Gary L. Darmstadt, MD, MS, is Associate Dean for Maternal and Child Health, and Professor of Neonatal and Developmental Medicine in the Department of Pediatrics at the Stanford University School of Medicine. He recently led the Steering Committee for The Lancet Series on Gender Equality, Norms and Health. Previously Dr. Darmstadt was Senior Fellow in the Global Development Program at the Bill & Melinda Gates Foundation (BMGF), where he catalyzed gender equality programs including establishment of Grand Challenges on Putting Women and Girls at the Center of Development. Prior to this role, he served as BMGF Director of Family Health, leading strategy development and implementation across nutrition, family planning and maternal, newborn and child health.

Darmstadt was formerly Associate Professor and Founding Director of the International Center for Advancing Neonatal Health in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. He has trained in Pediatrics at Johns Hopkins University, in Dermatology at Stanford University, and in Pediatric Infectious Disease as a fellow at the University of Washington, Seattle, where he also was Assistant Professor in the Departments of Pediatrics and Medicine.

Administrative Appointments

  • Affiliated Faculty Member, Stanford Woods Institute for the Environment (2015 - Present)
  • Associate Dean for Maternal and Child Health, Stanford University School of Medicine (2015 - Present)
  • Co-Director of Global Pediatric Research, Department of Pediatrics, Stanford University School of Medicine (2015 - Present)
  • Faculty Affiliate, King Center on Global Development (2015 - Present)
  • Faculty Affiliate, Stanford Center for China's Economy and Institutions (2015 - Present)
  • Faculty Affiliate, Stanford Program on Water, Health, & Development (2015 - Present)
  • Faculty Director, Global Center for Gender Equality (2015 - Present)
  • Faculty Fellow, Center for Innovation in Global Health (CIGH) at Stanford University School of Medicine (2015 - Present)
  • Member, Stanford Medicine Teaching and Mentoring Academy, Stanford University (2015 - Present)
  • Member, Center for Population Health Sciences (2015 - Present)
  • Senior Fellow, Freeman Spogli Institute for International Studies (2015 - Present)
  • Senior Fellow, Global Development Division, Bill & Melinda Gates Foundation, Seattle, WA (2013 - 2014)
  • Director, Family Health Programs, Global Development Division, Bill & Melinda Gates Foundation, Seattle, WA (2010 - 2013)
  • Interim Deputy Director, Strategic Project Team Lead, Maternal, MNCH, IHSD, Global Health Program, Bill and Melinda Gates Foundation, Seattle, WA (2008 - 2010)
  • Senior Program Officer, Newborn Health, MNCH Team Member, IHSD, Global Health Program, Bill and Melinda Gates Foundation, Seattle, WA (2008 - 2008)
  • Associate Professor, Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University (2005 - 2008)
  • Founding Director, International Center for Advancing Neonatal Health, Bloomberg School of Public Health, The Johns Hopkins University (2005 - 2008)
  • Assistant Professor, Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University (2002 - 2004)
  • Senior Research Advisor, Saving Newborn Lives Initiative, Office of Health, Save the Children Federation-US, Washington, DC (2000 - 2005)
  • Assistant Professor, Division of Dermatology, Department of Pediatrics, Children's Hospital & Regional Medical Center (1999 - 2000)
  • Assistant Professor, Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA (1999 - 2000)
  • Assistant Professor, Division of Infectious Disease, Rheumatology & Immunology, Department of Pediatrics, Children's Hospital & Regional Medical Center (1999 - 2000)
  • Adjunct Assistant Professor, Division of Community Health and Health Systems, Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University (1998 - 2002)
  • Acting Assistant Professor, Division of Dermatology, Department of Pediatrics, Children's Hospital & Regional Medical Center (1998 - 1999)
  • Acting Assistant Professor, Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA (1998 - 1999)
  • Acting Assistant Professor, Division of Infectious Disease, Rheumatology & Immunology, Department of Pediatrics, Children's Hospital & Regional Medical Center (1998 - 1999)
  • Staff Pediatrician, Department of Pediatrics, Kaiser Permanente Medical Group, Hayward and Redwood City, CA (1992 - 1994)

Honors & Awards

  • Outstanding Alumnus, Johns Hopkins University (2021)
  • Faculty Research Fellow, Clayman Institute for Gender Research, Stanford University (2017-2018)
  • 2017 Outstanding Alumnus, University of California, San Diego (2017)
  • Society of Scholars, Johns Hopkins University (2016)
  • Sidney Hurwitz Visiting Professor, Society for Pediatric Dermatology (2015)
  • Top 10 Global Health Milestones of 2012, First Place, LondonSummit on Family Planning Ignites $2.6 billion in Commitment (2012)
  • Holy Cow Award (for extraordinary contribution in Social and Behavioral Change initiatives), Bill & Melinda Gates Foundation (2011)
  • BRAVO Award (for most outstanding cross-program), India Project Team, Bill & Melinda Gates Foundation (2010)
  • Paper of the Year nomination, British Medical Journal (for article in Pediatrics 2007) (2009)
  • Paper of the Year, The Lancet (2008)
  • Best Poster, Countdown to 2015, Tracking Progress in Child Survival (2005)
  • Best Communication, The skin and nutritional problems of the newborn, International Congress of Neonatal Dermatology (1998)
  • First Place, San Francisco Dermatologic Society Resident Forum (1994)
  • Johns Hopkins Francis F. Schwentker Research Award, Department of Pediatrics, JHU (1992)
  • Johns Hopkins Francis F. Schwentker Research Award, Department of Pediatrics, JHU, Dermatitis as a presenting sign of cystic fibrosis (1991)
  • Secretary's Award for Innovations in Health Promotion and Disease Prevention, Honorable Mention, Establishment of community-based child abuse prevention services in North San Diego County (1988)
  • Highest Honors, California Polytechnic State University (CPSU) Graduation (1979)
  • Honors, Gamma Sigma Delta (Agricultural) Honor Society (1979)
  • President's Honor List, California Polytechnic State University (1979)
  • Phi Kappa Phi, Honor Society (1978)

Boards, Advisory Committees, Professional Organizations

  • Advisory Board, Universal Scientific Education and Research Network (2021 - Present)
  • Co-chair, Kangaroo Mother Care Working Group, World Health Organization (2021 - Present)
  • Chair, WHO Low Birth Weight Infant Guidelines Development Group, World Health Organization (2020 - Present)
  • Strategic and Technical Advisory Group of Experts (STAGE), Committee on Maternal, Newborn, Child, Adolescent Health, and Nutrition (MNCAH&N), World Health Organization (2020 - Present)
  • Board of Directors, Kenyan Women and Children's Wellness Center, Nairobi, Kenya (2020 - 2021)
  • Advisory Board, The 2030 Collaborative (2019 - Present)
  • Inclusion & Diversity Advisory Board, Elsevier (2019 - Present)
  • Scientific Advisory Team, Avadim Health (2019 - 2021)
  • Advisory Group, Research prioritization of maternal, newborn, child and adolescent health (MNCAH) in humanitarian emergencies, World Health Organization (2018 - Present)
  • Global Mental Health External Advisory Board, University of Washington (2018 - Present)
  • Advisory Group, Global Scales of Early Development Project, World Health Organization (2018 - 2020)
  • UNICEF Specialist Advisor, Children with Developmental Delays and Disabilities (2018 - 2019)
  • Advisory Council, Global Health 50/50 (2017 - 2020)
  • Member, Global Hygiene Council (2016 - Present)
  • Steering Comittee, Coalition of Centres in Global Child Health (2016 - Present)
  • Pediatric Infectious Diseases Society (PIDS) Liaison, Infectious Diseases Society of America (IDSA) (2016 - 2020)
  • Program Planning Committee, Pediatric Academic Society (2016 - 2018)
  • Steering Committee, Reproductive Maternal Newborn Child Health & Nutrition Care in Humanitarian Crises (2016 - 2017)
  • Advisory Board, Maternal Child Health, World Health Organization, South East Asia Region (2015 - Present)
  • Member, Society for Pediatric Dermatology (2015 - Present)
  • Steering Committee Chair, The Lancet Series on Gender Equality, Norms, and Health (2015 - 2019)
  • Global Steering Committee, Public-Private Partnership to Prevent Preterm Birth (2015 - 2017)
  • Advisory Group, The Lancet series on Ending Preventable Stillbirths (2015 - 2016)
  • Expert Advisory Group, Aetiology of Neonatal Infections in South Asia (ANISA) (2015 - 2016)
  • Board member, Autism Speaks, Global Action Committee of the Board (2014 - Present)
  • Strategic Advisory Group, Saving Newborn Lives, Save the Children (2013 - Present)
  • Board of Directors, Project Mercy (2013 - 2020)
  • R&D Advisory Board, GlaxoSmithKline - Save the Children (2013 - 2020)
  • Executive Committee, Forum on Investing in Young Children Globally, Institute of Medicine (2013 - 2017)
  • Strategic Advisory Group, Saving Newborn Lives, Save the Children (2013 - 2017)
  • Steering Committee, Co-chair, Early Child Development Lancet Series (2013 - 2016)
  • Advisory Group, Every Newborn Action Plan (2013 - 2014)
  • Advisory Group, @Socialgoodformoms (Mom Bloggers Network) (2013 - 2014)
  • Chair, Evaluation Committee, Partnership for Maternal, Newborn and Child Health (PMNCH) (2013 - 2014)
  • Steering Committee, Every Newborn Lancet Series (2013 - 2014)
  • Strategic Advisory Group, Maternal, Adolescent, Reproductive and Child Health Department, London School of Hygiene and Tropical Medicine (2013 - 2014)
  • Founding Curator, (crowd-funding platform for women's and girls' empowerment) (2012 - 2014)
  • Member, Washington State Academy of Science (2011 - Present)
  • Global Health Advisory Board, National Academy of Medicine (2011 - 2017)
  • External Program Oversight Board, Global Maternal and Newborn Health Training Program, University of Washington (2011 - 2014)
  • Steering Committee, Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization (2011 - 2014)
  • Global Action Council on Population Growth, World Economic Forum (2011 - 2013)
  • Board of Directors, Agros International (2010 - 2015)
  • Board of Directors Co-Chair and Member, Global Alliance for Improved Nutrition (2010 - 2013)
  • Steering Committee, Saving Lives at Birth, A Grand Challenge for Development (2010 - 2013)
  • Senior Officials Group, Scaling Up Nutrition (2010 - 2012)
  • Member, Global Health Council (2010 - 2000)
  • Technical Advisory Group, Saving Newborn Lives Program (2008 - 2010)
  • Technical Advisory Group, Simplified antibiotic treatment regimens, World Health Organization (2008 - 2010)
  • International Scientific Advisory Council for Prevention of Prematurity and Stillbirths, Global Alliance for the Prevention of Prematurity and Stillbirths, Seattle Children's Hospital (2008 - 2009)
  • Chair, Outputs Task Force, Partnership for Maternal, Neonatal and Child Health (2008 - 2008)
  • Developmental Disabilities Task Force, Johns Hopkins Medical Institutions (2007 - 2008)
  • Joint Steering Committee, Interactive Autism Network, Kennedy Krieger Institute and Autism Speaks, Johns Hopkins Medical Institutions (2007 - 2008)
  • Chlorhexidine Working Group, USAID/NIH (2005 - 2007)
  • Steering Committee, Lancet Neonatal Survival Series (2004 - 2006)
  • Technical Advisor, Neonatal Health, INCLEN Childnet (2003 - 2005)
  • Member, Society for Pediatric Research (2002 - Present)
  • Member, American Public Health Association (2002 - Present)
  • Neonatal Health Advisor, Child Health Epidemiology Reference Group (CHERG) (2002 - 2007)
  • Steering Committee, US Coalition for Child Survival, Global Health Council (2002 - 2006)
  • Technical Advisor, IndiaCLEN (2002 - 2005)
  • Steering Committee, WHO Young Infant Clinical Signs Study Group (2001 - 2008)
  • Scientific Advisory Group, Project Spring, Procter & Gamble (2001 - 2003)
  • Member and Neonatal Health Expert, Research Task Force, US Coalition for Child Survival (2001 - 2002)
  • Goals and Awards Committee, Society for Pediatric Dermatology (1999 - 2003)
  • Member, Pediatrics Infectious Disease Society (1995 - Present)
  • Fellow, American Academy of Pediatrics (1993 - Present)
  • Fellow, American Academy of Dermatology (1992 - Present)
  • Member, Harriet Lane Alumni Association, Johns Hopkins University (1992 - Present)

Professional Education

  • Exectutive Education, Harvard Kennedy School, Boston, MA, Leadership for the 21st Century (2013)
  • Gear Up Program, Bill & Melinda Gates Foundation, Seattle, WA, Manager effectiveness training (2013)
  • Executive Education, Harvard Kennedy School, Boston, MA, Leadership Decision Making: Optimizing Organizational Performance (2012)
  • Fellow, Children's Hospital & Medical Center, University of Washington School of Medicine, Seattle, WA, Division of Infectious Disease (1997)
  • Resident, Stanford University School of Medicine, Stanford, CA, Department of Dermatology (1994)
  • Resident, Johns Hopkins University School of Medicine, Baltimore, MD, Pediatrics (1992)
  • M.D., University of California, San Diego (UCSD), Dermatology (1989)
  • M.S., University of Wisconsin, Madison, Agronomy (Plant Physiology) (1982)
  • B.S., California Polytechnic State University (CPSU), San Luis Obispo (graduated with Highest Honors), Crop Science (1979)

Community and International Work

  • Determination of gestational age and preterm birth rates in low resource settings using newborn metabolic profiles


    Maternal & Child Health

    Partnering Organization(s)

    Bill and Melinda Gates Foundation



    Ongoing Project


    Opportunities for Student Involvement


  • Landscaping women’s economic empowerment (WEE) in East Africa


    Gender Equality

    Partnering Organization(s)

    Bill and Melinda Gates Foundation



    Ongoing Project


    Opportunities for Student Involvement


  • Gender integration in the African Union COVID-19 Response


    Gender Equality

    Partnering Organization(s)

    Bill and Melinda Gates Foundation



    Ongoing Project


    Opportunities for Student Involvement


  • Ethiopia gender transformative leadership project, Ethiopia


    Gender Equality

    Partnering Organization(s)

    Bill and Melinda Gates Foundation



    Ongoing Project


    Opportunities for Student Involvement


  • Gender integration strategy support and product development


    Gender Equality

    Partnering Organization(s)

    Bill and Melinda Gates Foundation

    Ongoing Project


    Opportunities for Student Involvement


  • A Mobile Autism Risk Initiative (AMARI) to detect Autism Spectrum Disorder in Bangladeshi children under the age of 4, Bangladesh



    Partnering Organization(s)

    Islamic Development Bank



    Ongoing Project


    Opportunities for Student Involvement


  • Emollient for preterm newborns study in Uganda, Uganda


    Maternal & Child Health



    Ongoing Project


    Opportunities for Student Involvement


  • Delivery of an integrated childhood development strategy in rural China, China


    Global poverty

    Partnering Organization(s)

    Enlight Foundation



    Ongoing Project


    Opportunities for Student Involvement


  • Developing a Learning Agenda for WASH Up! in Kenya and India


    Water, Health, & Development

    Partnering Organization(s)

    WHD, Sesame Workshop, World Vision



    Ongoing Project


    Opportunities for Student Involvement


  • Etiology and Incidence of Neonatal Infections in South Asia, Bangladesh, Pakistan, & India


    Neonatal Infections

    Partnering Organization(s)

    Child Health Research Foundation

    Populations Served

    Newborns in Bangladesh, Pakistan, & India



    Ongoing Project


    Opportunities for Student Involvement


  • Topical emollient therapy in the management of severe acute malnutrition, Dhaka, Bangladesh


    Treatment of Severe Acute Malnutition

    Partnering Organization(s)

    icddr,b, GlaxoSmithKline

    Populations Served

    Under-2 Children in Bangladesh



    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

I have extensive experience in the development of global health innovations and in working to test and scale-up health interventions. At Stanford University, I am playing a leading role in developing global women and children’s health research and educational programs, including the establishment of a Global Center for Gender Equality at Stanford University. My research focuses on advancing child health and development in low resource settings and advancing gender equality and health globally, and includes several applications of artificial intelligence. Before joining Stanford, I was Senior Fellow at the Bill & Melinda Gates Foundation (BMGF), where I led the development of initiatives to address gender inequalities and empower women and girls. Prior to this role, I served as the BMGF Director of Family Health, leading strategy development and implementation across maternal, newborn and child health, nutrition, and family planning. In this role, I was responsible for investments ranging from scientific discovery to intervention development and delivery of interventions at scale. I worked closely with the Discovery team to shape discovery and development investments and was a co-founder of the Saving Lives at Birth Development Grand Challenge, the Putting Women and Girls at the Center of Development Grand Challenge, and the Healthy Birth, Growth and Development initiative. Based on these experiences, I understand how to identify knowledge gaps and generate evidence of impact for new interventions, and how to utilize evidence to influence the policy dialogue leading to programmatic adoption and scale-up of interventions in low income settings. As Director of Family Health, I also co-led the development and implementation of the BMGF global health strategy for India, which cuts across multiple health and development sectors. Before joining BMGF, I was Associate Professor and Founding Director of the International Center for Advancing Neonatal Health in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. I led the development of newborn health research, including numerous facility- and community-based maternal and child health research trials. Before joining Johns Hopkins, I was Senior Research Advisor for the $50M Saving Newborn Lives program of Save the Children-US, where I led the development and implementation of the global research strategy for newborn health and survival.

Clinical Trials

  • Emollient Therapy for Premature Infants in Zimbabwe Not Recruiting

    The purpose of this study is to assess the efficacy of topical emollient treatments in improving neonatal growth and mortality rates.

    Stanford is currently not accepting patients for this trial. For more information, please contact Gary Darmstadt, MD, MS, 650-724-6014.

    View full details


  • Lancet Series on the Next Generation of Gender Equality, Stanford University (11/1/2015 - 12/2019)

    Major new visibility on the importance of investing in women and girls has created new opportunities to accelerate advances in health and development of nations around the world. A more intentional approach to addressing gender norms and gender inequalities in policies, programs and research is critical to this effort. We are working with the Lancet to develop a series of papers on the following topics:

    1. Unlocking human potential through shaping gender norms
    2. Unlocking gender norm data
    3. Unlocking gender norm change to achieve health and development impact at scale
    4. Unlocking gender norm change in systems to ensure sustainability of health and development impact
    5. Unlocking global action to shape gender norms and optimize health and development across the life course

    Through these papers, we hope to i) propose a conceptual framework for associations between gender norms, gender inequalities and health and development, ii) place the development and shaping of gender norms and gender equality in historical perspective, iii) define the global scope and size of issues of unhealthy gender norms and gender inequalities across the life course (with a focus on early childhood, adolescence, and early and late adulthood), including costs of inaction, in high, middle and low-income countries, iv) synthesize the existing evidence for approaches to shape gender norms, v) quantify the benefits of addressing unhealthy gender norms and gender inequalities for women, girls, men and boys, vi) calculate the cost to implement these solutions at scale, vii) define global metrics, and viii) develop a concrete action plan to advance healthy gender norms as well as health and development of women, men, girls and boys, and of societies worldwide.


    Stanford, CA

  • Topical emollient Therapy in the Management of Severe Acute Malnutrition: A Randomized Controlled Clinical Trial in Bangladesh, icddr,b, GlaxoSmithKline (4/2015 - 12/2017)

    Topical emollient therapy in the management of severe acute malnutrition: A randomized controlled clinical trial in Bangladesh to test whether rehabilitation from severe acute malnutrition can be accelerated through topical applications of sunflower seed oil.




    • Rachel Gibson, Senior Discovery Medicine Scientist, Maternal and Neonatal Health Unit, GlaxoSmithKline, London, UK
    • Pauline Williams, Vice President, Health of Global Health R&D, GlaxoSmithKline, London, UK
    • KM Shahuuja, Clinical Researcher, icddr,b, Dhaka, Bangladesh
    • Tahmeed Ahmed, Director, Centre for Nutrition and Food Security, icddrb, Dhaka, Bangladesh
    • Md Igbal Hossain, Senior Scientist, icddr,b, Dhaka, Bangladesh
  • Reducing infectious disease exposure among school-aged children in developing countries: The WaSH Up! Alliance, Stanford University (July 1, 2016 - 2/2021)

    WaSH Up! is a partnership between Sesame Street, World Vision, and Stanford University to reduce child disease and death by ensuring children have access to safe water and sanitation by practice healthy behaviors relators to water, sanitation and hygiene (WaSH). Sesame Workshop has worked to created a new Muppet character named Raya, a girl ambassador who promotes safe WaSH practices. Sesame Workshop with World Vision announces a commitment to roll out WaSH Up! across 15 countries in the next six years. The team at Stanford University will be the primary evaluator and research partner, investigating school- and community-based interventions. Stanford will contribute a strong theoretical grounding leading to improvements
    in program design and impact, to design a rigorous evaluation of the program’s impacts, and to
    identify and pursue complementary research opportunities.


    Lusaka, Zambia


    • Jenna Davis, Professor of Civil and Environmental Engineering and Senior Fellow at the Woods Institute for the Environment, Stanford University
  • Creating a Scalable Model to End Poverty: Delivery of an Integrated Childhood Development Strategy in Rural China

    To building on existing programs and collaborations between the Rural Education and Action Program (REAP) and the Chinese government to pilot, deliver, and evaluate an integrated, community-based program for children 0-3 years in existing parenting center in rural China.


    Shaanxi, China


  • The Lancet Series: Advancing Early Childhood Development: from Science to Scale, The Lancet

    The 2016 Lancet Early Childhood Development Series highlights early childhood development at a time when it has been universally endorsed in the 2030 Sustainable Development Goals. This Series considers new scientific evidence for interventions, building on the findings and recommendations of previous Lancet Series on child development (2007, 2011), and proposes pathways for implementation of early childhood development at scale. The Series emphasises 'nurturing care', especially of children below three years of age, and multi-sectoral interventions starting with health, which can have wide reach to families and young children through health and nutrition.



  • Learning from Ananya - Scaling Up Improved Family Health, Stanford University (12/2016 - 12/2019)

    The Stanford University (SU) School of Medicine “Co-Creation” group will employ a mixed quantitative and qualitative methods approach to analyze/mine existing data sets, dialogue with implementers and evaluators, and share the knowledge and data gained from the Bill and Melinda Gates Foundation (BMGF)-funded Ananya program in Bihar, India. SU will conduct this analysis to disseminate learning from Ananya to inform the scale-up of national and global family health (reproductive, maternal, newborn and child health and nutrition, RMNCHN) interventions. In close collaboration with the BMGF India Country Office (ICO), and Ananya implementation and evaluation partners, SU will analyze and synthesize a range of existing data sources, which – together with the primary qualitative data we will collect – will inform the development of core peer-reviewed articles and additional papers and policy briefs. These insights will help the BMGF Program Strategy Teams (PSTs), the government of Bihar, Ananya grantees, and the broader global health community make evidence-informed decisions to optimize the coverage, quality and impact of their investments in improving maternal and child health outcomes.


    Bihar, India


    • Mark Cullen, Professor, Stanford University School of Medicine
    • Wolfgang Munar, Research Professor, Department of Global Health, George Washington University
  • Uncovering gender inequalities in East Africa: Using artificial intelligence to gain insights from media data, Stanford Human-centered Artificial Intelligence Institute (5/2019 - 4/2020)

    Major goals: 1) Create word embeddings for gendered terms utilizing East-African corpora of media data to gain insights into the ways different gender groups may be perceived and labelled in the region; 2) create a database of word embeddings trained on publicly available sources, focusing on Kenya; 3) overlay relevant country-level statistics to assess how gender stereotypes identified through word embeddings reflect gender-inequitable behavior in the region, and 4) measure bias contained in embeddings of words related to women and men separately as they compare to embeddings containing neutral words



  • Women’s Empowerment Collectives (WEC) Research Consortium Global Data and Learning Partnership, American Institutes for Research (though a grant from the Bill and Melinda Gates Foundation) (11/2018 - 10/2022)

    Major goals: Consolidate and strengthen the evidence base on the impact and cost-effectiveness of WECs, through three streams of work: (a) design and implement a portfolio evaluation, (b) serve as an evaluation anchor to provide technical assistance to BMGF and evaluation teams supported by BMGF, and (c) contribute to the global evidence base through synthesizing existing research and producing research based on primary data.



  • Landscaping women’s economic empowerment (WEE) in East Africa, Bill and Melinda Gates Foundation (11/2018 - 12/2019)

    Major goals: Landscape WEE in East Africa, including a mapping of gender equality researchers, policies, programs, practitioners, data, publications, media coverage and funders.



  • Gender integration strategy support and product development, Bill and Melinda Gates Foundation (11/2018 - 12/2020)

    Major goals: Support expansion of the BMGF’s gender integration work through development of an on-demand model for technical assistance and learning on gender integration. Support program teams to become gender intentional; develop customized gender integration tools, disseminate key lessons learned, and provide strategic support to leadership to set appropriate targets, measures and accountability mechanisms.



  • Determination of gestational age and preterm birth rates in low resource settings using newborn metabolic profiles, Bill and Melinda Gates Foundation (11/2017 - 12/2020)

    Major goals: Investigate approaches to improve the methodology, and demonstrate the feasibility of using newborn blood spots, cord blood and/or maternal blood to estimate gestational age of newborns in Africa and Asia through metabolic and computational analysis in collaboration with the Ottawa Hospital Research Initiative and the Ontario Newborn Screening Program.


    Africa and Asia

  • Reducing hospital-acquired infections (HAIs) in Bangladesh, Centers for Disease Control and Prevention (9/2016 - 9/2021)

    Majors goals: 1) Identify a potential set of evidence-based interventions for reducing HAIs in neonates in low- and middle-income countries; 2) Perform a pilot study to test interventions at three facilities in Bangladesh to assess their acceptance, feasibility, and cost; and select interventions to bundle for implementation; 3) Conduct a baseline evaluation to assess current incidence of HAIs and identify current newborn care practices, and then evaluate the efficacy of the selected bundle of interventions to reduce HAIs and mortality in neonatal wards and NICUs at three hospitals in Bangladesh; 4) Engage frontline hospital staff across the three facilities in a collaborative effort to integrate a sustainable culture of quality improvement into neonatal wards/NICUs at all three hospitals.



  • Creating a scalable model to end poverty: Delivery of an integrated childhood development strategy in rural China, The Enlight Foundation Fund (9/2016 - 8/2024)

    Major goals: To build on existing programs and collaborations between the Rural Education and Action Program (REAP) and the Chinese government to pilot, deliver, and evaluate an integrated, community-based health, nutrition and child stimulation program for children 0-3 years in rural China.



  • Bringing it Home: Driving School-based WASH Messaging into the Household Environment, USAID (4/2019 - 9/2021)




    • Jenna Davis, Professor of Civil and Environmental Engineering and Senior Fellow at the Woods Institute for the Environment, Stanford University
  • Using existing data to investigate relationships between social norms and adolescent health behaviors and outcomes, Bill and Melinda Gates Foundation (2016 - 2019)



  • Emollient therapy for severe acute malnutrition (SAM): Randomized controlled clinical trial in Bangladesh, Thrasher Research Fund (2015 - 2018)



  • Ethiopia Gender Transformational Leadership (12/2019 - 3/2021)



  • Gender integration work with Echidna Giving (1/2020 - 12/2020)



  • Bihar data repository and analysis (5/2020 - 12/2020)


    Bihar, India

  • Gender equality mainstreaming philanthropy resources & workshops #GESI (6/2020 - 11/2021)



  • Analysis and dissemination of learning from Aetiology of Neonatal Infection in South Asia, New Venture Fund (6/2020 - 6/2021)



  • Risk factors for an emerging threat: patterns of antibiotic-resistant Campylobacter in households in rural Sitapur, India, Stanford Center for Innovation in Global Health Seed Award (3/2020 - 2/2021)


    Sitapur, India


    • Alexandria Boehm, Professor of Civil and Environmental Engineering and Senior Fellow at the Woods Institute for the Environment, Stanford University
  • Thematic research on National Rural Livelihoods project in India, International Initiative for Impact Evaluation (3ie) (11/2020 - 6/2021)



  • Skin barrier repair therapy for prevention of serious infections and atopic diseases in young children in Bangladesh, Islamic Development Bank Transform Fund (1/2021)



  • A Mobile Autism Risk Initiative (AMARI) to detect Autism Spectrum Disorder in Bangladeshi children under the age of 4, Islamic Development Bank Transform Fund (1/2021)



2023-24 Courses

Stanford Advisees

Graduate and Fellowship Programs

All Publications

  • Integrating evidence and causal mapping of help-seeking behaviour of migrant women with postpartum depression in Shanghai, China: a scoping review protocol. BMJ open Lee, Y. J., Taft, A., Kacham, R., Wong, C., Cai, Y., Li, H., Darmstadt, G. L. 2024; 14 (6): e082571


    The estimated prevalence of postpartum depression (PPD) worldwide, in China, and Shanghai is 17.2%, 18.0% and 23.2%, respectively. In 2021, Shanghai housed a population of 3.2 million childbearing-age migrant women, most of whom migrated to the city with their husbands for economic reasons. There is a general lack of help-seeking behaviour for mental disorders in China due to the perceived risk of social stigmatisation. In Shanghai, 70% of women did not seek professional help for perinatal mental health problems. We aim to gather information from multiple perspectives, such as the migrant women with PPD and perinatal depression (PND), their caregivers, health service providers and communities, to understand the help-seeking behaviour of postpartum migrant women with PPD or PND in China.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework for Scoping Reviews will guide this review. A bilingual research librarian developed a comprehensive search strategy to retrieve published and unpublished English and Chinese studies involving factors influencing women's PPD or PND help-seeking behaviour in China. This literature includes perceptions, views, patterns, acceptance and refusal, tendencies, probability, service accessibility and utilisation, and facts. We will search PubMed, Embase, Web of Science and CINAHL for English literature and CINKI for Chinese literature. Backward and forward snowball approaches will be used to identify additional relevant papers from the reference lists of selected papers. Two independent reviewers will screen the title and abstract and review the full text of selected papers to identify eligible articles for data extraction. We will build a Microsoft Access database to record the extracted data. The results will be presented in tables and a causal map to demonstrate the relationships between extracted variables and help-seeking behaviours for PPD and PND. A conceptual simulation model will be formulated based on the information from the literature to validate the logic of the relationships between variables, identify knowledge gaps and gain insights into potential intervention approaches. Experts and stakeholders will be invited to critique and comment on the results during group model building (GMB) workshops in Shanghai. These comments will be essential to validate the findings, receive feedback and obtain additional insights.The literature review component of our study does not require ethical approval because the information and data collected will be obtained from publicly available sources and will not involve human subjects. Our collaborating research partner, International Peach Maternal Child Hospital, obtained the IRB approval (GKLW-A-2023-020-01) for screening and enrolling participants in GMB workshops. Stanford University received IRB approval under protocol number 67 419. The full review will be presented at a relevant conference and submitted to a peer-reviewed scientific journal for publication to report findings.

    View details for DOI 10.1136/bmjopen-2023-082571

    View details for PubMedID 38951005

  • Maternal empowerment, feeding knowledge, and infant nutrition: Evidence from rural China. Journal of global health Chen, Y., Guo, Y., Wu, Y., Medina, A., Zhou, H., Darmstadt, G. L. 2024; 14: 04094


    Background: Maternal empowerment - the capacity to make decisions within households - is linked to better child feeding and nutritional outcomes, but few studies have considered the mediating role of caregiver knowledge. Further, existing literature centres primarily on the husband-wife dyad while overlooking grandmothers as important childcare decision-makers.Methods: We collected primary data through household surveys in 2019 and 2021 from 1190 households with infants zero to six months living in rural western China. We identified the primary and secondary caregivers for each infant and assessed their feeding knowledge and practices, as well as infant nutritional status. We constructed a maternal empowerment index using a seven-item decision-making questionnaire and examined the relationship between maternal empowerment in childcare and household decisions, caregivers' feeding knowledge, and infant feeding practices and nutritional outcomes.Results: Mothers had significantly higher levels of feeding knowledge than secondary caregivers (most were grandmothers, 72.7%), with average knowledge scores of 5.4 vs. 4.1, respectively, out of 9. Mothers and secondary caregivers with higher levels of feeding knowledge had significantly higher exclusive breastfeeding rates by 13-15 percentage points (P<0.01) and 11-13 percentage points (P<0.01), respectively. The knowledge of secondary caregivers was even more strongly associated with not feeding formula (15 percentage points, P<0.01). Mothers empowered to make childcare decisions were more likely to exclusively breastfeed (12-13 percentage points, P<0.01), less likely to formula feed (9-10 percentage points, P<0.05), and more likely to have children with higher Z-scores for length-for-age (0.32-0.33, P<0.01) and weight-for-age (0.24-0.25, P<0.05). Effects remained after controlling for maternal feeding knowledge.Conclusions: While mothers' and grandmothers' feeding knowledge was both important for optimal infant feeding, grandmothers' knowledge was particularly critical for practicing exclusive breastfeeding. Given the disparity in feeding knowledge between the two caregivers, our study further shows that mothers empowered in childcare decision-making were more likely to exclusively breastfeed their infants. This implies that some mothers with adequate knowledge may not practice optimal feeding because of lower decision-making power. Overall, our study highlights the role of secondary caregivers (grandmothers) in infant care and suggests that future child nutritional interventions may benefit from involving secondary caregivers (grandmothers).Registration: Parent trial registration: ISRCTN16800789.

    View details for DOI 10.7189/jogh.14.04094

    View details for PubMedID 38845456

  • Overview of the Global and US Burden of Preterm Birth. Clinics in perinatology Ward, V. C., Lee, A. C., Hawken, S., Otieno, N. A., Mujuru, H. A., Chimhini, G., Wilson, K., Darmstadt, G. L. 2024; 51 (2): 301-311


    Preterm birth (PTB) is the leading cause of morbidity and mortality in children globally, yet its prevalence has been difficult to accurately estimate due to unreliable methods of gestational age dating, heterogeneity in counting, and insufficient data. The estimated global PTB rate in 2020 was 9.9% (95% confidence interval: 9.1, 11.2), which reflects no significant change from 2010, and 81% of prematurity-related deaths occurred in Africa and Asia. PTB prevalence in the United States in 2021 was 10.5%, yet with concerning racial disparities. Few effective solutions for prematurity prevention have been identified, highlighting the importance of further research.

    View details for DOI 10.1016/j.clp.2024.02.015

    View details for PubMedID 38705642

  • Skin science to advance emollient therapy in the care and health of preterm infants. EClinicalMedicine Darmstadt, G. L. 2024; 72: 102618

    View details for DOI 10.1016/j.eclinm.2024.102618

    View details for PubMedID 38707909

    View details for PubMedCentralID PMC11066507

  • Estimating Gestational Age and Prediction of Preterm Birth Using Metabolomics Biomarkers. Clinics in perinatology Ward, V. C., Hawken, S., Chakraborty, P., Darmstadt, G. L., Wilson, K. 2024; 51 (2): 411-424


    Preterm birth (PTB) is a leading cause of morbidity and mortality in children aged under 5 years globally, especially in low-resource settings. It remains a challenge in many low-income and middle-income countries to accurately measure the true burden of PTB due to limited availability of accurate measures of gestational age (GA), first trimester ultrasound dating being the gold standard. Metabolomics biomarkers are a promising area of research that could provide tools for both early identification of high-risk pregnancies and for the estimation of GA and preterm status of newborns postnatally.

    View details for DOI 10.1016/j.clp.2024.02.012

    View details for PubMedID 38705649

  • Legal pluralism and tribalism: Drivers of gender and health inequalities. Journal of global health Moalla, K. T., Darmstadt, G. L. 2024; 14: 03020

    View details for DOI 10.7189/jogh.14.03020

    View details for PubMedID 38813678

  • Postnatal care and acceptability of emollient therapy in very low birthweight infants in Harare, Zimbabwe: a qualitative analysis. BMC pediatrics Hui, A., Chimhini, G., Saungweme, M., Kaisi, D., Munetsi, E., Mujuru, H. A., Darmstadt, G. L. 2024; 24 (1): 187


    Preterm birth (birth before 37 completed weeks of pregnancy) is the leading cause of neonatal and child under-five mortality globally, both of which are highest regionally in sub-Saharan Africa. The skin barrier plays a critical role in neonatal health and increasing evidence supports the use of topical emollient therapy to promote postnatal growth and reduce hospital-acquired infections in preterm infants. The World Health Organization (WHO) currently recommends emollient therapy in preterm or low birthweight infants globally but calls for further research on impacts of emollient use, especially in Africa. Little is known about postnatal skincare practices and the tradition of oil massage across sub-Saharan Africa. Further documentation is necessary to understand the context for future emollient intervention trials.61 semi-structured interviews with mothers who just delivered preterm or term infants and 4 focus group discussions (32 participants) with physician and nurse providers of newborn care were conducted at Sally Mugabe Central Hospital (SMCH), in Harare, Zimbabwe. SMCH is the principal public-sector tertiary care hospital for newborn infants in the northern part of the country. Mothers and healthcare professionals were questioned about newborn care at the hospital, current neonatal skincare and bathing practices, and the community's receptivity to a future emollient therapy clinical trial.Postnatal skincare is centrally important to Zimbabwean communities and petroleum jelly application is nearly universal. The use of cooking oil and other natural oils on infants is also part of traditional customs. The primary needs and desires of mothers who have just given birth to preterm infants are having greater agency in their children's care and financial support in purchasing prescribed medications while at the hospital. Community receptivity to emollient therapy as a cost-effective treatment is high, particularly if mothers are trained to assist with the intervention.Emollient therapy will likely be well-received by communities in and around Harare because of its accordance with current skincare practices and perceptions; however, cultural norms and the experiences of new mothers who have given birth at a facility highlight challenges and considerations for future clinical trial NCT05461404.

    View details for DOI 10.1186/s12887-024-04661-x

    View details for PubMedID 38493088

    View details for PubMedCentralID 8786667

  • Subnational estimates of vitamin A supplementation coverage in children: a geospatial analysis of 45 low- and middle-income countries. Public health Seufert, J., Krishnan, N., Darmstadt, G. L., Wang, G., Bärnighausen, T., Geldsetzer, P. 2024; 228: 194-199


    Vitamin A supplementation (VAS) can protect children from the adverse health consequences of vitamin A deficiency. Granular data on VAS coverage can guide global and national efforts to achieve universal VAS coverage. To provide geographically precise targeting of VAS programs and to monitor progress in reducing geographic disparities, we aimed to create high-resolution (5 × 5 km2) maps of VAS coverage in children under 5 years across VAS priority countries.We used cross-sectional data from the Demographic and Health Surveys (DHS) program.We used data from the DHS program for United Nations Children's Fund -designated VAS priority countries between 2000 and 2017 with data available from 2005 or later. The outcome variable was the proportion of children under 5 years who received a vitamin A dose in each sampled cluster. We applied a Bayesian geostatistical approach incorporating geographic, climatic, and nutritional covariates to estimate VAS coverage for each cell. We estimated and mapped absolute VAS coverage, Bayesian uncertainty intervals, and exceedance probabilities.Our sample included countries from Latin America and the Caribbean, Asia, and Africa. Most countries had estimated VAS coverage levels <70%, and our exceedance probabilities indicated high certainty that our estimates fell below this threshold in most grid cells. International variations were most notable in the Latin America and the Caribbean region and Africa. Intranational variations were greatest in some South Asian and West and Central African countries.These prevalence and exceedance maps, especially used with data on indicators of VAS need, could help to improve equity.

    View details for DOI 10.1016/j.puhe.2024.01.018

    View details for PubMedID 38394746

  • 28 NICUs participating in a quality improvement collaborative targeting early-onset sepsis antibiotic use. Journal of perinatology : official journal of the California Perinatal Association Payton, K. S., Bennett, M. V., Schulman, J., Benitz, W. E., Stellwagen, L., Darmstadt, G. L., Quinn, J., Kristensen-Cabrera, A. I., Breault, C. C., Bolaris, M., Lefrak, L., Merrill, J., Sharek, P. J. 2024


    There is widespread overuse of antibiotics in neonatal intensive care units (NICUs). The objective of this study was to safely reduce antibiotic use in participating NICUs by targeting early-onset sepsis (EOS) management.Twenty-eight NICUs participated in this statewide multicenter antibiotic stewardship quality improvement collaborative. The primary aim was to reduce the total monthly mean antibiotic utilization rate (AUR) by 25% in participant NICUs.Aggregate AUR was reduced by 15.3% (p < 0.001). There was a wide range in improvement among participant NICUs. There were no increases in EOS rates or nosocomial infection rates related to the intervention.Participation in this multicenter NICU antibiotic stewardship collaborative targeting EOS was associated with an aggregate reduction in antibiotic use. This study informs efforts aimed at sustaining improvements in NICU AURs.

    View details for DOI 10.1038/s41372-024-01885-8

    View details for PubMedID 38378826

    View details for PubMedCentralID 7848759

  • Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh. BMC pediatrics Jahan, F., Parvez, S. M., Rahman, M., Billah, S. M., Yeasmin, F., Jahir, T., Hasan, R., Darmstadt, G. L., Arifeen, S. E., Hoque, M. M., Shahidullah, M., Islam, M. S., Ashrafee, S., Foote, E. M. 2024; 24 (1): 123


    There is an unmet need for phototherapy treatment in low- and middle-income countries (LMICs) to prevent disability and death of newborns with neonatal hyperbilirubinemia. Home phototherapy deployed by community health workers (CHWs) in LMICs may help increase access to essential newborn postnatal care in a more acceptable way for families and lead to an increase in indicated treatment rates for newborns with hyperbilirubinemia. We aimed to investigate the operational feasibility and acceptability of a CHW-led home phototherapy intervention in a rural sub-district of Bangladesh for families and CHWs where home delivery was common and a treatment facility for neonatal hyperbilirubinemia was often more than two hours from households. We enrolled 23 newborns who were ≥ 2 kg in weight and ≥ 35 weeks gestational age, without clinical danger signs, and met the American Academy of Pediatric treatment criteria for phototherapy for hyperbilirubinemia. We employed a mixed-method investigation to evaluate the feasibility and acceptability of home phototherapy through surveys, in-depth interviews and focus group discussions with CHWs, mothers, and grandparents. Mothers and family members found home phototherapy worked well, saved them money, and was convenient and easy to operate. CHWs found it feasible to deploy home phototherapy and identified hands-on training, mHealth job aids, a manageable workload, and prenatal education as facilitating factors for implementation. Feasibility and acceptability concerns were limited amongst parents and included: a lack of confidence in CHWs' skills, fear of putting newborn infants in a phototherapy device, and unreliable home power supply. CHW-led home phototherapy was acceptable to families and CHWs in rural Bangladesh. Further investigation should be done to determine the impact of home phototherapy on treatment rates and on preventing morbidity associated with neonatal hyperbilirubinemia. Clinical Trial (CT) registration ID: NCT03933423, full protocol can be accessed at . Name of the trial registry: Clinical Trial (CT) registration Date: 01/05/2019.

    View details for DOI 10.1186/s12887-024-04584-7

    View details for PubMedID 38360716

    View details for PubMedCentralID PMC10868082

  • Integrating evidence and causal mapping of factors that influence medication decision-making by pregnant women at risk of hypertensive disorder: protocol for a scoping review. BMJ open Lee, Y. J., Taft, A., Stevenson, D. K., Darmstadt, G. L. 2024; 14 (2): e074775


    INTRODUCTION: In 2018, the American College of Obstetricians and Gynecologists recommended low-dose aspirin to prevent the onset of pre-eclampsia among women who were at high risk. Factors influencing women's acceptance of this recommendation span multiple sectors and levels. Understanding how these factors interact will help stakeholders design effective population-level intervention strategies. Our study aims to identify and map relationships among factors influencing the medication decisions of pregnant women at risk of hypertensive disorders.METHODS AND ANALYSIS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines will be followed for this review. A research librarian developed a comprehensive search strategy to retrieve published and unpublished English studies after 1 January 1980, involving factors that influence pregnant women's uptake and adherence to medication for gestational hypertensive disorders. This literature includes perceptions, patterns, acceptance, refusal, tendencies, probability and service utilisation. We will search PubMed, Embase, Web of Science and CINAHL. Reference lists of the selected papers will be searched manually to identify more relevant studies. A two-stage independent screening, consisting of title and abstract screening, followed by full-text screening, will be conducted by two independent reviewers to identify eligible articles. Extracted data will be recorded in a customised variable extraction form and input into a Microsoft Access database. The PRISMA-ScR will be used to guide the presentation of the results, which will be presented in a table and causal map to demonstrate the relationships between extracted variables and medication uptake and adherence. A conceptual simulation model will be formulated to validate the logic of the relationships between variables and identify knowledge gaps. Lastly, experts and stakeholders will be invited to critique and comment on the results.ETHICS AND DISSEMINATION: This study does not require ethical approval. The full review results will be presented at a relevant conference and submitted to a peer-reviewed scientific journal for publication.

    View details for DOI 10.1136/bmjopen-2023-074775

    View details for PubMedID 38316590

  • Gender mainstreaming at 25 years: Toward an inclusive, collaborative, and structured research agenda. Journal of global health Caywood, K., Darmstadt, G. L. 2024; 14: 04011


    Background: Gender mainstreaming has been central to the development agenda for advancing gender equality globally for nearly three decades. We examined key learning across gender mainstreaming models and experiences and assess key successes and challenges in actualising gender mainstreaming's transformative potential, in order to inform future research agendas.Methods: We reviewed 27 years of peer-reviewed literature on gender mainstreaming (1995-2022) and described scholarly publishing trends on the topic based on a set of 528 articles and bibliographic data retrieved from the Scopus database and supplemental coding. The review provides a thematic synthesis of the extant literature, assessing the evidence base to identify gaps and opportunities for future research and collaboration with practitioners. We also contextualise recent research by tracing common threads of scholarly and practitioner discussions over the last two decades.Results: Publications on gender mainstreaming have increased, primarily from authors with European and USA academic affiliations and funding. Gender mainstreaming in the health and law and policy sectors has been researched most frequently. Trends in co-authorship suggest increasing collaboration among academics, yet limited collaboration among researchers and practitioners. Widespread low citation counts raise concerns about engagement with the literature. Key challenges in gender mainstreaming identified include conceptual clarity, academic-practitioner disjunctures, politics, leadership and organisational culture, men's roles, intersectionality, monitoring and evaluation, and public health sectoral concerns.Conclusions: The gender mainstreaming literature has expanded considerably over the last 25 years, yet there remain critical knowledge gaps, theoretical inconsistencies, weak research methods and evaluation processes, and implementation challenges. Funders, researchers, and practitioners have failed to prioritise bridging north-south and academic-practitioner divides in gender mainstreaming policy, programmes, and research. Integration of intersectionality also remains nascent. A more inclusive, collaborative, and structured research agenda on gender mainstreaming is needed to effect greater change in the face of persistent and new challenges. Engaging and empowering regional women's organisations, collaborative learning and research programmes, and joint research and advocacy groups; implementing gender-attuned editorial policies; and incorporating gender mainstreaming in educational curricula are recommended.

    View details for DOI 10.7189/jogh.14.04011

    View details for PubMedID 38275086

  • Gender norms in a context of legal pluralism: Impacts on the health of women and girls in Ethiopia. Global public health Cohen, D., Jasper, K., Zhao, A., Moalla, K. T., Nwuke, K., Nesamoney, S., Darmstadt, G. L. 2024; 19 (1): 2326016


    To achieve Sustainable Development Goal 5 for gender equality by 2030, it is crucial for health and development professionals and governmental officials to understand how legal systems empower or oppress populations on the basis of gender worldwide, including opportunities and challenges of statutory provisions created by legal pluralism. Using Ethiopia as a case study, this paper examines how local laws applied in Sharia and Customary Dispute Resolution courts impact gender equality and the health of women and girls inspite of the inculcation of human rights statutes into national legislation, including the Constitution. We identify several key issues with the substantive law and its enforcement. First, laws which have been instituted at the national level to improve gender equally have been poorly enforced at the local level. Second, there is a sustained enforcement of laws that oppress women and that protect male perpetrators of gender-based violations. Third, local courts limit female representation and uphold patriarchy. To improve the health of women and girls, stakeholders must take into consideration the ways in which legal systems uphold harmful gender norms and obstruct and/or advance progress towards equal representation, opportunities, and constitutionally-mandated protections for all.

