its first report and country profiles, the Countdown to 2015 for Maternal, Newborn, and Child Survival has reached its originally ...proposed lifespan. Major reductions in the deaths of mothers and children have occurred since Countdown's inception, even though most of the 75 priority countries failed to achieve Millennium Development Goals 4 and 5. The coverage of life-saving interventions tracked in Countdown increased steadily over time, but wide inequalities persist between and within countries. Key drivers of coverage such as financing, human resources, commodities, and conducive health policies also showed important, yet insufficient increases. As a multistakeholder initiative of more than 40 academic, international, bilateral, and civil society institutions, Countdown was successful in monitoring progress and raising the visibility of the health of mothers, newborns, and children. Lessons learned from this initiative have direct bearing on monitoring progress during the Sustainable Development Goals era.
Summary Background Countries with high rates of child mortality tend to have shortages of qualified health workers. Little rigorous evidence has been done to assess how much the quality of care ...varies between types of health workers. We compared the performance of different categories of health workers who are trained in Integrated Management of Childhood Illness (IMCI). Methods We analysed data obtained from first-level health facility surveys in Bangladesh (2003), Brazil (2000), Uganda (2002), and Tanzania (2000). We compared the clinical performance of health workers with longer duration of preservice training (those with >4 years of post-secondary education in Brazil or >3 years in the other three countries) and shorter duration (all other health workers providing clinical care). We calculated quality of care with indicators of assessment, classification, and management of sick children according to IMCI guidelines. Every child was examined twice, by the IMCI-trained health worker being assessed and by a gold-standard supervisor. Findings 272 children were included in Bangladesh, 147 in Brazil, 231 in Tanzania, and 612 in Uganda. The proportions of children correctly managed by health workers with longer duration of preservice training in Brazil were 57·8% (n=43) versus 83·7% (n=61) for those with shorter duration of training (p=0·008), and 23·1% (n=47) versus 32·6% (n=134) (p=0·03) in Uganda. In Tanzania, those with longer duration of training did better than did those with shorter duration in integrated assessment of sick children (mean index of integrated assessment 0·94 SD 0·15 vs 0·88 0·13; p=0·004). In Bangladesh, both categories of health worker did much the same in all clinical tasks. We recorded no significant difference in clinical performance in all the other clinical tasks in the four countries. Interpretation IMCI training is associated with much the same quality of child care across different health worker categories, irrespective of the duration and level of preservice training. Strategies for scaling up IMCI and other child-survival interventions might rely on health workers with shorter duration of preservice training being deployed in underserved areas. Funding Bill & Melinda Gates Foundation and the US Agency for International Development.
Summary Background Breastfeeding has clear short-term benefits, but its long-term consequences on human capital are yet to be established. We aimed to assess whether breastfeeding duration was ...associated with intelligence quotient (IQ), years of schooling, and income at the age of 30 years, in a setting where no strong social patterning of breastfeeding exists. Methods A prospective, population-based birth cohort study of neonates was launched in 1982 in Pelotas, Brazil. Information about breastfeeding was recorded in early childhood. At 30 years of age, we studied the IQ (Wechsler Adult Intelligence Scale, 3rd version), educational attainment, and income of the participants. For the analyses, we used multiple linear regression with adjustment for ten confounding variables and the G-formula. Findings From June 4, 2012, to Feb 28, 2013, of the 5914 neonates enrolled, information about IQ and breastfeeding duration was available for 3493 participants. In the crude and adjusted analyses, the durations of total breastfeeding and predominant breastfeeding (breastfeeding as the main form of nutrition with some other foods) were positively associated with IQ, educational attainment, and income. We identified dose-response associations with breastfeeding duration for IQ and educational attainment. In the confounder-adjusted analysis, participants who were breastfed for 12 months or more had higher IQ scores (difference of 3·76 points, 95% CI 2·20–5·33), more years of education (0·91 years, 0·42–1·40), and higher monthly incomes (341·0 Brazilian reals, 93·8–588·3) than did those who were breastfed for less than 1 month. The results of our mediation analysis suggested that IQ was responsible for 72% of the effect on income. Interpretation Breastfeeding is associated with improved performance in intelligence tests 30 years later, and might have an important effect in real life, by increasing educational attainment and income in adulthood. Funding Wellcome Trust, International Development Research Center (Canada), CNPq, FAPERGS, and the Brazilian Ministry of Health.
Summary Background Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how ...inequalities in maternal, newborn, and child health interventions vary by intervention and country. Methods We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality. Findings Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals. Interpretation We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries' poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent. Funding Bill & Melinda Gates Foundation, Norad, The World Bank.
Summary Background UNICEF implemented the Accelerated Child Survival and Development (ACSD) programme in 11 west African countries between 2001 and 2005 to reduce child mortality by at least 25% by ...the end of 2006. We undertook a retrospective evaluation of the programme in Benin, Ghana, and Mali. Methods We used data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys to compare changes in coverage for 14 ACSD interventions, nutritional status (stunting and wasting), and mortality in children younger than 5 years in the ACSD focus districts with those in the remainder of every country (comparison areas), after excluding major metropolitan areas. Findings Mortality in children younger than 5 years decreased in ACSD areas by 13% in Benin (absolute decrease 18 deaths per 1000 livebirths, p=0·12), 20% in Ghana (21 per 1000 livebirths, p=0·10), and 24% in Mali (63 per 1000 livebirths, p<0·0001), but these decreases were not greater than those in comparison areas in Benin (25%; absolute decrease 36 deaths per 1000 livebirths, p=0·15) or Mali (31%; 76 per 1000 livebirths, p=0·30; comparison data not available for Ghana). ACSD districts showed significantly greater increases than did comparison areas in coverage for preventive interventions delivered through outreach and campaign strategies in Ghana and Mali, but not Benin. Coverage in ACSD areas for correct treatment of childhood pneumonia, diarrhoea, and malaria did not differ significantly from before to after programme implementation in Benin and Mali, but decreased significantly in Ghana for malaria (from 78% to 53%, p<0·0001) and diarrhoea (from 39% to 28%, p=0·05). We recorded no significant improvements in nutritional status attributable to ACSD in the three countries. Interpretation The ACSD project did not accelerate child survival in Benin and Mali focus districts relative to comparison areas, probably because coverage for effective treatment interventions for malaria and pneumonia were not accelerated, causes of neonatal deaths and undernutrition were not addressed, and stock shortages of insecticide-treated nets restricted the potential effect of this intervention. Changes in policy and nationwide programme strengthening may have benefited from inputs by UNICEF and other partners, making an acceleration effect in the ACSD focus districts difficult to capture. Funding UNICEF, Canadian International Development Agency, Coordenação de Aperfeiçoamento de Pessoal do Nível Superior (Brazil), and Fulbright Fellowship.
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