    View details for DOI 10.1080/17441692.2024.2326016

    View details for PubMedID 38471035

  • Separation of Maternal and Newborn Care in US Hospitals: A Systemic Threat to Survival, Health and Well-Being. Health systems and reform Anjur, K. I., Darmstadt, G. L. 2023; 9 (1): 2267255


    Through greater understanding of past social, cultural, economic, political, scientific and technological forces which shaped our current health systems to separate mothers and newborn infants, we can begin to devise effective approaches to reshape these systems to meet the needs of mothers and newborn infants today. Medical science and technology have evolved vastly in the last century; however, effects of historical factors persist in our current health care systems, reflected in separate maternal and neonatal care in different departments with distinct guidelines, providers, and treatment locations. This separation prevents maternal-infant skin-to-skin contact and bonding, which significantly affects infant development, well-being, and that of their caregivers. We explore historical precedents for the separation of maternal-newborn care, including the transition from midwifery home care to hospital obstetric care, reasons for the increase in hospital births and hospital nursery development, and the effects of world wars, federal acts, health insurance, rooming-in practices, and the development of medical advances such as antibiotics, on hospital infrastructure. This information is evaluated in the context of modern scientific advancements to show that the conditions which shaped health systems to separate mothers and newborns in the past no longer hold. The insights gained will help to identify strategic actions to reshape health care systems to enable more integrated maternal-newborn care and the practice of Kangaroo Mother Care, and to improve survival outcomes and well-being for mothers, families, and their newborn infants.

    View details for DOI 10.1080/23288604.2023.2267255

    View details for PubMedID 37890078

  • In-Hospital Formula Feeding Hindered Exclusive Breastfeeding: Breastfeeding Self-Efficacy as a Mediating Factor. Nutrients Liu, L., Wu, Y., Xian, X., Feng, J., Mao, Y., Balakrishnan, S., Weber, A. M., Darmstadt, G. L., Chen, Y., Sylvia, S., Zhou, H., Rozelle, S. 2023; 15 (24)


    Breastfeeding self-efficacy (BSE), defined as a mother's confidence in her ability to breastfeed, has been confirmed to predict the uptake of exclusive breastfeeding (EBF). Early experiences during the birth hospital stay, especially in-hospital formula feeding (IHFF), can impact both EBF and maternal breastfeeding confidence. Therefore, our objective was to examine the association between IHFF and EBF outcomes and investigate whether this association is influenced by BSE. The study included 778 infants from a larger cohort study conducted in 2021, with a one-year follow-up in rural areas of Sichuan Province, China. We used a causal mediation analysis to estimate the total effect (TE), natural direct (NDE), and nature indirect effects (NIE) using the paramed command in Stata. Causal mediation analyses revealed that IHFF was negatively associated with EBF (TE odds ratio = 0.47; 95% CI, 0.29 to 0.76); 28% of this association was mediated by BSE. In the subgroup analysis, there were no significant differences in the effects between parity subgroups, as well as between infant delivery subgroups. Our study found that IHFF hindered later EBF and that BSE mediated this association. Limiting the occurrence of in-hospital formula feeding or improving maternal breastfeeding self-efficacy is likely to improve exclusive breastfeeding outcomes.

    View details for DOI 10.3390/nu15245074

    View details for PubMedID 38140332

    View details for PubMedCentralID PMC10746093

  • Effectiveness of ten-valent pneumococcal conjugate vaccine on invasive pneumococcal disease among children <2 years old: A prospective population-based study in rural Bangladesh. Vaccine Malaker, R., Hasanuzzaman, M., Hooda, Y., Rahman, H., Chandra Das, R., Kanon, N., Saha, S., Tanmoy, A. M., Ranjan Chakraborty, S., Saha, S., Islam, M., Darmstadt, G. L., Baqui, A. H., Sathosam, M., El-Arifeen, S., Whitney, C. G., Saha, S. K. 2023


    The 10-valent pneumococcal conjugate vaccine (PCV10) was introduced in March 2015 in Bangladesh. In this study, we aimed to estimate the impact of PCV10 on invasive pneumococcal disease (IPD) identified by blood cultures and severe pneumonia identified clinically and its effectiveness on invasive disease caused by vaccine serotypes. We conducted population-based surveillance among children aged 2- <24 months between April 2012 through March 2019 in Mirzapur, a rural sub-district of Bangladesh. We compared incidence of IPD and severe pneumonia before (April 2012 to March 2015) and after (April 2015 to March 2019) the introduction of PCV10. Vaccine effectiveness was measured using an indirect cohort analysis of data from four sentinel sites in which PCV10 vaccination status was compared between children with IPD caused by vaccine serotype vs. non-vaccine serotypes. We identified 24 IPD cases by blood culture and 1,704 severe pneumonia hospitalizations during the surveillance period. IPD incidence in under-2-year-old children fell 25 % (95 % CI: -1.2 % to 76 %; p-value = 0.59) from 106 cases per 100,000 child-years at baseline to 79.3 in April 2018- March 2019. Vaccine serotype-IPD incidence was lower (77 % reduction, 95 % CI: -0.45 % to 96 %; p-value = 0.068) in April 2018 - March 2019 than in the pre-vaccine period (85.7 cases to 19.8/100,000 child-years). A significant decline of 54.0 % (95 % CI: 47.0 % to 59.0 %; p-value < 0.001) was observed in hospitalizations due to severe pneumonia. From indirect cohort analysis, the effectiveness of PCV10 against vaccine serotype IPD was 37 % (95 % CI: -141.0 % to 83.5 %; p = 0.5) after the 1st dose and 63.1 % (95 % CI: -3.3 % to 85.9 %, p = 0.0411) after the 2nd or the 3rd dose. This study demonstrates that PCV10 introduction prevented hospitalizations with severe pneumonia and provided individual protection against vaccine serotypes.

    View details for DOI 10.1016/j.vaccine.2023.12.007

    View details for PubMedID 38071104

  • Strengthening theories of change in women's group interventions to improve learning. Journal of global health Anderson, C. L., Toole, R., Schmidt, C., Darmstadt, G. L. 2023; 13: 04098


    Supporting women's groups is increasingly seen as an important intervention strategy for advancing women's empowerment, economic outcomes, and family health in low- and middle-income countries. We argue that learning from investments in women's group platforms is often limited by the lack of a well-articulated, evaluable theory of change (ToC) developed by those designing the programmes.We first identify a simple set of steps important to specifying a ToC that is evaluable and supports learning (what could be done). We then propose a framework in which we hope social scientists can find a common starting point (reconciling what could be and is being done). The framework emphasises identifying untested assumptions around pathways for introducing and adopting new knowledge, opportunities, technologies, interventions or implementation approaches, and pathways from group participation to behaviour change. Finally, we apply this framework to a portfolio of 46 women's groups investments made by the Bill and Melinda Gates Foundation between 2005 and 2017 to understand the prevalence and clarity of their grantees' theories of change (some of what is done).The majority of the investment documents reviewed did not make clear the embedded assumptions or hypothesised pathways from decisions to join a group, to women's group participation, to behaviour change and and whether pathways are connected or work independently.We use an example from an actual investment to illustrate how this framework can support accounting for assumptions in the ToC used to guide the evaluation, the testing and measuring of mechanisms assumed to be driving behaviour change and disentangling the effects of implementationfrom context. A ToC for group-based programmes should specify in what capacities the group-based model is essential to the hypothesised pathways of impact vs. its role as an efficient delivery mechanism for programmes that would potentially generate impacts even if delivered directly to individuals. In addition, without fully specifying the motivation for individuals to change behaviour in terms of their risk/return calculus and testing underlying assumptions, we miss an opportunity to better understand the pathways for how the programme influences or fails to influence individuals' health behaviours. However, fully specifying (and measuring) every link in the programme's ToC is not costless. We present suggestions for developing ToCs with testable hypotheses that foster learning about why a women's group intervention achieved or failed to achieve its intended impact.

    View details for DOI 10.7189/jogh.13.04098

    View details for PubMedID 38038374

  • Transforming women's, children's, and adolescents' health and wellbeing through primary health care LANCET Homer, C., Abajobir, A., Agarwal, K., Agustina, R., Albuhairan, F., Ariff, S., Kumararora, N., Aryeetey, R., Ashorn, P., Azzopardi, P., Bazirete, O., Berkley, J., Darmstadt, G. L., Dewey, K., Duke, T., El Kak, F., Jehan, F., Kabiru, C., Kanbur, N., Kirkwood, B., Klein, J., Garcia, D., Postma, S., Richter, L., Sandall, J., Suwantika, A., Ahmed, N., Waiswa, P., Walker, D., Zlotkin, S., WHO Strategic Tech Advisory Grp 2023; 402 (10413): 1606-1608
  • Variation in rates of sexual assault crisis counsellor usage during forensic examination in California: an observational study. BMJ open Serenska, A., Sarnquist, C. C., Darmstadt, G. L. 2023; 13 (10): e072635


    A critical asset to post-assault care of survivors is support from sexual assault crisis counsellors (SACCs). We sought to elucidate variation in implementation between California counties in SACC accompaniment during Sexual Assault Forensic Examination (SAFE).SACC attendance data from 2019 was obtained from the California Governor's Office of Emergency Services (CalOES). To assess SACC attendance rates during SAFEs, we requested SAFE quantity data from sheriffs and public health departments, the State Forensic Bureau, and the California Department of Justice (DOJ), but all requests were unanswered or denied. We also sought SAFE data from District Attorneys (DAs) in each county, and received responses from Marin and Contra Costa Counties. To estimate numbers of SAFEs per county, we gathered crime statistics from the Federal Bureau of Investigation's (FBI's) Uniform Crime Reporting Program and OpenJustice, a transparency initiative by the California DOJ. For each data source, we compared SACC attendance to SAFE quantities and incidences of sexual assault statewide.At the state level, data on SACC attendance per CalOES and DOJ archival data on sexual assault were used to approximate relative rates of SACC accompaniment at SAFEs; 83% (30 of 36) of counties had values <50%. The joint sexual assault crisis centre for Contra Costa and Marin Counties reported that 140 SACCs were dispatched in 2019, while DAs in Contra Costa and Marin reported completion of 87 SAFEs in 2019, for a calculated SACC accompaniment rate of 161%. Proxy data sourced from FBI and DOJ crime statistics displayed significant inconsistencies, and DOJ data was internally inconsistent.SACC accompaniment at SAFEs appears to be low in most California counties, however, limited data accessibility and data discrepancies and inaccuracies (e.g., rates over 100%) prevented reliable determination of SACC accompaniment rates during SAFEs. Substantial improvements in data accuracy and transparency are needed to ensure survivors' adequate access to resources.

    View details for DOI 10.1136/bmjopen-2023-072635

    View details for PubMedID 37865414

  • Effects of an educational planetary plate graphic on meat consumption in aStanford University dining hall: a randomized controlled trial. BMC nutrition Marcone, A. L., Darmstadt, G. L., Challamel, G. A., Mathur, M. B., Gardner, C. D. 2023; 9 (1): 106


    BACKGROUND: Assess the impact of an educational Planetary Health Plate (PHP) graphic on meat-related dietary choices of Stanford University dining hall patrons using a randomized controlled trial crossover design. All patrons entering the dining hall during study periods were enrolled as participants. Control, n=631; PHP, n=547.METHODS: Compare dietary behavior without signage to behavior while exposed to PHP during four equivalent dinner meals. The primary outcome was total meat-dish weight adjusted for the number of people entering the dining hall. Secondary outcomes included the number of meat-dish servings and average meat-dish serving weight. Analysis using T-tests, Poisson generalized linear model.RESULTS: Differences in total meat-dish weight, (1.54kg; 95% Confidence Interval [CI]=-4.41,1.33; P=.19) and average meat-dish serving weight (0.03kg; 95% CI=0.00, 0.06; P=.07) between PHP and control patrons did not reach significance. The rate at which PHP patrons took meat was significantly lower (Incidence Rate Ratio 0.80; 95% CI=0.71, 0.91; P<.001).CONCLUSION: Exposure to an educational plate graphic decreased the proportion of patrons taking meat but had no impact on total meat consumption or meat-dish serving weight. Statistical methods used in this study may inform future investigations on dietary change in the dining hall setting. Further research on the role of educational signage in influencing dietary behavior is warranted, with an aim to improve human health and environmental sustainability.TRIAL REGISTRATION:, NCT05565859, registered 4 October 2022.

    View details for DOI 10.1186/s40795-023-00764-3

    View details for PubMedID 37749609

  • New World Health Organization recommendations for care of preterm or low birth weight infants: health policy ECLINICALMEDICINE Darmstadt, G. L., Al Jaifi, N., Arif, S., Bahl, R., Blennow, M., Cavallera, V., Chou, D., Chou, R., Comrie-Thomson, L., Edmond, K., Feng, Q., Riera, P., Grummer-Strawn, L., Gupta, S., Hill, Z., Idowu, A., Kenner, C., Kirabira, V., Klinkott, R., De Leon-Mendoza, S., Mader, S., Manji, K., Marriott, R., Morgues, M., Nangia, S., Portela, A., Rao, S., Shahidullah, M., Tran, H., Weeks, A., Worku, B., Yunis, K., Care Preterm Low Birthweight Infa 2023; 63: 102155


    Approximately 11% of infants are born preterm, and complications of prematurity are the most common cause of death in children aged under five years. Almost one million preterm infants die each year across low, high and middle income countries. In 2021, the World Health Organization (WHO) convened a Guideline Development Group (GDG) to examine evidence and formulate recommendations for care of preterm or low birthweight (LBW) infants according to WHO Guideline Review Committee (GRC) criteria. GRADE methods were used to assess the certainty of evidence and the GDG developed judgements using the DECIDE (Developing and Evaluating Communication strategies to support Informed Decisions and practice based on Evidence) framework. Twenty-five recommendations were made; 11 recommendations were new, and 16 were for preventive and promotive care. Kangaroo Mother Care (KMC) was recommended to start immmediately after birth as routine care for all preterm or LBW newborns (except for critically ill infants who are in shock, unable to breath spontaneously after resuscitation, or require ventilatory support) both in the facility and at home. New recommendations were also made for caffeine to treat apnoea and for extubation; family involvement in routine care for preterm or LBW infants; and for post-discharge home-visit follow-up care. New recommendations were also made to consider use of probiotics, emollient therapy, caffeine for prevention of apnoea, continuous positive airway pressure (CPAP) immediately after birth (with or without respiratory distress) in infants less than 32 weeks gestational age; and for family support to enable the care of preterm or LBW infants. The recommendations confirm the pivotal role of preventive and promotive care for preterm and LBW infants, especially the importance of keeping the baby and mother together, and empowering and supporting families to care for their preterm or LBW infant. WHO is now working to help scale up care for small and sick newborns, including organizational shifts in all 'health system building blocks' such as infrastructure, commodities, workforce and monitoring.Nil.

    View details for DOI 10.1016/j.eclinm.2023.102155

    View details for Web of Science ID 001094646200001

    View details for PubMedID 37753445

    View details for PubMedCentralID PMC10518507

  • Research priorities for care of preterm or low birth weight infants: health policy HEALTH POLICY Darmstadt, G. L., Al Jaifi, N., Ariff, S., Bahl, R., Blennow, M., Cavallera, V., Chou, D., Chou, R., Comrie-Thomson, L., Edmond, K., Feng, Q., Riera, P., Grummer-Strawn, L., Gupta, S., Hill, Z., Idowu, A., Kenner, C., Kirabira, V., Klinkott, R., De Leon-Mendoza, S., Mader, S., Manji, K., Marriott, R., Morgues, M., Nangia, S., Rao, S., Shahidullah, M., Tran, H., Weeks, A. D., Worku, B., Yunis, K., Care Preterm Low Birthweight Infa 2023; 63: 102126


    Research priorities for preterm or low birth weight (LBW) infants were advanced in 2012, and other research priority-setting exercises since then have included more limited, context-specific research priorities pertaining to preterm infants. While developing new World Health Organization (WHO) guidelines for care of preterm or LBW infants, we conducted a complementary research prioritisation exercise. A diverse, globally representative guideline development group (GDG) of experts - all authors of this paper along with WHO steering group for preterm-LBW guidelines - was assembled by the WHO to examine evidence and consider a variety of factors in intervention effectiveness and implementation, leading to 25 new recommendations and one good practice statement for care of preterm or LBW infants. The GDG generated research questions (RQs) based on contributions to improvements in care and outcomes of preterm or LBW infants, public health impacts, answerability, knowledge gaps, feasibility of implementation, and promotion of equity, and then ranked the RQs based on their likelihood to further change or influence the WHO guidelines for the care of preterm or LBW infants in the future. Thirty-six priority RQs were identified, 32 (89%) of which focused on aspects of intervention effectiveness, and the remaining four addressed implementation ("how") questions. Of the top 12 RQs, seven focused on further advancing new recommendations - such as family involvement and support in caring for preterm or LBW infants, emollient therapy, probiotics, immediate KMC for critically ill newborns, and home visits for post-discharge follow-up of preterm or LBW infants - and three RQs addressed issues of feeding (breastmilk promotion, milk banks, individualized feeding). RQs prioritised here will be critical for optimising the effectiveness and delivery of new WHO recommendations for care of preterm or LBW infants. The RQs encompass unanswered research priorities for preterm or LBW infants from prior prioritisation exercises which were conducted using Child Health and Nutrition Research Initiative (CHNRI) methodology.Nil.

    View details for DOI 10.1016/j.eclinm.2023.102126

    View details for Web of Science ID 001083140100001

    View details for PubMedID 37753444

    View details for PubMedCentralID PMC10518498

  • The burden of antimicrobial resistance in the Americas in 2019: a cross-country systematic analysis LANCET REGIONAL HEALTH-AMERICAS Aguilar, G., Swetschinski, L. R., Weaver, N., Ikuta, K. S., Mestrovic, T., Gray, A. P., Chung, E., Wool, E. E., Han, C., Hayoon, A., Araki, D. T., Abdollahi, A., Abu-Zaid, A., Adnan, M., Agarwal, R., Dehkordi, J., Aravkin, A. Y., Areda, D., Azzam, A. Y., Berezin, E. N., Bhagavathula, A., Bhutta, Z. A., Bhuyan, S. S., Browne, A. J., Castaneda-Orjuela, C. A., Chandrasekar, E. K., Ching, P. R., Dai, X., Darmstadt, G. L., De la Hoz, F., Diao, N., Diaz, D., dos Santos, W., Eyre, D., Garcia, C., Haines-Woodhouse, G., Hassen, M., Henry, N. J., Hopkins, S., Hossain, M., Iregbu, K., Iwu, C. D., Jacobs, J., Janko, M. M., Jones, R., Karaye, I. M., Khalil, I. A., Khan, I. A., Khan, T., Khubchandani, J., Khusuwan, S., Kisa, A., Koyaweda, G., Krapp, F., Kumaran, E. P., Kyu, H., Lim, S. S., Liu, X., Luby, S., Maharaj, S. B., Maronga, C., Martorell, M., May, J., McManigal, B., Mokdad, A. H., Moore, C. E., Mostafavi, E., Murillo-Zamora, E., Mussi-Pinhata, M., Nanavati, R., Nassereldine, H., Natto, Z. S., Qamar, F., Nunez-Samudio, V., Ochoa, T. J., Ojo-Akosile, T. R., Olagunju, A. T., Olivas-Martinez, A., Ortiz-Brizuela, E., Ounchanum, P., Paredes, J. L., Patthipati, V., Pawar, S., Pereira, M., Pollard, A., Ponce-De-Leon, A., Prates, E., Qattea, I., Reyes, L., Roilides, E., Rosenthal, V., Rudd, K. E., Sangchan, W., Seekaew, S., Seylani, A., Shababi, N., Sham, S., Sifuentes-Osornio, J., Singh, H., Stergachis, A., Tasak, N., Tat, N. Y., Thaiprakong, A., Valdez, P. R., Yada, D. Y., Yunusa, I., Zastrozhin, M., Hay, S. I., Dolecek, C., Sartorius, B., Murray, C. L., Naghavi, M., Antimicrobial Resistance Colla 2023; 25: 100561


    Antimicrobial resistance (AMR) is an urgent global health challenge and a critical threat to modern health care. Quantifying its burden in the WHO Region of the Americas has been elusive-despite the region's long history of resistance surveillance. This study provides comprehensive estimates of AMR burden in the Americas to assess this growing health threat.We estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with AMR for 23 bacterial pathogens and 88 pathogen-drug combinations for countries in the WHO Region of the Americas in 2019. We obtained data from mortality registries, surveillance systems, hospital systems, systematic literature reviews, and other sources, and applied predictive statistical modelling to produce estimates of AMR burden for all countries in the Americas. Five broad components were the backbone of our approach: the number of deaths where infection had a role, the proportion of infectious deaths attributable to a given infectious syndrome, the proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of pathogens resistant to an antibiotic class, and the excess risk of mortality (or duration of an infection) associated with this resistance. We then used these components to estimate the disease burden by applying two counterfactual scenarios: deaths attributable to AMR (compared to an alternative scenario where resistant infections are replaced with susceptible ones), and deaths associated with AMR (compared to an alternative scenario where resistant infections would not occur at all). We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity.We estimated 569,000 deaths (95% UI 406,000-771,000) associated with bacterial AMR and 141,000 deaths (99,900-196,000) attributable to bacterial AMR among the 35 countries in the WHO Region of the Americas in 2019. Lower respiratory and thorax infections, as a syndrome, were responsible for the largest fatal burden of AMR in the region, with 189,000 deaths (149,000-241,000) associated with resistance, followed by bloodstream infections (169,000 deaths [94,200-278,000]) and peritoneal/intra-abdominal infections (118,000 deaths [78,600-168,000]). The six leading pathogens (by order of number of deaths associated with resistance) were Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Streptococcus pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. Together, these pathogens were responsible for 452,000 deaths (326,000-608,000) associated with AMR. Methicillin-resistant S. aureus predominated as the leading pathogen-drug combination in 34 countries for deaths attributable to AMR, while aminopenicillin-resistant E. coli was the leading pathogen-drug combination in 15 countries for deaths associated with AMR.Given the burden across different countries, infectious syndromes, and pathogen-drug combinations, AMR represents a substantial health threat in the Americas. Countries with low access to antibiotics and basic health-care services often face the largest age-standardised mortality rates associated with and attributable to AMR in the region, implicating specific policy interventions. Evidence from this study can guide mitigation efforts that are tailored to the needs of each country in the region while informing decisions regarding funding and resource allocation. Multisectoral and joint cooperative efforts among countries will be a key to success in tackling AMR in the Americas.Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.

    View details for DOI 10.1016/j.lana.2023.100561

    View details for Web of Science ID 001094633400001

    View details for PubMedID 37727594

    View details for PubMedCentralID PMC10505822

  • Comparative predictive power of serum vs plasma proteomic signatures in feto-maternal medicine. AJOG global reports Espinosa, C., Ali, S. M., Khan, W., Khanam, R., Pervin, J., Price, J. T., Rahman, S., Hasan, T., Ahmed, S., Raqib, R., Rahman, M., Aktar, S., Nisar, M. I., Khalid, J., Dhingra, U., Dutta, A., Deb, S., Stringer, J. S., Wong, R. J., Shaw, G. M., Stevenson, D. K., Darmstadt, G. L., Gaudilliere, B., Baqui, A. H., Jehan, F., Rahman, A., Sazawal, S., Vwalika, B., Aghaeepour, N., Angst, M. S. 2023; 3 (3): 100244


    Blood proteins are frequently measured in serum or plasma, because they provide a wealth of information. Differences in the ex vivo processing of serum and plasma raise concerns that proteomic health and disease signatures derived from serum or plasma differ in content and quality. However, little is known about their respective power to predict feto-maternal health outcomes. Predictive power is a sentinel characteristic to determine the clinical use of biosignatures.This study aimed to compare the power of serum and plasma proteomic signatures to predict a physiological pregnancy outcome.Paired serum and plasma samples from 73 women were obtained from biorepositories of a multinational prospective cohort study on pregnancy outcomes. Gestational age at the time of sampling was the predicted outcome, because the proteomic signatures have been validated for such a prediction. Multivariate and cross-validated models were independently derived for serum and plasma proteins.A total of 1116 proteins were measured in 88 paired samples from 73 women with a highly multiplexed platform using proximity extension technology (Olink Proteomics Inc, Watertown, MA). The plasma proteomic signature showed a higher predictive power (R=0.64; confidence interval, 0.42-0.79; P=3.5×10-6) than the serum signature (R=0.45; confidence interval, 0.18-0.66; P=2.2×10-3). The serum signature was validated in plasma with a similar predictive power (R=0.58; confidence interval, 0.34-0.75; P=4.8×10-5), whereas the plasma signature was validated in serum with reduced predictive power (R=0.53; confidence interval, 0.27-0.72; P=2.6×10-4). Signature proteins largely overlapped in the serum and plasma, but the strength of association with gestational age was weaker for serum proteins.Findings suggest that serum proteomics are less informative than plasma proteomics. They are compatible with the view that the partial ex-vivo degradation and modification of serum proteins during sample processing are an underlying reason. The rationale for collecting and analyzing serum and plasma samples should be carefully considered when deriving proteomic biosignatures to ascertain that specimens of the highest scientific and clinical yield are processed. Findings suggest that plasma is the preferred matrix.

    View details for DOI 10.1016/j.xagr.2023.100244

    View details for PubMedID 37456144

    View details for PubMedCentralID PMC10339042

  • Neonatal emollient therapy and massage practices in Africa: a scoping review. International health Blanks, K. J., Musaba, M. W., Ren, L., Burgoine, K., Mukunya, D., Clarke, A., Williams, S., Gebremichael, T., Waiswa, P., Darmstadt, G. L. 2023


    There have been few reports from Africa on the use and health effects of emollient therapy for newborn infants. We aimed to describe neonatal skin care practices in Africa, and to illuminate opportunities to introduce evidence-based interventions to improve these practices. We conducted a scoping review of the quantitative and qualitative published peer-reviewed and grey literature in English on emollient use in Africa. Outcomes of interest included neonatal skin care practices, with a focus on the application of oils and other products to infant skin, including in association with bathing and massage. We screened 5257 articles and summarised findings from 23 studies-13 qualitative, nine quantitative and one mixed methods-that met our study criteria. Seven studies reported the use of emollients for perceived benefits, including thermal care, treatment for illness, promotion of growth and development, infection reduction, skin condition improvement, spirituality and lubrication to aid massage. Four studies reported the quantitative health impact of skin care product applications, including improvements in skin condition, neurodevelopment and bone growth, as well as a reduction in nosocomial infections. This review highlights opportunities for skin care intervention and future research on neonatal skin care practices in Africa.

    View details for DOI 10.1093/inthealth/ihad052

    View details for PubMedID 37480339

  • Associations of in-hospital postpartum feeding experiences with exclusive breastfeeding practices among infants in rural Sichuan, China. International breastfeeding journal Weber, A. M., Guo, Y., Zhang, E., Gruber, S., Medina, A., Zhou, H., Darmstadt, G. L. 2023; 18 (1): 34


    BACKGROUND: In rural China, exclusive breastfeeding (EBF) prevalence is low and hospitals often fail to attain baby-friendly feeding objectives, such as≥75% of newborns exclusively breastfed from birth to discharge. Empirical evidence for the impact of increased hospital compliance with recommended feeding guidelines on continued EBF in rural China is lacking. We sought to measure and model the association of newborns' in-hospital feeding experiences with EBF practice in infancy to inform policies for EBF promotion.METHODS: Data were cross-sectional from 785 caregivers of infants<6months of age, collected from November to December 2019 in four underdeveloped counties/districts in Sichuan Province. In-hospital feeding practices were determined, and prevalence of current infant feeding practices was calculated from 24-h recall and categorized according to WHO/UNICEF Infant and Young Child Feeding categories as EBF, breastfed with non-milk liquids, mixed feeding, breastfed with solids, and not breastfed. Relative risk ratios were estimated using adjusted multinomial logistic regression to examine risk factors for non-EBF practices compared to EBF, including in-hospital feeding experiences. The regression model was used to investigate change in EBF prevalence under alternative in-hospital experiences.RESULTS: Only 38.1% of under-six-month-old infants were being exclusively breastfed when data were collected; 61.8% and 77.6% had been fed water and infant formula, respectively, in the hospital. Infants who were fed water or formula before discharge were estimated as 2-3 times as likely to be non-EBF than EBF up to age six months. According to our model, EBF prevalence would have increased to 53.7% (95% confidence interval (CI) 46.1, 61.2) had≥75% of infants been exclusively breastfed and water-based feeds eliminated in-hospital.CONCLUSIONS: Given the importance of infants' first feeding experiences in the establishment and continuation of EBF, it is imperative that rural Chinese hospitals actively seek to limit infant formula feeds to medically indicated situations and eliminate water-based feeds.

    View details for DOI 10.1186/s13006-023-00567-z

    View details for PubMedID 37443078

  • Development of a Urine Metabolomics Biomarker-Based Prediction Model for Preeclampsia during Early Pregnancy. Metabolites Zhang, Y., Sylvester, K. G., Jin, B., Wong, R. J., Schilling, J., Chou, C. J., Han, Z., Luo, R. Y., Tian, L., Ladella, S., Mo, L., Maric, I., Blumenfeld, Y. J., Darmstadt, G. L., Shaw, G. M., Stevenson, D. K., Whitin, J. C., Cohen, H. J., McElhinney, D. B., Ling, X. B. 2023; 13 (6)


    Preeclampsia (PE) is a condition that poses a significant risk of maternal mortality and multiple organ failure during pregnancy. Early prediction of PE can enable timely surveillance and interventions, such as low-dose aspirin administration. In this study, conducted at Stanford Health Care, we examined a cohort of 60 pregnant women and collected 478 urine samples between gestational weeks 8 and 20 for comprehensive metabolomic profiling. By employing liquid chromatography mass spectrometry (LCMS/MS), we identified the structures of seven out of 26 metabolomics biomarkers detected. Utilizing the XGBoost algorithm, we developed a predictive model based on these seven metabolomics biomarkers to identify individuals at risk of developing PE. The performance of the model was evaluated using 10-fold cross-validation, yielding an area under the receiver operating characteristic curve of 0.856. Our findings suggest that measuring urinary metabolomics biomarkers offers a noninvasive approach to assess the risk of PE prior to its onset.

    View details for DOI 10.3390/metabo13060715

    View details for PubMedID 37367874

  • Multiomic signals associated with maternal epidemiological factors contributing to preterm birth in low- and middle-income countries. Science advances Espinosa, C. A., Khan, W., Khanam, R., Das, S., Khalid, J., Pervin, J., Kasaro, M. P., Contrepois, K., Chang, A. L., Phongpreecha, T., Michael, B., Ellenberger, M., Mehmood, U., Hotwani, A., Nizar, A., Kabir, F., Wong, R. J., Becker, M., Berson, E., Culos, A., De Francesco, D., Mataraso, S., Ravindra, N., Thuraiappah, M., Xenochristou, M., Stelzer, I. A., Marić, I., Dutta, A., Raqib, R., Ahmed, S., Rahman, S., Hasan, A. S., Ali, S. M., Juma, M. H., Rahman, M., Aktar, S., Deb, S., Price, J. T., Wise, P. H., Winn, V. D., Druzin, M. L., Gibbs, R. S., Darmstadt, G. L., Murray, J. C., Stringer, J. S., Gaudilliere, B., Snyder, M. P., Angst, M. S., Rahman, A., Baqui, A. H., Jehan, F., Nisar, M. I., Vwalika, B., Sazawal, S., Shaw, G. M., Stevenson, D. K., Aghaeepour, N. 2023; 9 (21): eade7692


    Preterm birth (PTB) is the leading cause of death in children under five, yet comprehensive studies are hindered by its multiple complex etiologies. Epidemiological associations between PTB and maternal characteristics have been previously described. This work used multiomic profiling and multivariate modeling to investigate the biological signatures of these characteristics. Maternal covariates were collected during pregnancy from 13,841 pregnant women across five sites. Plasma samples from 231 participants were analyzed to generate proteomic, metabolomic, and lipidomic datasets. Machine learning models showed robust performance for the prediction of PTB (AUROC = 0.70), time-to-delivery (r = 0.65), maternal age (r = 0.59), gravidity (r = 0.56), and BMI (r = 0.81). Time-to-delivery biological correlates included fetal-associated proteins (e.g., ALPP, AFP, and PGF) and immune proteins (e.g., PD-L1, CCL28, and LIFR). Maternal age negatively correlated with collagen COL9A1, gravidity with endothelial NOS and inflammatory chemokine CXCL13, and BMI with leptin and structural protein FABP4. These results provide an integrated view of epidemiological factors associated with PTB and identify biological signatures of clinical covariates affecting this disease.

    View details for DOI 10.1126/sciadv.ade7692

    View details for PubMedID 37224249

  • WHO Global Position Paper and Implementation Strategy on kangaroo mother care call for fundamental reorganisation of maternal-infant care. Lancet (London, England) Darmstadt, G. L., Kirkwood, B., Gupta, S. 2023

    View details for DOI 10.1016/S0140-6736(23)01000-0

    View details for PubMedID 37207686

  • Perceptions, beliefs, and current practices regarding neonatal skin care and emollient use in eastern Uganda: a qualitative study. BMC pediatrics Wenani, D., Burgoine, K., Williams, S. L., Musaba, M., Gebremichael, T., Clarke, A., Blanks, K. J., Nantale, R., Nawanga, J., Kiguli, S., English, M., Waiswa, P., Darmstadt, G. L., Matovu, J. K., Mukunya, D. 2023; 23 (1): 223


    BACKGROUND: The skin is a major route of infection in the neonatal period, especially in low birthweight (LBW) infants. Appropriate and safe neonatal skin care practices are required to reduce this risk. The perceptions and beliefs of mothers and other caregivers towards various neonatal skin care practices in our setting have been documented. Data from Asia suggests that the application of emollient to the skin of LBW infants can promote growth, reduce serious neonatal infections, and potentially reduce mortality. This is the first study to explore the acceptability of emollients and massage as part of neonatal skin care in a low-resource setting in sub-Saharan Africa (SSA) that is representative of the majority of government health facilities in Uganda and many in SSA.OBJECTIVE: To explore perceptions, beliefs, and current practices regarding neonatal skin care and emollient use in eastern Uganda.METHODS: We conducted a qualitative study consisting of three focus group discussions (30 participants), eight in-depth interviews with mothers/caregivers of preterm and term neonates and 12 key informant interviews with midwives, doctors and community health workers involved in neonatal care, to explore the perceptions and practices surrounding neonatal skin care and emollient use. Data collected were transcribed and analyzed using thematic content analysis.RESULTS: Mothers perceived that skin care began in utero. Skincare practices depended on the place of delivery; for deliveries in a health facility the skincare practices were mainly based on the health worker's advice. Vernix caseosa was often washed off due to its perceived undesirability and was attributed to sexual intercourse in the last trimester. Despite their deleterious attributes found in previous studies, petrolatum-based oils, petrolatum-based jellies and talcum baby powders were the most commonly reported items used in neonatal skin care. In our population, there was high acceptability of emollient therapy use; however, neonatal massage was treated with scepticism as mothers feared damaging the vulnerable neonate. Mothers suggested massage and emollient application be undertaken by health workers, if it becomes an intervention.CONCLUSIONS: In eastern Uganda, the perceptions and beliefs of mothers/caregivers toward neonatal skincare influenced their practices of which some could potentially be beneficial, and others harmful. Emollient use would be easily accepted if adequate sensitisation is conducted and using the gatekeepers such as health workers.

    View details for DOI 10.1186/s12887-023-04040-y

    View details for PubMedID 37147698

  • Universal research index: An inclusive metric to quantify scientific research output JOURNAL OF ACADEMIC LIBRARIANSHIP Keshavarz-Fathi, M., Yazdanpanah, N., Kolahchi, S., Ziaei, H., Darmstadt, G. L., Dorigo, T., Dochy, F., Levin, L., Thongboonkerd, V., Ogino, S., Chen, W., Perc, M., Tremblay, M. S., Olusanya, B. O., Rao, I. M., Hatziargyriou, N., Moradi-Lakeh, M., Bella, F., Rosivall, L., Gandomi, A. H., Sorooshian, A., Gupta, M., Gal, C., Lozano, A. M., Weaver, C., Tanzer, M., Poggi, A., Sepanlou, S. G., Weiskirchen, R., Jambrak, A., Torres, P. J., Capanoglu, E., Barba, F. J., Ernest, C., Sigman, M., Pluchino, S., Gharehpetian, G. B., Fereshtehnejad, S., Yang, M., Thomas, S., Cai, W., Comini, E., Scolding, N. J., Myles, P. S., Nieto, J. J., Perry, G., Sedikides, C., Rezaeia, N., USERN Advisory Board Members 2023; 49 (3)
  • The needs of children born preterm are too often overlooked - Authors' reply. Lancet (London, England) Darmstadt, G. L., Mader, S., Edmond, K. 2023; 401 (10383): 1156-1157

    View details for DOI 10.1016/S0140-6736(23)00243-X

    View details for PubMedID 37030886

  • The needs of children born preterm are too often overlooked Reply LANCET Darmstadt, G. L., Mader, S., Edmond, K. 2023; 401 (10383): 1156-1157
  • Feasibility and acceptability of home-based neonatal hyperbilirubinemia screening by community health workers using transcutaneous bilimeters in Bangladesh. BMC pediatrics Rahman, M., Jahan, F., Billah, S. M., Yeasmin, F., Rahman, M. J., Jahir, T., Parvez, S. M., Das, J. B., Amin, R., Hossain, K., Grant, H., Hasan, R., Darmstadt, G. L., Hoque, M. M., Shahidullah, M., Islam, M. S., Ashrafee, S., Foote, E. M. 2023; 23 (1): 155


    BACKGROUND: Universal screening for neonatal hyperbilirubinemia risk assessment is recommended by the American Academy of Pediatrics to reduce related morbidity. In Bangladesh and in many low- and middle-income countries, there is no screening for neonatal hyperbilirubinemia. Furthermore, neonatal hyperbilirubinemia may not be recognized as a medically significant condition by caregivers and community members. We aimed to evaluate the acceptability and operational feasibility of community health worker (CHW)-led, home-based, non-invasive neonatal hyperbilirubinemia screening using a transcutaneous bilimeter in Shakhipur, a rural subdistrict in Bangladesh.METHODS: We employed a two-step process. In the formative phase, we conducted eight focus group discussions with parents and grandparents of infants and eight key informant interviews with public and private healthcare providers and managers to explore their current knowledge, perceptions, practices, and challenges regarding identification and management of neonatal hyperbilirubinemia. Next, we piloted a prenatal sensitization intervention and home-based screening by CHWs using transcutaneous bilimeters and evaluated the acceptability and operational feasibility of this approach through focus group discussions and key informant interviews with parents, grandparents and CHWs.RESULTS: Formative findings identified misconceptions regarding neonatal hyperbilirubinemia causes and health risks among caregivers in rural Bangladesh. CHWs were comfortable with adoption, maintenance and use of the device in routine home visits. Transcutaneous bilimeter-based screening was also widely accepted by caregivers and family members due to its noninvasive technique and immediate display of findings at home. Prenatal sensitization of caregivers and family members helped to create a supportive environment in the family and empowered mothers as primary caregivers.CONCLUSION: Adopting household neonatal hyperbilirubinemia screening in the postnatal period by CHWs using a transcutaneous bilimeter is an acceptable approach by both CHWs and families and may increase rates of screening to prevent morbidity and mortality.

    View details for DOI 10.1186/s12887-023-03969-4

    View details for PubMedID 37009866

  • Nurturing the nurturing care environment. The Lancet. Child & adolescent health Weber, A. M., Darmstadt, G. L. 2023

    View details for DOI 10.1016/S2352-4642(23)00054-8

    View details for PubMedID 37011651

  • Public leadership for gender equality: A framework and capacity development approach for gender transformative policy change. EClinicalMedicine Munive, A., Donville, J., Darmstadt, G. L. 2023; 56: 101798


    Public leadership is essential in social change, and pivotal in transforming social and institutional norms related to gender inequality, going well beyond equal representation. It must embrace the potential for all public health leaders, of all genders, to become agents of change who challenge gender injustices and institutionalise gender transformative policies and programmes in public health. To support officials, initially in Ethiopia, and catalyse transformative change, we created a new framework and capacity development approach - Public Leadership for Gender Equality (PL4GE) - which can be customised to respond to each country's context. Drawing from three areas of leadership thought - public, transformative, and feminist leadership - PL4GE takes a public values approach in positioning gender equality as a human right, a common good, and a means to improve health outcomes. PL4GE promotes six key leadership practices - defining purpose and articulating vision, co-creating public value, empowering people, fostering strategic partnerships, navigating power, and embodying personal commitment - and guides public leaders through a capacity development journey of change, facilitating them to identify and activate opportunities for gender transformative change in their work and in turn, more broadly within the public whom they serve.Funding: Bill & Melinda Gates Foundation INV-002664 to Stanford University.

    View details for DOI 10.1016/j.eclinm.2022.101798

    View details for PubMedID 36593791

  • Effect of the mHealth-supported Healthy Future programme delivered by community health workers on maternal and child health in rural China: study protocol for a cluster randomised controlled trial. BMJ open Chen, Y., Wu, Y., Dill, S. E., Guo, Y., Westgard, C. M., Medina, A., Weber, A. M., Darmstadt, G. L., Zhou, H., Rozelle, S., Sylvia, S. 2023; 13 (1): e065403


    Millions of young rural children in China still suffer from poor health and malnutrition, partly due to a lack of knowledge about optimal perinatal and child care among rural mothers and caregivers. Meanwhile, there is an urgent need to improve maternal mental health in rural communities. Comprehensive home visiting programmes delivered by community health workers (CHWs) can bridge the caregiver knowledge gap and improve child health and maternal well-being in low-resource settings, but the effectiveness of this approach is unknown in rural China. Additionally, grandmothers play important roles in child care and family decision-making in rural China, suggesting the importance of engaging multiple caregivers in interventions. The Healthy Future programme seeks to improve child health and maternal well-being by developing a staged-based curriculum that CHWs deliver to mothers and caregivers of young children through home visits with the assistance of a tablet-based mHealth system. This protocol describes the design and evaluation plan for this programme.We designed a cluster-randomised controlled trial among 119 rural townships in four nationally designated poverty counties in Southwestern China. We will compare the outcomes between three arms: one standard arm with only primary caregivers participating in the intervention, one encouragement arm engaging primary and secondary caregivers and one control arm with no intervention. Families with pregnant women or infants under 6 months of age are invited to enrol in the 12-month study. Primary outcomes include children's haemoglobin levels, exclusive breastfeeding rates and dietary diversity in complementary feeding. Secondary outcomes include a combination of health, behavioural and intermediate outcomes.Ethical approval has been provided by Stanford University, Sichuan University and the University of Nevada, Reno. Trial findings will be disseminated through national and international peer-reviewed publications and conferences.ISRCTN16800789.

    View details for DOI 10.1136/bmjopen-2022-065403

    View details for PubMedID 36669837

  • Improving planetary health is integral to improving children's health-a call to action. Pediatric research Sampath, V., Nadeau, K. C., Ebi, K. L., Narvaez, D., Tessema, M. T., Pak-Gorstein, S., Darmstadt, G. L. 2022


    IMPACT: This article summarizes the adverse effects of climate and environmental change on children's health. We call for policy change, education, and advocacy to halt further deterioration of planetary health and for specific measures to prevent the negative effects of climate and environmental change on children's health. We offer an agenda for research, policy change, and healthcare practices to improve the resilience of pediatric populations in the face of climate change.

    View details for DOI 10.1038/s41390-022-02432-x

    View details for PubMedID 36564478

  • Early prediction and longitudinal modeling of preeclampsia from multiomics. Patterns (New York, N.Y.) Maric, I., Contrepois, K., Moufarrej, M. N., Stelzer, I. A., Feyaerts, D., Han, X., Tang, A., Stanley, N., Wong, R. J., Traber, G. M., Ellenberger, M., Chang, A. L., Fallahzadeh, R., Nassar, H., Becker, M., Xenochristou, M., Espinosa, C., De Francesco, D., Ghaemi, M. S., Costello, E. K., Culos, A., Ling, X. B., Sylvester, K. G., Darmstadt, G. L., Winn, V. D., Shaw, G. M., Relman, D. A., Quake, S. R., Angst, M. S., Snyder, M. P., Stevenson, D. K., Gaudilliere, B., Aghaeepour, N. 2022; 3 (12): 100655


    Preeclampsia is a complex disease of pregnancy whose physiopathology remains unclear. We developed machine-learning models for early prediction of preeclampsia (first 16weeks of pregnancy) and over gestation by analyzing six omics datasets from a longitudinal cohort of pregnant women. For early pregnancy, a prediction model using nine urine metabolites had the highest accuracy and was validated on an independent cohort (area under the receiver-operating characteristic curve [AUC]= 0.88, 95% confidence interval [CI] [0.76, 0.99] cross-validated; AUC= 0.83, 95% CI [0.62,1] validated). Univariate analysis demonstrated statistical significance of identified metabolites. An integrated multiomics model further improved accuracy (AUC= 0.94). Several biological pathways were identified including tryptophan, caffeine, and arachidonic acid metabolisms. Integration with immune cytometry data suggested novel associations between immune and proteomic dynamics. While further validation in a larger population is necessary, these encouraging results can serve as a basis for a simple, early diagnostic test for preeclampsia.

    View details for DOI 10.1016/j.patter.2022.100655

    View details for PubMedID 36569558

  • Updated WHO recommendations on antenatal corticosteroids and tocolytic therapy for improving preterm birth outcomes LANCET GLOBAL HEALTH Vogel, J. P., Ramson, J., Darmstadt, G. L., Qureshi, Z. P., Chou, D., Bahl, R., Oladapo, O. T. 2022; 10 (12): E1707-E1708
  • Updated WHO recommendations on antenatal corticosteroids and tocolytic therapy for improving preterm birth outcomes. The Lancet. Global health Vogel, J. P., Ramson, J., Darmstadt, G. L., Qureshi, Z. P., Chou, D., Bahl, R., Oladapo, O. T. 2022; 10 (12): e1707-e1708

    View details for DOI 10.1016/S2214-109X(22)00434-X

    View details for PubMedID 36400080

  • Real world external validation of metabolic gestational age assessment in Kenya. PLOS global public health Hawken, S., Ward, V., Bota, A. B., Lamoureux, M., Ducharme, R., Wilson, L. A., Otieno, N., Munga, S., Nyawanda, B. O., Atito, R., Stevenson, D. K., Chakraborty, P., Darmstadt, G. L., Wilson, K. 2022; 2 (11): e0000652


    Using data from Ontario Canada, we previously developed machine learning-based algorithms incorporating newborn screening metabolites to estimate gestational age (GA). The objective of this study was to evaluate the use of these algorithms in a population of infants born in Siaya county, Kenya. Cord and heel prick samples were collected from newborns in Kenya and metabolic analysis was carried out by Newborn Screening Ontario in Ottawa, Canada. Postnatal GA estimation models were developed with data from Ontario with multivariable linear regression using ELASTIC NET regularization. Model performance was evaluated by applying the models to the data collected from Kenya and comparing model-derived estimates of GA to reference estimates from early pregnancy ultrasound. Heel prick samples were collected from 1,039 newborns from Kenya. Of these, 8.9% were born preterm and 8.5% were small for GA. Cord blood samples were also collected from 1,012 newborns. In data from heel prick samples, our best-performing model estimated GA within 9.5 days overall of reference GA [mean absolute error (MAE) 1.35 (95% CI 1.27, 1.43)]. In preterm infants and those small for GA, MAE was 2.62 (2.28, 2.99) and 1.81 (1.57, 2.07) weeks, respectively. In data from cord blood, model accuracy slightly decreased overall (MAE 1.44 (95% CI 1.36, 1.53)). Accuracy was not impacted by maternal HIV status and improved when the dating ultrasound occurred between 9 and 13 weeks of gestation, in both heel prick and cord blood data (overall MAE 1.04 (95% CI 0.87, 1.22) and 1.08 (95% CI 0.90, 1.27), respectively). The accuracy of metabolic model based GA estimates in the Kenya cohort was lower compared to our previously published validation studies, however inconsistency in the timing of reference dating ultrasounds appears to have been a contributing factor to diminished model performance.

    View details for DOI 10.1371/journal.pgph.0000652

    View details for PubMedID 36962760

    View details for PubMedCentralID PMC10021775

  • New WHO recommendations for the care of preterm or low birthweight infants have the potential to transform maternal and newborn health-care delivery LANCET Darmstadt, G. L., Al Jaifi, N., Arif, S., Bahl, R., Blennow, M., Cavallera, V., Chou, D., Chou, R., Comrie-Thomson, L., Edmond, K., Feng, Q., Riera, P., Grummer-Strawn, L., Gupta, S., Hassan, R., Hill, Z., Idowu, A., Kenner, C., Kirabira, V., Klinkott, R., De Leon-Mendoza, S., Mader, S., Manji, K., Marriott, R., Morgues, M., Nangia, S., Portela, A., Rao, S., Shahidullah, M., Hoang Thi Tran, Weeks, A. D., Worku, B., Yunis, K., Paul, V. K., Care Preterm Low Birthweight Infan 2022; 400 (10366): 1828-1831
  • Improving the precision of maternal, newborn, and child health impact through geospatial analysis of the association of contextual and programmatic factors with health trends in Bihar, India. Journal of global health Abdalla, S., Pair, E., Mehta, K., Ward, V., Mahapatra, T., Darmstadt, G. L. 2022; 12: 04064


    Background: There is a scarcity of research that comprehensively examines programme impact from a context-specific perspective. We aimed to determine the conditions under which the Bihar Technical Support Programme led to more favourable outcomes for maternal and child health in Bihar.Methods: We obtained block-level data on maternal and child health indicators during the state-wide scale-up of the pilot Ananya programme and data on health facility readiness, along with geographical and sociodemographic variables. We examined the associations of these factors with increases in the levels of indicators using multilevel logistic regression, and the associations with rates of change in the indicators using Bayesian Hierarchical modelling.Results: Frontline worker (FLW) visits between 2014-2017 were more likely to increase in blocks with better night lighting (odds ratio (OR)=1.23, 95% confidence interval (CI)=1.01-1.51). Birth preparedness increased in blocks with increasing FLW visits (OR=3.43, 95% CI=1.15-10.21), while dry cord care practice increased in blocks where satisfaction with FLW visits was increasing (OR=1.52, 95% CI=1.10-2.11). Age-appropriate frequency of complementary feeding increased in blocks with higher development index (OR=1.55, 95% CI=1.16-2.06) and a higher percentage of scheduled caste or tribe (OR=3.21, 95% CI=1.13-9.09). An increase in most outcomes was more likely in areas with lower baseline levels.Conclusions: Contextual factors (eg, night lighting and development) not targeted by the programme and FLW visits were associated with favourable programme outcomes. Intervention design, including intervention selection for a particular geography, should be modified to fit the local context in the short term. Expanding collaborations beyond the health sector to influence modifiable contextual factors in the long term can result in a higher magnitude and more sustainable impact.Registration: NCT02726230.

    View details for DOI 10.7189/jogh.12.04064

    View details for PubMedID 36412069

  • Maternal gender discrimination and child emotional and behavioural problems: A population-based, longitudinal cohort study in the Czech Republic. EClinicalMedicine Stepanikova, I., Acharya, S., Colon-Lopez, A., Abdalla, S., Klanova, J., Darmstadt, G. L. 2022; 53: 101627


    Background: Gender discrimination may be a novel mechanism through which gender inequality negatively affects the health of women and girls. We investigated whether children's mental health varied with maternal exposure to perceived gender discrimination.Methods: Complete longitudinal data was available on 2,567 mother-child dyads who were enrolled between March 1, 1991 and June 30, 1992 in the European Longitudinal Cohort Study of Pregnancy and Childhood-Czech cohort and were surveyed at multiple time points between pregnancy and child age up to 15 years. The Strengths and Difficulties Questionnaire (SDQ) was administered at child age 7, 11, and 15 years to assess child emotional/behavioural difficulties. Perceived gender discrimination was self-reported in mid-pregnancy and child age 7 and 11 years. Multilevel mixed-effects linear regression of SDQ scores were estimated. Mediation was tested using structural equation models.Findings: Perceived gender discrimination, reported by 11.2% of mothers in mid-pregnancy, was related to increased emotional/behavioural difficulties among children in bivariate analysis (slope=0.24 [95% confidence interval (CI): 0.15, 0.32], p<0.0001) and in the fully adjusted model (slope=0.18 [95% CI: 0.09, 0.27], p<0.0001). Increased difficulties were evident among children of mothers with more depressive symptoms (slope=0.04 [95% CI: 0.03, 0.05], p<0.0001), boys (slope=0.26 [95% CI: 0.19, 0.34], p<0.0001), first children (slope=0.16 [95% CI: 0.09, 0.23], p<0.0001), and families under financial hardship (slope=0.09 [95% CI: 0.04, 0.14], p<0.0001). Effects were attenuated for married mothers (slope-0.12 [95% CI: -0.22, -0.01], p<0.05]. Maternal depressive symptoms and financial hardship mediated about 37% and 13%, respectively, of the total effect of perceived gender discrimination on SDQ scores.Interpretation: Perceived gender discrimination among child-bearing women in family contexts was associated with more mental health problems among their children and adolescents, extending prior research showing associations with maternal mental health problems. Maternal depressive symptoms and, to a lesser extent, financial hardship both partially mediated the positive relationship between perceived gender discrimination and child emotional/behavioural problems. This should be taken into consideration when measuring the societal burden of gender inequality and gender-based discrimination. Moreover, gender-based discrimination affects more than one gender and more than one generation, extending to boys in the household even moreso than girls, highlighting that gender discrimination is everyone's issue. Further research is required on the intergenerational mechanisms whereby gender discrimination may lead to maternal and child mental health consequences.Funding: Bill and Melinda Gates Foundation; Ministry of Education, Youth and Sports, Czech Republic and European Structural and Investment Funds.

    View details for DOI 10.1016/j.eclinm.2022.101627

    View details for PubMedID 36060515

  • A SCOPING REVIEW ON DELIVERY OF ESSENTIAL NEWBORN CARE IN ARMED-CONFLICT SETTINGS Mediratta, R. P., Moutwakil, A., Nelson, B. D., Amsalu, R., Li, A. T., Kumar, A., Huang, C., Balter, L. E., Woodward, A., Darmstadt, G. L. LIPPINCOTT WILLIAMS & WILKINS. 2022
  • Risk factors for community-acquired bacterial infection among young infants in South Asia: a longitudinal cohort study with nested case-control analysis. BMJ global health Connor, N. E., Islam, M. S., Mullany, L. C., Shang, N., Bhutta, Z. A., Zaidi, A. K., Soofi, S., Nisar, I., Panigrahi, P., Panigrahi, K., Satpathy, R., Bose, A., Isaac, R., Baqui, A. H., Mitra, D. K., Sadeq-Ur Rahman, Q., Hossain, T., Schrag, S. J., Winchell, J. M., Arvay, M. L., Diaz, M. H., Waller, J. L., Weber, M. W., Hamer, D. H., Hibberd, P., Nawshad Uddin Ahmed, A. S., Islam, M., Hossain, M. B., Qazi, S. A., El Arifeen, S., Darmstadt, G. L., Saha, S. K. 2022; 7 (11)


    OBJECTIVE: Risk factors predisposing infants to community-acquired bacterial infections during the first 2months of life are poorly understood in South Asia. Identifying risk factors for infection could lead to improved preventive measures and antibiotic stewardship.METHODS: Five sites in Bangladesh, India and Pakistan enrolled mother-child pairs via population-based pregnancy surveillance by community health workers. Medical, sociodemographic and epidemiological risk factor data were collected. Young infants aged 0-59days with signs of possible serious bacterial infection (pSBI) and age-matched controls provided blood and respiratory specimens that were analysed by blood culture and real-time PCR. These tests were used to build a Bayesian partial latent class model (PLCM) capable of attributing the probable cause of each infant's infection in the ANISA study. The collected risk factors from all mother-child pairs were classified and analysed against the PLCM using bivariate and stepwise logistic multivariable regression modelling to determine risk factors of probable bacterial infection.RESULTS: Among 63114 infants born, 14655 were assessed and 6022 had signs of pSBI; of these, 81% (4859) provided blood samples for culture, 71% (4216) provided blood samples for quantitative PCR (qPCR) and 86% (5209) provided respiratory qPCR samples. Risk factors associated with bacterial-attributed infections included: low (relative risk (RR) 1.73, 95% credible interval (CrI) 1.42 to 2.11) and very low birth weight (RR 5.77, 95% CrI 3.73 to 8.94), male sex (RR 1.27, 95% CrI 1.07 to 1.52), breathing problems at birth (RR 2.50, 95% CrI 1.96 to 3.18), premature rupture of membranes (PROMs) (RR 1.27, 95% CrI 1.03 to 1.58) and being in the lowest three socioeconomic status quintiles (first RR 1.52, 95% CrI 1.07 to 2.16; second RR 1.41, 95% CrI 1.00 to 1.97; third RR 1.42, 95% CrI 1.01 to 1.99).CONCLUSION: Distinct risk factors: birth weight, male sex, breathing problems at birth and PROM were significantly associated with the development of bacterial sepsis across South Asian community settings, supporting refined clinical discernment and targeted use of antimicrobials.

    View details for DOI 10.1136/bmjgh-2022-009706

    View details for PubMedID 36319031

  • Paediatric use of emergency medical services in India: A retrospective cohort study of one million children. Journal of global health Newberry, J. A., Rao, S. J., Matheson, L., Anurudran, A. S., Acker, P., Darmstadt, G. L., Mahadevan, S. V., Rao, G. V., Strehlow, M. 2022; 12: 04080


    Millions of children in low- and middle-income countries (LMICs) experience illness or trauma amenable to emergency medical interventions, but local resources are not sufficient to treat them. Emergency medical services (EMS), including ambulance transport, bridge the gap between local services and higher-level hospital care, and data collected by EMS could be used to elucidate patterns of paediatric health care need and use. Here we conducted a retrospective observational study of patterns of paediatric use of EMS services by children who used EMS in India, a leader in maternal and child EMS development, to inform public health needs and system interventions to improve EMS effectiveness.We analysed three years (2013-2015) of data from patients <18 years of age from a large prehospital EMS system in India, including 1 101 970 prehospital care records across 11 states and a union territory.Overall, 38.3% of calls were for girls (n = 422 370), 40.5% were for adolescents (n = 445 753), 65.9% were from rural areas (n = 726 154), and most families were from a socially disadvantaged caste or lower economic status (n = 834 973, 75.8%). The most common chief complaints were fever (n = 247 594, 22.5%), trauma (n = 231 533, 21.0%), and respiratory difficulty (n = 161 120, 14.6%). However, transport patterns, including patient sex and age and type of destination hospital, varied by state, as did data collection.EMS in India widely transports children with symptoms of the leading causes of child mortality and provides access to higher levels of care for geographically and socioeconomically vulnerable populations, including care for critically ill neonates, mental health and burn care for girls, and trauma care for adolescents. EMS in India is an important mechanism for overcoming transport and cost as barriers to access, and for reducing the urban-rural gap found across causes of child mortality. Further standardisation of data collection will provide the foundation for assessing disparities and identifying targets for quality improvement of paediatric care.

    View details for DOI 10.7189/jogh.12.04080

    View details for PubMedID 36243953

  • A scalable health system model to achieve high coverage and quality of Kangaroo mother care in Uttar Pradesh, India. Acta paediatrica (Oslo, Norway : 1992) Kumar, A., Tiwari, M., Krishna, R., Singh, P. K., Sahu, A., Singh, V., Mishra, A., Kumar, P., Kumar, A., Darmstadt, G. L., Kumar, V. 2022


    AIM: To design a health system model for scaling-up Kangaroo mother care (KMC) and assess its impact on the population-level coverage and quality of KMC in Uttar Pradesh, India.METHODS: We co-developed the model with mothers and health system stakeholders using human-centred design over multiple cycles of implementation, learning and data-driven refinement. Infants with birthweight <2000g in the study district were prospectively followed to assess the 'effective coverage' of KMC. Effective coverage referred to the proportion of eligible infants receiving ≥8h of daily skin-to-skin contact and exclusive breastfeeding.RESULTS: High delivery load facilities were equipped with a KMC Lounge to ensure comfort, respectful care of mothers and high-quality KMC over prolonged periods. Systems to ensure weighing at birth, referral of infants with birthweight <2000g to KMC facilities, initiation of KMC for all stable low birthweight infants, improving quality of care within KMC facilities and supporting families to continue KMC at home post discharge, were integrated into existing services. KMC was initiated in 93.3% of eligible infants with effective coverage of 52.7% and 64.8% at discharge and 7days post discharge, respectively.CONCLUSION: The model addressed critical barriers to KMC implementation and adoption, contributing to its scale-up across the state.

    View details for DOI 10.1111/apa.16534

    View details for PubMedID 36184883

  • Social normative origins of the taboo gap and implications for adolescent risk for HIV infection in Zambia. Social science & medicine (1982) Nesamoney, S. N., Mejia-Guevara, I., Cislaghi, B., Weber, A. M., Mbizvo, M. T., Darmstadt, G. L. 2022; 312: 115391


    Zambian Demographic and Health Survey data reveal that increased discordance between professed attitudes and measures of behaviour regarding premarital sex among adults is strongly associated with increased risk of HIV in adolescents, particularly girls. We hypothesised that this was due to the reluctance to talk about premarital sex, resulting in a situation we call the "taboo gap" where sexual behaviour is a forbidden topic and adolescents feel unable to seek advice or sexual and reproductive health services. Our analysis revealed that the taboo gap is rooted in harmful gender norms that are perpetuated by schools, churches, cultural influences, development programmes and health systems. Challenges like food insecurity and household poverty may place girls in positions where they are vulnerable to sexual exploitation, increasing their risk of exposure to HIV. Unmarried adolescents, particularly girls, report being ridiculed when they go to reproductive health clinics, which discourages them from seeking care in the future. Strengthening peer support and parent-child interactions are important programmatic elements. We conclude that discordance serves as a novel measure and harbinger for the presence of gender norms which generated a taboo gap that impeded carseeking and increased risk for HIV among adolescents, especially girls, in Zambia. We propose that successful interventions must involve a multifaceted, gender transformative approach which engages peers and stakeholders in schools, churches, clinics, and families, particularly parents, to reduce the gendered gap in HIV risk and transmission.

    View details for DOI 10.1016/j.socscimed.2022.115391

    View details for PubMedID 36183540

  • Global climate change: the defining issue of our time for our children's health. Pediatric research Bearer, C. F., Molloy, E. J., Tessema, M. T., Pak-Gorstein, S., Montecillo-Narvaez, D., Darmstadt, G. L., Sampath, V., Mulkey, S., Nadeau, K. C. 2022

    View details for DOI 10.1038/s41390-022-02290-7

    View details for PubMedID 36075986

  • Infectious aetiologies of neonatal illness in south Asia classified using WHO definitions: a primary analysis of the ANISA study. The Lancet. Global health Arvay, M. L., Shang, N., Qazi, S. A., Darmstadt, G. L., Islam, M. S., Roth, D. E., Liu, A., Connor, N. E., Hossain, B., Sadeq-Ur Rahman, Q., El Arifeen, S., Mullany, L. C., Zaidi, A. K., Bhutta, Z. A., Soofi, S. B., Shafiq, Y., Baqui, A. H., Mitra, D. K., Panigrahi, P., Panigrahi, K., Bose, A., Isaac, R., Westreich, D., Meshnick, S. R., Saha, S. K., Schrag, S. J. 2022; 10 (9): e1289-e1297


    Globally, neonatal mortality accounts for almost half of all deaths in children younger than 5 years. Aetiological agents of neonatal infection are difficult to identify because the clinical signs are non-specific. Using data from the Aetiology of Neonatal Infections in south Asia (ANISA) cohort, we aimed to describe the spectrum of infectious aetiologies of acute neonatal illness categorised post-hoc using the 2015 WHO case definitions of critical illness, clinical severe infection, and fast breathing only.Eligible infants were aged 0-59 days with possible serious bacterial infection and healthy infants enrolled in the ANISA study in Bangladesh, India, and Pakistan. We applied a partial latent class Bayesian model to estimate the prevalence of 27 pathogens detectable on PCR, pathogens detected by blood culture only, and illness not attributed to any infectious aetiology. Infants with at least one clinical specimen available were included in the analysis. We assessed the prevalence of these aetiologies according to WHO's case definitions of critically ill, clinical severe infection, and infants with late onset, isolated fast breathing. For the clinical severe definition, we compared the prevalence of signs by bacterial versus viral aetiology.There were 934 infants (992 episodes) in the critically ill category, 3769 (4000 episodes) in the clinical severe infection category, and 738 (771 episodes) in the late-onset isolated fast breathing category. We estimated the proportion of illness attributable to bacterial infection was 32·7% in infants in the critically ill group, 15·6% in the clinical severe infection group, and 8·8% among infants with late-onset isolated fast breathing group. An infectious aetiology was not identified in 58-82% of infants in these categories. Among 4000 episodes of clinical severe infection, those with bacterial versus viral attribution had higher proportions of hypothermia, movement only when stimulated, convulsions, and poor feeding.Our modelled results generally support the revised WHO case definitions, although a revision of the most severe case definition could be considered. Clinical criteria do not clearly differentiate between young infants with and without infectious aetiologies. Our results highlight the need for improved point-of-care diagnostics, and further study into neonatal deaths and episodes with no identified aetiology, to ensure antibiotic stewardship and targeted interventions.The Bill and Melinda Gates Foundation.

    View details for DOI 10.1016/S2214-109X(22)00244-3

    View details for PubMedID 35961352

  • Infectious aetiologies of neonatal illness in south Asia classified using WHO definitions: a primary analysis of the ANISA study LANCET GLOBAL HEALTH Arvay, M. L., Shang, N., Qazi, S. A., Darmstadt, G. L., Islam, M., Roth, D. E., Liu, A., Connor, N. E., Hossein, B., Rahman, Q., El Arifeen, S., Mullany, L. C., Zaidi, A. M., Bhutta, Z. A., Soofi, S. B., Shafiq, Y., Baqui, A. H., Mitra, D. K., Panigrahi, P., Panigrahi, K., Bose, A., Isaac, R., Westreich, D., Meshnickt, S. R., Saha, S. K., Schrag, S. J. 2022; 10 (9): E1289-E1297
  • Effect of imbalanced sampling and missing data on associations between gender norms and risk of adolescent HIV. EClinicalMedicine Gupta, R., Abdalla, S., Meausoone, V., Vicas, N., Mejia-Guevara, I., Weber, A. M., Cislaghi, B., Darmstadt, G. L. 2022; 50: 101513


    Background: Despite strides towards gender equality, inequalities persist or remain unstudied, due potentially to data gaps. Although mapped, the effects of key data gaps remain unknown. This study provides a framework to measure effects of gender- and age-imbalanced and missing covariate data on gender-health research. The framework is demonstrated using a previously studied pathway for effects of pre-marital sex norms among adults on adolescent HIV risk.Methods: After identifying gender-age-imbalanced Demographic and Health Survey (DHS) datasets, we resampled responses and restricted covariate data from a relatively complete, balanced dataset derived from the 2007 Zambian DHS to replicate imbalanced gender-age sampling and covariate missingness. Differences in model outcomes due to sampling were measured using tests for interaction. Missing covariate effects were measured by comparing fully-adjusted and reduced model fitness.Findings: We simulated data from 25 DHS surveys across 20 countries from 2005-2014 on four sex-stratified models for pathways of adult attitude-behaviour discordance regarding pre-marital sex and adolescent risk of HIV. On average, across gender-age-imbalanced surveys, males comprised 29.6% of responses compared to 45.3% in the gender-balanced dataset. Gender-age-imbalanced sampling significantly affected regression coefficients in 40% of model-scenarios (N=40 of 100) and biased relative-risk estimates away from gender-age-balanced sampling outcomes in 46% (N=46) of model-scenarios. Model fitness was robust to covariate removal with minor effects on male HIV models. No consistent trends were observed between sampling distribution and risk of biased outcomes.Interpretation: Gender-health model outcomes may be affected by sampling gender-age-imbalanced data and less-so by missing covariates. Although occasionally attenuated, the effect magnitude of gender-age-imbalanced sampling is variable and may mask true associations, thus misinforming policy dialogue. We recommend future surveys improve balanced gender-age sampling to promote research reliability.Funding: Bill & Melinda Gates Foundation grant OPP1140262 to Stanford University.

    View details for DOI 10.1016/j.eclinm.2022.101513

    View details for PubMedID 35784444

  • Unlocking the global health potential of dried blood spot cards. Journal of global health Bota, B., Ward, V., Lamoureux, M., Santander, E., Ducharme, R., Hawken, S., Potter, B. K., Atito, R., Nyamanda, B., Munga, S., Otieno, N., Chakraborty, S., Saha, S., Stringer, J. S., Mwape, H., Price, J. T., Mujuru, H. A., Chimhini, G., Magwali, T., Chakraborty, P., Darmstadt, G. L., Wilson, K. 2022; 12: 03027

    View details for DOI 10.7189/jogh.12.03027

    View details for PubMedID 35841606

  • Quantitative decision making for investment in global health intervention trials: Case study of the NEWBORN study on emollient therapy in preterm infants in Kenya. Journal of global health Stylianou, A., Blanks, K. J., Gibson, R. A., Kendall, L. K., English, M., Williams, S., Mehta, R., Clarke, A., Kanyuuru, L., Aluvaala, J., Darmstadt, G. L. 2022; 12: 04045


    Partners from an NGO, academia, industry and government applied a tool originating in the private sector - Quantitative Decision Making (QDM) - to rigorously assess whether to invest in testing a global health intervention. The proposed NEWBORN study was designed to assess whether topical emollient therapy with sunflower seed oil in infants with very low birthweight <1500 g in Kenya would result in a significant reduction in neonatal mortality compared to standard of care.The QDM process consisted of prior elicitation, modelling of prior distributions, and simulations to assess Probability of Success (PoS) via assurance calculations. Expert opinion was elicited on the probability that emollient therapy with sunflower seed oil will have any measurable benefit on neonatal mortality based on available evidence. The distribution of effect sizes was modelled and trial data simulated using Statistical Analysis System to obtain the overall assurance which represents the PoS for the planned study. A decision-making framework was then applied to characterise the ability of the study to meet pre-selected decision-making endpoints.There was a 47% chance of a positive outcome (defined as a significant relative reduction in mortality of ≥15%), a 45% chance of a negative outcome (defined as a significant relative reduction in mortality <10%), and an 8% chance of ending in the consider zone (ie, a mortality reduction of 10 to <15%) for infants <1500 g.QDM is a novel tool from industry which has utility for prioritisation of investments in global health, complementing existing tools [eg, Child Health and Nutrition Research Initiative]. Results from application of QDM to the NEWBORN study suggests that it has a high probability of producing clear results. Findings encourage future formation of public-private partnerships for health.

    View details for DOI 10.7189/jogh.12.04045

    View details for PubMedID 35972445

  • Gender Norms and Gender Equality in Full-Time Employment and Health: A 97-Country Analysis of the World Values Survey. Frontiers in psychology Cislaghi, B., Bhatia, A., Hallgren, E. S., Horanieh, N., Weber, A. M., Darmstadt, G. L. 2022; 13: 689815


    Almost nowhere in the world do women participate as much as men in the labor force. Despite differences in countries' economic, social and cultural contexts, gender norms-unwritten rules of acceptable actions for men and women-have been found to affect women's labor participation across contexts. Gender norms include those regulating who takes care of children, who is expected to earn more, and in which sectors men and women should work. Importantly, norms affect access to labor markets at times of scarcity: when there's only work for one, gender norms can dictate whether a woman or man gets the job. Advocates of equal labor force participation point to evidence that employment can contribute to people's health and well-being; yet the evidence is mixed and contradictory, and mostly comes from high-income countries. In restrictive normative contexts in which women are assigned the role of family caretaker, full time employment (FTE) might be particularly burdensome. At the same time, the literature lacks a cross-country analysis of how gender norms affect women's FTE and their health when employed full time, despite qualitative research providing clear evidence of the influence of gender norms on labor participation.In this paper we examine: (1) how gender norms affect women's access to FTE across 97 countries; (2) associations between FTE and women's self-reported health self-rated (SRH) across different normative contexts (i.e., countries where it is common vs. uncommon for women to stay home); and (3) how women's FTE and gender norms changed over time in four countries.We used time-series data from the World Values Survey and European Values Survey conducted in over 100 countries between 1981 and 2014. Both surveys attempt to capture norms, beliefs and values in addition to sociodemographic information among a nationally representative adult population in each country. The sample for the cross-sectional analyses (aims 1 and 2) included 97 countries and 131,132 respondents. The sample for aim 3 included data from Argentina, Egypt, Finland and Japan.Our outcome of interest was pro-equality norms in the context of access to the labor market for women. Respondents were asked "if jobs are scarce, men should have more right to a job than women do?". Response options included no, neither or yes. We created a binary variable to represent pro-equality norms. We included employment status and SRH as exposures of interest.We used individual-level data to generate on-average and sex-stratified estimates of the outcome and exposures for each country, at each time point. We estimated the percentage of all respondents, of women, and of men who held pro-equality norms (believe that men should not have more right to a job than women), the percentage who were employed full time, and the average level of SRH. To measure gender inequality in FTE, we also estimated the absolute difference in FTE between women and men for each country at each time point. First, we conducted descriptive, cross-sectional ecological analyses using one survey per country from wave 5 or 6 (whichever was most recent) to examine associations between pro-equality norms and employment status as a proxy for associations between norms and the context of employment in each country. We also examined associations between pro-equality norms and SRH. We then specified adjusted logistic regression models with controls for age, sex and education to examine associations between pro-equality norms and employment status. To examine if the relationship between FTE and SRH varied by normative context, we grouped countries in quartiles of pro-equality norms. Finally, we conducted descriptive ecological analyses of the relationship between pro-equality norms and employment status over time in four countries.Objective 1: Gender norms intersect with socio-cultural contexts in determining women's FTE. While in some countries gender norms aligned positively with women's access to employment (i.e., more equal norms matched more equality in FTE), in Eastern Europe and South America we observed a mismatch. In Eastern Europe we found strong norms against equal access but small sex differences in FTE. In South America, we observed a stark difference in FTE favoring men, despite positive gender norms promoting women's paid employment. Objective 2: We found the association between SRH and FTE to vary across normative contexts. For instance, while in Scandinavian countries it was protective to be a woman in FTE and harmful not to work full-time, we found the opposite effect in Middle Eastern countries. Objective 3: We found a general tendency to move toward greater equality in norms and FTE over time everywhere in the world. However, political and economic events can generate variations over time and setbacks in progress toward equality.We specifically looked at 4 countries: Argentina, Egypt, Finland and Japan and assessed the effects of economic, political and national legislative changes on FTE over time.This paper contributes to the conversation on tensions between universal justice and contextual factors affecting one's health. To achieve purposeful and global universal health and justice, policy makers and global health practitioners must design effective, context-relevant interventions that are deeply and transparently informed by the values they embody. As we strive to achieve global gender equality, its meanings and purposes will vary across contexts in ways that demand people-led conversations and interventions.

    View details for DOI 10.3389/fpsyg.2022.689815

    View details for PubMedID 35769749

    View details for PubMedCentralID PMC9234689

  • Optimised emollient mixture for skin barrier repair: Applications to global child health. Journal of global health Elias, P. M., Man, M., Darmstadt, G. L. 2022; 12: 03019

    View details for DOI 10.7189/jogh.12.03019

    View details for PubMedID 35486585

  • Evaluation of community health worker's performance at home-based newborn assessment supported by mHealth in rural Bangladesh. BMC pediatrics Jahan, F., Foote, E., Rahman, M., Shoab, A. K., Parvez, S. M., Nasim, M. I., Hasan, R., El Arifeen, S., Billah, S. M., Sarker, S., Hoque, M. M., Shahidullah, M., Islam, M. S., Ashrafee, S., Darmstadt, G. L. 2022; 22 (1): 218


    BACKGROUND: In low to middle-income countries where home births are common and neonatal postnatal care is limited, community health worker (CHW) home visits can extend the capability of health systems to reach vulnerable newborns in the postnatal period. CHW assessment of newborn danger signs supported by mHealth have thepotential to improve the quality of danger sign assessments and reduce CHW training requirements. We aim to estimate the validity (sensitivity, specificity, positive and negative predictive value) of CHW assessment of newborn infants aided by mHealth compared to physician assessment.METHODS: In this prospective study, ten CHWs received five days of theoretical and hands-on training on the physical assessment of newborns including ten danger signs. CHWs assessed 273 newborn infants for danger signs within 48h of birth and then consecutively for three days. A physician repeated 20% (n=148) of the assessments conducted by CHWs. Both CHWs and the physician evaluated newborns for ten danger signs and decided on referral. We used the physician's danger sign identification and referral decision as the gold standard to validate CHWs' identification of danger signs and referral decisions.RESULTS: The referrals made by the CHWs had high sensitivity (93.3%), specificity (96.2%), and almost perfect agreement (K=0.80) with the referrals made by the physician. CHW identification of all the danger signs except hypothermia showed moderate to high sensitivity (66.7-100%) compared to physician assessments. All the danger signs assessments except hypothermia showed moderate to high positive predictive value (PPV) (50-100%) and excellent negative predictive value (NPV) (99-100%). Specificity was high (99-100%) for all ten danger signs.CONCLUSION: CHW's identification of neonatal danger signs aided by mHealth showed moderate to high validity in comparison to physician assessments. mHealth platforms may reduce CHW training requirements and while maintaining quality CHW physical assessment performance extending the ability of health systems to provide neonatal postnatal care in low-resource communities.TRIAL REGISTRATION: NCT03933423 , January 05, 2019.

    View details for DOI 10.1186/s12887-022-03282-6

    View details for PubMedID 35459113

  • The taboo gap: implications for adolescent risk of HIV infection. The Lancet. Child & adolescent health Nesamoney, S. N., Mejia-Guevara, I., Weber, A. M., Cislaghi, B., Mbizvo, M. T., Darmstadt, G. L. 1800

    View details for DOI 10.1016/S2352-4642(21)00398-9

    View details for PubMedID 35012710

  • Effects of emollient therapy with sunflower seed oil on neonatal growth and morbidity in Uttar Pradesh, India: a cluster-randomized, open-label, controlled trial. The American journal of clinical nutrition Kumar, V., Kumar, A., Mishra, S., Kan, P., Ashraf, S., Singh, S., Blanks, K. J., Baiocchi, M., Limcaoco, M., Ghosh, A. K., Kumar, A., Krishna, R., Stevenson, D. K., Tian, L., Darmstadt, G. L. 2022


    Newborn oil massage is a widespread practice. Vigorous massage with potentially harmful products and forced removal of vernix may disrupt skin barrier integrity. Hospitalized, very preterm infants treated with sunflower seed oil (SSO) have demonstrated improved growth but community-based data on growth and health outcomes are lacking.We aimed to test whether SSO therapy enhances neonatal growth and reduces morbidity at population-level.We conducted an open-label, controlled trial in rural Uttar Pradesh, India, randomly allocating 276 village clusters equally to comparison (usual care) and intervention comprised of promotion of improved massage practices exclusively with SSO, using intention-to-treat and per-protocol mixed-effects regression analysis.We enrolled 13,478 and 13,109 newborn infants in demographically similar intervention and comparison arms, respectively. Adherence to exclusive SSO increased from 22.6% of intervention infants enrolled in the first study quartile to 37.2% in the last quartile. Intervention infants gained significantly more weight by 0.94 grams/kilogram/day (g/kg/d) [95% confidence interval (CI): 0.07, 1.82, p = 0.03] than comparison infants by intention-to-treat analysis. Restricted cubic spline regression revealed the largest benefits in weight gain (2-4 g/kg/day) occurred in infants <2000 g. Weight gain in intervention infants was higher by 1.31 g/kg/d (95% CI: 0.17, 2.46, p = 0.02) by per-protocol analysis. Morbidities were similar by intention-to-treat analysis but in per-protocol analysis rates of hospitalization and of any illness were reduced by 36% [odds ratio (OR): 0.64; 95% CI: 0.44, 0.94, p = 0.02] and 44% (OR: 0.56; 95% CI: 0.40, 0.77, p<0.001), respectively, in treated infants.SSO therapy improved neonatal growth, and reduced morbidities when applied exclusively, across the facility-community continuum of care at population-level. Further research is needed to improve demand for recommended therapy inside hospital as well as in community settings, and to confirm these results in other settings. Clinical Trial Registry: The trial was registered at the ISRCTN (ISRCTN38965585) and CTRI (CTRI/2014/12/005282) registries with WHO UTN # U1111-1158-4665.

    View details for DOI 10.1093/ajcn/nqab430

    View details for PubMedID 34982820

  • Quantitative decision making for investment in global health intervention trials: Case study of the NEWBORN study on emollient therapy in preterm infants in Kenya JOURNAL OF GLOBAL HEALTH Stylianou, A., Blanks, K. H., Gibson, R. A., Kendall, L. K., English, M., Williams, S., Mehta, R., Clarke, A., Kanyuuru, L., Aluvaala, J., Darmstadt, G. L. 2022; 12
  • Maternal stress and its consequences - biological strain. American journal of perinatology Stevenson, D. K., Gotlib, I. H., Buthmann, J. L., Maric, I., Aghaeepour, N., Gaudilliere, B., Angst, M. S., Darmstadt, G. L., Druzin, M. L., Wong, R. J., Shaw, G. M., Katz, M. 2022


    Understanding the role of stress in pregnancy and its consequences is important, particularly given documented associations between maternal stress and preterm birth and other pathologic outcomes. Physical and psychological stressors can elicit the same biological responses, known as biological strain. Chronic stressors, like poverty and racism (race-based discriminatory treatment), may create a legacy or trajectory of biological strain that no amount of coping can relieve in the absence of larger-scale socio-behavioral or societal changes. An integrative approach that takes into consideration simultaneously social and biological determinants of stress may provide the best insights into risk for preterm birth. The most successful computational approaches and the most predictive machine-learning models are likely to be those that combine information about the stressors and the biological strain (for example, as measured by different omics) experienced during pregnancy.

    View details for DOI 10.1055/a-1798-1602

    View details for PubMedID 35292943

  • Necessary conditions for sustainable water and sanitation service delivery in schools: A systematic review. PloS one Pu, C. J., Patel, P., Hornsby, G., Darmstadt, G. L., Davis, J. 2022; 17 (7): e0270847


    Access to water, sanitation, and hygiene (WASH) services confers significant health and economic benefits, especially for children, but only if those services can be delivered on a consistent basis. The challenge of sustainable, school-based WASH service delivery has been widely documented, particularly in resource-constrained contexts. We conducted a systematic review of published research that identifies drivers of, or tests solutions to, this challenge within low- and middle-income countries (PROSPERO 2020 CRD42020199163). Authors in the first group employ cross-sectional research designs and interrogate previously implemented school WASH interventions. Most conclude that dysfunctional accountability and information sharing mechanisms drive school WASH service delivery failures. By contrast, most of the interventions developed and tested experimentally by authors in the second group focus on increasing the financial and material resources available to schools for WASH service delivery. Overall, these authors find negligible impact of such infusions of cash, infrastructure, and supplies across a variety of sustainability outcome metrics. Taken together, the evidence suggests that sustainable service delivery depends on three simultaneously necessary components: resources, information, and accountability. Drawing upon theory and evidence from social psychology, public management, and political science, we identify priority knowledge gaps that can meaningfully improve the design of effective interventions. We also highlight the importance of both interdisciplinary collaboration and local expertise in designing WASH programming that aligns with sociocultural and institutional norms, and is thus more likely to generate sustainable impact.

    View details for DOI 10.1371/journal.pone.0270847

    View details for PubMedID 35857721

  • MULTIOMICS LONGITUDINAL MODELING OF PREECLAMPTIC PREGNANCIES Espinosa, C., Maric, I., Contrepois, K., Moufarrej, M., Stelzer, I. S., Feyaerts, D., Han, X., Tang, A., Wong, R. J., Darmstadt, G. L., Winn, V. D., Shaw, G. M., Relman, D. A., Quake, S. R., Angst, M. S., Snyder, M., Stevenson, D. K., Gaudilliere, B., Aghaeepour, N. BMJ PUBLISHING GROUP. 2022: 309
  • Gender and the impact of COVID-19 on demand for and access to health care: Intersectional analysis of before-and-after data from Kenya, Nigeria, and South Africa JOURNAL OF GLOBAL HEALTH Abdalla, S., Katz, E. G., Hartley, A., Darmstadt, G. L. 2022; 12: 05024


    Global health emergencies can impact men and women differently due to gender norms related to health care and social and economic disruptions. We investigated the intersectionality of gender differences of the impact of COVID-19 on health care access with educational and socio-economic factors in Kenya, Nigeria, and South Africa.Data were collected by Opinion Research Business International using census data as the sampling frame. We used conditional logistic regression to estimate the change in access to health care after the emergence of the pandemic among men and women, stratified by educational level. We also examined the change in demand for various health care services, stratified by self-reported experiences of financial difficulty due to the pandemic.Among those reporting a need to seek health care in South Africa, there was a statistically significant decline in the ability to see a health care provider during the pandemic among women, but not among men; this gender gap was more evident in those who did not have post-secondary education (odds ratio (OR) = 0.08, P = 0.041 among women; no change among men) than for those with post-secondary education (OR = 0.20, P = 0.142 among women; OR = 0.50, P = 0.571 among men). South African women financially affected by the pandemic had a significant decline in seeking preventive care during the pandemic (OR = 0.23, P = 0.022). No conclusive effects were noted in Nigeria or Kenya.In South Africa, the pandemic and its strict control measures have adversely and disproportionately impacted disadvantaged women, which has implications for the nature of the long-term impact as well as mitigation and preparedness plans.

    View details for DOI 10.7189/jogh.12.05024

    View details for Web of Science ID 000841585000001

    View details for PubMedID 35959957

    View details for PubMedCentralID PMC9373834

  • Validation of visual estimation of neonatal jaundice in low-income and middle-income countries: a multicentre observational cohort study. BMJ open Darmstadt, G. L., Hamer, D. H., Carlin, J. B., Jeena, P. M., Mazzi, E., Narang, A., Deorari, A. K., Addo-Yobo, E., Chowdhury, M. A., Kumar, P., Abu-Sarkodie, Y., Yeboah-Antwi, K., Ray, P., Bartos, A. E., Saha, S. K., Foote, E., Bahl, R., Weber, M. W. 1800; 11 (12): e048145


    OBJECTIVE: Determine the sensitivity and specificity of neonatal jaundice visual estimation by primary healthcare workers (PHWs) and physicians as predictors of hyperbilirubinaemia.DESIGN: Multicentre observational cohort study.SETTING: Hospitals in Chandigarh and Delhi, India; Dhaka, Bangladesh; Durban, South Africa; Kumasi, Ghana; La Paz, Bolivia.PARTICIPANTS: Neonates aged 1-20days (n=2642) who presented to hospitals for evaluation of acute illness. Infants referred for any reason from another health facility or those needing immediate cardiopulmonary resuscitation were excluded.OUTCOME MEASURES: Infants were evaluated for distribution (head, trunk, distal extremities) and degree (mild, moderate, severe) of jaundice by PHWs and physicians. Serum bilirubin level was determined for infants with jaundice, and analyses of sensitivity and specificity of visual estimations of jaundice used bilirubin thresholds of >260mol/L (need for phototherapy) and >340mol/L (need for emergency intervention in at-risk and preterm babies).RESULTS: 1241 (47.0%) neonates had jaundice. High sensitivity for detecting neonates with serum bilirubin >340mol/L was found for 'any jaundice of the distal extremities (palms or soles) OR deep jaundice of the trunk or head' for both PHWs (89%-100%) and physicians (81%-100%) across study sites; specificity was more variable. 'Any jaundice of the distal extremities' identified by PHWs and physicians had sensitivity of 71%-100%and specificity of 55%-95%, excluding La Paz. For the bilirubin threshold >260mol/L, 'any jaundice of the distal extremities OR deep jaundice of the trunk or head' had the highest sensitivity across sites (PHWs: 58%-93%, physicians: 55%-98%).CONCLUSIONS: In settings where serum bilirubin cannot be measured, neonates with any jaundice on the distal extremities should be referred to a hospital for evaluation and management, where delays in serum bilirubin measurement and appropriate treatment are anticipated following referral, the higher sensitivity sign, any jaundice on the distal extremities or deep jaundice of the trunk or head, may be preferred.

    View details for DOI 10.1136/bmjopen-2020-048145

    View details for PubMedID 34972760

  • World Health Organization and knowledge translation in maternal, newborn, child and adolescent health and nutrition. Archives of disease in childhood STAGE (Strategic Technical Advisory Group of Experts), Duke, T., AlBuhairan, F. S., Agarwal, K., Arora, N. K., Arulkumaran, S., Bhutta, Z. A., Binka, F., Castro, A., Claeson, M., Dao, B., Darmstadt, G. L., English, M., Jardali, F., Merson, M., Ferrand, R. A., Golden, A., Golden, M. H., Homer, C., Jehan, F., Kabiru, C. W., Kirkwood, B., Lawn, J. E., Li, S., Patton, G. C., Ruel, M., Sandall, J., Sachdev, H. S., Tomlinson, M., Waiswa, P., Walker, D., Zlotkin, S. 1800


    The World Health Organization (WHO) has a mandate to promote maternal and child health and welfare through support to governments in the form of technical assistance, standards, epidemiological and statistical services, promoting teaching and training of healthcare professionals and providing direct aid in emergencies. The Strategic and Technical Advisory Group of Experts (STAGE) for maternal, newborn, child and adolescent health and nutrition (MNCAHN) was established in 2020 to advise the Director-General of WHO on issues relating to MNCAHN. STAGE comprises individuals from multiple low-income and middle-income and high-income countries, has representatives from many professional disciplines and with diverse experience and interests.Progress in MNCAHN requires improvements in quality of services, equity of access and the evolution of services as technical guidance, community needs and epidemiology changes. Knowledge translation of WHO guidance and other guidelines is an important part of this. Countries need effective and responsive structures for adaptation and implementation of evidence-based interventions, strategies to improve guideline uptake, education and training and mechanisms to monitor quality and safety. This paper summarises STAGE's recommendations on how to improve knowledge translation in MNCAHN. They include support for national and regional technical advisory groups and subnational committees that coordinate maternal and child health; support for national plans for MNCAHN and their implementation and monitoring; the production of a small number of consolidated MNCAHN guidelines to promote integrated and holistic care; education and quality improvement strategies to support guidelines uptake; monitoring of gaps in knowledge translation and operational research in MNCAHN.

    View details for DOI 10.1136/archdischild-2021-323102

    View details for PubMedID 34969670

  • Gender-related data missingness, imbalance and bias in global health surveys. BMJ global health Weber, A. M., Gupta, R., Abdalla, S., Cislaghi, B., Meausoone, V., Darmstadt, G. L. 2021; 6 (11)


    Global surveys have built-in gender-related biases associated with data missingness across the gender dimensions of people's lives, imbalanced or incomplete representation of population groups, and biased ways in which gender information is elicited and used. While increasing focus is being placed on the integration of sex-disaggregated statistics into national programmes and on understanding effects of gender-based disparities on the health of all people, the data necessary for elucidating underlying causes of gender disparities and designing effective intervention programmes continue to be lacking. Approaches exist, however, that can reasonably address some shortcomings, such as separating questions of gender identification from biological sex. Qualitative research can elucidate ways to rephrase questions and translate gendered terms to avoid perpetuating historical gender biases and prompting biased responses. Non-health disciplines may offer lessons in collecting gender-related data. Ultimately, multidisciplinary global collaborations are needed to advance this evolving field and to set standards for how we measure gender in all its forms.

    View details for DOI 10.1136/bmjgh-2021-007405

    View details for PubMedID 34836912

  • The impact of on-premises piped water supply on fecal contamination pathways in rural Zambia NPJ CLEAN WATER Winter, J. C., Darmstadt, G. L., Boehm, A. B., Davis, J. 2021; 4 (1)
  • The potential of school-based WASH programming to support children as agents of change in rural Zambian households. BMC public health Winter, J. C., Darmstadt, G. L., Lee, S. J., Davis, J. 2021; 21 (1): 1812


    BACKGROUND: Water, sanitation, and hygiene (WASH) interventions frequently assume that students who learn positive WASH behaviors will disseminate this information to their families. This is most prominent in school-based programs, which rely on students to act as "agents of change" to translate impact from school to home. However, there is little evidence to support or contradict this assumption.METHODS: We conducted a quasi-experimental, prospective cohort study in 12 schools in rural, southern Zambia to measure the impact of WASH UP!, a school-based WASH program designed by the creators of Sesame Street. WASH UP! is an educational program that uses stories and interactive games to teach students in grades 1-4 about healthy behaviors, such as washing hands and using the latrine. We completed in-person interviews with grade 1 and 4 students (N=392 and 369, respectively), their teachers (N=24) and caregivers (N=729) using structured surveys containing both open- and closed-ended questions. We measured changes in knowledge and whether students reported sharing WASH-related messages learned in school with their caregivers at home.RESULTS: Student knowledge increased significantly, but primarily among students in grade 1. Overall rates of students reporting that they shared messages from the curriculum with their caregivers rose from 7 to 23% (p<0.001). Students in grade 4 were 5.2 times as likely as those in grade 1 to report sharing a WASH-related message with their caregivers (ARR=5.2, 95% C.I. = (2.3, 8.9); p<0.001).CONCLUSIONS: Although we measured only modest levels of student dissemination of WASH UP! messages from the school to the home, students in grade 4 showed significantly more promise as agents of change than those in grade 1. Future work should prioritize developing curricula that reflect the variability in needs, capabilities and support in the home and community among primary school students rather than a single approach for a wide range of ages and contexts.

    View details for DOI 10.1186/s12889-021-11824-3

    View details for PubMedID 34625029

  • Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019 LANCET Paulson, K. R., Kamath, A. M., Alam, T., Bienhoff, K., Abady, G., Abbas, J., Abbasi-Kangevari, M., Abbastabar, H., Abd-Allah, F., Abd-Elsalam, S. M., Abdoli, A., Abedi, A., Abolhassani, H., Abreu, L., Abu-Gharbieh, E., Abu-Rmeileh, N. E., Abushouk, A., Adamu, A. L., Adebayo, O. M., Adegbosin, A., Adekanmbi, V., Adetokunboh, O. O., Adeyinka, D., Adsuar, J. C., Afshari, K., Aghaali, M., Agudelo-Botero, M., Ahinkorah, B., Ahmad, T., Ahmadi, K., Ahmed, M., Aji, B., Akalu, Y., Akinyemi, O., Aklilu, A., Al-Aly, Z., Alam, K., Alanezi, F., Alanzi, T. M., Alcalde-Rabanal, J., Al-Eyadhy, A., Ali, T., Alicandro, G., Alif, S., Alipour, V., Alizade, H., Aljunid, S., Almasi-Hashiani, A., Almasri, N. A., Al-Mekhlafi, H. M., Alonso, J., Al-Raddadi, R. M., Altirkawi, K. A., Alumran, A., Alvis-Guzman, N., Alvis-Zakzuk, N. J., Ameyaw, E., Amini, S., Amini-Rarani, M., Amit, A. L., Amugsi, D. A., Ancuceanu, R., Anderlini, D., Andrei, C., Ansari, F., Ansari-Moghaddam, A., Antonio, C. T., Antriyandarti, E., Anvari, D., Anwer, R., Aqeel, M., Arabloo, J., Arab-Zozani, M., Aripov, T., Arnlov, J., Artanti, K., Arzani, A., Asaad, M., Asadi-Aliabadi, M., Asadi-Pooya, A. A., Jafarabadi, M., Athari, S., Athari, S., Atnafu, D., Atreya, A., Atteraya, M., Ausloos, M., Awan, A., Quintanilla, B., Ayano, G., Ayanore, M., Aynalem, Y., Azari, S., Azarian, G., Azene, Z., Darshan, B. B., Babaee, E., Badiye, A. D., Baig, A., Banach, M., Banik, P., Barker-Collo, S., Barqawi, H., Bassat, Q., Basu, S., Baune, B. T., Bayati, M., Bedi, N., Beghi, E., Beghi, M., Bell, M. L., Bendak, S., Bennett, D. A., Bensenor, I. M., Berhe, K., Berman, A. E., Bezabih, Y., Bhagavathula, A., Bhandari, D., Bhardwaj, N., Bhardwaj, P., Bhattacharyya, K., Bhattarai, S., Bhutta, Z. A., Bikbov, B., Biondi, A., Birihane, B., Biswas, R., Bohlouli, S., Bragazzi, N., Breusov, A., Brunoni, A. R., Burkart, K., Nagaraja, S., Busse, R., Butt, Z. A., dos Santos, F., Cahuana-Hurtado, L., Camargos, P., Camera, L., Cardenas, R., Carreras, G., Carrero, J. J., Carvalho, F., Castaldelli-Maia, J., Castaneda-Orjuela, C. A., Castelpietra, G., Cerin, E., Chang, J., Chanie, W., Charan, J., Chatterjee, S., Chattu, S., Chattu, V., Chaturvedi, S., Chen, S., Cho, D., Choi, J., Chu, D., Ciobanu, L. G., Cirillo, M., Conde, J., Costa, V., Couto, R. S., Dachew, B., Dahlawi, S. A., Dai, H., Dai, X., Dandona, L., Dandona, R., Daneshpajouhnejad, P., Darmstadt, G. L., Das, J. K., Davila-Cervantes, C., Davis, A. C., Davletov, K., De la Hoz, F., De Leo, D., Deeba, F., Denova-Gutierrez, E., Dervenis, N., Desalew, A., Deuba, K., Dey, S., Dharmaratne, S., Dhingra, S., Dhungana, G., da Silva, D., Diaz, D., Dorostkar, F., Doshmangir, L., Dubljanin, E., Duraes, A., Eagan, A., Edinur, H., Efendi, F., Eftekharzadeh, S., El Sayed, I., El Tantawi, M., Elbarazi, I., Elgendy, I. Y., El-Jaafary, S., Emami, A., Enany, S., Eyawo, O., Ezzikouri, S., Faris, P., Farzadfar, F., Fattahi, N., Fauk, N., Fazlzadeh, M., Feigin, V. L., Ferede, T. Y., Fereshtehnejad, S., Fernandes, E., Ferrara, P., Filip, I., Fischer, F., Fisher, J. L., Foigt, N. A., Folayan, M., Foroutan, M., Franklin, R., Freitas, M., Friedman, S. D., Fukumoto, T., Gad, M. M., Gaidhane, A., Gaidhane, S., Gaihre, S., Gallus, S., Garcia-Basteiro, A. L., Garcia-Gordillo, M., Gardner, W. M., Fonseca, M., Gebremedhin, K., Getacher, L., Ghashghaee, A., Gholamian, A., Gilani, S., Gill, T. K., Giussani, G., Gnedovskaya, E., Godinho, M., Goel, A., Golechha, M., Gona, P. N., Gopalani, S., Goudarzi, H., Grivna, M., Gugnani, H., Guido, D., Guimaraes, R., Das Gupta, R., Gupta, R., Hafezi-Nejad, N., Haider, M., Haj-Mirzaian, A., Hamidi, S., Hanif, A., Hankey, G. J., Hargono, A., Hasaballah, A., Hasan, M., Hasan, S., Hassan, A., Hassanipour, S., Hassankhani, H., Havmoeller, R. J., Hayat, K., Heidari-Soureshjani, R., Henry, N. J., Herteliu, C., Hole, M. K., Holla, R., Hossain, N., Hosseini, M., Hosseinzadeh, M., Hostiuc, M., Hostiuc, S., Househ, M., Huang, J., Humayun, A., Hwang, B., Iavicoli, I., Ibitoye, S., Ikuta, K. S., Ilesanmi, O., Ilic, I. M., Ilic, M. D., Inamdar, S., Inbaraj, L., Iqbal, K., Iqbal, U., Islam, M., Islam, S., Iso, H., Iwagami, M., Iwu, C. D., Jaafari, J., Jacobsen, K. H., Jagnoor, J., Jain, V., Janodia, M., Javaheri, T., Javanmardi, F., Jayaram, S., Jayatilleke, A., Jenabi, E., Jha, R., Ji, J. S., John, O., Jonas, J. B., Joo, T., Joseph, N., Joukar, F., Jozwiak, J., Jurisson, M., Kabir, A., Kabir, Z., Kalankesh, L. R., Kamyari, N., Kanchan, T., Kapoor, N., Matin, B., Karch, A., Karimi, S., Kassahun, G., Kayode, G. A., Karyani, A., Kemmer, L., Khalid, N., Khalilov, R., Khammarnia, M., Khan, E., Khan, G., Khan, M., Khan, M., Khang, Y., Khatab, K., Khater, A. M., Khater, M. M., Khayamzadeh, M., Khosravi, A., Kim, D., Kim, Y., Kim, Y., Kimokoti, R. W., Kisa, A., Kisa, S., Kissoon, N., Kopec, J. A., Kosen, S., Koul, P. A., Laxminarayana, S., Koyanagi, A., Krishan, K., Krishnamoorthy, V., Defo, B., Bicer, B., Kulkarni, V., Kumar, G., Kumar, M., Kumar, N., Kurmi, O. P., Kusuma, D., La Vecchia, C., Lacey, B., Lalloo, R., Lami, F., Landires, I., Larsson, A. O., Lasrado, S., Lassi, Z. S., Lauriola, P., Lee, P. H., Lee, S., Lee, Y., Leigh, J., Leonardi, M., Lewycka, S., Li, B., Li, S., Liang, J., Lim, L., Limenih, M., Lin, R., Liu, X., Lodha, R., Lopez, A. D., Lozano, R., Lugo, A., Lunevicius, R., Mackay, M. T., Kunjathur, S., Magnani, F., Prasad, D., Maheri, M., Mahmoudi, M., Majeed, A., Maled, V., Maleki, A., Maleki, S., Malekzadeh, R., Malik, A., Malta, D., Mamun, A. A., Mansouri, B., Mansournia, M., Martinez, G., Martini, S., Martins-Melo, F., Masoumi, S., Maulik, P. K., McAlinden, C., McGrath, J. J., Medina-Solis, C., Nasab, E., Mejia-Rodriguez, F., Memish, Z. A., Mendoza, W., Menezes, R. G., Mengesha, E., Mensah, G. A., Meretoja, A., Meretoja, T. J., Mersha, A. M., Mestrovic, T., Miazgowski, B., Miazgowski, T., Michalek, I., Miller, T. R., Mini, G. K., Miri, M., Mirica, A., Mirrakhimov, E. M., Mirzaei, H., Mirzaei, M., Moazen, B., Moghadaszadeh, M., Mohajer, B., Mohamad, O., Mohammad, Y., Mohammadi, S., Mohammadian-Hafshejani, A., Mohammed, S., Mokdad, A. H., Molokhia, M., Monasta, L., Mondello, S., Moni, M., Moore, C. E., Moradi, G., Moradi, M., Moradzadeh, R., Moraga, P., Morawska, L., Morrison, S., Mosser, J. F., Khaneghah, A., Mustafa, G., Naderi, M., Nagarajan, A., Nagaraju, S., Naghavi, M., Naghshtabrizi, B., Naimzada, M., Nangia, V., Swamy, S., Nascimento, B., Naveed, M., Nazari, J., Ndejjo, R., Negoi, I., Negoi, R., Nena, E., Nepal, S., Netsere, H., Nguefack-Tsague, G., Ngunjiri, J. W., Chi Thi Yen Nguyen, Cuong Tat Nguyen, Huong Lan Thi Nguyen, Nigatu, Y. T., Nigussie, S., Nixon, M. R., Nnaji, C. A., Nomura, S., Noor, N. M., Noubiap, J., Nunez-Samudio, V., Nwatah, V., Oancea, B., Odukoya, O., Ogbo, F., Olusanya, B., Olusanya, J., Bali, A., Onwujekwe, O. E., Ortiz, A., Otoiu, A., Otstavnov, N., Otstavnov, S. S., Owolabi, M. O., Mahesh, P. A., Padubidri, J., Pakhale, S., Pakshir, K., Pal, P., Palladino, R., Pana, A., Panda-Jonas, S., Pandey, A., Pandey, A., Pandi-Perumal, S. R., Pangaribuan, H., Pardo-Montano, A., Park, E., Patel, S., Patton, G. C., Pawar, S., Toroudi, H., Peden, A. E., Pepito, V., Peprah, E. K., Pereira, J., Perez-Gomez, J., Perico, N., Pesudovs, K., Pilgrim, T., Pinheiro, M., Piradov, M. A., Pirsaheb, M., Platts-Mills, J. A., Pokhrel, K., Postma, M. J., Pourjafar, H., Prada, S., Prakash, S., Pupillo, E., Syed, Z., Rabiee, N., Radfar, A., Rafiee, A., Rafiei, A., Raggi, A., Rahimzadeh, S., Rahman, M., Rahmani, A., Ramezanzadeh, K., Rana, J., Ranabhat, C., Rao, S. J., Rasella, D., Rastogi, P., Rathi, P., Rawaf, D., Rawaf, S., Rawasia, W., Rawassizadeh, R., Jr, R., Remuzzi, G., Renzaho, A. N., Reshmi, B., Resnikoff, S., Rezaei, N., Rezaei, N., Rezapour, A., Riahi, S., Ribeiro, D., Rickard, J., Roever, L., Ronfani, L., Rothenbacher, D., Rubagotti, E., Rumisha, S., Ryan, P., Saddik, B., Sadeghi, E., Moghaddam, S., Sagar, R., Sahebkar, A., Salahshoor, M., Salehi, S., Salem, M., Salimzadeh, H., Salomon, J. A., Samodra, Y., Samy, A. M., Sanabria, J., Santric-Milicevic, M. M., Saraswathy, S., Sarker, A., Sarrafzadegan, N., Sarveazad, A., Sathian, B., Sathish, T., Sattin, D., Saxena, S., Saya, G., Saylan, M., Schiavolin, S., Schlaich, M. P., Schwebel, D. C., Schwendicke, F., Senthilkumaran, S., Sepanlou, S. G., Servan-Mori, E., Sha, F., Shafaat, O., Shahabi, S., Shahbaz, M., Shaheen, A. A., Shahid, I., Shaikh, M., Shakiba, S., Shalash, A. S., Shams-Beyranvand, M., Shannawaz, M., Sharafi, K., Sheikh, A., Sheikhbahaei, S., Shiferaw, W., Shigematsu, M., Shin, J., Shiri, R., Shiue, I., Shuval, K., Siddiqi, T., Sidemo, N., Sigfusdottir, I., Sigurvinsdottir, R., Silva, J., Silverberg, J. S., Simonetti, B., Singh, B., Singh, J. A., Singhal, D., Sinha, D., Skiadaresi, E., Skryabin, V., Skryabina, A., Sleet, D. A., Sobaih, B., Sobhiyeh, M., Soltani, S., Soriano, J. B., Spurlock, E., Sreeramareddy, C. T., Steiropoulos, P., Stokes, M. A., Stortecky, S., Sufiyan, M., Abdulkader, R., Sulo, G., Swope, C. B., Sykes, B. L., Szeto, M. D., Szocska, M., Tabares-Seisdedos, R., Tadesse, E., Taherkhani, A., Tamiru, A., Tareque, M., Tehrani-Banihashemi, A., Temsah, M., Tesfay, F., Tessema, G., Tessema, Z., Thankappan, K., Thapar, R., Tolani, M., Tovani-Palone, M., Traini, E., Bach Xuan Tran, Tripathy, J., Tsapparellas, G., Tsatsakis, A., Car, L., Uddin, R., Ullah, A., Umeokonkwo, C., Unim, B., Unnikrishnan, B., Upadhyay, E., Usman, M., Vacante, M., Vaezi, M., Tahbaz, S., Valdez, P. R., Vasankari, T., Venketasubramanian, N., Verma, M., Violante, F. S., Vlassov, V., Vo, B., Giang Thu Vu, Wado, Y., Waheed, Y., Wamai, R. G., Wang, Y., Wang, Y., Wang, Y., Ward, P., Werdecker, A., Westerman, R., Wickramasinghe, N., Wilner, L. B., Wiysonge, C., Wu, A., Wu, C., Xie, Y., Jabbari, S., Yamagishi, K., Yandrapalli, S., Yaya, S., Yazdi-Feyzabadi, V., Yip, P., Yonemoto, N., Yoon, S., Younis, M. Z., Yousefi, Z., Yousefinezhadi, T., Yu, C., Yusuf, S., Zaidi, S., Bin Zaman, S., Zamani, M., Zamanian, M., Zastrozhin, M., Zastrozhina, A., Zhang, Y., Zhang, Z., Zhao, X., Ziapour, A., Hay, S., Murray, C. L., Wang, H., Kassebaum, N. J., GBD 2019 Under-5 Mortality Collabo 2021; 398 (10303): 870-905


    Sustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival.We completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (U5MR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index.Global U5MR decreased from 71·2 deaths per 1000 livebirths (95% uncertainty interval [UI] 68·3-74·0) in 2000 to 37·1 (33·2-41·7) in 2019 while global NMR correspondingly declined more slowly from 28·0 deaths per 1000 live births (26·8-29·5) in 2000 to 17·9 (16·3-19·8) in 2019. In 2019, 136 (67%) of 204 countries had a U5MR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030, 154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9·65 million (95% UI 9·05-10·30) in 2000 and 5·05 million (4·27-6·02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3·76 million [95% UI 3·53-4·02]) in 2000 to 48% (2·42 million; 2·06-2·86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0·80 (95% UI 0·71-0·86) deaths per 1000 livebirths and U5MR to 1·44 (95% UI 1·27-1·58) deaths per 1000 livebirths, and in 2019, there were as many as 1·87 million (95% UI 1·35-2·58; 37% [95% UI 32-43]) of 5·05 million more deaths of children younger than 5 years than the survival potential frontier.Global child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve U5MR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress.Bill & Melinda Gates Foundation.

    View details for DOI 10.1016/S0140-6736(21)01207-1

    View details for Web of Science ID 000692628000023

    View details for PubMedID 34416195

    View details for PubMedCentralID PMC8429803

  • Scaling up Kangaroo Mother Care in Ethiopia and India: a multi-site implementation research study BMJ GLOBAL HEALTH Mony, P. K., Tadele, H., Gobezayehu, A., Chan, G. J., Kumar, A., Mazumder, S., Beyene, S., Jayanna, K., Kassa, D., Mohammed, H., Estifanos, A., Kumar, P., Jadaun, A., Hailu Abay, T., Washington, M., Gebriel, F. W., Alamineh, L., Fikre, A., Kumar, A., Trikha, S., Ashebir Gebregizabher, F., Kar, A., Bilal, S., Belew, M., Debere, M., Krishna, R., Dalpath, S., Amare, S., Mohan, H. L., Brune, T., Sibley, L. M., Tariku, A., Sahu, A., Kumar, T., Hadush, M., Gowda, P., Aziz, K., Duguma, D., Singh, P., Darmstadt, G. L., Agarwal, R., Gebremariam, D., Martines, J., Portela, A., Jaiswal, H., Bahl, R., Rao, S. N., Tadesse, B., Cranmer, J. N., Hailemariam, D., Kumar, V., Bhandari, N., Medhanyie, A., KMC Scale-Up Study Grp 2021; 6 (9)
  • Comparison of Culture, Antigen Test, and Polymerase Chain Reaction for Pneumococcal Detection in Cerebrospinal Fluid of Children. The Journal of infectious diseases Hasanuzzaman, M., Saha, S., Malaker, R., Rahman, H., Sajib, M. S., Das, R. C., Islam, M., Hamer, D. H., Darmstadt, G. L., Saha, S. K. 2021; 224 (Supplement_3): S209-S217


    BACKGROUND: Sensitivity of culture for the detection of Streptococcus pneumoniae is limited by prior antibiotic exposure. Immunochromatographic test (ICT) is highly sensitive and specific for pneumococcal antigen detection in the cerebrospinal fluid (CSF) of meningitis cases. We determined the specificity and sensitivity of culture, ICT, and polymerase chain reaction (PCR) and the effect of antibiotic exposure on their performance.METHODS: CSF specimens from suspected meningitis cases admitted to Dhaka Shishu Hospital, Bangladesh, were tested using culture, ICT and PCR. Additionally, 165 specimens collected from 69 pneumococcal cases after antibiotic treatment were tested.RESULTS: Of 1883 specimens tested, culture detected 9, quantitative PCR (qPCR) detected 184, and ICT detected 207 pneumococcal cases (including all culture and qPCR positives). In comparison to ICT, sensitivity of culture was 4.4% and of qPCR was 90.6%; both were 100% specific. After antibiotic exposure, culture sensitivity plummeted rapidly; conventional PCR and qPCR sensitivity disappeared after day 6 and 20, respectively. ICT detected pneumococcal antigen for >10 weeks.CONCLUSIONS: While culture provides the most information about bacterial characteristics, in high antibiotic exposure settings, ICT exhibits maximum sensitivity. We recommend culture and ICT as mainstay for pneumococcal diagnosis and surveillance; qPCR can generate additional molecular data where possible.

    View details for DOI 10.1093/infdis/jiab073

    View details for PubMedID 34469562

  • Scaling up Kangaroo Mother Care in Ethiopia and India: a multi-site implementation research study. BMJ global health Mony, P. K., Tadele, H., Gobezayehu, A. G., Chan, G. J., Kumar, A., Mazumder, S., Beyene, S. A., Jayanna, K., Kassa, D. H., Mohammed, H. A., Estifanos, A. S., Kumar, P., Jadaun, A. S., Hailu Abay, T., Washington, M., W/Gebriel, F., Alamineh, L., Fikre, A., Kumar, A., Trikha, S., Ashebir Gebregizabher, F., Kar, A., Bilal, S. M., Belew, M. L., Debere, M. K., Krishna, R., Dalpath, S. K., Amare, S. Y., Mohan, H. L., Brune, T., Sibley, L. M., Tariku, A., Sahu, A., Kumar, T., Hadush, M. Y., Gowda, P. D., Aziz, K., Duguma, D., Singh, P. K., Darmstadt, G. L., Agarwal, R., Gebremariam, D. S., Martines, J., Portela, A., Jaiswal, H. V., Bahl, R., Rao Pn, S., Tadesse, B. T., Cranmer, J. N., Hailemariam, D., Kumar, V., Bhandari, N., Medhanyie, A. A., KMC Scale-Up Study Group 2021; 6 (9)


    OBJECTIVES: Kangaroo Mother Care (KMC), prolonged skin-to-skin care of the low birth weight baby with the mother plus exclusive breastfeeding reduces neonatal mortality. Global KMC coverage is low. This study was conducted to develop and evaluate context-adapted implementation models to achieve improved coverage.DESIGN: This study used mixed-methods applying implementation science to develop an adaptable strategy to improve implementation. Formative research informed the initial model which was refined in three iterative cycles. The models included three components: (1) maximising access to KMC-implementing facilities, (2) ensuring KMC initiation and maintenance in facilities and (3) supporting continuation at home postdischarge.PARTICIPANTS: 3804 infants of birth weight under 2000g who survived the first 3days, were available in the study area and whose mother resided in the study area.MAIN OUTCOME MEASURES: The primary outcomes were coverage of KMC during the 24 hours prior to discharge and at 7days postdischarge.RESULTS: Key barriers and solutions were identified for scaling up KMC. The resulting implementation model achieved high population-based coverage. KMC initiation reached 68%-86% of infants in Ethiopian sites and 87% in Indian sites. At discharge, KMC was provided to 68% of infants in Ethiopia and 55% in India. At 7days postdischarge, KMC was provided to 53%-65% of infants in all sites, except Oromia (38%) and Karnataka (36%).CONCLUSIONS: This study shows how high coverage of KMC can be achieved using context-adapted models based on implementation science. They were supported by government leadership, health workers' conviction that KMC is the standard of care, women's and families' acceptance of KMC, and changes in infrastructure, policy, skills and practice.TRIAL REGISTRATION NUMBERS: ISRCTN12286667; CTRI/2017/07/008988; NCT03098069; NCT03419416; NCT03506698.

    View details for DOI 10.1136/bmjgh-2021-005905

    View details for PubMedID 34518203

  • Effects of integrated economic and health interventions with women's groups on health-related knowledge, behaviours and outcomes in low-income and middle-income countries: a systematic review protocol. BMJ open Desai, S., Mehta, K. M., Singh, R. J., Westley, A. K., Dirisu, O., Wong, C., De Hoop, T., Darmstadt, G. L. 2021; 11 (7): e046856


    INTRODUCTION: Economic groups, such as microfinance or self-help groups are widely implemented in low-income and middle-income countries (LMICs). Women's groups are voluntary groups, which aim to improve the well-being of members through activities, such as joint savings, credit, livelihoods development and/or health activities. Health interventions are increasingly added on to existing women's economic groups as a public health intervention for women and their families. Here, we present the protocol for a mixed-methods systematic review we will conduct of the evidence on integrated economic and health interventions on women's groups to assess whether and how they improve health-related knowledge, behaviour and outcomes in LMICs.METHODS AND ANALYSIS: We will search seven electronic databases for published literature, along with manual searches and consultation. The review will include (1) randomised trials and non-randomised quasiexperimental studies of intervention effects of integrated economic and health interventions delivered through women's groups in LMICs, and (2) sibling studies that examine factors related to intervention content, context, implementation processes and costs. We will appraise risk of bias and study quality using standard tools. High and moderate quality studies will be grouped by health domain and synthesised without meta-analysis. Qualitative evidence will be thematically synthesised and integrated into the quantitative synthesis using a matrix approach.ETHICS AND DISSEMINATION: This protocol was reviewed and deemed exempt by the institutional review board at the American Institutes for Research. Findings will be shared through peer-reviewed publication and disseminated with programme implementers and policymakers engaged with women's groups.PROSPERO REGISTRATION NUMBER: CRD42020199998.

    View details for DOI 10.1136/bmjopen-2020-046856

    View details for PubMedID 34253668

  • Association between maternity waiting home stay and obstetric outcomes in Yetebon, Ethiopia: a mixed-methods observational cohort study. BMC pregnancy and childbirth Erickson, A. K., Abdalla, S., Serenska, A., Demeke, B., Darmstadt, G. L. 2021; 21 (1): 482


    BACKGROUND: A strategy for reducing adverse pregnancy outcomes is the expanded implementation of maternity waiting homes (MWHs). We assessed factors influencing MWH use, as well as the association between MWH stay and obstetric outcomes in a hospital in rural Ethiopia.METHODS: Data from medical records of the Glenn C. Olson Memorial Primary Hospital obstetric ward were cross matched with records from the affiliated MWH between 1 and 2011 to 31 March 2014. Poisson regression with robust variance was conducted to estimate the relative risk (RR) of childbirth complications associated with MWH use vs. non-use. Five key informant interviews of a convenience sample of three MWH staff and two users were conducted and a thematic analysis performed of social, cultural, and economic factors underlying MWH use.RESULTS: During the study period, 489 women gave birth at the hospital, 93 of whom were MWH users. Common reasons for using the MWH were post-term status, previous caesarean section/myomectomy, malposition/malpresentation, and low-lying placenta, placenta previa, or antepartum hemorrhage, and hypertension or preeclampsia. MWH users were more likely than non-users to have had a previous caesarean Sec.(15.1% vs. 5.3%, p<0.001) and to be post-term (21.5% vs. 3.8%, p<0.001). MWH users were also more likely to undergo a caesarean Sec.(51.0% vs. 35.4%, p<0.05) and less likely (p<0.05) to have a spontaneous vaginal delivery (49.0% vs. 63.6%), obstructed labor (6.5% vs. 14.4%) or stillbirth (1.1% vs. 8.6%). MWH use (N=93) was associated with a 77% (adjusted RR=0.23, 95% Confidence Interval (CI) 0.12-0.46, p<0.001) lower risk of childbirth complications, a 94% (adjusted RR=0.06, 95% CI 0.01-0.43, p=0.005) lower risk of fetal and newborn complications, and a 73% (adjusted RR=0.27, 95% CI 0.13-0.56, p<0.001) lower risk of maternal complications compared to MWH non-users (N=396). Birth weight [median 3.5kg (interquartile range 3.0-3.8) vs. 3.2kg (2.8-3.5), p<0.001] and 5-min Apgar scores (adjusted difference=0.25, 95% CI 0.06-0.44, p<0.001) were also higher in offspring of MWH users. Opportunity costs due to missed work and need to arrange for care of children at home, long travel times, and lack of entertainment were suggested as key barriers to MWH utilization.CONCLUSIONS: This observational, non-randomized study suggests that MWH usage was associated with significantly improved childbirth outcomes. Increasing facility quality, expanding services, and providing educational opportunities should be considered to increase MWH use.

    View details for DOI 10.1186/s12884-021-03913-3

    View details for PubMedID 34217232

  • Implementing health communication tools at scale: mobile audio messaging and paper-based job aids for front-line workers providing community health education to mothers in Bihar, India. BMJ global health Ward, V., Abdalla, S., Raheel, H., Weng, Y., Godfrey, A., Dutt, P., Mitra, R., Sastry, P., Chamberlain, S., Shannon, M., Mehta, K., Bentley, J., Darmstadt Md, G. L., Ananya Study Group, Atmavilas, Y., Bentley, J., Bhattacharya, D., Borkum, E., Carmichael, S. L., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Krishnan, S., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W., Nanda, P., Pepper, K., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Schooley, J., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Walker, D., Weng, Y., Wilhelm, J. 2021; 6 (Suppl 5)


    INTRODUCTION: As part of an investment by the Bill & Melinda Gates Foundation to support the Government of Bihar to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide, BBC Media Action implemented multiple communication tools to support front-line worker (FLW) outreach. We analyse the impacts of a package of mHealth audio messaging and paper-based job aids used by FLWs during government-sponsored village health, sanitation and nutrition days (VHSNDs) on knowledge and practices of childbearing women across the RMNCHN continuum of care.METHODS: Data from two surveys collected between July and September 2016 were analysed using logistic regression to compare health-related knowledge and behaviours between women who had been exposed at VHSNDs to the mHealth GupShup Potli (GSP) audio recordings or interpersonal communication (IPC) tools versus those who were unexposed.RESULTS: Exposure to GSP recordings (n=2608) was associated with improved knowledge across all continuum-of-care domains, as well as improved health-related behaviours in some domains. The odds of having taken iron-folic acid (IFA) tablets were significantly higher in exposed women (OR 1.5, 95% CI 1.1 to 2.2), as was contraceptive use (OR 2.0, 95% CI 1.2 to 3.2). There were no differences in birth preparedness or complementary feeding practices between groups. Exposure to IPC paper-based tools (n=2002) was associated with a twofold increased odds of IFA consumption (OR 2.3, 95% CI 1.7 to 3.2) and contraceptive use (OR 1.8, 95% CI 1.2 to 2.8). Women exposed to both tools were generally at least twice as likely to subsequently discuss the messages with others.CONCLUSION: BBC Media Action's mHealth audio messaging job aids and paper-based IPC tools were associated with improved knowledge and practices of women who were exposed to them across multiple domains, suggesting their important potential for improving health outcomes for beneficiaries at scale in low-resource settings.TRIAL REGISTRATION NUMBER: NCT02726230.

    View details for DOI 10.1136/bmjgh-2021-005538

    View details for PubMedID 34312155

  • Africa is not a museum: the ethics of encouraging new parenting practices in rural communities in low-income and middle-income countries. BMJ global health Weber, A. M., Diop, Y., Gillespie, D., Ratsifandrihamanana, L., Darmstadt, G. L. 2021; 6 (7)


    The Nurturing Care Framework for Early Childhood Development urges stakeholders to implement strategies that help children worldwide achieve their developmental potential. Related programmes range from the WHO's and UNICEF's Care for Child Development intervention, implemented in 19 countries, to locally developed programmes, such as non-governmental organisation Tostan's Reinforcement of Parental Practices in Senegal. However, some researchers argue that these programmes are unethical as they impose caregiving practices and values from high-income countries (HICs) on low-income communities, failing to consider local culture, communities' goals for their children and generalisability of scientific findings from HICs. We explore these criticisms within a public health framework, applying principles of beneficence, autonomy and justice to the arguments. To facilitate the change communities themselves desire for their children, we recommend that practitioners codevelop programmes and cooperate with communities in implementation to harness local beliefs and customs and promote evidence-based and locally adapted practices.

    View details for DOI 10.1136/bmjgh-2021-006218

    View details for PubMedID 34266849

  • Effect of topical applications of sunflower seed oil on systemic fatty acid levels in under-two children under rehabilitation for severe acute malnutrition in Bangladesh: a randomized controlled trial. Nutrition journal Shahunja, K. M., Sevin, D. C., Kendall, L., Ahmed, T., Hossain, M. I., Mahfuz, M., Zhu, X., Singh, K., Singh, S., Crowther, J. M., Gibson, R. A., Darmstadt, G. L. 2021; 20 (1): 51


    BACKGROUND: Children with severe acute malnutrition (SAM) have inadequate levels of fatty acids (FAs) and limited capacity for enteral nutritional rehabilitation. We hypothesized that topical high-linoleate sunflower seed oil (SSO) would be effective adjunctive treatment for children with SAM.METHODS: This study tested a prespecified secondary endpoint of a randomized, controlled, unblinded clinical trial with 212 children with SAM aged 2 to 24months in two strata (2 to <6months, 6 to 24months in a 1:2 ratio) at Dhaka Hospital of icddr,b, Bangladesh between January 2016 and December 2017. All children received standard-of-care management of SAM. Children randomized to the emollient group also received whole-body applications of 3g/kg SSO three times daily for 10 days. We applied difference-in-difference analysis and unsupervised clustering analysis using t-distributed stochastic neighbor embedding (t-SNE) to visualize changes in FA levels in blood from day 0 to day 10 of children with SAM treated with emollient compared to no-emollient.RESULTS: Emollient therapy led to systematically higher increases in 26 of 29 FAs over time compared to the control. These effects were driven primarily by changes in younger subjects (27 of 29 FAs). Several FAs, especially those most abundant in SSO showed high-magnitude but non-significant incremental increases from day 0 to day 10 in the emollient group vs. the no-emollient group; for linoleic acid, a 237 mug/mL increase was attributable to enteral feeding and an incremental 98 mug/mL increase (41%) was due to emollient therapy. Behenic acid (22:0), gamma-linolenic acid (18:3n6), and eicosapentaenoic acid (20:5n3) were significantly increased in the younger age stratum; minimal changes were seen in the older children.CONCLUSIONS: SSO therapy for SAM augmented the impact of enteral feeding in increasing levels of several FAs in young children. Further research is warranted into optimizing this novel approach for nutritional rehabilitation of children with SAM, especially those <6months.TRIAL REGISTRATION: : NCT02616289 .

    View details for DOI 10.1186/s12937-021-00707-3

    View details for PubMedID 34092255

  • Levels and potential drivers of under-five mortality sex ratios in low- and middle-income countries. Paediatric and perinatal epidemiology Costa, J. C., Weber, A. M., Abdalla, S., Darmstadt, G. L., Victora, C. G. 2021


    Non-biological childhood mortality sex ratios may reflect community sex preferences and gender discrimination in health care.We assessed the association between contextual factors and gender bias in under-five mortality rates (U5MR) in low- and middle-income countries.Full birth histories available from Demographic and Health Surveys and Multiple Indicator Cluster Surveys (2010-2018) in 80 countries were used to estimate U5MR male-to-female sex ratios. Expected sex ratios and their residuals (difference of observed and expected) were derived from a linear regression model, adjusted for overall mortality. Negative residuals indicate more likelihood of discrimination against girls, and we refer to this as a measure of potential gender bias. Associations between residuals and national development and gender inequality indices and with survey-derived child health care indicators were tested using Spearman's correlation.Mortality residuals for under-five mortality were not associated with national development, education, religion, or gender inequality indices. Negative residuals were more common in countries where boys were more likely to be taken to health services than girls (rho -0.24, 95% confidence interval -0.45, -0.01).Countries where girls were more likely to die than boys, accounting for overall mortality levels, were also countries where boys were more likely to receive health care than girls. Further research is needed to understand which national characteristics explain the presence of gender bias, given that the analyses of development levels and gender equality did not discriminate between countries with or without excess mortality of girls. Reporting on child mortality separately by sex is required to enable such advances.

    View details for DOI 10.1111/ppe.12763

    View details for PubMedID 34080692

  • Levels and potential drivers of under-five mortality sex ratios in low- and middle-income countries PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Costa, J., Weber, A. M., Abdalla, S., Darmstadt, G. L., Victora, C. G. 2021

    View details for DOI 10.1111/ppe.12763

    View details for Web of Science ID 000654436400001

  • Impact of emollient therapy for preterm infants in the neonatal period on child neurodevelopment in Bangladesh: an observational cohort study. Journal of health, population, and nutrition Darmstadt, G. L., Khan, N. Z., Rosenstock, S., Muslima, H., Parveen, M., Mahmood, W., Ahmed, A. S., Chowdhury, M. A., Zeger, S., Saha, S. K. 2021; 40 (1): 24


    BACKGROUND: Topical treatment with sunflower seed oil (SSO) or Aquaphor reduced sepsis and neonatal mortality in hospitalized preterm infants <33 weeks' gestational age in Bangladesh. We sought to determine whether the emollient treatments improved neurodevelopmental outcomes during early childhood.METHODS: 497 infants were randomized to receive SSO, Aquaphor, or neither through the neonatal period or hospital discharge. 159 infant survivors were enrolled in the longitudinal follow-up study using a validated Rapid Neurodevelopmental Assessment tool and the Bayley Scales of Infant Development II (BSID II) administered at three-monthly intervals for the first year and thereafter at six-monthly intervals. Lowess smoothing was used to display neurodevelopmental status across multiple domains by age and treatment group, and Generalized Estimating Equations (GEE) were used to compare treatment groups across age points.RESULTS: 123 children completed at least one follow-up visit. Lowess graphs suggest that lower proportions of children who received massage with either SSO or Aquaphor had neurodevelopmental delays than control infants in a composite outcome of disabilities. In GEE analysis, infants receiving SSO showed a significant protective effect on the development of fine motor skills [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.86-0.98, p=0.006]. The Psychomotor Development Index (PDI) in the BSID II showed significantly lower disability rates in the Aquaphor group (23.6%) compared to the control (55.2%) (OR 0.21, 95% CI 0.06-0.72, p=0.004).CONCLUSIONS: Emollient massage of very preterm, hospitalized newborn infants improved some child neurodevelopmental outcomes over the first 2 years of follow-up. Findings warrant further confirmatory research.TRIAL REGISTRATION: (98-04-21-03-2) under weblink

    View details for DOI 10.1186/s41043-021-00248-9

    View details for PubMedID 34039435

  • Gendered effects of COVID-19 on young girls in regions of conflict LANCET Nesamoney, S. N., Darmstadt, G. L., Wise, P. H. 2021; 397 (10288): 1880-1881
  • Gendered effects of COVID-19 on young girls in regions of conflict. Lancet (London, England) Nesamoney, S. N., Darmstadt, G. L., Wise, P. H. 2021; 397 (10288): 1880-1881

    View details for DOI 10.1016/S0140-6736(21)00936-3

    View details for PubMedID 34022981

  • Addressing the impacts of COVID-19 on gender equality and global health security in regions of violent conflict. Journal of global health Nesamoney, S. N., Darmstadt, G. L., Wise, P. H. 2021; 11: 03074

    View details for DOI 10.7189/jogh.11.03074

    View details for PubMedID 34055324

  • Integrated trajectories of the maternal metabolome, proteome, and immunome predict labor onset. Science translational medicine Stelzer, I. A., Ghaemi, M. S., Han, X., Ando, K., Hedou, J. J., Feyaerts, D., Peterson, L. S., Rumer, K. K., Tsai, E. S., Ganio, E. A., Gaudilliere, D. K., Tsai, A. S., Choisy, B., Gaigne, L. P., Verdonk, F., Jacobsen, D., Gavasso, S., Traber, G. M., Ellenberger, M., Stanley, N., Becker, M., Culos, A., Fallahzadeh, R., Wong, R. J., Darmstadt, G. L., Druzin, M. L., Winn, V. D., Gibbs, R. S., Ling, X. B., Sylvester, K., Carvalho, B., Snyder, M. P., Shaw, G. M., Stevenson, D. K., Contrepois, K., Angst, M. S., Aghaeepour, N., Gaudilliere, B. 2021; 13 (592)


    Estimating the time of delivery is of high clinical importance because pre- and postterm deviations are associated with complications for the mother and her offspring. However, current estimations are inaccurate. As pregnancy progresses toward labor, major transitions occur in fetomaternal immune, metabolic, and endocrine systems that culminate in birth. The comprehensive characterization of maternal biology that precedes labor is key to understanding these physiological transitions and identifying predictive biomarkers of delivery. Here, a longitudinal study was conducted in 63 women who went into labor spontaneously. More than 7000 plasma analytes and peripheral immune cell responses were analyzed using untargeted mass spectrometry, aptamer-based proteomic technology, and single-cell mass cytometry in serial blood samples collected during the last 100 days of pregnancy. The high-dimensional dataset was integrated into a multiomic model that predicted the time to spontaneous labor [R = 0.85, 95% confidence interval (CI) [0.79 to 0.89], P = 1.2 * 10-40, N = 53, training set; R = 0.81, 95% CI [0.61 to 0.91], P = 3.9 * 10-7, N = 10, independent test set]. Coordinated alterations in maternal metabolome, proteome, and immunome marked a molecular shift from pregnancy maintenance to prelabor biology 2 to 4 weeks before delivery. A surge in steroid hormone metabolites and interleukin-1 receptor type 4 that preceded labor coincided with a switch from immune activation to regulation of inflammatory responses. Our study lays the groundwork for developing blood-based methods for predicting the day of labor, anchored in mechanisms shared in preterm and term pregnancies.

    View details for DOI 10.1126/scitranslmed.abd9898

    View details for PubMedID 33952678

  • Setting research priorities for sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian settings. Conflict and health Kobeissi, L., Nair, M., Evers, E. S., Han, M. D., Aboubaker, S., Say, L., Rollins, N., Darmstadt, G. L., Blanchet, K., Garcia, D. M., Hagon, O., Ashorn, P., Members of the WHO research prioritization group for SRMNCAH promotion in humanitarian settings, Abbas, D., Abdi, H., Al-Nsour, M., Baingana, F. K., Bashour, H. N., Casey, S., Chi, P. C., Dakkak, H., Devakumar, D., Hynes, M., Garry, S., Ippe, J., Mitu, N. J., Jojan, S. A., Kozuki, N., Mahmood, Q., Mann, P., Mates, E., Mangen, P. O., Ozmert, E., Petrucci, R., Tappis, H., Wood, G. 2021; 15 (1): 16


    BACKGROUND: An estimated 70.8 million people are forcibly displaced worldwide, 75% of whom are women and children. Prioritizing a global research agenda to inform guidance, service delivery, access to and quality of services is essential to improve the survival and health of women, children and adolescents in humanitarian settings.METHOD: A mixed-methods design was adapted from the Child Health and Nutrition Research Initiative (CHNRI) methodology to solicit priority research questions across the sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) domains in humanitarian settings. The first step (CHNRI) involved data collection and scoring of perceived priority questions, using a web-based survey over two rounds (first, to generate the questions and secondly, to score them). Over 1000 stakeholders from across the globe were approached; 177 took part in the first survey and 69 took part in the second. These research questions were prioritized by generating a research prioritization score (RPP) across four dimensions: answerability, program feasibility, public health relevance and equity. A Delphi process of 29 experts followed, where the 50 scored and prioritized CHRNI research questions were shortlisted. The top five questions from the CHNRI scored list for each SRMNCAH domain were voted on, rendering a final list per domain.RESULTS: A total of 280 questions were generated. Generated questions covered sexual and reproductive health (SRH) (n=90, 32.1%), maternal health (n=75, 26.8%), newborn health (n=42, 15.0%), child health (n=43, 15.4%), and non-SRH aspects of adolescent health (n=31, 11.1%). A shortlist of the top ten prioritized questions for each domain were generated on the basis of the computed RPPs. During the Delphi process, the prioritized questions, based on the CHNRI process, were further refined. Five questions from the shortlist of each of the SRMNCAH domain were formulated, resulting in 25 priority questions across SRMNCAH. For example, one of the prioritized SRH shortlisted and prioritized research question included: "What are effective strategies to implement good quality comprehensive contraceptive services (long-acting, short-acting and EC) for women and girls in humanitarian settings?"CONCLUSION: Data needs, effective intervention strategies and approaches, as well as greater efficiency and quality during delivery of care in humanitarian settings were prioritized. The findings from this research provide guidance for researchers, program implementers, as well as donor agencies on SRMNCAH research priorities in humanitarian settings. A global research agenda could save the lives of those who are at greatest risk and vulnerability as well as increase opportunities for translation and innovation for SRMNCAH in humanitarian settings.

    View details for DOI 10.1186/s13031-021-00353-w

    View details for PubMedID 33771212

  • Understanding how biologic and social determinants affect disparities in preterm birth and outcomes of preterm infants in the NICU. Seminars in perinatology Stevenson, D. K., Aghaeepour, N., Maric, I., Angst, M. S., Darmstadt, G. L., Druzin, M. L., Gaudilliere, B., Ling, X. B., Moufarrej, M. N., Peterson, L. S., Quake, S. R., Relman, D. A., Snyder, M. P., Sylvester, K. G., Shaw, G. M., Wong, R. J. 2021: 151408


    To understand the disparities in spontaneous preterm birth (sPTB) and/or its outcomes, biologic and social determinants as well as healthcare practice (such as those in neonatal intensive care units) should be considered. They have been largely intractable and remain obscure in most cases, despite a myriad of identified risk factors for and causes of sPTB. We still do not know how they might actually affect and lead to the different outcomes at different gestational ages and if they are independent of NICU practices. Here we describe an integrated approach to study the interplay between the genome and exposome, which may drive biochemistry and physiology, with health disparities.

    View details for DOI 10.1016/j.semperi.2021.151408

    View details for PubMedID 33875265

  • Gender and the impact of COVID-19 on demand for and access to health care: analysis of data from Kenya, Nigeria, and South Africa Abdalla, S., Katz, E. G., Darmstadt, G. L. ELSEVIER SCI LTD. 2021: 7
  • The role of piped water supplies in advancing health, economic development, and gender equality in rural communities. Social science & medicine (1982) Winter, J. C., Darmstadt, G. L., Davis, J. 2021: 113599


    In rural areas of sub-Saharan Africa, one in eight households obtain drinking water from a piped system; the rest fetch water from improved and unimproved sources located at some distance from their homes. This task falls primarily to women and girls, creating time poverty and risks to safety and health. In this paper, we present a conceptual model that elaborates the mechanisms linking access to piped water with food security and long-term economic impacts. These hypotheses were tested in a quasi-experimental study of four villages in rural Zambia using a combination of household surveys, Global Positioning System transponders, and water meters to measure time spent fetching water, water consumption, and how water was being utilized for domestic and productive activities. Households receiving the piped water intervention spent a median of 3.8h per week less fetching water, savings that accrued primarily to women and girls. Household water consumption increased 32%, which was used for both domestic and productive uses. Increases in the frequency of gardening and the size of garden plots in treatment households were observed. Households receiving piped water reported being happier, healthier, and having more time to participate in work inside or outside the home. We find that piped water supplies can promote the economic development and well-being of rural households, with particular benefits to women and girls, conditional upon pricing and management models that ensure sustainable service.

    View details for DOI 10.1016/j.socscimed.2020.113599

    View details for PubMedID 33485713

  • A novel way of determining gestational age upon the birth of a child. Journal of global health Wilson, K., Ward, V., Chakraborty, P., Darmstadt, G. L. 2021; 11: 03078

    View details for DOI 10.7189/jogh.11.03078

    View details for PubMedID 34552714

  • Topical emollient therapy with sunflower seed oil alters the skin microbiota of young children with severe acute malnutrition in Bangladesh: A randomised, controlled study. Journal of global health Fischer, N., Darmstadt, G. L., Shahunja, K. M., Crowther, J. M., Kendall, L., Gibson, R. A., Ahmed, T., Relman, D. A. 2021; 11: 04047


    Background: Topical emollient therapy with sunflower seed oil (SSO) reduces risk of sepsis and mortality in very preterm infants in low- or middle-income countries (LMICs). Proposed mechanisms include modulation of skin and possibly gut barrier function. The skin and gut microbiota play important roles in regulating barrier function, but the effects of emollient therapy on these microbiotas are poorly understood.Methods: We characterised microbiota structure and diversity with 16S rRNA gene amplicon sequence data and ecological statistics in 20 children with severe acute malnutrition (SAM) aged 2-24 months, at four skin sites and in stool, during a randomised, controlled trial of emollient therapy with SSO in Bangladesh. Microbes associated with therapy were identified with tree-based sparse discriminant analysis.Results: The skin microbiota of Bangladeshi children with SAM was highly diverse and displayed significant variation in structure as a function of physical distance between sites. Microbiota structure differed between the study groups (P=0.005), was more diverse in emollient-treated subjects-including on the forehead which did not receive direct treatment-and changed with each day (P=0.005) at all skin sites. Overall, Prevotellaceae were the most differentially affected by emollient treatment; several genera within this family became more abundant in the emollient group than in the controls across several skin sites. Gut microbiota structure was associated with sample day (P=0.045) and subject age (P=0.045), but was not significantly affected by emollient treatment (P=0.060).Conclusions: Emollient therapy altered the skin microbiota in a consistent and temporally coherent manner. We speculate that therapy with SSO enhances skin barrier function in part through alterations in the microbiota, and through systemic mechanisms. Strategies to strengthen skin and gut barrier function in populations at risk, such as children in LMICs like Bangladesh, might include deliberate manipulation of their skin microbiota.Trial registration: NCT02616289.

    View details for DOI 10.7189/jogh.11.04047

    View details for PubMedID 34386216

  • Protocol for a scoping review of neonatal emollient therapy and massage practices throughout sub-Saharan Africa. Gates open research Blanks, K. J., Musaba, M. W., Ren, L., Burgoine, K., Mukunya, D., Clarke, A., Williams, S., Gebremichael, T., Waiswa, P., Darmstadt, G. L. 2021; 5: 142


    Background: Serious infections and other complications from very low birth weight and prematurity are the leading causes of death for neonates worldwide. Infections partly result from the compromised skin barrier function in preterm neonates. Optimal skin care practices for neonates, especially in settings with limited access to adequate hygienic conditions, hold potential to reduce infection and avoid these preventable preterm neonatal deaths. The purpose of this protocol is to support a scoping review of neonatal skin care, emollient therapy and massage practices throughout sub-Saharan Africa. Protocol: The proposed review will follow a methodological framework consisting of the following five steps: (i) identifying the research question, (ii) identifying relevant studies, (iii) selection of eligible studies, (iv) charting the data, and (v) collating and summarizing the results. In addition, we will reflect on the implications of the findings for the feasibility and design of randomized controlled trials to examine the impact of emollient therapy on survival, growth, infection and neurodevelopment of very low birth weight infants in sub-Saharan Africa. We will search domestic and international databases for literature published in English between January 1, 2000, and July 12, 2021. Articles will be chosen based on standardized inclusion criteria. The primary criteria for inclusion will be a report on skin care practices administered to neonates in Africa. Conclusions: Documentation of common neonatal skin care practices throughout Africa has the potential to highlight opportunities for skin care intervention and future research on neonatal skin care practices in sub-Saharan Africa, and support the development of future emollient intervention trials for preterm and low birthweight neonates in low- and middle-income countries.

    View details for DOI 10.12688/gatesopenres.13359.1

    View details for PubMedID 35299830

  • Creating the Strategic and Technical Advisory Group of Experts (STAGE) to advance maternal, newborn, child, adolescent health and nutrition: a new approach BMJ GLOBAL HEALTH AlBuhairan, F., Agarwal, K., Arora, N., Arulkumaran, S., Bhutta, Z., Binka, F., Castro, A., Claeson, M., Dao, B., Darmstadt, G., Duke, T., English, M., Jardali, F., Merson, M., Ferrand, R., Golden, A., Golden, M., Homer, C., Jehan, F., Kabiru, C., Kirkwood, B., Lawn, J., Li, S., Patton, G., Ruel, M., Sandall, J., Sachdev, H., Tomlinson, M., Waiswa, P., Walker, D., Zlotkin, S., Strategic Tech Advisory Grp Expert 2021; 6 (7)

    View details for DOI 10.1136/bmjgh-2021-006726

    View details for Web of Science ID 000691867800004

    View details for PubMedID 34285044

    View details for PubMedCentralID PMC8292823

  • Centering and humanising health systems: empowerment through Kangaroo Mother Care JOURNAL OF GLOBAL HEALTH Willson, M., Kumar, V., Darmstadt, G. L. 2021; 11: 03105

    View details for DOI 10.7189/jogh.11.03105

    View details for Web of Science ID 000731629100001

    View details for PubMedID 34956631

    View details for PubMedCentralID PMC8684780

  • Quantification of Gender Bias and Sentiment Toward Political Leaders Over 20 Years of Kenyan News Using Natural Language Processing. Frontiers in psychology Pair, E., Vicas, N., Weber, A. M., Meausoone, V., Zou, J., Njuguna, A., Darmstadt, G. L. 1800; 12: 712646


    Background: Despite a 2010 Kenyan constitutional amendment limiting members of elected public bodies to < two-thirds of the same gender, only 22 percent of the 12th Parliament members inaugurated in 2017 were women. Investigating gender bias in the media is a useful tool for understanding socio-cultural barriers to implementing legislation for gender equality. Natural language processing (NLP) methods, such as word embedding and sentiment analysis, can efficiently quantify media biases at a scope previously unavailable in the social sciences. Methods: We trained GloVe and word2vec word embeddings on text from 1998 to 2019 from Kenya's Daily Nation newspaper. We measured gender bias in these embeddings and used sentiment analysis to predict quantitative sentiment scores for sentences surrounding female leader names compared to male leader names. Results: Bias in leadership words for men and women measured from Daily Nation word embeddings corresponded to temporal trends in men and women's participation in political leadership (i.e., parliamentary seats) using GloVe (correlation 0.8936, p = 0.0067, r 2 = 0.799) and word2vec (correlation 0.844, p = 0.0169, r 2 = 0.712) algorithms. Women continue to be associated with domestic terms while men continue to be associated with influence terms, for both regular gender words and female and male political leaders' names. Male words (e.g., he, him, man) were mentioned 1.84 million more times than female words from 1998 to 2019. Sentiment analysis showed an increase in relative negative sentiment associated with female leaders (p = 0.0152) and an increase in positive sentiment associated with male leaders over time (p = 0.0216). Conclusion: Natural language processing is a powerful method for gaining insights into and quantifying trends in gender biases and sentiment in news media. We found evidence of improvement in gender equality but also a backlash from increased female representation in high-level governmental leadership.

    View details for DOI 10.3389/fpsyg.2021.712646

    View details for PubMedID 34955949

  • Innovative methods to analyse the impact of gender norms on adolescent health using global health survey data. Social science & medicine (1982) Cislaghi, B., Weber, A. M., Shakya, H. B., Abdalla, S., Bhatia, A., Domingue, B. W., Mejía-Guevara, I., Stark, L., Seff, I., Richter, L. M., Baptista Menezes, A. M., Victora, C. G., Darmstadt, G. L. 2021; 293: 114652


    Understanding how gender norms affect health is an important entry point into designing programs and policies to change norms and improve gender equality and health. However, it is rare for global health datasets to include questions on gender norms, especially questions that go beyond measuring gender-related attitudes, thus limiting gender analysis.We developed five case studies using health survey data from six countries to demonstrate approaches to defining and operationalising proxy measures and analytic approaches to investigating how gender norms can affect health. Key findings, strengths and limitations of our norms proxies and methodological choices are summarised.Case studies revealed links between gender norms and multiple adolescent health outcomes. Proxys for norms were derived from data on attitudes, beliefs, and behaviours, as well as differences between attitudes and behaviours. Data were cross-sectional, longitudinal, census- and social network-based. Analytic methods were diverse. We found that gender norms affect: 1) Intimate partner violence in Nigeria; 2) Unhealthy weight control behaviours in Brazil and South Africa; 3) HIV status in Zambia; 4) Health and social mobility in the US; and 5) Childbirth in Honduras.Researchers can use existing global health survey data to examine pathways through which gender norms affect health by generating proxies for gender norms. While direct measures of gender norms can greatly improve the understanding of how gender affects health, proxy measures for norms can be designed for the specific health-related outcome and normative context, for instance by either aggregating behaviours or attitudes or quantifying the difference (dissonance) between them. These norm proxies enable evaluations of the influence of gender norms on health and insights into possible reference groups and sanctions for non-compliers, thus informing programmes and policies to shape norms and improve health.

    View details for DOI 10.1016/j.socscimed.2021.114652

    View details for PubMedID 34915243

  • Men’s attitude towards contraception and sexuality, women’s empowerment, and demand satisfied for family planning in India Frontiers in Sociology Mejía-Guevara, I., Cislaghi, B., Darmstadt, G. L. 2021; 6 (689980): 1-14

    View details for DOI 10.3389/fsoc.2021.689980

  • Prevalence and Stigma of Postpartum Common Mental Disorders in the Gurage Region of Ethiopia: A Mixed-Methods Observational Cohort Study. Frontiers in psychology Monaghan, S., Akale, M. A., Demeke, B., Darmstadt, G. L. 2021; 12: 626797


    Objectives: Mental disorders are vastly underdiagnosed in low-income countries that disproportionately affect women. We aimed to evaluate the prevalence of common mental disorders in newly postpartum women, and stigma associated with mental health reporting in an Ethiopian community using a validated World Health Organization survey. Methods: The Self Reporting Questionnaire (SRQ) for psychological distress was administered in Amharic by nurses to 118 women aged 18-37 years who had given birth in the prior 3 months in the Glenn C. Olsen Memorial Primary Hospital in Yetebon. Mental health stigma among the four nursing staff was assessed using Link and Phelan's Components of Stigma. Results: Among 118 women surveyed, 18% had a probable common mental disorder using the SRQ 4/5 cutoff and 2% admitted to suicidal thoughts. Presence of stigma in the healthcare staff was verified, including labeling, stereotyping, separating, and status loss and discrimination. Conclusion: Postpartum mental health disorders as well as stigma against such diagnoses are common in the Yetebon community. There is an urgent need for increased availability of properly trained and supervised healthcare staff in the identification and referral of postpartum women with common mental disorders.

    View details for DOI 10.3389/fpsyg.2021.626797

    View details for PubMedID 33897534

  • Prevalence and psychosocial impact of atopic dermatitis in Bangladeshi children and families. PloS one Pedersen, C. J., Uddin, M. J., Saha, S. K., Darmstadt, G. L. 2021; 16 (4): e0249824


    Skin conditions are the fourth leading cause of nonfatal disease globally, with atopic dermatitis (AD) a major and rising contributor. Though atopic dermatitis (AD) is rising in prevalence, little is known about its psychosocial effects on children and families in low- and middle-income countries (LMICs).We conducted a community-based, cross-sectional survey of 2242 under-5 children in rural Bangladesh using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire to measure AD prevalence and severity, the Patient-Oriented Eczema Measure (POEM) to measure severity, and the Infants' Dermatitis Quality of Life index (IDQoL) and Dermatitis Family Index (DFI) to measure quality of life.Overall AD prevalence in under-five children was 11.9% [95% confidence interval (CI) 10.6-13.3%]. Prevalence was highest in children age 30-35 months [16.2% (95% CI 11.4-21.0)]. IDQoL was significantly higher in males (2.67) vs. females (1.95, p = 0.015), the lowest (3.06) vs. highest (1.63) wealth quintile (p<0.001), and among mothers with < primary (2.41) vs. > secondary (1.43) education (p = 0.039). POEM severity was correlated with IDQoL (r = 0.77, p<0.001) and DFI (r = 0.56, p<0.001). Severe disease as rated by caretakers was correlated with POEM (r = 0.73, p<0.001), IDQoL (r = 0.82, p<0.001) and DFI (r = 0.57, p<0.001).Severe AD significantly affects quality of life for children and families in Bangladesh. As access to healthcare expands in LMICs, identification and treatment of both the medical and psychosocial morbidities associated with the disease are needed.

    View details for DOI 10.1371/journal.pone.0249824

    View details for PubMedID 33861780

  • Effect of sunflower seed oil emollient therapy on newborn infant survival in Uttar Pradesh, India: A community-based, cluster randomized, open-label controlled trial. PLoS medicine Kumar, A., Mishra, S., Singh, S., Ashraf, S., Kan, P., Ghosh, A. K., Kumar, A., Krishna, R., Stevenson, D. K., Tian, L., Elias, P. M., Darmstadt, G. L., Kumar, V. 2021; 18 (9): e1003680


    Hospitalized preterm infants with compromised skin barrier function treated topically with sunflower seed oil (SSO) have shown reductions in sepsis and neonatal mortality rate (NMR). Mustard oil and products commonly used in high-mortality settings may possibly harm skin barrier integrity and enhance risk of infection and mortality in newborn infants. We hypothesized that SSO therapy may reduce NMR in such settings.This was a population-based, cluster randomized, controlled trial in 276 clusters in rural Uttar Pradesh, India. All newborn infants identified through population-based surveillance in the study clusters within 7 days of delivery were enrolled from November 2014 to October 2016. Exclusive, 3 times daily, gentle applications of 10 ml of SSO to newborn infants by families throughout the neonatal period were recommended in intervention clusters (n = 138 clusters); infants in comparison clusters (n = 138 clusters) received usual care, such as massage practice typically with mustard oil. Primary analysis was by intention-to-treat with NMR and post-24-hour NMR as the primary outcomes. Secondary analysis included per-protocol analysis and subgroup analyses for NMR. Regression analysis was adjusted for caste, first-visit weight, delivery attendant, gravidity, maternal age, maternal education, sex of the infant, and multiple births. We enrolled 13,478 (52.2% male, mean weight: 2,575.0 grams ± standard deviation [SD] 521.0) and 13,109 (52.0% male, mean weight: 2,607.0 grams ± SD 509.0) newborn infants in the intervention and comparison clusters, respectively. We found no overall difference in NMR in the intervention versus the comparison clusters [adjusted odds ratio (aOR) 0.96, 95% confidence interval (CI) 0.84 to 1.11, p = 0.61]. Acceptance of SSO in the intervention arm was high at 89.3%, but adherence to exclusive applications of SSO was 30.4%. Per-protocol analysis showed a significant 58% (95% CI 42% to 69%, p < 0.01) reduction in mortality among infants in the intervention group who were treated exclusively with SSO as intended versus infants in the comparison group who received exclusive applications of mustard oil. A significant 52% (95% CI 12% to 74%, p = 0.02) reduction in NMR was observed in the subgroup of infants weighing ≤1,500 g (n = 589); there were no statistically significant differences in other prespecified subgroup comparisons by low birth weight (LBW), birthplace, and wealth. No severe adverse events (SAEs) were attributable to the intervention. The study was limited by inability to mask allocation to study workers or participants and by measurement of emollient use based on caregiver responses and not actual observation.In this trial, we observed that promotion of SSO therapy universally for all newborn infants was not effective in reducing NMR. However, this result may not necessarily establish equivalence between SSO and mustard oil massage in light of our secondary findings. Mortality reduction in the subgroup of infants ≤1,500 g was consistent with previous hospital-based efficacy studies, potentially extending the applicability of emollient therapy in very low-birth-weight (VLBW) infants along the facility-community continuum. Further research is recommended to develop and evaluate therapeutic regimens and continuum of care delivery strategies for emollient therapy for newborn infants at highest risk of compromised skin barrier function.ISRCTN Registry ISRCTN38965585 and Clinical Trials Registry-India (CTRI/2014/12/005282) with WHO UTN # U1111-1158-4665.

    View details for DOI 10.1371/journal.pmed.1003680

    View details for PubMedID 34582448

  • Learning from Ananya: Lessons for primary health care performance improvement. Journal of global health Darmstadt, G. L., Ananya Study Group 2020; 10 (2): 020356

    View details for DOI 10.7189/jogh.10.020356

    View details for PubMedID 33110552

  • Statewide implementation of a quality improvement initiative for reproductive, maternal, newborn and child health and nutritionin Bihar, India. Journal of global health Creanga, A. A., Srikantiah, S., Mahapatra, T., Das, A., Sonthalia, S., Moharana, P. R., Gore, A., Daulatrao, S., Durbha, R., Kaul, S., Galavotti, C., Laterra, A., Pepper, K. T., Darmstadt, G. L., Shah, H. 2020; 10 (2): 021008


    Background: CARE India designed and implemented a comprehensive, statewide quality improvement (QI) initiative to improve reproductive, maternal, newborn, and child health and nutrition (RMNCHN) services in public facilities in Bihar. We provide a description of this initiative and its key results during 2014-2017.Methods: We reviewed program documents to identify QI strategies employed and ascertain their coverage. We analysed data from: a) two public facility assessments to ascertain the availability of essential equipment and supplies and the distribution of human resources by facility level; b) a four-phase provider mentoring and training intervention covering 319 facilities to examine changes in emergency obstetric and newborn care (EmONC) practices; and c) four state-representative household surveys to explore changes in selected RMNCHN service utilisation by health sector. Associations of interest were ascertained using chi2 tests.Results: Thirty-eight District Quality Assurance Committees and QI teams in 98% of facilities were formed to develop an implementation plan for the QI initiative and oversee its execution. QI strategies were to strengthen facilities' infrastructure; build the state's contracting, procurement, and inventory management capacities; rationalise human resources; improve providers' skills; and modernise data systems. Implementation led to facility infrastructure upgrades, improved clinical staff distribution, and higher availability of equipment and supplies over time, especially in higher-level facilities. Following the mentoring and training intervention in facilities offering both basic and comprehensive EmONC, performance of key practices (eg, adequate administration of uterotonics <1 minute after birth, initiation of skin-to-skin care <5 minutes after birth) improved significantly (P<0.05). CARE India collected program data and assisted with modernising data systems for tracking human resources, supplies, and program progress statewide. Of women seeking antenatal care, the proportion obtaining key screenings (eg, weight, blood pressure measurements) in public facilities increased over time (P<0.05). A 6-percentage point decline in home deliveries during 2016-2017 was accompanied by a higher increase of deliveries in public than private facilities (5- vs 1-percentage point; P<0.05).Conclusion: Substantial advances were made in improving RMNCHN service quality in Bihar. Continued improvement building on the established QI platform is expected and should be guided by data from now functional data systems.

    View details for DOI 10.7189/jogh.10.021008

    View details for PubMedID 33425332

  • Geospatial variations in trends of reproductive, maternal, newborn and child health and nutrition indicators at block level in Bihar, India, during scale-up of Ananya program interventions. Journal of global health Abdalla, S., Pair, E., Mehta, K. M., Ward, V. C., Darmstadt, G. L. 2020; 10 (2): 021004


    Background: Geographical variations in the levels and trajectory of health indicators at local level can inform the adaptation of interventions and development of targeted approaches for efficient scale-up of intervention impact. We examined the hypothesis that time trends of a set of reproductive, maternal, newborn, and child health and nutrition (RMNCHN) indicators varied at block-level during the statewide scale-up phase of the Ananya program in Bihar, India.Methods: We used data on 22 selected indicators from four rounds of the Community-based Household Survey carried out between 2014 and 2017. Indicator levels at each round were estimated for each block. We used hierarchical Bayesian spatiotemporal modelling to smooth the raw estimates for each block with the estimates from its neighbouring blocks, and to examine space-time interaction models for evidence of variations in trends of indicators across blocks. We expressed the uncertainty around the smoothed levels and the trends with 95% credible intervals.Results: There was evidence of variations in trends at block level in all but three indicators: facility delivery, public facility delivery, and age-appropriate initiation of complementary feeding. Fifteen indicators showed trends in opposite directions (increases in some blocks and declines in others). All blocks had at least 97.5% probability of a rise in immediate breastfeeding, early pregnancy registration, and having at least four antenatal care visits. All blocks had at least 97.5% probability of a decline in seeking care for pregnancy complications.Conclusions: The findings underscore the value of monitoring and evaluation at local level for targeted implementation of RMNCHN interventions. There is a need for identifying systematic factors leading to universal trends, or variable contextual or implementation factors leading to variable trends, in order to optimise primary health care program impact.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021004

    View details for PubMedID 33425328

  • Time poverty: Obstacle to women's human rights, health and sustainable development JOURNAL OF GLOBAL HEALTH Hyde, E., Greene, M. E., Darmstadt, G. L. 2020; 10 (2): 020313

    View details for DOI 10.7189/jogh.10.020313

    View details for Web of Science ID 000612476300028

    View details for PubMedID 33282212

    View details for PubMedCentralID PMC7688061

  • Health layering of self-help groups: impacts on reproductive, maternal, newborn and child health and nutrition in Bihar, India. Journal of global health Mehta, K. M., Irani, L., Chaudhuri, I., Mahapatra, T., Schooley, J., Srikantiah, S., Abdalla, S., Ward, V., Carmichael, S. L., Bentley, J., Creanga, A., Wilhelm, J., Tarigopula, U. K., Bhattacharya, D., Atmavilas, Y., Nanda, P., Weng, Y., Pepper, K. T., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021007


    Background: Self-help group (SHG) interventions have been widely studied in low and middle income countries. However, there is little data on specific impacts of health layering, or adding health education modules upon existing SHGs which were formed primarily for economic empowerment. We examined three SHG interventions from 2012-2017 in Bihar, India to test the hypothesis that health-layering of SHGs would lead to improved health-related behaviours of women in SHGs.Methods: A model for health layering of SHGs - Parivartan - was developed by the non-governmental organisation (NGO), Project Concern International, in 64 blocks of eight districts. Layering included health modules, community events and review mechanisms. The health layering model was adapted for use with government-led SHGs, called JEEViKA+HL, in 37 other blocks of Bihar. Scale-up of government-led SHGs without health layering (JEEViKA) occurred contemporaneously in 433 other blocks, providing a natural comparison group. Using Community-based Household Surveys (CHS, rounds 6-9) by CARE India, 62 reproductive, maternal, newborn and child health and nutrition (RMNCHN) and sanitation indicators were examined for SHGs with health layering (Pavivartan SHGs and JEEViKA+HL SHGs) compared to those without. We calculated mean, standard deviation and odds ratios of indicators using surveymeans and survey logistic regression.Results: In 2014, 64% of indicators were significantly higher in Parivartan members compared to non-members residing in the same blocks. During scale up, from 2015-17, half (50%) of indicators had significantly higher odds in health layered SHG members (Parivartan or JEEViKA+HL) in 101 blocks compared to SHG members without health layering (JEEViKA) in 433 blocks.Conclusions: Health layering of SHGs was demonstrated by an NGO-led model (Parivartan), adapted and scaled up by a government model (JEEViKA+HL), and associated with significant improvements in health compared to non-health-layered SHGs (JEEViKA). These results strengthen the evidence base for further layering of health onto the SHG platform for scale-level health change.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021007

    View details for PubMedID 33425331

  • Health impact of self-help groups scaled-up statewide in Bihar, India. Journal of global health Mehta, K. M., Irani, L., Chaudhuri, I., Mahapatra, T., Schooley, J., Srikantiah, S., Abdalla, S., Ward, V. C., Carmichael, S. L., Bentley, J., Creanga, A., Wilhelm, J., Tarigopula, U. K., Bhattacharya, D., Atmavilas, Y., Nanda, P., Weng, Y., Pepper, K. T., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021006


    Background: The objective of this study was to assess the impact of self-help groups (SHGs) and subsequent scale-up on reproductive, maternal, newborn, child health, and nutrition (RMNCHN) and sanitation outcomes among marginalised women in Bihar, India from 2014-2017.Methods: We examined RMNCHN and sanitation behaviors in women who were members of any SHGs compared to non-members, without differentiating between types of SHGs. We analysed annual surveys across 38 districts of Bihar covering 62690 women who had a live birth in the past 12 months. All analyses utilised data from Community-based Household Surveys (CHS) rounds 6-9 collected in 2014-2017 by CARE India as part of the Bihar Technical Support Program funded by the Bill & Melinda Gates Foundation. We examined 66 RMNCHN and sanitation indicators using survey logistic regression; the comparison group in all cases was age-comparable women from the geographic contexts of the SHG members but who did not belong to SHGs. We also examined links between discussion topics in SHGs and changes in relevant behaviours, and stratification of effects by parity and mother's age.Results: SHG members had higher odds compared to non-SHG members for 60% of antenatal care indicators, 22% of delivery indicators, 70% of postnatal care indicators, 50% of nutrition indicators, 100% of family planning and sanitation indicators and no immunisation indicators measured. According to delivery platform, most FLW performance indicators (80%) had increased odds, followed by maternal behaviours (57%) and facility care and outreach service delivery (22%) compared to non-SHG members. Self-report of discussions within SHGs on specific topics was associated with increased related maternal behaviours. Younger SHG members (<25 years) had attenuated health indicators compared to older group members (≥25 years), and women with more children had more positive indicators compared to women with fewer children.Conclusions: SHG membership was associated with improved RMNCHN and sanitation indicators at scale in Bihar, India. Further work is needed to understand the specific impacts of health layering upon SHGs. Working through SHGs is a promising vehicle for improving primary health care.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021006

    View details for PubMedID 33425330

  • Impact of mHealth interventions for reproductive, maternal, newborn and child health and nutrition at scale: BBC Media Action and the Ananya program in Bihar, India. Journal of global health Ward, V. C., Raheel, H., Weng, Y., Mehta, K. M., Dutt, P., Mitra, R., Sastry, P., Godfrey, A., Shannon, M., Chamberlain, S., Kaimal, R., Carmichael, S. L., Bentley, J., Abdalla, S., Pepper, K. T., Mahapatra, T., Srikantiah, S., Borkum, E., Rangarajan, A., Sridharan, S., Rotz, D., Nanda, P., Tarigopula, U. K., Atmavilas, Y., Bhattacharya, D., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021005


    Background: Mobile health (mHealth) tools have potential for improving the reach and quality of health information and services through community health workers in low- and middle-income countries. This study evaluates the impact of an mHealth tool implemented at scale as part of the statewide reproductive,maternal, newborn and child health and nutrition (RMNCHN) program in Bihar, India.Methods: Three survey-based data sets were analysed to compare the health-related knowledge, attitudes and behaviours amongst childbearing women exposed to the Mobile Kunji and Dr. Anita mHealth tools during their visits with frontline workers compared with those who were unexposed.Results: An evaluation by Mathematica (2014) revealed that exposure to Mobile Kunji and Dr. Anita recordings were associated with significantly higher odds of consuming iron-folic acid tablets (odds ratio (OR)=2.3, 95% confidence interval (CI)=1.8-3.1) as well as taking a set of three measures for delivery preparedness (OR=2.8, 95% CI=1.9-4.2) and appropriate infant complementary feeding (OR=1.9, 95% CI=1.0-3.5). CARE India's Community-based Household Surveys (2012-2017) demonstrated significant improvements in early breastfeeding (OR=1.64, 95% CI=1.5-1.78) and exclusive breastfeeding (OR=1.46, 95% CI=1.33-1.62) in addition to birth preparedness practices. BBC Media Action's Usage & Engagement Survey (2014) demonstrated a positive association between exposure to Mobile Kunji and Dr. Anita and exclusive breastfeeding (58% exposed vs 43% unexposed, P<0.01) as well as maternal respondents' trust in their frontline worker.Conclusions: Significant improvements in RMNCHN-related knowledge and behaviours were observed for Bihari women who were exposed to Mobile Kunji and Dr. Anita. This analysis is unique in its rigorous evaluation across multiple data sets of mHealth interventions implemented at scale. These results can help inform global understanding of how best to use mHealth tools, for whom, and in what contexts.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021005

    View details for PubMedID 33425329

  • Evaluation of a large-scale reproductive, maternal, newborn and child health and nutrition program in Bihar, India, through an equity lens. Journal of global health Ward, V. C., Weng, Y., Bentley, J., Carmichael, S. L., Mehta, K. M., Mahmood, W., Pepper, K. T., Abdalla, S., Atmavilas, Y., Mahapatra, T., Srikantiah, S., Borkum, E., Rangarajan, A., Sridharan, S., Rotz, D., Bhattacharya, D., Nanda, P., Tarigopula, U. K., Shah, H., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021011


    Background: Despite increasing focus on health inequities in low- and middle income countries, significant disparities persist. We analysed impacts of a statewide maternal and child health program among the most compared to the least marginalised women in Bihar, India.Methods: Utilising survey-weighted logistic regression, we estimated programmatic impact using difference-in-difference estimators from Mathematica data collected at the beginning (2012, n=10174) and after two years of program implementation (2014, n=9611). We also examined changes in disparities over time using eight rounds of Community-based Household Surveys (CHS) (2012-2017, n=48349) collected by CARE India.Results: At baseline for the Mathematica data, least marginalised women generally performed desired health-related behaviours more frequently than the most marginalised. After two years, most disparities persisted. Disparities increased for skilled birth attendant identification [+16.2% (most marginalised) vs +32.6% (least marginalized), P<0.01) and skin-to-skin care (+14.8% vs +20.4%, P<0.05), and decreased for immediate breastfeeding (+10.4 vs -4.9, P<0.01). For the CHS data, odds ratios compared the most to the least marginalised women as referent. Results demonstrated that disparities were most significant for indicators reliant on access to care such as delivery in a facility (OR range: 0.15 to 0.48) or by a qualified doctor (OR range: 0.08 to 0.25), and seeking care for complications (OR range: 0.26 to 0.64).Conclusions: Disparities observed at baseline generally persisted throughout program implementation. The most significant disparities were observed amongst behaviours dependent upon access to care. Changes in disparities largely were due to improvements for the least marginalised women without improvements for the most marginalised. Equity-based assessments of programmatic impacts, including those of universal health approaches, must be undertaken to monitor disparities and to ensure equitable and sustainable benefits for all.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021011

    View details for PubMedID 33425335

  • Impact of the Ananya program on reproductive, maternal, newborn and child health and nutrition in Bihar, India: early results from a quasi-experimental study. Journal of global health Darmstadt, G. L., Weng, Y., Pepper, K. T., Ward, V. C., Mehta, K. M., Borkum, E., Bentley, J., Raheel, H., Rangarajan, A., Bhattacharya, D., Tarigopula, U. K., Nanda, P., Sridharan, S., Rotz, D., Carmichael, S. L., Abdalla, S., Munar, W., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Bentley, J., Borkum, E., Carmichael, S., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W. A., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Delhi, N., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V., Weng, Y., Walker, D., Wilhelm, J. 2020; 10 (2): 021002


    Background: The Government of Bihar (GoB) in India, the Bill and Melinda Gates Foundation and several non-governmental organisations launched the Ananya program aimed to support the GoB to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide. Here we summarise changes in indicators attained during the initial two-year pilot phase (2012-2013) of implementation in eight focus districts of approximately 28 million population, aimed to inform subsequent scale-up.Methods: The quasi-experimental impact evaluation included statewide household surveys at two time points during the pilot phase: January-April 2012 ("baseline") including an initial cohort of beneficiaries and January-April 2014 ("midline") with a new cohort. The two arms were: 1) eight intervention districts, and 2) a comparison arm comprised of the remaining 30 districts in Bihar where Ananya interventions were not implemented. We analysed changes in indicators across the RMNCHN continuum of care from baseline to midline in intervention and comparison districts using a difference-in-difference analysis.Results: Indicators in the two arms were similar at baseline. Overall, 40% of indicators (20 of 51) changed significantly from baseline to midline in the comparison districts unrelated to Ananya; two-thirds (n=13) of secular indicator changes were in a direction expected to promote health. Statistically significant impact attributable to the Ananya program was found for 10% (five of 51) of RMNCHN indicators. Positive impacts were most prominent for mother's behaviours in contraceptive utilisation.Conclusions: The Ananya program had limited impact in improving health-related outcomes during the first two-year period covered by this evaluation. The program's theories of change and action were not powered to observe statistically significant differences in RMNCHN indicators within two years, but rather aimed to help inform program improvements and scale-up. Evaluation of large-scale programs such as Ananya using theory-informed, equity-sensitive (including gender), mixed-methods approaches can help elucidate causality and better explain pathways through which supply- and demand-side interventions contribute to changes in behaviour among the actors involved in the production of population-level health outcomes. Evidence from Bihar indicates that deep structural constraints in health system organisation and delivery of interventions pose substantial limitations on behaviour change among health care providers and beneficiaries.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021002

    View details for PubMedID 33427822

  • Trends in reproductive, maternal, newborn and child health and nutrition indicators during five years of piloting and scaling-up of Ananya interventions in Bihar, India. Journal of global health Abdalla, S., Weng, Y., Mehta, K. M., Mahapatra, T., Srikantiah, S., Shah, H., Ward, V. C., Pepper, K. T., Bentley, J., Carmichael, S. L., Creanga, A., Wilhelm, J., Tarigopula, U. K., Nanda, P., Bhattacharya, D., Atmavilas, Y., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bentley, J., Bhattacharya, D., Borkum, E., Carmichael, S. L., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Delhi, N., Irani, L., Delhi, N., Krishnan, S., Mahapatra, T., Mehta, K. M., Francisco, S., Mitra, R., Munar, W., Nanda, P., Pepper, K. T., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Schooley, J., Shah, H., Srikantiah, S., Tarigopula, U. K., Ward, V. C., Walker, D., Weng, Y., Wilhelm, J. 2020; 10 (2): 021003


    Background: The Ananya program in Bihar implemented household and community-level interventions to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) in two phases: a first phase of intensive ancillary support to governmental implementation and innovation testing by non-government organisation (NGO) partners in eight focus districts (2012-2014), followed by a second phase of state-wide government-led implementation with techno-managerial assistance from NGOs (2014 onwards). This paper examines trends in RMNCHN indicators in the program's implementation districts from 2012-2017.Methods: Eight consecutive rounds of cross-sectional Community-based Household Surveys conducted by CARE India in 2012-2017 provided comparable data on a large number of indicators of frontline worker (FLW) performance, mothers' behaviours, and facility-based care and outreach service delivery across the continuum of maternal and child care. Logistic regression, considering the complex survey design and sample weights generated by that design, was used to estimate trends using survey rounds 2-5 for the first phase in the eight focus districts and rounds 6-9 for the second phase in all 38 districts statewide, as well as the overall change from round 2-9 in focus districts. To aid in contextualising the results, indicators were also compared amongst the formerly focus and the non-focus districts at the beginning of the second phase.Results: In the first phase, the levels of 34 out of 52 indicators increased significantly in the focus districts, including almost all indicators of FLW performance in antenatal and postnatal care, along with mother's birth preparedness, some breastfeeding practices, and immunisations. Between the two phases, 33 of 52 indicators declined significantly. In the second phase, the formerly focus districts experienced a rise in the levels of 14 of 50 indicators and a decline in the levels of 14 other indicators. There was a rise in the levels of 22 out of 50 indicators in the non-focus districts in the second phase, with a decline in the levels of 13 other indicators.Conclusions: Improvements in indicators were conditional on implementation support to program activities at a level of intensity that was higher than what could be achieved at scale so far. Successes during the pilot phase of intensive support suggests that RMNCHN can be improved statewide in Bihar with sufficient investments in systems performance improvements.Study registration: number NCT02726230.

    View details for DOI 10.7189/jogh.10.021003

    View details for PubMedID 33427818

  • Best practices in global health evaluation: Reflections on learning from an independent program analysis in Bihar, India. Journal of global health Mehta, K. M., Ward, V. C., Darmstadt, G. L. 2020; 10 (2): 020395

    View details for DOI 10.7189/jogh.10.020395

    View details for PubMedID 33403103

  • Prevalence and perceptions of infant massage in India: study from Maharashtra and Madhya Pradesh states. BMC pediatrics Chaturvedi, S., Randive, B., Pathak, A., Agarkhedkar, S., Tillu, G., Darmstadt, G. L., Patwardhan, B. 2020; 20 (1): 512


    BACKGROUND: Knowledge of the prevailing infant care practices and their effects is important to inform practice and public programs. Infant massage is a traditional practice in India but remains less studied. This study was conducted to study the prevalence and perceptions of infant massage practices in two states of India.METHODS: A total of 1497 caretakers of children under 18months of age were interviewed in a cross-sectional study at immunisation units of medical schools in Maharashtra (MH) and Madhya Pradesh (MP) states and through home visits in villages in MH during March through August 2018.RESULTS: Infant massage was a prevalent practice (93.8% [95%CI: 92.4,94.9]) in both study states - 97.9%[95%CI:96.9,98.8] in MH and 85.3%[95%CI: 81.9,88.3] in MP - and the prevalence did not vary between male (94.5%) and female (93.5%) infants (p=0.44). Massage was mostly initiated in the first week of life (82%); it is widely viewed as a traditional practice. It was common to massage the baby once daily (77%), before bathing (77%), and after feeding (57%). Massage was mostly conducted using oils (97%). In MH, preferred oils were a sesame oil-based proprietary traditional medicine oil (36%) and coconut oil (18%) while olive (29%) and mustard (20%) oils were most popular in MP. Commonly reported application techniques included gentle massage with minimal pressure, pressing (30%) and manually stretching certain joints (60%). Commonly reported perceived benefits of infant massage included increased bone strength, better sleep and growth, while no harm was perceived (95%).CONCLUSION: Infant oil massage is a highly prevalent traditional practice in MH and MP. Clear guidance on the use of massage, choice of oil, and techniques for application is required to optimize benefits and minimize risks of this popular traditional practice.

    View details for DOI 10.1186/s12887-020-02416-y

    View details for PubMedID 33167905

  • Prevalence of atopic dermatitis, asthma and rhinitis from infancy through adulthood in rural Bangladesh: a population-based, cross-sectional survey. BMJ open Pedersen, C. J., Uddin, M. J., Saha, S. K., Darmstadt, G. L. 2020; 10 (11): e042380


    OBJECTIVE: Describe the pattern of atopic disease prevalence from infancy to adulthood.DESIGN: Cross-sectional household survey.SETTING: Community-based demographic surveillance site, Mirzapur, Bangladesh.PARTICIPANTS: 7275 individuals in randomly selected clusters within 156 villages.PRIMARY AND SECONDARY OUTCOME MEASURES: The 12-month prevalence of atopic dermatitis (by UK Working Party Criteria (UK criteria) and International Study of Asthma and Allergies in Childhood (ISAAC)), asthma and rhinitis (by ISAAC); disease severity (by ISAAC); history of ever receiving a medical diagnosis.RESULTS: Children aged 2 years had the highest prevalence of atopic dermatitis-18.8% (95% CI 15.2% to 22.4%) by UK criteria and 14.9% (95% CI 11.6% to 18.1%) by ISAAC- and asthma (20.1%, 95%CI 16.4% to 23.8%). Prevalence of rhinitis was highest among 25-29year olds (6.0%, (95% CI% 4.5 to 7.4%). History of a medical diagnosis was lowest for atopic dermatitis (4.0%) and highest for rhinitis (27.3%) and was significantly associated with severe disease compared with those without severe disease for all three conditions (atopic dermatitis: 30.0% vs 11.7%, p=0.015; asthma; 85.0% vs 60.4%, p<0.001; rhinitis: 34.2% vs 7.3%, p<0.001) and having a higher asset-based wealth score for asthma (29.7% (highest quintile) vs 7.5% (lowest quintile), p<0.001) and rhinitis (39.8% vs 12.5%, p=0.003). Prevalence of having >1 condition was highest (36.2%) at 2 years and decreased with age. Having atopic dermatitis (ISAAC) was associated with significantly increased odds ratios (OR) for comorbid asthma (OR 5.56 (95% CI 4.26 to 7.26)] and rhinitis (3.68 (95% CI 2.73 to 4.96)). Asthma and rhinitis were also strongly associated with each other (OR 8.39 (95% CI 6.48 to 10.86)).CONCLUSIONS: Atopic disease burden was high in this rural Bangladeshi population. Having one atopic condition was significantly associated with the presence of another. Low incidence of ever obtaining a medical diagnosis highlights an important opportunity to increase availability of affordable diagnosis and treatment options for all age groups.

    View details for DOI 10.1136/bmjopen-2020-042380

    View details for PubMedID 33148768

  • Associations Among Early Stimulation, Stunting, and Child Development in Four Countries in the East Asia-Pacific INTERNATIONAL JOURNAL OF EARLY CHILDHOOD Rao, N., Richards, B., Lau, C., Weber, A. M., Sun, J., Darmstadt, G. L., Sincovich, A., Bacon-Shone, J., Ip, P. 2020
  • Association of collective attitudes and contraceptive practice in nine sub-Saharan African countries. Journal of global health Mejía-Guevara, I., Cislaghi, B., Weber, A., Hallgren, E., Meausoone, V., Cullen, M. R., Darmstadt, G. L. 2020; 10 (1): 010705


    There is ample evidence that gender norms affect contraceptive practice; however, data are mostly qualitative with limited geographical scope. We investigated that association quantitatively using collective community-level attitudes towards premarital sex and wife-beating as proxies for gender norms.Data came from nationally representative Demographic and Health Surveys (2005-2009) for women of reproductive age (15-49 years) in nine sub-Saharan African countries. Using multilevel logistic models, controlling for individual covariates and community-level indicators of women's empowerment, we assessed the community-level association of gender norms regarding premarital sex and wife-beating with individual contraception uptake and demand satisfied among fecund sexually active women. Norms were approximated as 'collective attitudinal norms' from female/male residents (aged 15-49 years) from the same community. We assessed the magnitude and significance of the community-level effects and attributed variance across communities. The same analysis was replicated for each country.In a fully-adjusted model with a pooled sample of 24 404 adolescent women, the odds of contraception use increased with a 1 standard deviation (SD) increase in the variation of collective permissive attitudes towards premarital sex of female (odds ratio (OR) = 1.08, 95% confidence interval (CI) = 1.02-1.15) and male (OR = 1.11, 95% CI = 1.05-1.17) peers (15-24 years), while odds of contraceptive use declined by 10% (OR = 0.90, 95% CI = 0.85-0.96) with collective accepting attitudes towards wife-beating of women aged 15-49 years. Similar results were found in separate models that controlled for adults' permissive attitudes towards premarital sex. The community-level attributed variance (V2 = 1.62, 95% CI = 1.45-1.80) represented 33% (intra-class correlation (ICC) = 33.0, 95% CI = 30.0-35.4) of the total variation of contraception use, and attitudes towards premarital sex and violence jointly explained nearly 26% of that V2 variance. The community-level shared of attributed variation of contraceptive use varied significantly across countries, from 3.5% in Swaziland (ICC = 3.5, 95% CI = 0.8-13.7) to 60.2% in Nigeria (OR = 60.2, 95% CI = 56.0-64.2).Overall, significant positive associations of collective permissive attitudes of both adolescent and adult women towards premarital sex were found for use of, and demand for, contraception, whereas collective accepting attitudes towards wife-beating were negatively associated with the use and demand for contraception. Ours is the first study to define quantitatively the influence of proxies for gender norms at the community level on women's family planning decisions. These findings offer new insights for understanding the role of sex-related attitudes and norms as important factors in shaping contraceptive practices and improving the effectiveness of family planning policies by targeting individuals as well as their groups of influence.

    View details for DOI 10.7189/jogh.10.010705

    View details for PubMedID 32257163

    View details for PubMedCentralID PMC7101087

  • Applying a gender lens to global health and well-being: Framing a Journal of Global Health special collection JOURNAL OF GLOBAL HEALTH Stark, L., Seff, I., Weber, A., Darmstadt, G. L. 2020; 10 (1)
  • Towards personalized medicine in maternal and child health: integrating biologic and social determinants. Pediatric research Stevenson, D. K., Wong, R. J., Aghaeepour, N., Maric, I., Angst, M. S., Contrepois, K., Darmstadt, G. L., Druzin, M. L., Eisenberg, M. L., Gaudilliere, B., Gibbs, R. S., Gotlib, I. H., Gould, J. B., Lee, H. C., Ling, X. B., Mayo, J. A., Moufarrej, M. N., Quaintance, C. C., Quake, S. R., Relman, D. A., Sirota, M., Snyder, M. P., Sylvester, K. G., Hao, S., Wise, P. H., Shaw, G. M., Katz, M. 2020

    View details for DOI 10.1038/s41390-020-0981-8

    View details for PubMedID 32454518

  • Gender discrimination and depressive symptoms among child-bearing women: ELSPAC-CZ cohort study. EClinicalMedicine Stepanikova, I., Acharya, S., Abdalla, S., Baker, E., Klanova, J., Darmstadt, G. L. 2020; 20: 100297


    Background: Depression is approximately two-fold more prevalent among women than men. Social theories suggest that discrimination is a pathway through which gender inequalities affect women's lives, but data are lacking. This cohort study evaluates whether perceived gender discrimination is linked to depressive symptoms among child-bearing women.Methods: Data were obtained from 4,688 participants enrolled in pregnancy in 1991-92 in the European Longitudinal Cohort Study of Pregnancy and Childhood, Czech Republic. Perceived gender discrimination was assessed in mid-pregnancy, year seven, and year eleven. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale at eight time-points between mid-pregnancy and year eleven post-delivery. Linear mixederror-component models of depressive symptoms were estimated.Findings: Perceived gender discrimination, reported by 10.7% of women, was related to higher depressive symptoms, both in the unadjusted analysis (b=0.15 [95% confidence interval (CI): 0.12, 0.19], p<0.001) and in the fully adjusted model (b=0.12 [95% CI: 0.09, 0.16], p<0.001). Covariates linked to higher depressive symptoms included financial hardship (b=0.12 [95% CI: 0.10, 0.14], p<0.001), childhood emotional/physical neglect (b=0.18 [95% CI: 0.14, 0.22], p<0.001), and childhood sexual abuse (b=0.04 [95% CI: 0.03, 0.06], p<0.001); an inverse relationship was evident for social support (-0.05 [95% CI: -0.07, -0.04], p<0.001) and having a partner who performs female-stereotypical household tasks (b=-0.03 [95% CI: -0.05, -0.01], p=0.001).Interpretation: The findings provide the first evidence that perceived gender discrimination is associated with depressive symptoms among child-bearing women. Social intervention programs aimed at reducing gender discrimination can potentially contribute to better mental health of women.Funding: Bill and Melinda Gates Foundation.

    View details for DOI 10.1016/j.eclinm.2020.100297

    View details for PubMedID 32300743

  • Gender equality: Framing a special collection of evidence for all. EClinicalMedicine Darmstadt, G. L. 2020; 20: 100307

    View details for DOI 10.1016/j.eclinm.2020.100307

    View details for PubMedID 32300751

  • Attitudinal Acceptance of Intimate Partner Violence Among Adolescents and Young Adults in Nigeria and Tanzania: An Exploration Into Target Reference Groups Order and Affiliation of Authorship. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Meinhart, M., Seff, I., Darmstadt, G. L., Weber, A. M., Stark, L. 2020; 66 (1S): S3–S8


    PURPOSE: Attitudinal programming for the prevention of intimate partner violence (IPV) among adolescents and young adults often focuses on whom to target based on gender or age; yet other pivotal junctures may relate to when to intervene, such as critical events (e.g., marriage). Using data from the nationally representative Violence Against Children Survey in Nigeria and Tanzania, this study examines the gendered association of acceptance of IPV across 3 reference groups-age, marital status, and education attainment-for male and female adolescents and young adults.METHODS: Data were analyzed from a sample of 2,437 and 1,771 males in Nigeria and Tanzania, respectively, and 1,766 and 1,968 females in each respective country. Logistic regressions were used to estimate the odds of agreeing with at least one of 5 scenarios when it is acceptable for a husband to beat his wife. A second model examined how experience of IPV in the prior 12 months influences the attitudinal outcome for females.RESULTS: Age was not found to be a significant predictor for attitudinal acceptance of IPV in either country or for either gender. Level of schooling was found to be a significant predictor for decreased odds of attitudinal acceptance of IPV for males but not females in both countries. In contrast, being married was associated with IPV acceptance for females in Tanzania (adjusted odds ratio [aOR]: 1.56; confidence intervals [CIs]: 1.03-2.37) and Nigeria (aOR: 1.66; CIs: 1.19-2.30), but not for males. The significance of marriage for females in Nigeria remained (aOR: 1.67; CIs: 1.20-2.33), even adjusted for past 12-month IPV experience (aOR: 1.85; CIs: 1.11-3.07) and the interaction of IPV experience and marriage (aOR: 3.42, CIs: 1.72-6.80).CONCLUSIONS: Among adolescents and young adults in Nigeria and Tanzania, there are gendered associations for attitudinal acceptance of IPV. Marriage appears to be a strong predictor for females, even adjusted for IPV experience, thus indicating that there is something unique to marriage among female adolescents and young adults that influences acceptance of IPV.

    View details for DOI 10.1016/j.jadohealth.2019.10.006

    View details for PubMedID 31866035

  • Applying a gender lens to global health and well-being: Framing a Journal of Global Health special collection. Journal of global health Stark, L. n., Seff, I. n., Weber, A. n., Darmstadt, G. L. 2020; 10 (1): 010103

    View details for DOI 10.7189/jogh.10.01013

    View details for PubMedID 32257130

    View details for PubMedCentralID PMC7125946

  • Gender equality and global health: intersecting political challenges. Journal of global health Cislaghi, B. n., Weber, A. M., Gupta, G. R., Darmstadt, G. L. 2020; 10 (1): 010701


    Women's and men's health outcomes are different. Some differences are biological, related to male and female sex, while others are related to their gender. Sex- and gender-related issues require different solutions, but policy makers lack straightforward heuristic strategies to identify gender-related health inequities.Using 169 causes of disability-adjusted life years (DALYs) from the 2017 Global Burden of Disease, we calculated the female-to-male (f:m) and male-to-female (m:f) ratios of global DALYs, rank-ordered the ratios by size and calculated the proportion of all-cause DALYs that each cause explained, separately for males and females 15-49 years old. Gender-related vs sex-related causes were categorised using literature on the drivers for the 15 causes with highest f:m and m:f ratios.Causes of DALYs with high m:f ratios appear to be gendered and include: road injuries, interpersonal violence, and drowning - totaling 12.4% of men's (15-49 years) all-cause DALYs. However, causes of DALYs with high f:m ratios are more likely a mix of sex-related and gender-related factors - including headache disorders, depressive disorders, and dietary iron deficiency - totaling 13.4% of women's (15-49 years) all-cause DALYs. Ratios vary by age, geography and Socio-demographic Index.Gender-related vs sex-related causes were categorised using available literature on the drivers for selected causes, illustrating that sex-disaggregated data represents a mix of social and biological influences. This analysis offers a model that policy makers can use to uncover potential gender inequalities in health, including intersections with other social factors. From it, new challenges emerge for global health policy makers and practitioners willing to address them. Global health actors will need to achieve a balance between the two agendas of global health and gender equality.

    View details for DOI 10.7189/jogh.10.010701

    View details for PubMedID 32257161

    View details for PubMedCentralID PMC7101083

  • Association of collective attitudes and contraceptive practice in nine sub-Saharan African countries Journal of Global Health Mejía-Guevara, I., Cislaghi, ., Weber, A., Hallgren, E., Meausoone, V., Cullen, M. R., Darmstadt, G. L. 2020; 10 (1)

    View details for DOI 10.7189/jogh.10.010705

  • Metabolic gestational age assessment in low resource settings: a validation protocol. Gates open research Bota, A. B., Ward, V., Hawken, S., Wilson, L. A., Lamoureux, M., Ducharme, R., Murphy, M. S., Denize, K. M., Henderson, M., Saha, S. K., Akther, S., Otieno, N. A., Munga, S., Atito, R. O., Stringer, J. S., Mwape, H., Price, J. T., Mujuru, H. A., Chimhini, G., Magwali, T., Mudawarima, L., Chakraborty, P., Darmstadt, G. L., Wilson, K. 2020; 4: 150


    Preterm birth is the leading global cause of neonatal morbidity and mortality. Reliable gestational age estimates are useful for quantifying population burdens of preterm birth and informing allocation of resources to address the problem. However, evaluating gestational age in low-resource settings can be challenging, particularly in places where access to ultrasound is limited. Our group has developed an algorithm using newborn screening analyte values derived from dried blood spots from newborns born in Ontario, Canada for estimating gestational age within one to two weeks. The primary objective of this study is to validate a program that derives gestational age estimates from dried blood spot samples (heel-prick or cord blood) collected from health and demographic surveillance sites and population representative health facilities in low-resource settings in Zambia, Kenya, Bangladesh and Zimbabwe. We will also pilot the use of an algorithm to identify birth percentiles based on gestational age estimates and weight to identify small for gestational age infants. Once collected from local sites, samples will be tested by the Newborn Screening Ontario laboratory at the Children's Hospital of Eastern Ontario (CHEO) in Ottawa, Canada. Analyte values will be obtained through laboratory analysis for estimation of gestational age as well as screening for other diseases routinely conducted at Ontario's newborn screening program. For select conditions, abnormal screening results will be reported back to the sites in real time to facilitate counseling and future clinical management. We will determine the accuracy of our existing algorithm for estimation of gestational age in these newborn samples. Results from this research hold the potential to create a feasible method to assess gestational age at birth in low- and middle-income countries where reliable estimation may be otherwise unavailable.

    View details for DOI 10.12688/gatesopenres.13155.1

    View details for PubMedID 33501414

  • What is considered as global health scholarship? A meta-knowledge analysis of global health journals and definitions BMJ GLOBAL HEALTH Abdalla, S. M., Solomon, H., Trinquart, L., Galea, S. 2020; 5 (10)


    Despite the rapid growth of the global health field over the past few decades, consensus on what qualifies as global health scholarship or practice remains elusive. We conducted a meta-knowledge analysis of the titles and abstracts of articles published in 25 journals labelled as global health journals between 2001 and 2019. We identified the major topics in these journals by creating clusters based on terms co-occurrence over time. We also conducted a review of global health definitions during the same period.The analysis included 16 413 articles. The number of journals, labelled as global health, and articles published in these journals, increased dramatically during the study period. The majority of global health publications focused on topics prevalent in low-resource settings. Governance, infectious diseases, and maternal and child health were major topics throughout the analysis period. Surveillance and disease outcomes appeared during the 2006-2010 epoch and continued, with increasing complexity, until the 2016-2019 epoch. Malaria, sexual and reproductive health, and research methodology appeared for only one epoch as major topics. We included 11 relevant definitions in this analysis. Definitions of global health were not aligned with the major topics identified in the analysis of articles published in global health journals.These results highlight a lack of alignment between what is published as global health scholarship and global health definitions, which often advocate taking a global perspective to population health. Our analysis suggests that global health has not truly moved beyond its predecessor, international health. There is a need to define the parameters of the discipline and investigate the disconnect between what is published in global health versus how the field is defined.

    View details for DOI 10.1136/bmjgh-2020-002884

    View details for Web of Science ID 000591350700003

    View details for PubMedID 33109635

    View details for PubMedCentralID PMC7592257

  • Topical emollient therapy in the management of severe acute malnutrition in children under two: A randomized controlled clinical trial in Bangladesh. Journal of global health Shahunja, K. M., Ahmed, T. n., Hossain, M. I., Mahfuz, M. n., Kendall, L. n., Zhu, X. n., Singh, K. n., Crowther, J. M., Singh, S. n., Gibson, R. A., Darmstadt, G. L. 2020; 10 (1): 010414


    Topical emollient therapy can improve neonatal health and growth and potentially provides an additional avenue for augmenting the provision of nutrition to children with severe acute malnutrition (SAM). We hypothesised that topical treatment of hospitalised children with SAM using sunflower seed oil (SSO), in addition to standard-of-care for SAM, would improve skin barrier function and weight gain, reduce risk of infection, and accelerate clinical recovery.We conducted a randomised, two-arm, controlled, unblinded clinical trial in 212 subjects aged 2 to 24 months who were admitted for care of SAM at the 'Dhaka Hospital' of icddr,b during January 2016 to November 2017. Enrollment was age-stratified into 2 to <6 months and 6 to 24 months age groups in a 1:2 ratio. All children received SAM standard-of-care, and the SSO group was also treated with 3 g of SSO per kg body weight three times daily for 10 days. Primary outcome was rate of weight gain over the 10-day study period. Secondary endpoints included rate of nosocomial infection, time to recovery from acute illness, skin condition score, rate of transepidermal water loss (TEWL) and C-reactive protein (CRP) level.Rate of weight gain was higher in the SSO than the control group (adjusted mean difference, AMD = 0.90 g/kg/d, 95% confidence interval (CI) = -1.22 to 3.03 in the younger age stratum), but did not reach statistical significance. Nosocomial infection rate was significantly lower in the SSO group in the older age stratum (adjusted odds ratio (OR) = 0.41, 95% CI = 0.19 to 0.85; P = 0.017), but was comparable in the younger age stratum and overall. Skin condition score improved (AMD = -14.88, 95% CI = -24.12 to -5.65, P = 0.002) and TEWL was reduced overall (AMD = -2.59, 95% CI = -3.86 to -1.31, P < 0.001) in the SSO group. Reduction in CRP level was significantly greater in the SSO group (median: -0.28) than the control group (median 0.00) (P = 0.019) in the younger age stratum.Topical therapy with SSO was beneficial for children with SAM when applied as adjunctive therapy. A community-based trial with a longer intervention period is recommended to validate these NCT02616289.

    View details for DOI 10.7189/jogh.10.010414

    View details for PubMedID 32509290

    View details for PubMedCentralID PMC7243074

  • "So Why Should I Call Them?": Survivor Support Service Characteristics as Drivers of Help-Seeking in India. Journal of interpersonal violence Newberry, J. A., Kaur, J. n., Gurrapu, S. n., Behl, R. n., Darmstadt, G. L., Halpern-Felsher, B. n., Rao, G. V., Mahadevan, S. V., Strehlow, M. C. 2020: 886260520970306


    Women in South Asia face the highest lifetime prevalence of intimate partner violence in the world, which is just one form of violence against women (VAW). In India, few women seek help after experiencing violence, particularly from formal resources, such as physicians or the police. While many studies have investigated the impact of survivor characteristics and patterns of violence on help-seeking behaviors, there is scant research on support service characteristics and their impact on help-seeking. The introduction of a novel crisis helpline in Gujarat, India provided an opportunity to better understand how successful help-seeking can be driven by the perceived and experienced characteristics of the helpline. We conducted in-depth interviews with helpline users to identify factors and pathways that promoted or discouraged help-seeking in general, help-seeking from a formal source, and help-seeking from this particular helpline. We analyzed 32 interviews of women who used the helpline. Participants were from eight districts across the state, representing a diverse range of sociodemographic backgrounds. After conducting a thematic analysis, we found that action-oriented service, timeliness, and women-focused staff influenced (positively and negatively) participants' feelings of safety, empowerment, and trust in the helpline, which ultimately impacted their decision to seek help from the helpline or even to seek help at all. This study illuminates how service characteristics, in and of themselves, can influence the likelihood that survivors will seek help, emphasizing the need for survivors to have a voice in the growth and refinement of VAW support services. Consequently, these areas must be a focus of future research and initiatives to improve help-seeking by VAW survivors.

    View details for DOI 10.1177/0886260520970306

    View details for PubMedID 33150827

  • Social normative and social network factors associated with adolescent pregnancy: a cross-sectional study of 176 villages in rural Honduras. Journal of global health Shakya, H. B., Darmstadt, G. L., Barker, K. M., Weeks, J. n., Christakis, N. A. 2020; 10 (1): 010706


    Adolescent pregnancy and childbirth are common throughout Central America. While gendered beliefs promoting motherhood are a known risk factor, their association with adolescent childbirth within the social networks of Central American communities is unknown.This was a cross-sectional study looking at adolescent childbirth amongst women ages 15-20 years (N = 2990) in rural Honduras, using reproductive health data on all individuals ≥15 years of age (N = 24 937 of 31 300 population) including social network contacts, all of whom were interviewed as part of the study. The outcome, adolescent childbirth, was defined as having had a child < age 20 years. Predictors included whether a woman's social contact had an adolescent childbirth and the social contact's reported perception of community support for adolescent childbirth.While girls who identified a father in the village as a social contact had a lower likelihood of adolescent childbirth regardless of whether or not they reported being in a partnership, this finding did not hold for girls who identified mothers. There was an association between a social contact's report of norms supporting adolescent childbirth and a girl's risk of adolescent childbirth; however, village-level aggregate norms attenuated that relationship. Independent significant associations were found between a girl's risk of adolescent childbirth and both a social contact's adolescent childbirth and the village proportion of women who had had an adolescent childbirth. The association between social contacts' adolescent childbirth and a girl's risk of adolescent childbirth across relationships was more robust for stronger relationships and when the social contact was closer in age to the girl.If, as this evidence suggests, a strong driver of adolescent childbirth is the frequency of the occurrence of adolescent childbirth both within the greater community and within a girl's proximal social network, the challenge for intervention strategies is to encourage norms that prevent adolescent childbirth without stigmatising those who have had an adolescent childbirth. Programmatic efforts to counter prevailing norms that limit a woman's role to motherhood, and that support and encourage strong norms for girls' education may play an important role in addressing this situation.

    View details for DOI 10.7189/jogh.10.010706

    View details for PubMedID 32373336

    View details for PubMedCentralID PMC7182389

  • Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya. Journal of global health Darmstadt, G. L., Pepper, K. T., Ward, V. C., Srikantiah, S. n., Mahapatra, T. n., Tarigopula, U. K., Bhattacharya, D. n., Irani, L. n., Schooley, J. n., Chaudhuri, I. n., Dutt, P. n., Sastry, P. n., Mitra, R. n., Chamberlain, S. n., Monaghan, S. n., Nanda, P. n., Atmavilas, Y. n., Saggurti, N. n., Borkum, E. n., Rangarajan, A. n., Mehta, K. M., Abdalla, S. n., Wilhelm, J. n., Weng, Y. n., Carmichael, S. L., Raheel, H. n., Bentley, J. n., Munar, W. A., Creanga, A. n., Trehan, S. n., Walker, D. n., Shah, H. n. 2020; 10 (2): 021001


    In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement - seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.

    View details for DOI 10.7189/jogh.10.021001

    View details for PubMedID 33414906

    View details for PubMedCentralID PMC7757841

  • Shifts in Women's Paid Employment Participation During the World War II Era and Later Life Health. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Falconi, A. M., Weber, A. M., Cullen, M. R., Stefanick, M. L., Michael, Y. L., Darmstadt, G. L. 2020; 66 (1S): S42–S50


    PURPOSE: The greatest proportional increase in female labor force participation of the 20th century occurred post-World War II (WWII) when shifts in policy and growth in service and clerical work spurred an influx of women into the labor force. Research has yet to demonstrate how variation in women's employment participation during this era related to their later life health. We examined how shifts in women's employment patterns during the WWII era influenced their disease and mortality risk.METHODS: Using data from the Women's Health Initiative Observational Study, we evaluated the employment history of a cohort of 6,158 women across the U.S. during the WWII era. We fit logistic regression models estimating the association between involvement in the workforce over 5-year intervals and health (i.e., cancer, cardiovascular disease, and mortality). We also ran models with a younger cohort (n= 12,435) of women to assess how associations between work and health varied between cohorts.RESULTS: The older cohort of women who entered the workforce before the onset of WWII showed mixed to no differences in health relative to homemakers. The younger cohort of women who entered the workforce during WWII tended to show negative relationships between work during their late/post-childbearing years and health, experiencing higher risks for mortality.CONCLUSIONS: The policies, social forces, and broader environment in which women live appear to significantly influence how involvement in the workforce over the life course influences health. Women whose entry into the workforce was initially encouraged socially but were later confronted with opposition experienced increased health risks.

    View details for DOI 10.1016/j.jadohealth.2019.10.005

    View details for PubMedID 31866037

  • Parent-Related Normative Perceptions of Adolescents and Later Weight Control Behavior: Longitudinal Analysis of Cohort Data From Brazil. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Abdalla, S., Buffarini, R., Weber, A. M., Cislaghi, B., Costa, J. C., Menezes, A. M., Goncalves, H., Wehrmeister, F. C., Meausoone, V., Victora, C. G., Darmstadt, G. L. 2020; 66 (1S): S9–S16


    PURPOSE: Body image-related norms can be imposed by parents and can shape adolescents' body satisfaction in consequential ways, yet evidence on long-term effects is scarce. Longitudinal data from a country with strong body image focus provided a unique opportunity to investigate long-term influences of normative parent-related perceptions.METHODS: Multinomial logistic regression was used on data from a 1993 birth cohort in Brazil to investigate the association of normal-body mass index (BMI) adolescents' perception of their parent's opinion of their weight at age 11years with their weight control attempts at 18years, testing a mediating role for body dissatisfaction at age 15years. All models controlled for body dissatisfaction at age 11years and BMI change between ages 11 and 15years.RESULTS: A total of 1150 boys and 1336 girls were included. Girls were more likely than boys to diet without nutritionist advice to lose weight (51.5% vs. 34.3% among boys) and use medication to gain weight (12.7% vs. 4.2%). Normal-BMI adolescents who reported at age 11years that their parents thought they were thin had higher odds of feeling thinner than ideal at age 15years (odds ratio 2.8, 95% confidence interval 1.8-3.2; and odds ratio 2.0, 95% confidence interval 1.5-2.7) among boys and girls, respectively). Feeling thinner than ideal at age 15years was associated among girls with higher odds of weight gain attempts at age 18years. Similar patterns appeared among girls reporting that their parents thought they were fat at age 11years, feeling fatter than ideal at age 15years and having higher odds of weight loss attempts at age 18years. Body dissatisfaction was a statistically significant mediator among girls but not boys.CONCLUSIONS: A long-term influence of parent-related perceptions via a likely trajectory of body dissatisfaction is evident among girls.

    View details for DOI 10.1016/j.jadohealth.2019.09.007

    View details for PubMedID 31866039

  • Relationships Between Maternal Factors and Weight Loss Attempts Among Urban Male and Female Adolescents Living in Soweto, Johannesburg, South Africa. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Cohen, E., Richter, L. M., Chidumwa, G., Abdalla, S., Weber, A. M., Darmstadt, G. L., Norris, S. A. 2020; 66 (1S): S17–S24


    PURPOSE: South Africa is undergoing rapid urban transition favoring ideals of thinness, which increases eating disorders risk for female adolescents, whereas older women continue to uphold corpulence as a female cultural value. This study aimed to assess the potential conflicting relationship between urban male and female adolescents' weight loss attempts (WLA) and maternal body image norms within households.METHODS: The study included a longitudinal sample of mother-daughter and mother-son pairs from the Birth to Twenty Plus Cohort (N= 1,613), using data collected at 13, 17, and 22years. Sociodemographic characteristics, eating attitudes, WLA, and body mass index were assessed in mothers and their offspring. Relationships between maternal factors and offspring's WLA were assessed using both logistic regression and structural equation modeling.RESULTS: More females had WLA compared with their male counterparts at 13, 17, and 22years. Multivariable models showed an independent positive association between maternal household socioeconomic status and boys' WLA at 13years, whereas independent negative associations were found between mothers' body mass index and boys' WLA at 17 and 22years. Mothers' age and sons' WLA at 22years showed an independent positive association. No association was found between maternal factors and daughters' WLA.CONCLUSIONS: Strong gender-differentiated intergenerational patterns were observed between maternal factors and offspring's WLA from early adolescence to early adulthood. The lack of relationship between maternal factors and daughters' behavior in contrast to that of sons suggests that Western acculturation may pose a greater risk for females to modern body image disturbances and eating disorders.

    View details for DOI 10.1016/j.jadohealth.2019.10.015

    View details for PubMedID 31866033

  • The Intersectionality of Gender and Wealth in Adolescent Health and Behavioral Outcomes in Brazil: The 1993 Pelotas Birth Cohort. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Buffarini, R., Abdalla, S., Weber, A. M., Costa, J. C., Menezes, A. M., Goncalves, H., Wehrmeister, F. C., Meausoone, V., Darmstadt, G. L., Victora, C. G. 2020; 66 (1S): S51–S57


    PURPOSE: Brazilian society is characterized by deep socioeconomic inequalities. Using data from a population-based birth cohort, we explored how the intersectionality of family income and gender may affect adolescent health and behavioral outcomes.METHODS: Children born in 1993 in the Brazilian city of Pelotas have been followed up prospectively at the age of 15years when the follow-up rate was 85.7% of the original cohort. Participants answered standardized questionnaires, and anthropometric measures were obtained. Outcomes in five domains were studied: overweight (body mass index above+1 SD of the World Health Organization standard for age and sex), cigarette smoking (in the previous month), violence (fight in which someone was injured, in the past year), self-reported unhappiness (based on a face scale), and psychological symptoms (Strengths and Difficulties Questionnaire). Monthly family income was recoded in quintiles.RESULTS: Results were available for more than 4,101-4,334 adolescents, depending on the outcome. Overweight was more common among boys than girls (29.7% and 25.6%; p= .004) and was directly related to family income among boys (p < .001), but not among girls (p= .681). Smoking was less common among boys than girls (12.3% and 21.0%, p < .001) and showed strong inverse association with income among girls (p < .001), but not among boys (p= .099). Reported violence was twice as common among boys than girls (16.4% vs. 8.0%; p < .001); an inverse association with income was present among girls (p < .001), but not for boys (p= .925). Boys and girls were similarly likely to report being unhappy (18.4% and 20.1%; p= .176), with an inverse association with family income in girls. Psychological symptoms were slightly less common among boys than girls (25.3% and 28.3%; p= .014), with strong inverse associations with income in both sexes (p < .001). Adolescent girls from poor families were the group with the highest prevalence for three of the five outcomes: smoking, unhappiness, and psychological problems.CONCLUSIONS: Gender norms influence adolescent health and behavioral outcomes, but the direction and strength of the associations are modified by socioeconomic position. Preventive strategies must take into account the intersectionality of gender and wealth.

    View details for DOI 10.1016/j.jadohealth.2019.08.029

    View details for PubMedID 31866038

  • Gender Norms and Weight Control Behaviors in U.S. Adolescents: A Prospective Cohort Study (1994-2002). The Journal of adolescent health : official publication of the Society for Adolescent Medicine Nagata, J. M., Domingue, B. W., Darmstadt, G. L., Weber, A. M., Meausoone, V., Cislaghi, B., Shakya, H. B. 2020; 66 (1S): S34–S41


    PURPOSE: The aim of this article was to determine the relationship between gender norms and weight control behaviors in U.S. adolescents.METHODS: We analyzed prospective cohort data from the National Longitudinal Study of Adolescent to Adult Health (N= 9,861), at baseline in 1994-1995 (ages 11-18years, Wave I), 1-year follow-up (ages 12-19years, Wave II), and 7-year follow-up (ages 18-26years, Wave III). The primary exposure variable was a measure of one's gender normativity based on the degree to which males and females behave in ways that are similar to the behaviors of their same-gender peers. The outcome variable was an individual's weight control attempts (trying to lose or gain weight) and behaviors (dieting, fasting/skipping meals, vomiting, or weight-loss pills/laxatives/diuretics to lose weight or ate different/more foods than usual or taking supplements to gain weight).RESULTS: In logistic regression analyses controlling for potential confounders, a higher baseline individual gender normativity score (higher femininity in females and higher masculinity in males) was associated with weight loss attempts (beta= .10; p= .01) and weight loss behaviors (beta= .18; p<.001) in girls but was associated with weight gain attempts (beta= .18; p < .001) and behaviors (beta= .16; p < .001) in boys at 1-year follow-up. Higher individual gender normativity score was protective of weight loss attempts (beta=-.15; p < .001) and weight loss behaviors (beta=-.17; p<.001) in males but not females at 7-year follow-up. Loess plots provided visualizations of significant relationships.CONCLUSIONS: Gender norms may reinforce a thinner body ideal for girls but a larger ideal for boys.

    View details for DOI 10.1016/j.jadohealth.2019.08.020

    View details for PubMedID 31866036

  • The Influence of Schooling on the Stability and Mutability of Gender Attitudes: Findings From a Longitudinal Study of Adolescent Girls in Zambia. The Journal of adolescent health : official publication of the Society for Adolescent Medicine Chae, S., Haberland, N., McCarthy, K. J., Weber, A. M., Darmstadt, G. L., Ngo, T. D. 2020; 66 (1S): S25–S33


    PURPOSE: Inequitable gender norms are thought to harm lifelong health and well-being. We explore the process of gender attitude change and the role of schooling in shifting or reinforcing gender norms among adolescent girls in Zambia.METHODS: We used longitudinal data collected from unmarried, vulnerable girls (aged 10-19years) as part of the Adolescent Girls Empowerment Program. We conducted random effects multinomial logistic regression to determine whether schooling-related factors were associated with shifts in adolescent girls' gender attitudes across three survey rounds and explored whether these relationships varied by age.RESULTS: Mean gender attitude scores at the aggregate level remained stable over time among rural girls and improved slightly for urban girls. At the individual level, about half the girls had relatively unchanged scores, whereas the other half shifted to higher or lower scores between rounds. Rural and urban girls currently attending school were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable. Educational attainment was not associated with shifts in gender attitudes among rural girls. Urban girls with higher educational attainment were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable or more equitable.CONCLUSIONS: Patterns of gender attitude stability and change differed more for urban girls than rural girls and varied by age and schooling-related factors. In general, schooling appears to be an institutional lever that holds promise for shifting gender attitudes toward greater equality. Our study highlights the importance of looking longitudinally at the effects of social context and reinforces calls for targeted, context-specific interventions for this age group.

    View details for DOI 10.1016/j.jadohealth.2019.08.031

    View details for PubMedID 31866034

  • Perpetration of intimate partner violence and mental health outcomes: sex- and gender-disaggregated associations among adolescents and young adults in Nigeria. Journal of global health Stark, L. n., Seff, I. n., Weber, A. M., Cislaghi, B. n., Meinhart, M. n., Bermudez, L. G., Atuchukwu, V. n., Onotu, D. n., Darmstadt, G. L. 2020; 10 (1): 010708


    The association between intimate partner violence (IPV) victimisation and poor mental health outcomes is well established. Less is known about the correlation between IPV perpetration and mental health, particularly among adolescents and young adults. Using data from the nationally representative Violence Against Children Survey, this analysis examines the association between IPV perpetration and mental health for male and female adolescents and young adults in Nigeria.Multivariate logistic regression models were used to examine associations between ever-perpetration of IPV and four self-reported mental health variables: severe sadness, feelings of worthlessness, suicide ideation, and alcohol use. Models were sex-disaggregated, controlled for age, marital status, and schooling, and tested with and without past exposure to violence. Standard errors were adjusted for sampling stratification and clustering. Observations were weighted to be representative of 13-24 year-olds in Nigeria.Males were nearly twice as likely as females to perpetrate IPV (9% v. 5%, respectively; P < 0.001), while odds of perpetration for both sexes were higher for those ever experiencing IPV (adjusted odds ratio (aOR) = 4.60 for males; aOR = 2.71 for females). Female perpetrators had 2.73 higher odds of reporting severe sadness (95% confidence interval CI = 1.44, 5.17; P = 0.002) and 2.72 times greater odds of reporting suicide ideation (1.28, 5.79; P = 0.010) than non-perpetrating females, even when controlling for past-year violence victimisation. In contrast, male perpetrators had 2.65 times greater odds of feeling worthless (1.09, 6.43; P = 0.031), and 2.36 times greater odds of reporting alcohol use in the last 30 days (1.50, 3.73; P < 0.001), as compared to non-perpetrating males.Among adolescents and young adults in Nigeria, IPV perpetration and negative mental health outcomes are associated but differ for males and females. Mindful of the cross-sectional nature of the data, it is possible that socially determined gender norms may shape the ways in which distress from IPV perpetration is understood and expressed. Additional research is needed to clarify these associations and inform violence prevention efforts.

    View details for DOI 10.7189/jogh.10.010708

    View details for PubMedID 32257165

    View details for PubMedCentralID PMC7101086

  • Multiomics Characterization of Preterm Birth in Low- and Middle-Income Countries. JAMA network open Jehan, F. n., Sazawal, S. n., Baqui, A. H., Nisar, M. I., Dhingra, U. n., Khanam, R. n., Ilyas, M. n., Dutta, A. n., Mitra, D. K., Mehmood, U. n., Deb, S. n., Mahmud, A. n., Hotwani, A. n., Ali, S. M., Rahman, S. n., Nizar, A. n., Ame, S. M., Moin, M. I., Muhammad, S. n., Chauhan, A. n., Begum, N. n., Khan, W. n., Das, S. n., Ahmed, S. n., Hasan, T. n., Khalid, J. n., Rizvi, S. J., Juma, M. H., Chowdhury, N. H., Kabir, F. n., Aftab, F. n., Quaiyum, A. n., Manu, A. n., Yoshida, S. n., Bahl, R. n., Rahman, A. n., Pervin, J. n., Winston, J. n., Musonda, P. n., Stringer, J. S., Litch, J. A., Ghaemi, M. S., Moufarrej, M. N., Contrepois, K. n., Chen, S. n., Stelzer, I. A., Stanley, N. n., Chang, A. L., Hammad, G. B., Wong, R. J., Liu, C. n., Quaintance, C. C., Culos, A. n., Espinosa, C. n., Xenochristou, M. n., Becker, M. n., Fallahzadeh, R. n., Ganio, E. n., Tsai, A. S., Gaudilliere, D. n., Tsai, E. S., Han, X. n., Ando, K. n., Tingle, M. n., Maric, I. n., Wise, P. H., Winn, V. D., Druzin, M. L., Gibbs, R. S., Darmstadt, G. L., Murray, J. C., Shaw, G. M., Stevenson, D. K., Snyder, M. P., Quake, S. R., Angst, M. S., Gaudilliere, B. n., Aghaeepour, N. n. 2020; 3 (12): e2029655


    Worldwide, preterm birth (PTB) is the single largest cause of deaths in the perinatal and neonatal period and is associated with increased morbidity in young children. The cause of PTB is multifactorial, and the development of generalizable biological models may enable early detection and guide therapeutic studies.To investigate the ability of transcriptomics and proteomics profiling of plasma and metabolomics analysis of urine to identify early biological measurements associated with PTB.This diagnostic/prognostic study analyzed plasma and urine samples collected from May 2014 to June 2017 from pregnant women in 5 biorepository cohorts in low- and middle-income countries (LMICs; ie, Matlab, Bangladesh; Lusaka, Zambia; Sylhet, Bangladesh; Karachi, Pakistan; and Pemba, Tanzania). These cohorts were established to study maternal and fetal outcomes and were supported by the Alliance for Maternal and Newborn Health Improvement and the Global Alliance to Prevent Prematurity and Stillbirth biorepositories. Data were analyzed from December 2018 to July 2019.Blood and urine specimens that were collected early during pregnancy (median sampling time of 13.6 weeks of gestation, according to ultrasonography) were processed, stored, and shipped to the laboratories under uniform protocols. Plasma samples were assayed for targeted measurement of proteins and untargeted cell-free ribonucleic acid profiling; urine samples were assayed for metabolites.The PTB phenotype was defined as the delivery of a live infant before completing 37 weeks of gestation.Of the 81 pregnant women included in this study, 39 had PTBs (48.1%) and 42 had term pregnancies (51.9%) (mean [SD] age of 24.8 [5.3] years). Univariate analysis demonstrated functional biological differences across the 5 cohorts. A cohort-adjusted machine learning algorithm was applied to each biological data set, and then a higher-level machine learning modeling combined the results into a final integrative model. The integrated model was more accurate, with an area under the receiver operating characteristic curve (AUROC) of 0.83 (95% CI, 0.72-0.91) compared with the models derived for each independent biological modality (transcriptomics AUROC, 0.73 [95% CI, 0.61-0.83]; metabolomics AUROC, 0.59 [95% CI, 0.47-0.72]; and proteomics AUROC, 0.75 [95% CI, 0.64-0.85]). Primary features associated with PTB included an inflammatory module as well as a metabolomic module measured in urine associated with the glutamine and glutamate metabolism and valine, leucine, and isoleucine biosynthesis pathways.This study found that, in LMICs and high PTB settings, major biological adaptations during term pregnancy follow a generalizable model and the predictive accuracy for PTB was augmented by combining various omics data sets, suggesting that PTB is a condition that manifests within multiple biological systems. These data sets, with machine learning partnerships, may be a key step in developing valuable predictive tests and intervention candidates for preventing PTB.

    View details for DOI 10.1001/jamanetworkopen.2020.29655

    View details for PubMedID 33337494

  • Progress on Sustainable Development Goal 5 and improved health through better measurement. SSM - population health Keats, E. C., Darmstadt, G. L., Bhutta, Z. A. 2019; 9: 100491

    View details for DOI 10.1016/j.ssmph.2019.100491

    View details for PubMedID 31998828

    View details for PubMedCentralID PMC6978490

  • Progress on Sustainable Development Goal 5 and improved health through better measurement SSM-POPULATION HEALTH Keats, E. C., Darmstadt, G. L., Bhutta, Z. A. 2019; 9
  • Religious affiliation and immunization coverage in 15 countries in Sub-Saharan Africa. Vaccine Costa, J. C., Weber, A. M., Darmstadt, G. L., Abdalla, S., Victora, C. G. 2019


    BACKGROUND: Although religious affiliation has been identified as a potential barrier to immunization in some African countries, there are no systematic multi-country analyses, including within-country variability, on this issue. We investigated whether immunization varied according to religious affiliation and sex of the child in sub-Saharan African (SSA) countries.METHODS: We used data from 15 nationally representative surveys from 2010 to 2016. The major religious groups were described by country in terms of wealth, residence, and education. Proportions of fully immunized and unvaccinated children were stratified by country, maternal religion, and sex of the child. Poisson regression with robust variance was used to assess whether the outcomes varied according to religion, with and without adjustment for the above cited sociodemographic confounders. Interactions between child sex and religion were investigated.RESULTS: Fifteen countries had >10% of families affiliated with Christianity and >10% affiliated with Islam, and four also had >10% practicing folk religions. In general, Christians were wealthier, more educated and more urban. Nine countries had significantly lower full immunization coverage among Muslims than Christians (pooled prevalence ratio=0.81; 95%CI: 0.79-0.83), of which seven remained significant after adjustment for confounders (pooled ratio=0.90; 0.87-0.92). Four countries had higher coverage among Muslims, of which two remained significant after adjustment. Regarding unvaccinated children, six countries showed higher proportions among Muslims, all of which remained significant after adjustment [crude pooled ratio=1.83 (1.59-2.07); adjusted=1.31 (1.14-1.48)]. Children from families practicing folk religions did not show any consistent patterns in immunization. Child sex was not consistently associated with vaccination.CONCLUSION: Muslim religion was associated with lower vaccine coverage in several SSA countries, both for boys and girls. The involvement of religious leaders is essential for increasing immunization coverage and supporting the leave no one behind agenda of the Sustainable Development Goals.

    View details for DOI 10.1016/j.vaccine.2019.11.024

    View details for PubMedID 31791811

  • Kangaroo Mother Care implementation research to develop models for accelerating scale-up in India and Ethiopia: study protocol for an adequacy evaluation. BMJ open Medhanyie, A. A., Alemu, H., Asefa, A., Beyene, S. A., Gebregizabher, F. A., Aziz, K., Bhandari, N., Beyene, H., Brune, T., Chan, G., Cranmer, J. N., Darmstadt, G., Duguma, D., Fikre, A., Andualem, B. G., Gobezayehu, A. G., Mariam, D. H., Abay, T. H., Mohan, H. L., Jadaun, A., Jayanna, K., Kajal, F. N., Kar, A., Krishna, R., Kumar, A., Kumar, V., Madhur, T. K., Belew, M. L., M, R., Martines, J., Mazumder, S., Amin, H., Mony, P. K., Muleta, M., Pileggi-Castro, C., Pn Rao, S., Estifanos, A. S., Sibley, L. M., Singhal, N., Tadele, H., Tariku, A., Lemango, E. T., Tadesse, B. T., Upadhyay, R., Worku, B., Hadush, M. Y., Bahl, R., KMC Scale-Up Study Group, Medhanyie, A. A., Alemu, H., Asefa, A., Beyene, S. A., Gebregizabher, F. A., Aziz, K., Bhandari, N., Beyene, H., Brune, T., Chan, G. J., Cranmer, J. N., Darmstadt, G. L., Duguma, D., Fikre, A., Andualem, B. G., Gobezayehu, A. G., Mariam, D. H., Abay, T. H., Mohan, H. L., Jadaun, A., Jayanna, K., Kajal, F. N., Kar, A., Krishna, R., Kumar, A., Kumar, V., Madhur, T. K., Belew, M. L., Rajini, M., Martines, J. C., Mazumder, S., Amin, H. M., Mony, P. K., Muleta, M., Pileggi-Castro, C., Rao, S., Estifanos, A. S., Sibley, L. M., Singhal, N., Tadele, H., Tariku, A., Lemango, E. T., Tadesse, B. T., Upadhyay, R. P., Worku, B., Hadush, M. Y., Bahl, R. 2019; 9 (11): e025879


    INTRODUCTION: Kangaroo Mother Care (KMC) is the practice of early, continuous and prolonged skin-to-skin contact between the mother and the baby with exclusive breastfeeding. Despite clear evidence of impact in improving survival and health outcomes among low birth weight infants, KMC coverage has remained low and implementation has been limited. Consequently, only a small fraction of newborns that could benefit from KMC receive it.METHODS AND ANALYSIS: This implementation research project aims to develop and evaluate district-level models for scaling up KMC in India and Ethiopia that can achieve high population coverage. The project includes formative research to identify barriers and contextual factors that affect implementation and utilisation of KMC and design scalable models to deliver KMC across the facility-community continuum. This will be followed by implementation and evaluation of these models in routine care settings, in an iterative fashion, with the aim of reaching a successful model for wider district, state and national-level scale-up. Implementation actions would happen at three levels: 'pre-KMC facility'-to maximise the number of newborns getting to a facility that provides KMC; 'KMC facility'-for initiation and maintenance of KMC; and 'post-KMC facility'-for continuation of KMC at home. Stable infants with birth weight<2000g and born in the catchment population of the study KMC facilities would form the eligible population. The primary outcome will be coverage of KMC in the preceding 24hours and will be measured at discharge from the KMC facility and 7days after hospital discharge.ETHICS AND DISSEMINATION: Ethics approval was obtained in all the project sites, and centrally by the Research Ethics Review Committee at the WHO. Results of the project will be submitted to a peer-reviewed journal for publication, in addition to national and global level dissemination.STUDY STATUS: WHO approved protocol: V.4-12 May 2016-Protocol ID: ERC 2716. Study implementation beginning: April 2017. Study end: expected March 2019.TRIAL REGISTRATION NUMBER: Community Empowerment Laboratory, Uttar Pradesh, India (ISRCTN12286667); St John's National Academy of Health Sciences, Bangalore, India and Karnataka Health Promotion Trust, Bangalore, India (CTRI/2017/07/008988); Society for Applied Studies, Delhi (NCT03098069); Oromia, Ethiopia (NCT03419416); Amhara, SNNPR and Tigray, Ethiopia (NCT03506698).

    View details for DOI 10.1136/bmjopen-2018-025879

    View details for PubMedID 31753865

  • Implications of gendered behaviour and contexts for social mobility in the USA: a nationally representative observational study. The Lancet. Planetary health Domingue, B. W., Cislaghi, B., Nagata, J. M., Shakya, H. B., Weber, A. M., Boardman, J. D., Darmstadt, G. L., Harris, K. M. 2019; 3 (10): e420–e428


    BACKGROUND: We constructed measures of an individual's gendered behaviour and their gendered environment to investigate the salience of gender norms during adolescence for social mobility during the next decade of life.METHODS: In this nationally representative observational study, we collected individual-level data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), which enrolled a cohort of nationally representative school students aged 11-19 years from across the USA and followed them up for 14 years (ie, to age 25-33 years). We characterised gendered behaviour for adolescents in a performative sense via self-reports of behaviours and beliefs. We aggregated this individual-level measure to create a proxy measure of an individual's social context by taking averages for an individual's peers of the same sex and school year.FINDINGS: Between Jan 5, 1994, and Dec 26, 1995, Add Health collected data on a cohort of 20 745 students. 14 540 respondents were followed-up 14 years later between April 3, 2007, and Feb 1, 2009, of whom 7722 (53·1%) were female. More masculine male respondents were downwardly mobile; they were enrolled in school for fewer years and were more likely to have lower status jobs than their less masculine same-sex school peers. More masculine male respondents were also more likely to have jobs in occupational categories with larger proportions of males than their same-sex school peers. Gendered behaviour was not predictive of future educational and occupational attainment for female respondents. Male adolescents in school years with more masculine same-sex peers than male adolescents in other school years also tended to have lower educational and occupational attainment than their male peers. Educational and occupational attainment in early midlife for female respondents was not affected by their gendered environment.INTERPRETATION: Gender, when measured as a set of gender-distinct behaviours in adolescence, was associated with differential patterns of social mobility from adolescence to young adulthood. Moreover, variation in an individual's local gender norms has implications for subsequent socioeconomic attainment, especially for male adolescents. These findings have potential implications for observed health disparities.FUNDING: Bill & Melinda Gates Foundation.

    View details for DOI 10.1016/S2542-5196(19)30191-3

    View details for PubMedID 31625514

  • Implications of gendered behaviour and contexts for social mobility in the USA: a nationally representative observational study LANCET PLANETARY HEALTH Domingue, B. W., Cislaghi, B., Nagata, J. M., Shakya, H. B., Weber, A. M., Boardman, J. D., Darmstadt, G. L., Harris, K. 2019; 3 (10): E420–E428
  • Detecting Developmental Delay and Autism Through Machine Learning Models Using Home Videos of Bangladeshi Children: Development and Validation Study JOURNAL OF MEDICAL INTERNET RESEARCH Tariq, Q., Fleming, S., Schwartz, J., Dunlap, K., Corbin, C., Washington, P., Kalantarian, H., Khan, N. Z., Darmstadt, G. L., Wall, D. 2019; 21 (4)

    View details for DOI 10.2196/13822

    View details for Web of Science ID 000465558900001

  • Pregnancy intervals after stillbirth, neonatal death and spontaneous abortion and the risk of an adverse outcome in the next pregnancy in rural Bangladesh. BMC pregnancy and childbirth Nonyane, B. A., Norton, M., Begum, N., Shah, R. M., Mitra, D. K., Darmstadt, G. L., Baqui, A. H., Projahnmo Study Group in Bangladesh 2019; 19 (1): 62


    BACKGROUND: Studies have revealed associations between preceding short and long birth-to-birth or birth-to-pregnancy intervals and poor pregnancy outcomes. Most of these studies, however, have examined the effect of intervals that began with live births. Using data from Bangladesh, we examined the effect of inter-outcome intervals (IOI) starting with a non-live birth or neonatal death, on outcomes in the next pregnancy. Pregnancy spacing behaviors in rural northeast Bangladesh have changed little since 2004.METHODS: We analyzed pregnancy histories for married women aged 15-49 years who had outcomes between 2000 and 2006 in Sylhet, Bangladesh. We examined the effects of the preceding outcome and the IOI length on the risk of stillbirth, neonatal death and spontaneous abortion using multinomial logistic regression models.RESULTS: Data included 64,897 pregnancy outcomes from 33,495 mothers. Inter-outcome intervals of 27-50 months and live births were baseline comparators. Stillbirths followed by IOI's <=6 months, 7-14 months or overall <=14 months had increased risks for spontaneous abortion with adjusted relative risk ratios (aRRR) and 95% confidence intervals = 29.6 (8.09, 108.26), 1.84 (0.84, 4.02) and 2.53 (1.19, 5.36), respectively. Stillbirths followed by IOIs 7-14 months had aRRR 2.00 (1.39, 2.88) for stillbirths. Neonatal deaths followed by IOIs <=6 months had aRRR 28.2 (8.59, 92.63) for spontaneous abortion. Neonatal deaths followed by IOIs 7-14 and 15-26 months had aRRRs 3.08 (1.82, 5.22) and 2.32 (1.38, 3.91), respectively, for stillbirths; and aRRRs 2.81 (2.06, 3.84) and 1.70 (1.24, 3.84), respectively, for neonatal deaths. Spontaneous abortions followed by IOIs <=6 months and 7-14 months had, respectively, aRRRs 23.21 (10.34, 52.13) and 1.80 (0.98, 3.33) for spontaneous abortion.CONCLUSION: In rural northeast Bangladesh, short inter-outcome intervals after stillbirth, neonatal death and spontaneous abortion were associated with a high risk of a similar outcome in the next pregnancy. These findings are aligned with other studies from Bangladesh. Two studies from similar settings have found benefits of waiting six months before conceiving again, suggesting that incorporating this advice into programs should be considered. Further research is warranted to confirm these findings.

    View details for PubMedID 30738434

  • Assessing Diversity in Early Childhood Development in the East Asia-Pacific CHILD INDICATORS RESEARCH Rao, N., Sun, J., Richards, B., Weber, A., Sincovich, A., Darmstadt, G. L., Ip, P. 2019; 12 (1): 235–54
  • Use of mobile technology by frontline health workers to promote reproductive, maternal, newborn and child health and nutrition: a cluster randomized controlled Trial in Bihar, India. Journal of global health Carmichael, S. L., Mehta, K. n., Srikantiah, S. n., Mahapatra, T. n., Chaudhuri, I. n., Balakrishnan, R. n., Chaturvedi, S. n., Raheel, H. n., Borkum, E. n., Trehan, S. n., Weng, Y. n., Kaimal, R. n., Sivasankaran, A. n., Sridharan, S. n., Rotz, D. n., Tarigopula, U. K., Bhattacharya, D. n., Atmavilas, Y. n., Pepper, K. T., Rangarajan, A. n., Darmstadt, G. L. 2019; 9 (2): 0204249


    mHealth technology holds promise for improving the effectiveness of frontline health workers (FLWs), who provide most health-related primary care services, especially reproductive, maternal, newborn, child health and nutrition services (RMNCHN), in low-resource - especially hard-to-reach - settings. Data are lacking, however, from rigorous evaluations of mHealth interventions on delivery of health services or on health-related behaviors and outcomes.The Information Communication Technology-Continuum of Care Service (ICT-CCS) tool was designed for use by community-based FLWs to increase the coverage, quality and coordination of services they provide in Bihar, India. It consisted of numerous mobile phone-based job aids aimed to improve key RMNCHN-related behaviors and outcomes. ICT-CCS was implemented in Saharsa district, with cluster randomization at the health sub-center level. In total, evaluation surveys were conducted with approximately 1100 FLWs and 3000 beneficiaries who had delivered an infant in the previous year in the catchment areas of intervention and control health sub-centers, about half before implementation (mid-2012) and half two years afterward (mid-2014). Analyses included bivariate and difference-in-difference analyses across study groups.The ICT-CCS intervention was associated with more frequent coordination of AWWs with ASHAs on home visits and greater job confidence among ASHAs. The intervention resulted in an 11 percentage point increase in FLW antenatal home visits during the third trimester (P = 0.04). In the post-implementation period, postnatal home visits during the first week were increased in the intervention (72%) vs the control (60%) group (P < 0.01). The intervention also resulted in 13, 12, and 21 percentage point increases in skin-to-skin care (P < 0.01), breastfeeding immediately after delivery (P < 0.01), and age-appropriate complementary feeding (P < 0.01). FLW supervision and other RMNCHN behaviors were not significantly impacted.Important improvements in FLW home visits and RMNCHN behaviors were achieved. The ICT-CCS tool shows promise for facilitating FLW effectiveness in improving RMNCHN behaviors.

    View details for DOI 10.7189/jogh.09.020424

    View details for PubMedID 31788233

    View details for PubMedCentralID PMC6875677

  • The D-score: a metric for interpreting the early development of infants and toddlers across global settings. BMJ global health Weber, A. M., Rubio-Codina, M., Walker, S. P., van Buuren, S., Eekhout, I., Grantham-McGregor, S. M., Araujo, M. C., Chang, S. M., Fernald, L. C., Hamadani, J. D., Hanlon, C., Karam, S. M., Lozoff, B., Ratsifandrihamanana, L., Richter, L., Black, M. M., Working group members and data contributors, Attanasio, O., Darmstadt, G. L., Doove, B. M., Galasso, E., Jervis, P., Medhin, G., Menezes, A. M., Pitchik, H., Reynolds, S., Schady, N. 2019; 4 (6): e001724


    Introduction: Early childhood development can be described by an underlying latent construct. Global comparisons of children's development are hindered by the lack of a validated metric that is comparable across cultures and contexts, especially for children under age 3years. We constructed and validated a new metric, the Developmental Score (D-score), using existing data from 16 longitudinal studies.Methods: Studies had item-level developmental assessment data for children 0-48 months and longitudinal outcomes at ages >4-18 years, including measures of IQ and receptive vocabulary. Existing data from 11 low-income, middle-income and high-income countries were merged for >36000 children. Item mapping produced 95 'equate groups' of same-skill items across 12 different assessment instruments. A statistical model was built using the Rasch model with item difficulties constrained to be equal in a subset of equate groups, linking instruments to a common scale, the D-score, a continuous metric with interval-scale properties. D-score-for-age z-scores (DAZ) were evaluated for discriminant, concurrent and predictive validity to outcomes in middle childhood to adolescence.Results: Concurrent validity of DAZ with original instruments was strong (average r=0.71), with few exceptions. In approximately 70% of data rounds collected across studies, DAZ discriminated between children above/below cut-points for low birth weight (<2500g) and stunting (-2 SD below median height-for-age). DAZ increased significantly with maternal education in 55% of data rounds. Predictive correlations of DAZ with outcomes obtained 2-16 years later were generally between 0.20 and 0.40. Correlations equalled or exceeded those obtained with original instruments despite using an average of 55% fewer items to estimate the D-score.Conclusion: The D-score metric enables quantitative comparisons of early childhood development across ages and sets the stage for creating simple, low-cost, global-use instruments to facilitate valid cross-national comparisons of early childhood development.

    View details for DOI 10.1136/bmjgh-2019-001724

    View details for PubMedID 31803508

  • 'Our village is dependent on us. That's why we can't leave our work'. Characterizing mechanisms of motivation to perform among Accredited Social Health Activists (ASHA) in Bihar. Health policy and planning Wahid, S. S., Munar, W. n., Das, S. n., Gupta, M. n., Darmstadt, G. L. 2019


    Community health workers (CHWs) play major roles in delivering primary healthcare services, linking communities to the formal health system and addressing the social determinants of health. Available evidence suggests that the performance of CHW programmes in low- and middle-income countries can be influenced by context-dependent causal mechanisms such as motivation to perform. There are gaps regarding what these mechanisms are, and what their contribution is to CHW performance. We used a theory-driven case study to characterize motivational mechanisms among Accredited Social Health Activists (ASHAs) in Bihar, India. Data were collected through semi-structured interviews with CHWs and focus group discussions with beneficiary women. Data were coded using a combined deductive and inductive approach. We found that ASHAs were motivated by a sense of autonomy and self-empowerment; a sense of competence, connection and community service; satisfaction of basic financial needs; social recognition; and feedback and answerability. Findings highlight the potential of ASHAs' intrinsic motivation to increase their commitment to communities and identification with the health system and of programme implementation and management challenges as sources of work dissatisfaction. Efforts to nurture and sustain ASHAs' intrinsic motivation while addressing these challenges are necessary for improving the performance of Bihar's ASHA programme. Further research is needed to characterize the dynamic interactions between ASHAs' motivation, commitment, job satisfaction and overall performance; also, to understand how work motivation is sustained or lost through time. This can inform policy and managerial reforms to improve ASHA programme's performance.

    View details for DOI 10.1093/heapol/czz131

    View details for PubMedID 31670772

  • Global research priorities to accelerate programming to improve early childhood development in the sustainable development era: a CHNRI exercise. Journal of global health Tomlinson, M. n., Darmstadt, G. L., Yousafzai, A. K., Daelmans, B. n., Britto, P. n., Gordon, S. L., Tablante, E. n., Dua, T. n. 2019; 9 (3): 020703


    Approximately 250 million children under the age of five in low and middle-income countries (LMICs) will not achieve their developmental potential due to poverty and stunting alone. Investments in programming to improve early childhood development (ECD) have the potential to disrupt the cycle of poverty and therefore should be prioritised. Support for ECD has increased in recent years. Nevertheless, donors and policies continue to neglect ECD, in part from lack of evidence to guide policy makers and donors about where they should focus policies and programmes. Identification and investment in research is needed to overcome these constraints and in order to achieve high quality implementation of programmes to improve ECD.The Child Health and Nutrition Research Initiative (CHNRI) priority setting methodology was applied in order to assess research priorities for improving ECD. A group of 348 global and local experts in ECD-related research were identified and invited to generate research questions. This resulted in 406 research questions which were categorised and refined by study investigators into 54 research questions across six thematic goals which were evaluated using five criteria: answerability, effectiveness, feasibility, impact, and effect on equity. Research options were ranked by their final research priority score multiplied by 100.The top three research priority options from the LMIC experts came from the third thematic goal of improving the impact of interventions, whereas the top three research priority options from high-income country experts came from different goals: improving the integration of interventions, increasing the understanding of health economics and social protection strategies, and improving the impact of interventions.The results of this process highlight that priorities for future research should focus on the need for services and support to parents to provide nurturing care, and the training of health workers and non-specialists in implementation of interventions to improve ECD. Three of the six thematic goals of the present priority setting centred on interventions (ie, improving impact, implementation of interventions and improving the integration of interventions). In order to achieve higher coverage through sustainable interventions to improve ECD with equitable reach, interventions should be integrated and not be sector driven.

    View details for DOI 10.7189/jogh.09.020703

    View details for PubMedID 31673352

    View details for PubMedCentralID PMC6815874

  • Effects of team-based goals and non-monetary incentives on front-line health worker performance and maternal health behaviours: a cluster randomised controlled trial in Bihar, India. BMJ global health Carmichael, S. L., Mehta, K., Raheel, H., Srikantiah, S., Chaudhuri, I., Trehan, S., Mohanty, S., Borkum, E., Mahapatra, T., Weng, Y., Kaimal, R., Sivasankaran, A., Sridharan, S., Rotz, D., Tarigopula, U. K., Bhattacharya, D., Atmavilas, Y., Munar, W., Rangarajan, A., Darmstadt, G. L., Ananya Study Group, Atmavilas, Y., Bhattacharya, D., Borkum, E., Carmichael, S. L., Chaudhuri, I., Creanga, A., Darmstadt, G. L., Dutt, P., Irani, L., Kaimal, R., Mahapatra, T., Mehta, K. M., Mitra, R., Munar, W., Pepper, K., Raheel, H., Rangarajan, A., Saggurti, N., Sastry, P., Schooley, J., Shah, H., Srikantiah, S., Kiran Tarigopula, U., Ward, V., Weng, Y., Wahid, S., Wilhelm, J. 2019; 4 (4): e001146


    Introduction: We evaluated the impact of a 'Team-Based Goals and Incentives' (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition.Methods: This study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention's team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year.Results: The TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid (IFA) tablets (7 PP, p=0.02), but non-significant changes in other health behaviours related to the trial's goals. Improvements were seen in selected attitudes related to coordination and teamwork among FLWs, and in the provision of advice to beneficiaries (ranging from 8 to 14 PP) related to IFA, cord care, breast feeding, complementary feeding and family planning.Conclusion: Results suggest that combining an integrated set of team-based coverage goals and targets, small non-cash incentives for teams who meet targets and team building to motivate FLWs resulted in improvements in FLW coordination and teamwork, and in the quality and quantity of FLW-beneficiary interactions. These improvements represent programmatically meaningful steps towards improving health behaviours and outcomes.Trial registration number: NCT03406221.

    View details for DOI 10.1136/bmjgh-2018-001146

    View details for PubMedID 31543982

  • Gender norms and health: insights from global survey data. Lancet (London, England) Weber, A. M., Cislaghi, B. n., Meausoone, V. n., Abdalla, S. n., Mejía-Guevara, I. n., Loftus, P. n., Hallgren, E. n., Seff, I. n., Stark, L. n., Victora, C. G., Buffarini, R. n., Barros, A. J., Domingue, B. W., Bhushan, D. n., Gupta, R. n., Nagata, J. M., Shakya, H. B., Richter, L. M., Norris, S. A., Ngo, T. D., Chae, S. n., Haberland, N. n., McCarthy, K. n., Cullen, M. R., Darmstadt, G. L. 2019


    Despite global commitments to achieving gender equality and improving health and wellbeing for all, quantitative data and methods to precisely estimate the effect of gender norms on health inequities are underdeveloped. Nonetheless, existing global, national, and subnational data provide some key opportunities for testing associations between gender norms and health. Using innovative approaches to analysing proxies for gender norms, we generated evidence that gender norms impact the health of women and men across life stages, health sectors, and world regions. Six case studies showed that: (1) gender norms are complex and can intersect with other social factors to impact health over the life course; (2) early gender-normative influences by parents and peers can have multiple and differing health consequences for girls and boys; (3) non-conformity with, and transgression of, gender norms can be harmful to health, particularly when they trigger negative sanctions; and (4) the impact of gender norms on health can be context-specific, demanding care when designing effective gender-transformative health policies and programmes. Limitations of survey-based data are described that resulted in missed opportunities for investigating certain populations and domains. Recommendations for optimising and advancing research on the health impacts of gender norms are made.

    View details for DOI 10.1016/S0140-6736(19)30765-2

    View details for PubMedID 31155273

  • Invasive Pneumococcal Infections in Children with Nephrotic Syndrome in Bangladesh. The Pediatric infectious disease journal Malaker, R. n., Saha, S. n., Hanif, M. n., Ahmed, A. n., Saha, S. n., Hasanuzzaman, M. n., Khondakar, T. n., Islam, M. n., Baqui, A. H., Santosham, M. n., Darmstadt, G. L., Whitney, C. G., Saha, S. K. 2019


    Children with nephrotic syndrome are susceptible to invasive bacterial infections. In this study, we aimed to: (1) determine the pathogens associated with infections in children with nephrotic syndrome and (2) describe antimicrobial susceptibility and serotype distribution of Streptococcus pneumoniae to guide evidence-based treatment and prevention policies.From June 2013 to March 2015, we collected blood and/or ascitic fluid from children hospitalized with nephrotic syndrome and suspected bacterial disease in the largest pediatric hospital of Bangladesh. We cultured all samples and performed polymerase chain reaction (PCR) and immunochromatographic test on ascitic fluid for detection of S. pneumoniae. Pneumococcal isolates were tested for antibiotic susceptibility using disc diffusion and serotyped using Quellung reaction and PCR.We identified 1342 children hospitalized with nephrotic syndrome. Among them, 608 children had suspected bacterial disease from whom blood and/or ascitic fluid were collected. A pathogen was identified in 8% (48/608) of cases, 94% (45/48) of which were S. pneumoniae. Most (73%, 33/45) pneumococcal infections were identified through culture of blood and ascitic fluid and 27% (12/45) through immunochromatographic test and PCR of ascitic fluid. In total, 24 different pneumococcal serotypes were detected; 51% are covered by PCV10 (+6A), 53% by PCV13 and 60% by PPSV23. All pneumococcal isolates were susceptible to penicillin.Because S. pneumoniae was the primary cause of invasive infections, pneumococcal vaccines may be considered as a preventive intervention in children with nephrotic syndrome. Additionally, penicillin can be used to prevent and treat pneumococcal infections in children with nephrotic syndrome in Bangladesh.

    View details for DOI 10.1097/INF.0000000000002386

    View details for PubMedID 31220048

  • Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms. Lancet (London, England) Heymann, J. n., Levy, J. K., Bose, B. n., Ríos-Salas, V. n., Mekonen, Y. n., Swaminathan, H. n., Omidakhsh, N. n., Gadoth, A. n., Huh, K. n., Greene, M. E., Darmstadt, G. L. 2019


    Evidence that gender inequalities and restrictive norms adversely affect health is extensive; however, far less research has focused on testing solutions. We first comprehensively reviewed the peer-reviewed and grey literature for rigorously evaluated programmes that aimed to reduce gender inequality and restrictive gender norms and improve health. We identified four mutually reinforcing factors underpinning change: (1) multisectoral action, (2) multilevel, multistakeholder involvement, (3) diversified programming, and (4) social participation and empowerment. Following this review, because little research has investigated the effects of national-level law and policy reforms, we conducted original quasi-experimental studies on laws and policies related to education, work, and income, all social determinants of health in which deep gender inequalities exist. We examined whether the laws and policies significantly affected health outcomes and gender norms, and whether law-induced and policy-induced changes in gender norms mediated the health effects, in areas for which longitudinal data existed. Laws and policies that made primary education tuition-free (13 intervention countries with the law and/or policy and ten control countries without) and that provided paid maternity and parental leave (seven intervention and 15 control countries) significantly improved women's and their children's health (odds ratios [OR] of 1·16-2·10, depending on health outcome) and gender equality in household decision making (OR 1·46 for tuition-free and 1·45 for paid maternity and parental leave) as a proxy indicator of gender norms. Increased equality partially mediated the positive effects on health outcomes. We conclude by discussing examples of how improved governance can support gender-equitable laws, policies, and programmes, immediate next steps, and future research needs.

    View details for DOI 10.1016/S0140-6736(19)30656-7

    View details for PubMedID 31155271

  • Adolescent gender norms and adult health outcomes in the USA: a prospective cohort study. The Lancet. Child & adolescent health Shakya, H. B., Domingue, B. n., Nagata, J. M., Cislaghi, B. n., Weber, A. n., Darmstadt, G. L. 2019


    Previous research has documented differences in health behaviours between men and women, with differential risks and health outcomes between the sexes. Although some sex-specific differences in health outcomes are caused by biological factors, many others are socially driven through gender norms. We therefore aimed to assess whether gender expression as an adolescent, determined by the degree to which an individual's behvaiours were typical of their gender, were associated with health behaviours and outcomes in adulthood.In this prospective cohort study, we used data from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative sample of US adolescents from whom data were collected during adolescence (ages 11-18 years) and adulthood (ages 24-32 years). We created a measure of gender expression that was based on the degree to which male and female adolescents and adults behave in stereotypically masculine (for men) or feminine (for women) ways relative to their same-gender peers. Adolescents were assessed for baseline sociodemographic characteristics and gender expression, and these participants were later assessed, during adulthood, for their gender expression and health behaviours and outcomes, which included depression, self-rated health, drug and alcohol use, cardiovascular risk factors, experience of sexual violence, diet, and obesity. These data were collected via surveys, except for body-mass index, cholesterol, and blood pressure, which were collected as biomarkers.Between April and December, 1995, self-reported data were collected from 10 480 female and 10 263 male adolescents; similar data were subsequently collected in several waves in this cohort, with a final collection between January, 2008, and February, 2009, when participants were aged 24-32 years. We used data from this final wave and from baseline, and our study represents a secondary analysis of these data. Of these participants, complete follow-up data from 6721 (80%) adult women and 5885 (80%) adult men were available. Gender expression was stable for men and women from adolescence to adulthood. High masculinity (vs low masculinity) in adolescent and adult men was positively associated with smoking in the past month, use of marijuana and recreational drugs, prescription drug misuse (adult gender expression only), and consumption of fast food and soda (adolescent gender expression only) in the past week. However, higher masculine gender expression in adult men was negatively associated with diagnosed depression and high cholesterol in adulthood, and masculine gender expression in adolescent and adult men was negatively associated with high blood pressure in adults. High femininity (vs low femininity) in adolescent or adult women was positively associated with high cholesterol and blood pressure (both adult gender expression only), depression, migraines (adult gender expression only), and physical limitations (ie, health problems that limited their daily activities). However, higher femininity in adolescence was negatively associated with self-rated good health in adulthood. Although feminine gender expression in adolescents was predictive of adult recreational and prescription drug and marijuana use and experience of sexual violence, feminine gender expression in adulthood was negatively associated with adult substance use and experience of sexual violence, suggesting that expressions of femininity typical of adolescents impart risks that expression of femininity as an adult does not. Individuals who are highly masculine or feminine seem to be at greatest risk of adverse health outcomes and behaviours.We found compelling evidence that adolescent gender expression is correlated with health in adulthood independently of gender expression as an adult. Although more research is needed to identify causal mechanisms, our results suggest that those designing health behaviour interventions should carefully consider integrating gender transformative components into interventions.Eunice Kennedy Shriver National Institute of Child Health and Human Development, Gender Equality, Integrated Delivery, HIV, Nutrition, Family Planning, and Water Sanitation and Hygiene Program Strategy Teams (Bill and Melinda Gates Foundation).

    View details for DOI 10.1016/S2352-4642(19)30160-9

    View details for PubMedID 31155319

  • Detecting Developmental Delay and Autism Through Machine Learning Models Using Home Videos of Bangladeshi Children: Development and Validation Study. Journal of medical Internet research Tariq, Q. n., Fleming, S. L., Schwartz, J. N., Dunlap, K. n., Corbin, C. n., Washington, P. n., Kalantarian, H. n., Khan, N. Z., Darmstadt, G. L., Wall, D. P. 2019; 21 (4): e13822


    Autism spectrum disorder (ASD) is currently diagnosed using qualitative methods that measure between 20-100 behaviors, can span multiple appointments with trained clinicians, and take several hours to complete. In our previous work, we demonstrated the efficacy of machine learning classifiers to accelerate the process by collecting home videos of US-based children, identifying a reduced subset of behavioral features that are scored by untrained raters using a machine learning classifier to determine children's "risk scores" for autism. We achieved an accuracy of 92% (95% CI 88%-97%) on US videos using a classifier built on five features.Using videos of Bangladeshi children collected from Dhaka Shishu Children's Hospital, we aim to scale our pipeline to another culture and other developmental delays, including speech and language conditions.Although our previously published and validated pipeline and set of classifiers perform reasonably well on Bangladeshi videos (75% accuracy, 95% CI 71%-78%), this work improves on that accuracy through the development and application of a powerful new technique for adaptive aggregation of crowdsourced labels. We enhance both the utility and performance of our model by building two classification layers: The first layer distinguishes between typical and atypical behavior, and the second layer distinguishes between ASD and non-ASD. In each of the layers, we use a unique rater weighting scheme to aggregate classification scores from different raters based on their expertise. We also determine Shapley values for the most important features in the classifier to understand how the classifiers' process aligns with clinical intuition.Using these techniques, we achieved an accuracy (area under the curve [AUC]) of 76% (SD 3%) and sensitivity of 76% (SD 4%) for identifying atypical children from among developmentally delayed children, and an accuracy (AUC) of 85% (SD 5%) and sensitivity of 76% (SD 6%) for identifying children with ASD from those predicted to have other developmental delays.These results show promise for using a mobile video-based and machine learning-directed approach for early and remote detection of autism in Bangladeshi children. This strategy could provide important resources for developmental health in developing countries with few clinical resources for diagnosis, helping children get access to care at an early age. Future research aimed at extending the application of this approach to identify a range of other conditions and determine the population-level burden of developmental disabilities and impairments will be of high value.

    View details for PubMedID 31017583

  • Disrupting gender norms in health systems: making the case for change. Lancet (London, England) Hay, K. n., McDougal, L. n., Percival, V. n., Henry, S. n., Klugman, J. n., Wurie, H. n., Raven, J. n., Shabalala, F. n., Fielding-Miller, R. n., Dey, A. n., Dehingia, N. n., Morgan, R. n., Atmavilas, Y. n., Saggurti, N. n., Yore, J. n., Blokhina, E. n., Huque, R. n., Barasa, E. n., Bhan, N. n., Kharel, C. n., Silverman, J. G., Raj, A. n. 2019


    Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

    View details for DOI 10.1016/S0140-6736(19)30648-8

    View details for PubMedID 31155270

  • Why now for a Series on gender equality, norms, and health? Lancet (London, England) Darmstadt, G. L., Heise, L. n., Gupta, G. R., Henry, S. n., Cislaghi, B. n., Greene, M. E., Hawkes, S. n., Hay, K. n., Heymann, J. n., Klugman, J. n., Levy, J. K., Raj, A. n., Weber, A. M. 2019

    View details for DOI 10.1016/S0140-6736(19)30985-7

    View details for PubMedID 31155268

  • Gender equality and gender norms: framing the opportunities for health. Lancet (London, England) Gupta, G. R., Oomman, N. n., Grown, C. n., Conn, K. n., Hawkes, S. n., Shawar, Y. R., Shiffman, J. n., Buse, K. n., Mehra, R. n., Bah, C. A., Heise, L. n., Greene, M. E., Weber, A. M., Heymann, J. n., Hay, K. n., Raj, A. n., Henry, S. n., Klugman, J. n., Darmstadt, G. L. 2019


    The Sustainable Development Goals offer the global health community a strategic opportunity to promote human rights, advance gender equality, and achieve health for all. The inability of the health sector to accelerate progress on a range of health outcomes brings into sharp focus the substantial impact of gender inequalities and restrictive gender norms on health risks and behaviours. In this paper, the fifth in a Series on gender equality, norms, and health, we draw on evidence to dispel three myths on gender and health and describe persistent barriers to progress. We propose an agenda for action to reduce gender inequality and shift gender norms for improved health outcomes, calling on leaders in national governments, global health institutions, civil society organisations, academic settings, and the corporate sector to focus on health outcomes and engage actors across sectors to achieve them; reform the workplace and workforce to be more gender-equitable; fill gaps in data and eliminate gender bias in research; fund civil-society actors and social movements; and strengthen accountability mechanisms.

    View details for DOI 10.1016/S0140-6736(19)30651-8

    View details for PubMedID 31155276

  • Achieving Gender and Social Equality: More Than Gender Parity is Needed. Academic medicine : journal of the Association of American Medical Colleges Raj, A. n., Kumra, T. n., Darmstadt, G. L., Freund, K. M. 2019


    In this Perspective, the authors review Association of American Medical Colleges data on gender parity and intersectionality, consider the literature on gender parity in academic medicine and the underlying gender norms that explain these statistics, and offer recommendations for moving past indicators of parity to achieve gender and social equality.Improvements in gender parity among medical school graduates have not translated to gender parity among practicing physicians or medical school faculty, particularly for racial/ethnic minorities. Further, gender parity does not correspond to gender equality, such that gender-based disparities in salaries and advancement persist. In addition, social norms related to traditional gender role expectations reinforce existing biases and lead to sexual harassment and the discrimination of women in the workplace.Building on their analysis of existing data and the literature, the authors offer concrete recommendations to achieve gender equality in academic medicine that not only improve parity but also support policies and practices to address the norms that further bias and discrimination. These recommendations include the collection, monitoring, and open reporting of data on salaries as well as on sex and race/ethnicity; stronger policies related to family leave and sexual discrimination and harassment; and accountability structures to ensure that policies are enforced. While these efforts alone cannot eliminate gender inequalities, academic medicine should be at the forefront of creating a climate in medicine that is supportive of gender equality as part of their larger goal of promoting social equality.

    View details for DOI 10.1097/ACM.0000000000002877

    View details for PubMedID 31335818

  • Characteristics of successful programmes targeting gender inequality and restrictive gender norms for the health and wellbeing of children, adolescents, and young adults: a systematic review. The Lancet. Global health Levy, J. K., Darmstadt, G. L., Ashby, C. n., Quandt, M. n., Halsey, E. n., Nagar, A. n., Greene, M. E. 2019


    In the context of the Sustainable Development Goals and the shifting global burden of disease, this systematic review analyses the evidence from rigorously evaluated programmes that seek to transform the gendered social norms undermining the health and wellbeing of children, adolescents, and young adults. The aim of this study was threefold: to describe the landscape of gender-transformative programmes that attempt to influence health-related outcomes; to identify mechanisms through which successful programmes work; and to highlight where gaps might exist in implementation and evaluation.We systematically reviewed rigorous evaluations published between Jan 1, 2000, and Nov 1, 2018 of programmes that sought to decrease gender inequalities and transform restrictive gender norms to improve the health and wellbeing of 0-24 year olds. We included rigorously evaluated health programmes that met the Interagency Gender Working Group definition of gender-transformative programming, regardless of where in the world they were implemented and what area of health they focused on.Among 22 993 articles identified by our search, 61 evaluations of 59 programmes met review criteria. Programmes were concentrated in sub-Saharan Africa (25 [42%]), south Asia (13 [22%]), and North America (13 [22%]) and mainly measured health indicators related to reproductive health (29 [48%]), violence (26 [43%]), or HIV (18 [30%]). Programmes most frequently focused on improving the individual power of the beneficiaries, rather than working on broader systems of inequality. 45 (74%) of the evaluations measured significant improvements in health-related and gender-related indicators; however, only ten (16%) showed evidence of, or potential for, broader norm change. These ten programmes worked with sectors beyond health, included multiple stakeholders, implemented diversified strategies, and fostered critical awareness and participation among affected community members.This review can accelerate efforts to improve global health by leading to more strategic investment in programmes that promote gender equality and target restrictive gender norms among young people. Such programmes can lead to a lifetime of improved health and wellbeing by challenging not only attitudes and behaviours related to gender at an early age, but also the gendered systems that surround them.Bill & Melinda Gates Foundation.

    View details for DOI 10.1016/S2214-109X(19)30495-4

    View details for PubMedID 31879212

  • Multiomics modeling of the immunome, transcriptome, microbiome, proteome and metabolome adaptations during human pregnancy BIOINFORMATICS Ghaemi, M., DiGiulio, D. B., Contrepois, K., Callahan, B., Ngo, T. M., Lee-McMullen, B., Lehallier, B., Robaczewska, A., Mcilwain, D., Rosenberg-Hasson, Y., Wong, R. J., Quaintance, C., Culos, A., Stanley, N., Tanada, A., Tsai, A., Gaudilliere, D., Ganio, E., Han, X., Ando, K., McNeil, L., Tingle, M., Wise, P., Maric, I., Sirota, M., Wyss-Coray, T., Winn, V. D., Druzin, M. L., Gibbs, R., Darmstadt, G. L., Lewis, D. B., Nia, V., Agard, B., Tibshirani, R., Nolan, G., Snyder, M. P., Relman, D. A., Quake, S. R., Shaw, G. M., Stevenson, D. K., Angst, M. S., Gaudilliere, B., Aghaeepour, N. 2019; 35 (1): 95–103
  • Multiomics modeling of the immunome, transcriptome, microbiome, proteome and metabolome adaptations during human pregnancy. Bioinformatics (Oxford, England) Ghaemi, M. S., DiGiulio, D. B., Contrepois, K., Callahan, B., Ngo, T. T., Lee-McMullen, B., Lehallier, B., Robaczewska, A., Mcilwain, D., Rosenberg-Hasson, Y., Wong, R. J., Quaintance, C., Culos, A., Stanley, N., Tanada, A., Tsai, A., Gaudilliere, D., Ganio, E., Han, X., Ando, K., McNeil, L., Tingle, M., Wise, P., Maric, I., Sirota, M., Wyss-Coray, T., Winn, V. D., Druzin, M. L., Gibbs, R., Darmstadt, G. L., Lewis, D. B., Partovi Nia, V., Agard, B., Tibshirani, R., Nolan, G., Snyder, M. P., Relman, D. A., Quake, S. R., Shaw, G. M., Stevenson, D. K., Angst, M. S., Gaudilliere, B., Aghaeepour, N. 2019; 35 (1): 95–103


    Motivation: Multiple biological clocks govern a healthy pregnancy. These biological mechanisms produce immunologic, metabolomic, proteomic, genomic and microbiomic adaptations during the course of pregnancy. Modeling the chronology of these adaptations during full-term pregnancy provides the frameworks for future studies examining deviations implicated in pregnancy-related pathologies including preterm birth and preeclampsia.Results: We performed a multiomics analysis of 51 samples from 17 pregnant women, delivering at term. The datasets included measurements from the immunome, transcriptome, microbiome, proteome and metabolome of samples obtained simultaneously from the same patients. Multivariate predictive modeling using the Elastic Net (EN) algorithm was used to measure the ability of each dataset to predict gestational age. Using stacked generalization, these datasets were combined into a single model. This model not only significantly increased predictive power by combining all datasets, but also revealed novel interactions between different biological modalities. Future work includes expansion of the cohort to preterm-enriched populations and in vivo analysis of immune-modulating interventions based on the mechanisms identified.Availability and implementation: Datasets and scripts for reproduction of results are available through: information: Supplementary data are available at Bioinformatics online.

    View details for PubMedID 30561547

  • Understanding health disparities. Journal of perinatology : official journal of the California Perinatal Association Stevenson, D. K., Wong, R. J., Aghaeepour, N., Angst, M. S., Darmstadt, G. L., DiGiulio, D. B., Druzin, M. L., Gaudilliere, B., Gibbs, R. S., B Gould, J., Katz, M., Li, J., Moufarrej, M. N., Quaintance, C. C., Quake, S. R., Relman, D. A., Shaw, G. M., Snyder, M. P., Wang, X., Wise, P. H. 2018


    Based upon our recent insights into the determinants of preterm birth, which is the leading cause of death in children under five years of age worldwide, we describe potential analytic frameworks that provides both a common understanding and, ultimately the basis for effective, ameliorative action. Our research on preterm birth serves as an example that the framing of any human health condition is a result of complex interactions between the genome and the exposome. New discoveries of the basic biology of pregnancy, such as the complex immunological and signaling processes that dictate the health and length of gestation, have revealed a complexity in the interactions (current and ancestral) between genetic and environmental forces. Understanding of these relationships may help reduce disparities in preterm birth and guide productive research endeavors and ultimately, effective clinical and public health interventions.

    View details for PubMedID 30560947

  • Application of machine-learning to predict early spontaneous preterm birth among nulliparous non-Hispanic black and white women. Annals of epidemiology Weber, A., Darmstadt, G. L., Gruber, S., Foeller, M. E., Carmichael, S. L., Stevenson, D. K., Shaw, G. M. 2018


    PURPOSE: Spontaneous preterm birth is a leading cause of perinatal mortality in the United States, occurring disproportionately among non-Hispanic black women compared to other race-ethnicities. Clinicians lack tools to identify first-time mothers at risk for spontaneous preterm birth. This study assessed prediction of early (<32weeks) spontaneous preterm birth among non-Hispanic black and white women by applying state-of-the-art machine-learning to multilevel data from a large birth cohort.METHODS: Data from birth certificate and hospital discharge records for 336,214 singleton births to nulliparous women in California from 2007 to 2011 were used in cross-validated regressions, with multiple imputation for missing covariate data. Residential census tract information was overlaid for 281,733 births. Prediction was assessed with areas under the receiver operator characteristic curves (AUCs).RESULTS: Cross-validated AUCs were low (0.62 [min=0.60, max=0.63] for non-Hispanic blacks and 0.63 [min=0.61, max=0.65] for non-Hispanic whites). Combining racial-ethnic groups improved prediction (cross-validated AUC=0.67 [min=0.65, max=0.68]), approaching what others have achieved using biomarkers. Census tract-level information did not improve prediction.CONCLUSIONS: The resolution of administrative data was inadequate to precisely predict individual risk for early spontaneous preterm birth despite the use of advanced statistical methods.

    View details for PubMedID 30236415

  • Epidemiology of Otitis Media With Otorrhea Among Bangladeshi Children: Baseline Study for Future Assessment of Pneumococcal Conjugate Vaccine Impact PEDIATRIC INFECTIOUS DISEASE JOURNAL Naziat, H., Saha, S., Islam, M., Saha, S., Uddin, M. J., Hussain, M., Luby, S. P., Darmstadt, G. L., Whitney, C. G., Gessner, B. D., Saha, S. K. 2018; 37 (7): 715–21


    Otitis media (OM) poses a high disease burden on Bangladeshi children, but little is known about its etiologies. We conducted a surveillance study in the largest pediatric hospital to characterize pathogens responsible for OM.In the outpatient ear-nose-throat department of Dhaka Shishu Hospital, which serves 0 to 18-year-old children, we collected ear swabs from OM children with otorrhea from April 2014 to March 2015. We cultured all specimens for bacterial pathogens and assessed serotype and antimicrobial susceptibility of Streptococcus pneumoniae (Spn) and Haemophilus influenzae (Hi) isolates.We recorded 1111 OM episodes; 88% (981/1111) involved otorrhea, and we collected samples from 91% (891/981) of these children. Fifty-one percent (452/891) were culture positive (contaminants excluded), with Hi (21%, 187/891) and Spn (18%, 164/891) most commonly detected. Overall, 45 distinct single and mixed pathogens were revealed. Dominant pneumococcal serotypes were 19A, 19F, 3 and 14; 98% of Hi isolates were nontypeable. Pneumococcal conjugate vaccine (PCV)10 and PCV10 + 6A serotypes accounted for 8% and 9% of all OM and 46% and 49% of pneumococcus-positive cases, respectively, and were more likely to be nonsusceptible to at least 1 antibiotic (erythromycin and/or trimethoprim-sulfamethoxazole) than nonvaccine serotypes (91% vs. 77%). Staphylococcus aureus (9%, 83/891) and Pseudomonas aeruginosa (4%, 38/891) were also found.Nontypeable Hi (NTHi) and Spn are predominant causes of OM in Bangladesh. PCV10, introduced in March 2015, is likely to reduce pneumococcal and overall OM burden. Data collected post-PCV10 will provide comprehensive insight into the effects of this vaccine on these pathogens.

    View details for PubMedID 29634626

  • Reducing early infant mortality in India: results of a prospective cohort of pregnant women using emergency medical services BMJ OPEN Bills, C. B., Newberry, J. A., Darmstadt, G., Pirrotta, E. A., Rao, G., Mahadevan, S. V., Strehlow, M. C. 2018; 8 (4): e019937


    To describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India.Prospective observational study.Five Indian states using a centralised emergency medical services (EMS) agency that transported 3.1 million pregnant women in 2014.Over 6 weeks in 2014, this study followed a convenience sample of 1431 neonates born to women using a public-private ambulance service for a 'pregnancy-related' problem. Initial calls were deemed 'pregnancy related' if categorised by EMS dispatchers as 'pregnancy', 'childbirth', 'miscarriage' or 'labour pains'. Interfacility transfers, patients absent on ambulance arrival, refusal of care and neonates born to women beyond 7 days of using the service were excluded.death at 2, 7 and 42 days after delivery.Among 1684 women, 1411 gave birth to 1431 newborns within 7 days of initial ambulance transport. Median maternal age at delivery was 23 years (IQR 21-25). Most mothers were from rural/tribal areas (92.5%) and lower social (79.9%) and economic status (69.9%). Follow-up rates at 2, 7 and 42 days were 99.8%, 99.3% and 94.1%, respectively. Cumulative mortality rates at 2, 7 and 42 days follow-up were 43, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth (OR 2.89, 95% CI 1.67 to 5.00), twin deliveries (OR 2.80, 95% CI 1.10 to 7.15) and caesarean section (OR 2.21, 95% CI 1.15 to 4.23) were the strongest predictors of mortality.The perinatal mortality rate associated with this cohort of patients with high-acuity conditions of pregnancy was nearly two times the most recent rate for India as a whole (28 per 1000 births). EMS data have the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare and increase facility-based care through service of marginalised populations.

    View details for PubMedID 29654018

  • A Gender Lens on the Health and Well-being of Young Males JOURNAL OF ADOLESCENT HEALTH Patton, G. C., Darmstadt, G. L., Petroni, S., Sawyer, S. M. 2018; 62 (3): S6–S8

    View details for PubMedID 29455720

  • A genome-wide association study identifies only two ancestry specific variants associated with spontaneous preterm birth SCIENTIFIC REPORTS Rappoport, N., Toung, J., Hadley, D., Wong, R. J., Fujioka, K., Reuter, J., Abbott, C. W., Oh, S., Hu, D., Eng, C., Huntsman, S., Bodian, D. L., Niederhuber, J. E., Hong, X., Zhang, G., Sikora-Wohfeld, W., Gignoux, C. R., Wang, H., Oehlert, J., Jelliffe-Pawlowski, L. L., Gould, J. B., Darmstadt, G. L., Wang, X., Bustamante, C. D., Snyder, M. P., Ziv, E., Patsopoulos, N. A., Muglia, L. J., Burchard, E., Shaw, G. M., O'Brodovich, H. M., Stevenson, D. K., Butte, A. J., Sirota, M. 2018; 8: 226


    Preterm birth (PTB), or the delivery prior to 37 weeks of gestation, is a significant cause of infant morbidity and mortality. Although twin studies estimate that maternal genetic contributions account for approximately 30% of the incidence of PTB, and other studies reported fetal gene polymorphism association, to date no consistent associations have been identified. In this study, we performed the largest reported genome-wide association study analysis on 1,349 cases of PTB and 12,595 ancestry-matched controls from the focusing on genomic fetal signals. We tested over 2 million single nucleotide polymorphisms (SNPs) for associations with PTB across five subpopulations: African (AFR), the Americas (AMR), European, South Asian, and East Asian. We identified only two intergenic loci associated with PTB at a genome-wide level of significance: rs17591250 (P = 4.55E-09) on chromosome 1 in the AFR population and rs1979081 (P = 3.72E-08) on chromosome 8 in the AMR group. We have queried several existing replication cohorts and found no support of these associations. We conclude that the fetal genetic contribution to PTB is unlikely due to single common genetic variant, but could be explained by interactions of multiple common variants, or of rare variants affected by environmental influences, all not detectable using a GWAS alone.

    View details for PubMedID 29317701

  • Scaling up child development centres in Bangladesh CHILD CARE HEALTH AND DEVELOPMENT Khan, N. Z., Sultana, R., Ahmed, F., Shilpi, A. B., Sultana, N., Darmstadt, G. L. 2018; 44 (1): 19–30

    View details for DOI 10.1111/cch.12530

    View details for Web of Science ID 000417933500004

  • Scaling up early childhood development programmes in low and middle-income countries. Child: care, health and development Darmstadt, G. L., Khan, N. Z., Lombardi, J., Richter, L. M. 2018; 44 (1): 1-3

    View details for DOI 10.1111/cch.12441

    View details for PubMedID 29235168

  • Scaling up child development centres in Bangladesh. Child: care, health and development Khan, N. Z., Sultana, R., Ahmed, F., Shilpi, A. B., Sultana, N., Darmstadt, G. L. 2018; 44 (1): 19-30


    Child Development Centres (CDCs) have been established within government medical college tertiary hospitals across Bangladesh. Services entail a parent-professional partnership in a child and family friendly environment with a focus on assessment, diagnosis, and management of a range of neurodevelopmental disorders in children and adolescents 0-16 years of age. Services are provided by a multidisciplinary team of professionals (child health physician, child psychologist, and developmental therapist) who emphasize quality of services over the numbers of children seen.In 2008, Dhaka Shishu (Children's) Hospital was given the mandate by the government to conceptualize, train, and monitor CDCs nationwide. Here, we describe the rationale and processes for the establishment of the national network of CDCs and discuss lessons learned on scaling up early childhood development services in a low resource setting.Fifteen CDCs were established in major government hospitals across Bangladesh and have recorded 208,866 patient visits. The majority (79%) of children were from the lowest and middle-income families, and about one third (30%) were < 2 years of age at first presentation. Two thirds of children seen in follow-up demonstrated improvements in functional skills since their first visit, 77% in their adaptive behaviour (i.e., activities of daily living) and 70% in cognitive functions.CDCs are expanding coverage for child neurodevelopment services across Bangladesh through a tiered system of home-based screening, community- and clinic-based functional assessment, and CDC-based diagnosis, support, and referral. Vulnerable populations-the lowest income groups and younger children-comprised the majority of patients, among whom there is high unmet need for psychological services that is being met for the first time. Innovative human resource development, including a 3-month training for the multidisciplinary teams, enabled wide coverage for assessment and diagnosis of a range of neurodevelopmental problems. Demand for services is growing, especially among non-government and private hospitals.

    View details for DOI 10.1111/cch.12530

    View details for PubMedID 29235172

  • Scaling up early childhood development programmes in low and middle-income countries CHILD CARE HEALTH AND DEVELOPMENT Darmstadt, G. L., Khan, N. Z., Lombardi, J., Richter, L. M. 2018; 44 (1): 1–3

    View details for DOI 10.1111/cch.12441

    View details for Web of Science ID 000417933500001

  • Gender disparities in child development in the east Asia-Pacific region: a cross-sectional, population-based, multicountry observational study. The Lancet. Child & adolescent health Weber, A., Darmstadt, G. L., Rao, N. 2017; 1 (3): 213-224


    Gender differences in child development have been extensively studied in high-income countries, but few data are available from low-income and middle-income countries. Our objective was to assess gender disparities in child development that might arise from differential investment in child health, nutrition, and education in six countries across the east Asia-Pacific region.In this cross-sectional, population-based study we quantified the magnitude of gender differences in child development using the East Asia-Pacific Early Child Development Scales (EAP-ECDS) in six countries (Cambodia, China, Mongolia, Papua New Guinea, Timor-Leste, and Vanuatu). We used stratified random sampling (according to age, residence [urban vs rural], and sex) in all countries to recruit eligible children aged 3-5 years from non-ethnic minority populations with no identified or suspected special educational needs for whom EAP-ECDS scores for five or more of seven domains and urban-rural residence information were available. Gender differences in development associated with four national indicators of gender equality (sex ratio at birth, Gender Development Index, Gender Inequality Index, and Gender Parity Index for primary school enrolment) were also examined. We used generalised estimating equation regression to study moderation of differences by family socioeconomic status and wealth, and structural equation models with maximum likelihood to test mediation through health, nutrition, and education.Between June 1, 2013, and Dec 13, 2013, 7582 eligible children were included from Cambodia (n=1189), China (n=1618), Mongolia (n=1230), Papua New Guinea (n=1639), Timor-Leste (n=1176), and Vanuatu (n=730). Girls had significantly higher development scores than boys in Cambodia (difference in composite score: β=1·87 points, 95% CI 0·29 to 3·45; p=0·747), China (2·66 points, 1·20 to 4·13; p=0·0004), Vanuatu (3·10 points, 1·65 to 4·55; p<0·0001), and Mongolia (3·94 points, 2·67 to 5·21; p<0·0001), but not Papua New Guinea (-0·43 points, -1·19 to 0·33; p=0·272) or Timor-Leste (0·09 points, -0·96 to 1·14; p=0·861). Differences in favour of girls were the largest for language skills in Mongolia (5·30 points, 95% CI 4·45 to 6·15); differences in language skills were smallest in the two poorest countries, Timor-Leste (-0·07 points, -1·03 to 0·88) and Papua New Guinea (0·05 points, -1·02 to 1·12). Greater differences in composite scores for girls compared with boys-in favour of girls-were associated with higher national Gender Development Index values (R2=0·790). In Mongolia, smaller gender differences in development were associated with increased household wealth (6·07 points [95% CI 3·22 to 8·92] in the lowest wealth quartile vs 2·27 points [1·38 to 3·15] in the highest wealth quartile), whereas in Timor-Leste, girls only outperformed boys when living in households with higher socioeconomic status (2·87 points [0·27 to 5·47] in the highest wealth quartile and 3·74 points [2·17 to 5·31] in the highest quartile of parental socioeconomic status). Mediating pathways explained up to 37% (in Vanuatu) of the association between gender and development, controlling for family socioeconomic status.Girls aged 3-5 years generally outperformed boys on tests of development, and increasing levels of gender equality across six countries in the east Asia-Pacific region were associated with improved performance of young girls relative to boys. Greater opportunities for economic development are anticipated to result from improvements in gender equality and in the development of girls. Further study is warranted to understand family-level processes and societal norms that lead to gender differences in child development in the early years.UNICEF, the Asia-Pacific Regional Network for Early Childhood, and the Open Society Foundations.

    View details for DOI 10.1016/S2352-4642(17)30073-1

    View details for PubMedID 30169170

  • Global services and support for children with developmental delays and disabilities: Bridging research and policy gaps. PLoS medicine Collins, P. Y., Pringle, B., Alexander, C., Darmstadt, G. L., Heymann, J., Huebner, G., Kutlesic, V., Polk, C., Sherr, L., Shih, A., Sretenov, D., Zindel, M. 2017; 14 (9): e1002393


    Pamela Collins and colleagues explain the research and policy approaches needed globally to ensure children with developmental delays and disabilities are fully included in health and education services.

    View details for DOI 10.1371/journal.pmed.1002393

    View details for PubMedID 28922419

    View details for PubMedCentralID PMC5603146

  • Childhood Illness and the Gender Gap in Adolescent Education in Low- and Middle-Income Countries PEDIATRICS Alsan, M., Xing, A., Wise, P., Darmstadt, G. L., Bendavid, E. 2017; 140 (1)


    Achieving gender equality in education is an important development goal. We tested the hypothesis that the gender gap in adolescent education is accentuated by illnesses among young children in the household.Using Demographic and Health Surveys on 41 821 households in 38 low- and middle-income countries, we used linear regression to estimate the difference in the probability adolescent girls and boys were in school, and how this gap responded to illness episodes among children <5 years old. To test the hypothesis that investments in child health are related to the gender gap in education, we assessed the relationship between the gender gap and national immunization coverage.In our sample of 120 708 adolescent boys and girls residing in 38 countries, girls were 5.08% less likely to attend school than boys in the absence of a recent illness among young children within the same household (95% confidence interval [CI], 5.50%-4.65%). This gap increased to 7.77% (95% CI, 8.24%-7.30%) and 8.53% (95% CI, 9.32%-7.74%) if the household reported 1 and 2 or more illness episodes, respectively. The gender gap in schooling in response to illness was larger in households with a working mother. Increases in child vaccination rates were associated with a closing of the gender gap in schooling (correlation coefficient = 0.34, P = .02).Illnesses among children strongly predict a widening of the gender gap in education. Investments in early childhood health may have important effects on schooling attainment for adolescent girls.

    View details for PubMedID 28759395

    View details for PubMedCentralID PMC5495535

  • Prioritizing research for integrated implementation of early childhood development and maternal, newborn, child and adolescent health and nutrition platforms. Journal of global health Sharma, R., Gaffey, M. F., Alderman, H., Bassani, D. G., Bogard, K., Darmstadt, G. L., Das, J. K., de Graft-Johnson, J. E., Hamadani, J. D., Horton, S., Huicho, L., Hussein, J., Lye, S., Pérez-Escamilla, R., Proulx, K., Marfo, K., Mathews-Hanna, V., Mclean, M. S., Rahman, A., Silver, K. L., Singla, D. R., Webb, P., Bhutta, Z. A. 2017; 7 (1): 011002


    Existing health and nutrition services present potential platforms for scaling up delivery of early childhood development (ECD) interventions within sensitive windows across the life course, especially in the first 1000 days from conception to age 2 years. However, there is insufficient knowledge on how to optimize implementation for such strategies in an integrated manner. In light of this knowledge gap, we aimed to systematically identify a set of integrated implementation research priorities for health, nutrition and early child development within the 2015 to 2030 timeframe of the Sustainable Development Goals (SDGs).We applied the Child Health and Nutrition Research Initiative method, and consulted a diverse group of global health experts to develop and score 57 research questions against five criteria: answerability, effectiveness, deliverability, impact, and effect on equity. These questions were ranked using a research priority score, and the average expert agreement score was calculated for each question.The research priority scores ranged from 61.01 to 93.52, with a median of 82.87. The average expert agreement scores ranged from 0.50 to 0.90, with a median of 0.75. The top-ranked research question were: i) "How can interventions and packages to reduce neonatal mortality be expanded to include ECD and stimulation interventions?"; ii) "How does the integration of ECD and MNCAH&N interventions affect human resource requirements and capacity development in resource-poor settings?"; and iii) "How can integrated interventions be tailored to vulnerable refugee and migrant populations to protect against poor ECD and MNCAH&N outcomes?". Most highly-ranked research priorities varied across the life course and highlighted key aspects of scaling up coverage of integrated interventions in resource-limited settings, including: workforce and capacity development, cost-effectiveness and strategies to reduce financial barriers, and quality assessment of programs.Investing in ECD is critical to achieving several of the SDGs, including SDG 2 on ending all forms of malnutrition, SDG 3 on ensuring health and well-being for all, and SDG 4 on ensuring inclusive and equitable quality education and promotion of life-long learning opportunities for all. The generated research agenda is expected to drive action and investment on priority approaches to integrating ECD interventions within existing health and nutrition services.

    View details for DOI 10.7189/jogh.07.011002

    View details for PubMedID 28685048

    View details for PubMedCentralID PMC5481896

  • Group B Streptococcus among pregnant women and newborns in Mirzapur, Bangladesh: Colonization, vertical transmission and serotype distribution. Journal of clinical microbiology Saha, S. K., Ahmed, Z. B., Modak, J. K., Naziat, H., Saha, S., Uddin, M. A., Islam, M., Baqui, A. H., Darmstadt, G. L., Schrag, S. J. 2017


    Group B Streptococcus (GBS) infection is a leading cause of death in newborns in developed countries. Data on burden of GBS in Asian countries is lacking. This study aimed to understand i) rate of maternal recto-vaginal GBS carriage, ii) vertical transmission of GBS as determined by culturing ear, umbilicus and nasal swabs, and iii) distribution of GBS serotypes. This prospective observational study was conducted from September 2012 to November 2013 at Kumudini Hospital, a secondary level hospital, at Mirzapur, Bangladesh. The study enrolled pregnant women who visited the out-patient clinic for antenatal care (ANC) and/or delivered a child at the in-patient department of Kumudini Hospital, and babies born to these mothers. Among 1151 enrolled pregnant women, 172 (15%; 95% CI: 13%-17%) carried GBS and 26 (38%; 95% CI: 27%-51%) babies born to the mothers (n=68) with carriage had GBS on their body surface, indicating vertical transmission. Typing of the isolates (n=172) identified all 10 GBS serotypes, most commonly Ia (40%; 69/172), V (23%; 40/172), II (14%; 24/172), and III (12%; 20/172). This study shows that Bangladesh has all the ingredients for invasive GBS diseases, including colonization of mothers by invasive serotypes and vertical transmission to babies.

    View details for DOI 10.1128/JCM.00380-17

    View details for PubMedID 28515218

  • Detection of macrolide resistance genes in culture-negative specimens from Bangladeshi children with invasive pneumococcal diseases. Journal of global antimicrobial resistance Hasanuzzaman, M., Malaker, R., Islam, M., Baqui, A. H., Darmstadt, G. L., Whitney, C. G., Saha, S. K. 2017; 8: 131-134


    In recent years, an increasing prevalence of macrolide resistance among pneumococci in Bangladesh has been observed. However, the scenario remains incomplete, as few isolates (<1%) are available from pneumonia cases and most pneumococcal meningitis cases (>80%) are culture-negative. This study optimised a triplex PCR method to detect macrolide resistance genes (MRGs) (mefA and ermB) and cpsA from culture-negative pneumococcal cases to predict the prevalence and level of macrolide resistance.The presence of MRGs among pneumococcal strains (n=153) with a wide range of erythromycin MICs (<0.5 to ≥256mg/L) was determined by PCR. Triplex PCR was validated by simultaneous detection of MRG(s) and cpsA in culture-negative clinical specimens and corresponding isolates. The known impact of the presence of specific MRG(s) on MICs of strains was used to predict the MICs of non-culturable strains based on the presence/absence of MRG(s) in the specimens.None of the erythromycin-susceptible isolates possessed any of the MRGs, and all non-susceptible strains had ≥1 MRG. MICs were 2-16mg/L and ≥256mg/L for 93% of strains with mefA and ermB, respectively, whereas 100% of isolates with both genes had MICs≥256mg/L. PCR for body fluids showed 100% concordance with corresponding isolates when tested for MRG(s) in parallel.Erythromycin MICs can be predicted for non-culturable strains with 93-100% precision based on detection of ermB and/or mefA. This method will be useful for establishing comprehensive surveillance for macrolide resistance among pneumococci, specifically in the population with prior antibiotic use.

    View details for DOI 10.1016/j.jgar.2016.11.009

    View details for PubMedID 28132873

  • Investing in the foundation of sustainable development: pathways to scale up for early childhood development LANCET Richter, L. M., Daelmans, B., Lombardi, J., Heymann, J., Boo, F. L., Behrman, J. R., Lu, C., Lucas, J. E., Perez-Escamilla, R., Dua, T., Bhutta, Z. A., Stenberg, K., Gertler, P., Darmstadt, G. L. 2017; 389 (10064): 103-118
  • An immune clock of human pregnancy. Science immunology Aghaeepour, N. n., Ganio, E. A., Mcilwain, D. n., Tsai, A. S., Tingle, M. n., Van Gassen, S. n., Gaudilliere, D. K., Baca, Q. n., McNeil, L. n., Okada, R. n., Ghaemi, M. S., Furman, D. n., Wong, R. J., Winn, V. D., Druzin, M. L., El-Sayed, Y. Y., Quaintance, C. n., Gibbs, R. n., Darmstadt, G. L., Shaw, G. M., Stevenson, D. K., Tibshirani, R. n., Nolan, G. P., Lewis, D. B., Angst, M. S., Gaudilliere, B. n. 2017; 2 (15)


    The maintenance of pregnancy relies on finely tuned immune adaptations. We demonstrate that these adaptations are precisely timed, reflecting an immune clock of pregnancy in women delivering at term. Using mass cytometry, the abundance and functional responses of all major immune cell subsets were quantified in serial blood samples collected throughout pregnancy. Cell signaling-based Elastic Net, a regularized regression method adapted from the elastic net algorithm, was developed to infer and prospectively validate a predictive model of interrelated immune events that accurately captures the chronology of pregnancy. Model components highlighted existing knowledge and revealed previously unreported biology, including a critical role for the interleukin-2-dependent STAT5ab signaling pathway in modulating T cell function during pregnancy. These findings unravel the precise timing of immunological events occurring during a term pregnancy and provide the analytical framework to identify immunological deviations implicated in pregnancy-related pathologies.

    View details for PubMedID 28864494

  • Gender disparities in child development in the east Asia-Pacific region: a cross-sectional, population-based, multicountry observational study The Lancet Child & Adolescent Health Weber, A., Darmstadt, G. L., Rao, N. 2017; 1 (3)
  • Taking on the gender challenge in organisations: what does it take? GLOBAL PUBLIC HEALTH Henry, S. K., Sandler, J., Passerini, L., Darmstadt, G. L. 2017; 12 (7): 846-857
  • Risky Business: Meeting the Structural Needs of Transdisciplinary Science. The Journal of pediatrics Wise, P. H., Shaw, G. M., Druzin, M. L., Darmstadt, G. L., Quaintance, C. n., Mäkinen, E. n., Relman, D. A., Quake, S. R., Butte, A. J., Angst, M. S., Muglia, L. J., Macones, G. n., Driscoll, D. n., Ober, C. n., Simpson, J. L., Katz, M. n., Howse, J. n., Stevenson, D. K. 2017; 191: 255–58

    View details for PubMedID 29173314

  • Prevalence, Serotype Distribution and Mortality Risk Associated With Group B Streptococcus Colonization of Newborns in Rural Bangladesh PEDIATRIC INFECTIOUS DISEASE JOURNAL Islam, M. S., Saha, S. K., Islam, M., Modak, J. K., Shah, R., Talukder, R. R., El Arifeen, S., Baqui, A. H., Darmstadt, G. L., Mullany, L. C. 2016; 35 (12): 1309-1312


    Group B Streptococcus (GBS) is a predominant cause of early-onset neonatal sepsis globally; however, the impact of this organism on the health of newborns in South Asia is debated, due in part to a paucity of community-based assessments. We estimated the prevalence and serotypes of GBS colonization of the umbilical cord stump and the association of colonization with mortality in a population-based cohort of newborns in rural Sylhet District, Bangladesh.Umbilical cord swabs were collected from 646 newborns up to 3 times within the first week after birth (ages <24 hours, ~3 days, ~6 days) and processed to identify GBS serotypes.GBS was isolated from 6.3% (41/646) of newborns. Sixty-one percent of the GBS colonization occurred in neonates within 24 hours of delivery. Serotypes VII (37.1%, n = 13/36) and Ia (33.3%, n = 12/36) were the most predominant colonizing GBS isolates. Other detected serotypes were Ib (11.1%, n = 4/36), II (11.1%, n = 4/36), V (5.6%, n = 2/36) and VI (2.8%, n = 1/36). Mortality risk among newborns with GBS colonization was 6.6 (95% confidence interval: 2.1-20.4) times higher than for those without GBS.The overall prevalence of GBS colonization was lower than in settings, where GBS is a predominant etiology of neonatal illness. In addition, the GBS serotype distribution differed from that reported in the developed part of the world. However, further studies are needed to understand the true burden of GBS-related illness. Mortality risk was substantially increased in the presence of GBS on the umbilical stump, providing support for chlorhexidine antisepsis to the cord to prevent colonization of invasive pathogens.

    View details for DOI 10.1097/INF.0000000000001306

    View details for Web of Science ID 000388217900012

    View details for PubMedID 27455441

  • Does addressing gender inequalities and empowering women and girls improve health and development programme outcomes? Health policy and planning Taukobong, H. F., Kincaid, M. M., Levy, J. K., Bloom, S. S., Platt, J. L., Henry, S. K., Darmstadt, G. L. 2016; 31 (10): 1492-1514


    This article presents evidence supporting the hypothesis that promoting gender equality and women's and girls' empowerment (GEWE) leads to better health and development outcomes. We reviewed the literature across six sectors-family planning (FP); maternal, newborn and child health (MNCH); nutrition; agriculture; water, sanitation and hygiene; and financial services for the poor-and found 76 studies from low and middle-income countries that met our inclusion criteria. Across these studies, we identified common GEWE variables that emerged repeatedly as significant predictors of sector outcomes. We grouped these variables into 10 thematic categories, which we termed 'gender-related levers'. These levers were then classified by the strength of evidence into Wedges, Foundations and Facilitators. Wedges are gender-related levers that had strong associations with improved outcomes across multiple sectors. They include: 'control over income/assets/resources', 'decision-making power' and 'education'. Elements of these levers overlap, but combined, they encapsulate agency. Increasing female agency promotes equality and broadly improves health and development for women, their families and their communities. The second classification, Foundations, displayed strong, positive associations across FP, MNCH and nutrition. Foundations have a more proximal relationship with sector outcomes and include: 'equitable interpersonal relationships', 'mobility' and 'personal safety'. Finally, the third group of levers, Facilitators, was associated with improved outcomes in two to three sectors and include: 'access to information', 'community groups', 'paid labour' and 'rights'. These levers make it easier for women and girls to achieve their goals and are more traditional elements of development programmes. Overall, gender-related levers were associated with improvements in a variety of health and development outcomes. Furthermore, these associations were cross-sectoral, suggesting that to fully realize the benefits of promoting GEWE, the development community must collaborate in co-ordinated and integrated ways across multiple sectors. More research is needed to identify the mechanisms by which gendered interventions work and under what circumstances.

    View details for PubMedID 27371549

  • Mapping the Fetomaternal Peripheral Immune System at Term Pregnancy. Journal of immunology Fragiadakis, G. K., Baca, Q. J., Gherardini, P. F., Ganio, E. A., Gaudilliere, D. K., Tingle, M., Lancero, H. L., McNeil, L. S., Spitzer, M. H., Wong, R. J., Shaw, G. M., Darmstadt, G. L., Sylvester, K. G., Winn, V. D., Carvalho, B., Lewis, D. B., Stevenson, D. K., Nolan, G. P., Aghaeepour, N., Angst, M. S., Gaudilliere, B. L. 2016


    Preterm labor and infections are the leading causes of neonatal deaths worldwide. During pregnancy, immunological cross talk between the mother and her fetus is critical for the maintenance of pregnancy and the delivery of an immunocompetent neonate. A precise understanding of healthy fetomaternal immunity is the important first step to identifying dysregulated immune mechanisms driving adverse maternal or neonatal outcomes. This study combined single-cell mass cytometry of paired peripheral and umbilical cord blood samples from mothers and their neonates with a graphical approach developed for the visualization of high-dimensional data to provide a high-resolution reference map of the cellular composition and functional organization of the healthy fetal and maternal immune systems at birth. The approach enabled mapping of known phenotypical and functional characteristics of fetal immunity (including the functional hyperresponsiveness of CD4(+) and CD8(+) T cells and the global blunting of innate immune responses). It also allowed discovery of new properties that distinguish the fetal and maternal immune systems. For example, examination of paired samples revealed differences in endogenous signaling tone that are unique to a mother and her offspring, including increased ERK1/2, MAPK-activated protein kinase 2, rpS6, and CREB phosphorylation in fetal Tbet(+)CD4(+) T cells, CD8(+) T cells, B cells, and CD56(lo)CD16(+) NK cells and decreased ERK1/2, MAPK-activated protein kinase 2, and STAT1 phosphorylation in fetal intermediate and nonclassical monocytes. This highly interactive functional map of healthy fetomaternal immunity builds the core reference for a growing data repository that will allow inferring deviations from normal associated with adverse maternal and neonatal outcomes.

    View details for PubMedID 27793998

  • Early childhood development: the foundation of sustainable development. Lancet Daelmans, B., Darmstadt, G. L., Lombardi, J., Black, M. M., Britto, P. R., Lye, S., Dua, T., Bhutta, Z. A., Richter, L. M. 2016

    View details for DOI 10.1016/S0140-6736(16)31659-2

    View details for PubMedID 27717607

  • Investing in the foundation of sustainable development: pathways to scale up for early childhood development. Lancet Richter, L. M., Daelmans, B., Lombardi, J., Heymann, J., Boo, F. L., Behrman, J. R., Lu, C., Lucas, J. E., Perez-Escamilla, R., Dua, T., Bhutta, Z. A., Stenberg, K., Gertler, P., Darmstadt, G. L. 2016


    Building on long-term benefits of early intervention (Paper 2 of this Series) and increasing commitment to early childhood development (Paper 1 of this Series), scaled up support for the youngest children is essential to improving health, human capital, and wellbeing across the life course. In this third paper, new analyses show that the burden of poor development is higher than estimated, taking into account additional risk factors. National programmes are needed. Greater political prioritisation is core to scale-up, as are policies that afford families time and financial resources to provide nurturing care for young children. Effective and feasible programmes to support early child development are now available. All sectors, particularly education, and social and child protection, must play a role to meet the holistic needs of young children. However, health provides a critical starting point for scaling up, given its reach to pregnant women, families, and young children. Starting at conception, interventions to promote nurturing care can feasibly build on existing health and nutrition services at limited additional cost. Failure to scale up has severe personal and social consequences. Children at elevated risk for compromised development due to stunting and poverty are likely to forgo about a quarter of average adult income per year, and the cost of inaction to gross domestic product can be double what some countries currently spend on health. Services and interventions to support early childhood development are essential to realising the vision of the Sustainable Development Goals.

    View details for DOI 10.1016/S0140-6736(16)31698-1

    View details for PubMedID 27717610

  • Strengthening the Reporting of Observational Studies in Epidemiology for Newborn Infection (STROBE-NI): an extension of the STROBE statement for neonatal infection research LANCET INFECTIOUS DISEASES Fitchett, E. J., Seale, A. C., Vergnano, S., Sharland, M., Heath, P. T., Saha, S. K., Agarwal, R., Ayede, A. I., Bhutta, Z. A., Black, R., Bojang, K., Campbell, H., Cousens, S., Darmstadt, G. L., Madhi, S. A., Sobanjo-ter Meulen, A., Modi, N., Patterson, J., Qazi, S., Schrag, S. J., Stoll, B. J., Wall, S. N., Wammanda, R. D., Lawn, J. E. 2016; 16 (10): E202-E213


    Neonatal infections are estimated to account for a quarter of the 2·8 million annual neonatal deaths, as well as approximately 3% of all disability-adjusted life-years. Despite this burden, few data are available on incidence, aetiology, and outcomes, particularly regarding impairment. We aimed to develop guidelines for improved scientific reporting of observational neonatal infection studies, to increase comparability and to strengthen research in this area. This checklist, Strengthening the Reporting of Observational Studies in Epidemiology for Newborn Infection (STROBE- NI), is an extension of the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement. STROBE-NI was developed following systematic reviews of published literature (1996-2015), compilation of more than 130 potential reporting recommendations, and circulation of a survey to relevant professionals worldwide, eliciting responses from 147 professionals from 37 countries. An international consensus meeting of 18 participants (with expertise in infectious diseases, neonatology, microbiology, epidemiology, and statistics) identified priority recommendations for reporting, additional to the STROBE statement. Implementation of these STROBE-NI recommendations, and linked checklist, aims to improve scientific reporting of neonatal infection studies, increasing data utility and allowing meta-analyses and pathogen-specific burden estimates to inform global policy and new interventions, including maternal vaccines.

    View details for DOI 10.1016/S1473-3099(16)30082-2

    View details for Web of Science ID 000383469000001

    View details for PubMedID 27633910

  • Global research priorities to accelerate early child development in the sustainable development era. The Lancet. Global health Dua, T., Tomlinson, M., Tablante, E., Britto, P., Yousfzai, A., Daelmans, B., Darmstadt, G. L. 2016

    View details for DOI 10.1016/S2214-109X(16)30218-2

    View details for PubMedID 27717631

  • Validation of a rapid neurodevelopmental assessment tool for 10- to 16-year-old young adolescents in Bangladesh. Child: care, health and development Muslima, H., Khan, N. Z., Shilpi, A. B., Begum, D., Parveen, M., McConachie, H., Darmstadt, G. L. 2016; 42 (5): 658-665


    To validate a Rapid Neurodevelopmental Assessment (RNDA) tool for use by child health professionals to determine neurodevelopmental impairments (NDIs) in young adolescents aged 10-16 years in Bangladesh.In a convenience sample of community children (n = 47), inter-rater reliability was determined between four testers, and concurrent validity was determined by simultaneous administration of an intelligence quotient (IQ) test (Wechsler Intelligence Scale for Children, Revised) by a child psychologist.Inter-rater reliability was excellent between the testers on the 47 children administered the RNDA (kappa = 1.00). Significantly lower IQ scores were obtained in those identified with 'any (>1) NDI' (n = 34) compared with those with no NDI (n = 13) on Verbal IQ (P-value < 0.0001), Performance IQ (P-value < 0.0001) and Full-scale IQ (P-value < 0.0001) scores on the Wechsler Intelligence Scale for Children, Revised.The RNDA shows promise as a tool for use by child health professionals for identifying NDIs in young adolescents aged 10-16 years. A larger study sample is needed to determine its usefulness for identification of some impairments not found in the study population, i.e. gross motor, fine motor, hearing and seizures.

    View details for DOI 10.1111/cch.12362

    View details for PubMedID 27357744

  • PCR-Based Serotyping of Streptococcus pneumoniae from Culture-Negative Specimens: Novel Primers for Detection of Serotypes within Serogroup 18. Journal of clinical microbiology Tanmoy, A. M., Saha, S., Darmstadt, G. L., Whitney, C. G., Saha, S. K. 2016; 54 (8): 2178-2181


    Six multiplex-compatible PCR primers were designed to distinguish Streptococcus pneumoniae serotypes within serogroup 18 from culturable/nonculturable pneumococcal specimens, with no cross-reactivity with other serotypes and respiratory organisms. These primers will aid in the generation of better data on vaccine/nonvaccine serotypes in invasive and carriage pneumococcal surveillance and contribute to future vaccine formulation and impact studies.

    View details for DOI 10.1128/JCM.00419-16

    View details for PubMedID 27252464

    View details for PubMedCentralID PMC4963509

  • Prevention of Congenital Disorders and Care of Affected Children: A Consensus Statement. JAMA pediatrics Darmstadt, G. L., Howson, C. P., Walraven, G., Armstrong, R. W., Blencowe, H. K., Christianson, A. L., Kent, A., Malherbe, H., Murray, J. C., Padilla, C. D., Walani, S. R. 2016; 170 (8): 790-793


    As the Sustainable Development Goals are adopted by United Nations member states, children with congenital disorders remain left behind in policies, programs, research, and funding. Although this finding was recognized by the creation and endorsement of the 63rd World Health Assembly Resolution in 2010 calling on United Nations member states to strengthen prevention of congenital disorders and the improvement of care of those affected, there has been little to no action since then. The Sustainable Development Goals call for the global health and development community to focus first and foremost on the most vulnerable and those left behind in the Millennium Development Goal era. To maximize the opportunity for every woman and couple to have a healthy child and to reduce the mortality and severe disability associated with potentially avoidable congenital disorders and their consequences for the children affected, their families and communities, and national health care systems, we propose priority measures that should be taken urgently to address this issue.

    View details for DOI 10.1001/jamapediatrics.2016.0388

    View details for PubMedID 27366873

  • Epidemiology of Invasive Pneumococcal Disease in Bangladeshi Children Before Introduction of Pneumococcal Conjugate Vaccine PEDIATRIC INFECTIOUS DISEASE JOURNAL Saha, S. K., Hossain, B., Islam, M., Hasanuzzaman, M., Saha, S., Hasan, M., Darmstadt, G. L., Chowdury, M., El Arifeen, S., Baqui, A. H., Breiman, R. F., Santosham, M., Luby, S. P., Whitney, C. G. 2016; 35 (6): 655-661


    Because Bangladesh intended to introduce pneumococcal conjugate vaccine (PCV)-10 in 2015, we examined the baseline burden of invasive pneumococcal disease (IPD) to measure impact of PCV.During 2007-2013, we performed blood and cerebrospinal fluid cultures in children <5 years old with suspected IPD identified through active surveillance at 4 hospitals. Isolates were serotyped by quellung and tested for antibiotic susceptibility by disc diffusion and E-test. Serotyping of culture-negative cases, detected by Binax or polymerase chain reaction, was done by sequential multiplex polymerase chain reaction. Trends in IPD case numbers were analyzed by serotype and clinical syndrome.The study identified 752 IPD cases; 78% occurred in children <12 months old. Serotype information was available for 78% (442/568), including 197 of 323 culture-negative cases available for serotyping. We identified 50 serotypes; the most common serotypes were 2 (16%), 1 (10 %), 6B (7%), 14 (7%) and 5 (7%). PCV-10 and PCV-13 serotypes accounted for 46% (range 29%-57% by year) and 50% (range 37%-64% by year) of cases, respectively. Potential serotype coverage for meningitis and nonmeningitis cases was 45% and 49% for PCV-10, and 48% and 57% for PCV-13, respectively. Eighty-two percent of strains were susceptible to all antibiotics except cotrimoxazole.The distribution of serotypes causing IPD in Bangladeshi children is diverse, limiting the proportion of IPD cases PCV can prevent. However, PCV introduction is expected to have major benefits as the country has a high burden of IPD-related mortality, morbidity and disability.

    View details for DOI 10.1097/INF.0000000000001037

    View details for Web of Science ID 000379343700016

    View details for PubMedID 26658530

  • The Grand Divergence in Global Child Health: Confronting Data Requirements in Areas of Conflict and Chronic Political Instability. JAMA pediatrics Wise, P. H., Darmstadt, G. L. 2016; 170 (3): 195-197

    View details for DOI 10.1001/jamapediatrics.2015.4275

    View details for PubMedID 26809944

  • Effect of community-based newborn care on cause-specific neonatal mortality in Sylhet district, Bangladesh: findings of a cluster-randomized controlled trial JOURNAL OF PERINATOLOGY Baqui, A. H., Williams, E., El-Arifeen, S., APPLEGATE, J. A., Mannan, I., Begum, N., Rahman, S. M., Ahmed, S., BLACK, R. E., Darmstadt, G. L. 2016; 36 (1): 71-76

    View details for DOI 10.1038/jp.2015.139

    View details for PubMedID 26540248

  • A shortened verbal autopsy instrument for use in routine mortality surveillance systems BMC MEDICINE Serina, P., Riley, I., Stewart, A., Flaxman, A. D., Lozano, R., Mooney, M. D., Luning, R., Hernandez, B., Black, R., Ahuja, R., Alam, N., Alam, S. S., Ali, S. M., Atkinson, C., Baqui, A. H., Chowdhury, H. R., Dandona, L., Dandona, R., Dantzer, E., Darmstadt, G. L., Das, V., Dhingra, U., Dutta, A., Fawzi, W., Freeman, M., Gamage, S., Gomez, S., Hensman, D., James, S. L., Joshi, R., Kalter, H. D., Kumar, A., Kumar, V., Lucero, M., Mehta, S., Neal, B., Ohno, S. L., Phillips, D., Pierce, K., Prasad, R., Praveen, D., Premji, Z., Ramirez-Villalobos, D., Rampatige, R., Remolador, H., Romero, M., Said, M., Sanvictores, D., Sazawal, S., Streatfield, P. K., Tallo, V., Vadhatpour, A., Wijesekara, N., Murray, C. J., Lopez, A. D. 2015; 13


    Verbal autopsy (VA) is recognized as the only feasible alternative to comprehensive medical certification of deaths in settings with no or unreliable vital registration systems. However, a barrier to its use by national registration systems has been the amount of time and cost needed for data collection. Therefore, a short VA instrument (VAI) is needed. In this paper we describe a shortened version of the VAI developed for the Population Health Metrics Research Consortium (PHMRC) Gold Standard Verbal Autopsy Validation Study using a systematic approach.We used data from the PHMRC validation study. Using the Tariff 2.0 method, we first established a rank order of individual questions in the PHMRC VAI according to their importance in predicting causes of death. Second, we reduced the size of the instrument by dropping questions in reverse order of their importance. We assessed the predictive performance of the instrument as questions were removed at the individual level by calculating chance-corrected concordance and at the population level with cause-specific mortality fraction (CSMF) accuracy. Finally, the optimum size of the shortened instrument was determined using a first derivative analysis of the decline in performance as the size of the VA instrument decreased for adults, children, and neonates.The full PHMRC VAI had 183, 127, and 149 questions for adult, child, and neonatal deaths, respectively. The shortened instrument developed had 109, 69, and 67 questions, respectively, representing a decrease in the total number of questions of 40-55%. The shortened instrument, with text, showed non-significant declines in CSMF accuracy from the full instrument with text of 0.4%, 0.0%, and 0.6% for the adult, child, and neonatal modules, respectively.We developed a shortened VAI using a systematic approach, and assessed its performance when administered using hand-held electronic tablets and analyzed using Tariff 2.0. The length of a VA questionnaire was shortened by almost 50% without a significant drop in performance. The shortened VAI developed reduces the burden of time and resources required for data collection and analysis of cause of death data in civil registration systems.

    View details for DOI 10.1186/s12916-015-0528-8

    View details for PubMedID 26670275

  • Improving performance of the Tariff Method for assigning causes of death to verbal autopsies BMC MEDICINE Serina, P., Riley, I., Stewart, A., James, S. L., Flaxman, A. D., Lozano, R., Hernandez, B., Mooney, M. D., Luning, R., Black, R., Ahuja, R., Alam, N., Alam, S. S., Ali, S. M., Atkinson, C., Baqui, A. H., Chowdhury, H. R., Dandona, L., Dandona, R., Dantzer, E., Darmstadt, G. L., Das, V., Dhingra, U., Dutta, A., Fawzi, W., Freeman, M., Gomez, S., Gouda, H. N., Joshi, R., Kalter, H. D., Kumar, A., Kumar, V., Lucero, M., Maraga, S., Mehta, S., Neal, B., Ohno, S. L., Phillips, D., Pierce, K., Prasad, R., Praveen, D., Premji, Z., Ramirez-Villalobos, D., Rarau, P., Remolador, H., Romero, M., Said, M., Sanvictores, D., Sazawal, S., Streatfield, P. K., Tallo, V., Vadhatpour, A., Vano, M., Murray, C. J., Lopez, A. D. 2015; 13


    Reliable data on the distribution of causes of death (COD) in a population are fundamental to good public health practice. In the absence of comprehensive medical certification of deaths, the only feasible way to collect essential mortality data is verbal autopsy (VA). The Tariff Method was developed by the Population Health Metrics Research Consortium (PHMRC) to ascertain COD from VA information. Given its potential for improving information about COD, there is interest in refining the method. We describe the further development of the Tariff Method.This study uses data from the PHMRC and the National Health and Medical Research Council (NHMRC) of Australia studies. Gold standard clinical diagnostic criteria for hospital deaths were specified for a target cause list. VAs were collected from families using the PHMRC verbal autopsy instrument including health care experience (HCE). The original Tariff Method (Tariff 1.0) was trained using the validated PHMRC database for which VAs had been collected for deaths with hospital records fulfilling the gold standard criteria (validated VAs). In this study, the performance of Tariff 1.0 was tested using VAs from household surveys (community VAs) collected for the PHMRC and NHMRC studies. We then corrected the model to account for the previous observed biases of the model, and Tariff 2.0 was developed. The performance of Tariff 2.0 was measured at individual and population levels using the validated PHMRC database.For median chance-corrected concordance (CCC) and mean cause-specific mortality fraction (CSMF) accuracy, and for each of three modules with and without HCE, Tariff 2.0 performs significantly better than the Tariff 1.0, especially in children and neonates. Improvement in CSMF accuracy with HCE was 2.5%, 7.4%, and 14.9% for adults, children, and neonates, respectively, and for median CCC with HCE it was 6.0%, 13.5%, and 21.2%, respectively. Similar levels of improvement are seen in analyses without HCE.Tariff 2.0 addresses the main shortcomings of the application of the Tariff Method to analyze data from VAs in community settings. It provides an estimation of COD from VAs with better performance at the individual and population level than the previous version of this method, and it is publicly available for use.

    View details for DOI 10.1186/s12916-015-0527-9

    View details for PubMedID 26644140

  • Kangaroo mother care: a multi-country analysis of health system bottlenecks and potential solutions BMC PREGNANCY AND CHILDBIRTH Vesel, L., Bergh, A., Kerber, K. J., Valsangkar, B., Mazia, G., Moxon, S. G., Blencowe, H., Darmstadt, G. L., Johnson, J. d., Dickson, K. E., Ruiz Pelaez, J. G., von Xylander, S. R., Lawn, J. E. 2015; 15


    Preterm birth is now the leading cause of under-five child deaths worldwide with one million direct deaths plus approximately another million where preterm is a risk factor for neonatal deaths due to other causes. There is strong evidence that kangaroo mother care (KMC) reduces mortality among babies with birth weight <2000 g (mostly preterm). KMC involves continuous skin-to-skin contact, breastfeeding support, and promotion of early hospital discharge with follow-up. The World Health Organization has endorsed KMC for stabilised newborns in health facilities in both high-income and low-resource settings. The objectives of this paper are to: (1) use a 12-country analysis to explore health system bottlenecks affecting the scale-up of KMC; (2) propose solutions to the most significant bottlenecks; and (3) outline priority actions for scale-up.The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale-up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for KMC.Marked differences were found in the perceived severity of health system bottlenecks between Asian and African countries, with the former reporting more significant or very major bottlenecks for KMC with respect to all the health system building blocks. Community ownership and health financing bottlenecks were significant or very major bottlenecks for KMC in both low and high mortality contexts, particularly in South Asia. Significant bottlenecks were also reported for leadership and governance and health workforce building blocks.There are at least a dozen countries worldwide with national KMC programmes, and we identify three pathways to scale: (1) champion-led; (2) project-initiated; and (3) health systems designed. The combination of all three pathways may lead to more rapid scale-up. KMC has the potential to save lives, and change the face of facility-based newborn care, whilst empowering women to care for their preterm newborns.

    View details for DOI 10.1186/1471-2393-15-S2-S5

    View details for Web of Science ID 000381897700005

    View details for PubMedID 26391115

    View details for PubMedCentralID PMC4577801

  • Treatment of neonatal infections: a multi-country analysis of health system bottlenecks and potential solutions BMC PREGNANCY AND CHILDBIRTH Simen-Kapeu, A., Seale, A. C., Wall, S., Nyange, C., Qazi, S. A., Moxon, S. G., Young, M., Liu, G., Darmstadt, G. L., Dickson, K. E., Lawn, J. E. 2015; 15


    Around one-third of the world's 2.8 million neonatal deaths are caused by infections. Most of these deaths are preventable, but occur due to delays in care-seeking, and access to effective antibiotic treatment with supportive care. Understanding variation in health system bottlenecks to scale-up of case management of neonatal infections and identifying solutions is essential to reduce mortality, and also morbidity.A standardised bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the development of the Every Newborn Action Plan. Country workshops involved technical experts to complete a survey tool, to grade health system "bottlenecks" hindering scale up of maternal-newborn intervention packages. Quantitative and qualitative methods were used to analyse the data, combined with literature review, to present priority bottlenecks and synthesise actions to improve case management of newborn infections.For neonatal infections, the health system building blocks most frequently graded as major or significant bottlenecks, irrespective of mortality context and geographical region, were health workforce (11 out of 12 countries), and community ownership and partnership (11 out of 12 countries). Lack of data to inform decision making, and limited funding to increase access to quality neonatal care were also major challenges.Rapid recognition of possible serious bacterial infection and access to care is essential. Inpatient hospital care remains the first line of treatment for neonatal infections. In situations where referral is not possible, the use of simplified antibiotic regimens for outpatient management for non-critically ill young infants has recently been reported in large clinical trials; WHO is developing a guideline to treat this group of young infants. Improving quality of care through more investment in the health workforce at all levels of care is critical, in addition to ensuring development and dissemination of national guidelines. Improved information systems are needed to track coverage and adequately manage drug supply logistics for improved health outcomes. It is important to increase community ownership and partnership, for example through involvement of community groups.

    View details for DOI 10.1186/1471-2393-15-S2-S6

    View details for Web of Science ID 000381897700006

    View details for PubMedID 26391217

  • Taking on the gender challenge in organisations: what does it take? Global public health Henry, S. K., Sandler, J., Passerini, L., Darmstadt, G. L. 2015: 1-12


    Clear patterns emerged and are summarised on conditions for success in integrating a gender equality perspective across organisational programmes and culture. In short, organisations should consider five key 'ingredients' when designing their approach to integrating a gender equality perspective: (1) have a clear vision of success with measurable indicators; (2) have high-level, consistent, visible support; (3) take an intentional approach deeply rooted in the organisational culture and competencies; (4) ensure accountability at all levels and (5) invest both financial and technical resources. A vibrant community exists in virtually every region of the world of highly experienced gender equality experts that can support organisations on this path. Late adopters of integrating a gender equality perspective can benefit from decades of practice and a robust evidence base which has shifted focus among development organisations from asking 'why' addressing gender inequalities is important to learning 'how' to most effectively do this in programmes, policies, research and organisational culture while building a strong results framework.

    View details for PubMedID 26857439

  • Strategic governance: Addressing neonatal mortality in situations of political instability and weak governance SEMINARS IN PERINATOLOGY Wise, P. H., Darmstadt, G. L. 2015; 39 (5): 387-392


    Neonatal mortality is increasingly concentrated globally in situations of conflict and political instability. In 1991, countries with high levels of political instability accounted for approximately 10% of all neonatal deaths worldwide; in 2013, this figure had grown to 31%. This has generated a "grand divergence" between those countries showing progress in neonatal mortality reduction compared to those lagging behind. We present new analyses demonstrating associations of neonatal mortality with political instability (r = 0.55) and poor governance (r = 0.70). However, heterogeneity in these relationships suggests that progress is possible in addressing neonatal mortality even in the midst of political instability and poor governance. In order to address neonatal mortality more effectively in such situations, we must better understand how specific elements of "strategic governance"-the minimal conditions of political stability and governance required for health service implementation-can be leveraged for successful introduction of specific health services. Thus, a more strategic approach to policy and program implementation in situations of conflict and political instability could lead to major accelerations in neonatal mortality reduction globally. However, this will require new cross-disciplinary collaborations among public health professionals, political scientists, and country actors.

    View details for DOI 10.1053/j.semperi.2015.06.008

    View details for Web of Science ID 000359877300008

    View details for PubMedID 26166561

  • Ensuring healthy pregnancies, births, and babies. Seminars in perinatology Darmstadt, G. L. 2015; 39 (5): 321-5

    View details for DOI 10.1053/j.semperi.2015.06.001

    View details for PubMedID 26184342

  • Implementation of the Every Newborn Action Plan: Progress and lessons learned SEMINARS IN PERINATOLOGY Kinney, M. V., Cocoman, O., Dickson, K. E., Daelmans, B., Zaka, N., Rhoda, N. R., Moxon, S. G., Kak, L., Lawn, J. E., Khadka, N., Darmstadt, G. L. 2015; 39 (5): 326-337


    Progress in reducing newborn mortality has lagged behind progress in reducing maternal and child deaths. The Every Newborn Action Plan (ENAP) was launched in 2014, with the aim of achieving equitable and high-quality coverage of care for all women and newborns through links with other global and national plans and measurement and accountability frameworks. This article aims to assess country progress and the mechanisms in place to support country implementation of the ENAP. A country tracking tool was developed and piloted in October-December 2014 to collect data on the ENAP-related national milestones and implementation barriers in 18 high-burden countries. Simultaneously, a mapping exercise involving 47 semi-structured interviews with partner organizations was carried out to frame the categories of technical support available in countries to support care at and around the time of birth by health system building blocks. Existing literature and reports were assessed to further supplement analysis of country progress. A total of 15 out of 18 high-burden countries have taken concrete actions to advance newborn health; four have developed specific action plans with an additional six in process and a further three strengthening newborn components within existing plans. Eight high-burden countries have a newborn mortality target, but only three have a stillbirth target. The ENAP implementation in countries is well-supported by UN agencies, particularly UNICEF and WHO, as well as multilateral and bilateral agencies, especially in health workforce training. New financial commitments from development partners and the private sector are substantial but tracking of national funding remains a challenge. For interventions with strong evidence, low levels of coverage persists and health information systems require investment and support to improve quality and quantity of data to guide and track progress. Some of the highest burden countries have established newborn health action plans and are scaling up evidence based interventions. Further progress will only be made with attention to context-specific implementation challenges, especially in areas that have been neglected to date such as quality improvement, sustained investment in training and monitoring health worker skills, support to budgeting and health financing, and strengthening of health information systems.

    View details for DOI 10.1053/j.semperi.2015.06.004

    View details for Web of Science ID 000359877300002

    View details for PubMedID 26249104

  • Enculturating science: Community-centric design of behavior change interactions for accelerating health impact SEMINARS IN PERINATOLOGY Kumar, V., Kumar, A., Ghosh, A. K., Samphel, R., Yadav, R., Yeung, D., Darmstadt, G. L. 2015; 39 (5): 393-415


    Despite significant advancements in the scientific evidence base of interventions to improve newborn survival, we have not yet been able to "bend the curve" to markedly accelerate global rates of reduction in newborn mortality. The ever-widening gap between discovery of scientific best practices and their mass adoption by families (the evidence-practice gap) is not just a matter of improving the coverage of health worker-community interactions. The design of the interactions themselves must be guided by sound behavioral science approaches such that they lead to mass adoption and impact at a large scale. The main barrier to the application of scientific approaches to behavior change is our inability to "unbox" the "black box" of family health behaviors in community settings. The authors argue that these are not black boxes, but in fact thoughtfully designed community systems that have been designed and upheld, and have evolved over many years keeping in mind a certain worldview and a common social purpose. An empathetic understanding of these community systems allows us to deconstruct the causal pathways of existing behaviors, and re-engineer them to achieve desired outcomes. One of the key reasons for the failure of interactions to translate into behavior change is our failure to recognize that the content, context, and process of interactions need to be designed keeping in mind an organized community system with a very different worldview and beliefs. In order to improve the adoption of scientific best practices by communities, we need to adapt them to their culture by leveraging existing beliefs, practices, people, context, and skills. The authors present a systems approach for community-centric design of interactions, highlighting key principles for achieving intrinsically motivated, sustained change in social norms and family health behaviors, elucidated with progressive theories from systems thinking, management sciences, cross-cultural psychology, learning and social cognition, and the behavioral sciences. These are illustrated through a case study of designing effective interactions in Shivgarh, India, that led to rapid and substantial changes in newborn health behaviors and reduction in NMR by half over a span of 16 months.

    View details for DOI 10.1053/j.semperi.2015.06.010

    View details for Web of Science ID 000359877300009

    View details for PubMedID 26215599

  • Scaling-up impact in perinatology through systems science: Bridging the collaboration and translational divides in cross-disciplinary research and public policy SEMINARS IN PERINATOLOGY Munar, W., Hovmand, P. S., Fleming, C., Darmstadt, G. L. 2015; 39 (5): 416-423


    Despite progress over the past decade in reducing the global burden of newborn deaths, gaps in the knowledge base persist, and means of translating empirical findings into effective policies and programs that deliver life-saving interventions remain poorly understood. Articles in this issue highlight the relevance of transdisciplinary research in perinatology and calls for increased efforts to translate research into public policy and to integrate interventions into existing primary care delivery systems. Given the complexity and multi-causality of many of the remaining challenges in newborn health, and the effects that social and economic factors have over many newborn conditions, it has further been proposed that integrated, multi-sector public policies are also required. In this article, we discuss the application of systems science methods to advance transdisciplinary research and public policy-making in perinatology. Such approaches to research and public policy have been used to address various global challenges but have rarely been implemented in developing country settings. We propose that they hold great promise to improve not only our understanding of complex perinatology problems but can also help translate research-based insights into effective, multi-pronged solutions that deliver positive, intended effects. Examples of successful transdisciplinary science exist, but successes and failures are context specific, and there are no universal blueprints or formulae to reproduce what works in a specific context into different social system settings. Group model building is a tool, based in the field of System Dynamics, that we have used to facilitate transdisciplinary research and, to a lesser extent, policy formulation in a systematic and replicable way. In this article, we describe how group model building can be used and argue for scaling its use to further the translation of empirical evidence and insights into policy and action that increase maternal and neonatal survival and well-being.

    View details for DOI 10.1053/j.semperi.2015.06.003

    View details for Web of Science ID 000359877300010

    View details for PubMedID 26184341

  • Enhancing the child survival agenda to promote, protect, and support early child development SEMINARS IN PERINATOLOGY Jensen, S. K., Bouhouch, R. R., Walson, J. L., Daelmans, B., Bahl, R., Darmstadt, G. L., Dua, T. 2015; 39 (5): 373-386


    High rates of child mortality and lost developmental potential in children under 5 years of age remain important challenges and drivers of inequity in the developing world. Substantive progress has been made toward Millennium Development Goal (MDG) 4 to improve child survival, but as we move into the post-2015 sustainable development agenda, much more work is needed to ensure that all children can realize their full and holistic physical, cognitive, psychological, and socio-emotional development potential. This article presents child survival and development as a continuous and multifaceted process and suggests that a life-course perspective of child development should be at the core of future policy making, programing, and research. We suggest that increased attention to child development, beyond child survival, is key to operationalize the sustainable development goals (SDGs), address inequities, build on the demographic dividend, and maximize gains in human potential. An important step toward implementation will be to increase integration of existing interventions for child survival and child development. Integrated interventions have numerous potential benefits, including optimization of resource use, potential additive impacts across multiple domains of health and development, and opportunity to realize a more holistic approach to client-centered care. However, a notable challenge to integration is the continued division between the health sector and other sectors that support child development. Despite these barriers, empirical evidence is available to suggest that successful multi-sectoral coordination is feasible and leads to improved short- and long-term outcomes in human, social, and economic development.

    View details for DOI 10.1053/j.semperi.2015.06.002

    View details for Web of Science ID 000359877300007

    View details for PubMedID 26234921

  • Impact of family planning programs in reducing high-risk births due to younger and older maternal age, short birth intervals, and high parity SEMINARS IN PERINATOLOGY Brown, W., Ahmed, S., Roche, N., Sonneveldt, E., Darmstadt, G. L. 2015; 39 (5): 338-344


    Several studies show that maternal and neonatal/infant mortality risks increase with younger and older maternal age (<18 and >34 years), high parity (birth order >3), and short birth intervals (<24 months). Family planning programs are widely viewed as having contributed to substantial maternal and neonatal mortality decline through contraceptive use-both by reducing unwanted births and by reducing the burden of these high-risk births. However, beyond averting births, the empirical evidence for the role of family planning in reducing high-risk births at population level is limited. We examined data from 205 Demographic and Health Surveys (DHS), conducted between 1985 and 2013, to describe the trends in high-risk births and their association with the pace of progress in modern contraceptive prevalence rate (yearly increase in rate of MCPR) in 57 developing countries. Using Blinder-Oaxaca decomposition technique, we then examine the contributions of family planning program, economic development (GDP per capita), and educational improvement (secondary school completion rate) on the progress of MCPR in order to link the net contribution of family planning program to the reduction of high-risk births mediated through contraceptive use. Countries that had the fastest progress in improving MCPR experienced the greatest declines in high-risk births due to short birth intervals (<24 months), high parity births (birth order >3), and older maternal age (>35 years). Births among younger women <18 years, however, did not decline significantly during this period. The decomposition analysis suggests that 63% of the increase in MCPR was due to family planning program efforts, 21% due to economic development, and 17% due to social advancement through women's education. Improvement in MCPR, predominately due to family planning programs, is a major driver of the decline in the burden of high-risk births due to high parity, shorter birth intervals, and older maternal age in developing countries. The lack of progress in the decline of births in younger women <18 years of age underscores the need for more attention to ensure that quality contraceptive methods are available to adolescent women in order to delay first births. This study substantiates the significance of family planning programming as a major health intervention for preventing high-risk births and associated maternal and child mortality, but it highlights the need for concerted efforts to strengthen service provision for adolescents.

    View details for DOI 10.1053/j.semperi.2015.06.006

    View details for Web of Science ID 000359877300003

    View details for PubMedID 26169538

  • Population-based Incidence and Etiology of Community-acquired Neonatal Viral Infections in Bangladesh: A Community-based and Hospital-based Surveillance Study. Pediatric infectious disease journal Farzin, A., Saha, S. K., Baqui, A. H., Choi, Y., Ahmed, N. U., Simoes, E. A., El Arifeen, S., Al-Emran, H. M., Bari, S., Rahman, S. M., Mannan, I., Crook, D., Seraji, H. R., Begum, N., Black, R. E., Santosham, M., Darmstadt, G. L. 2015; 34 (7): 706-711


    The etiology of >90% of cases of suspected neonatal infection remains unknown. We conducted community-based surveillance in conjunction with hospital-based surveillance in a rural region in Bangladesh from June 2006 to September 2007 to assess the incidence and etiology of community-acquired viral infections among neonates.Community health workers (CHWs) assessed neonates at home on days 0, 2, 5 and 8 after birth and referred cases of suspected illness to the hospital (CHW surveillance). Among neonates with clinically suspected upper respiratory tract infection (URTI), pneumonia, sepsis and/or meningitis, virus identification studies were conducted on nasal wash, cerebrospinal fluid and/or blood specimens. In the hospital-based surveillance, similar screening was conducted among all neonates (referred by CHWs and self-referred) who were admitted to the hospital.CHW surveillance found an incidence rate of 15.6 neonatal viral infections per 1000 live births with 30% of infections identified on the day of birth. Among neonates with suspected sepsis, a viral etiology was identified in 36% of cases, with enterovirus accounting for two-thirds of those infections. Respiratory syncytial virus was the most common etiologic agent among those with viral pneumonia (91%) and URTI (68%). There was a low incidence (1.2%) of influenza in this rural population.Viral infections are commonly associated with acute newborn illness, even in the early neonatal period. The estimated incidence was 5-fold greater than reported previously for bacterial infections. Low-cost preventive measures for neonatal viral infections are urgently needed.

    View details for DOI 10.1097/INF.0000000000000726

    View details for PubMedID 25961894

  • Effective interventions and strategies for improving early child development. BMJ (Clinical research ed.) Daelmans, B., Black, M. M., Lombardi, J., Lucas, J., Richter, L., Silver, K., Britto, P., Yoshikawa, H., Perez-Escamilla, R., MacMillan, H., Dua, T., Bouhouch, R. R., Bhutta, Z., Darmstadt, G. L., Rao, N. 2015; 351: h4029-?

    View details for DOI 10.1136/bmj.h4029

    View details for PubMedID 26371213

  • Sex differences in morbidity and care-seeking during the neonatal period in rural southern Nepal. Journal of health, population, and nutrition Rosenstock, S., Katz, J., Mullany, L. C., Khatry, S. K., LeClerq, S. C., Darmstadt, G. L., Tielsch, J. M. 2015; 33 (1): 11-?


    South Asian studies, including those from Nepal, have documented increased risk of neonatal mortality among girls, despite their early biologic survival advantage. We examined sex differences in neonatal morbidity and care-seeking behavior to determine whether such differences could help explain previously observed excess late neonatal mortality among girls in Nepal.A secondary analysis of data from a trial of chlorhexidine use among neonates in rural Nepal was conducted. The objective was to examine sex differences in neonatal morbidity and care-seeking behavior for ill newborns. Girls were used as the reference group.Referral for care was higher during the early neonatal period (ENP: 0-7 days old) (50.7%) than the late neonatal period (LNP: 8-28 days old) (31.3%), but was comparable by sex. There were some significant differences in reasons for referral by sex. Boys were significantly more often referred for convulsions/stiffness, having yellow body/eyes, severe skin infection, and having at least two of the following: difficulty breathing, difficulty feeding, fever, or vomiting during the ENP. Girls were more often referred for hypothermia. During the LNP, boys were significantly more often referred for having yellow body/eyes, persistent watery stool, and severe skin infection. There were no referral types in the LNP for which girls were more often referred. Less than half of those referred at any point were taken for care (47.0%) and referred boys were more often taken than girls (Neonatal Period OR: 1.77, 95% CI: 1.64 - 1.91). Family composition differentially impacted the relationship between care-seeking and sex. The greatest differences were in families with only prior living girls (Pahadi - ENP OR: 1.78, 95% CI: 1.29 - 2.45 and LNP OR: 1.51, 95% CI: 1.03 - 2.21; Madeshi - ENP OR: 2.86, 95% CI: 2.28 - 3.59 and LNP OR: 2.45, 95% CI: 1.84 - 3.26).Care-seeking was inadequate for both sexes, but ill boys were consistently more often taken for care than girls, despite comparable referral. Behavioral interventions to improve care-seeking, especially in the early neonatal period, are needed to improve neonatal survival. Addressing gender bias in care-seeking, explicitly and within interventions, is essential to reducing neonatal mortality differentials between boys and girls.

    View details for DOI 10.1186/s41043-015-0014-0

    View details for PubMedID 26825276

  • Validation of Rapid Neurodevelopmental Assessment for 2-to 5-Year-Old Children in Bangladesh PEDIATRICS Khan, N. Z., Muslima, H., Shilpi, A. B., Begum, D., Parveen, M., Akter, N., Ferdous, S., Nahar, K., McConachie, H., Darmstadt, G. L. 2013; 131 (2): E486-E494


    Validate a tool to determine neurodevelopmental impairments (NDIs) in >2- to 5-year-old children in a country with limited child development expertise.Rapid Neurodevelopmental Assessment (RNDA) is a tool designed to detect functional status and NDIs across multiple neurodevelopmental domains. Validity was determined in 77 children enrolled by door-to-door sampling in Dhaka and who were administered the RNDA by 1 of 6 testers (4 developmental therapists, 2 special education teachers) and simultaneously administered a test of adaptive behavior (AB; Independent Behavior Assessment Scale) and intelligence quotient (IQ) tests (Bayley Scales of Infant Development II, Stanford Binet Intelligence Scale, Wechsler Preschool and Primary Scales of Intelligence) by psychologists.Interrater reliability ranged from good to excellent. There were significant differences in AB in mean percentile scores on the Independent Behavior Assessment Scale for motor (P = .0001), socialization (P = .001), communication (P = .001), and full-scale (P = .001) scores in children with ≥1 NDI ("any NDI") versus no NDI. Significant differences in those with versus those without "any NDI" were found on IQ scores. Sensitivity and specificity for "significant difficulties" (defined as AB z-scores < -2 SDs and/or IQ <70) and "mild difficulties included" (AB z-scores < -1SD and/or IQ <85) were 90% and 60% and 80% and 76%, respectively.The RNDA validity results are promising for use by child care professionals in field and clinical settings, but the tool needs further replication and refinement for assessment of specific impairments of vision, hearing, and seizures.

    View details for DOI 10.1542/peds.2011-2421

    View details for Web of Science ID 000314355100018

    View details for PubMedID 23359579

  • Evaluation of neonatal verbal autopsy using physician review versus algorithm-based cause-of-death assignment in rural Nepal PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Freeman, J. V., Christian, P., Khatry, S. K., Adhikari, R. K., LeClerq, S. C., Katz, J., Darmstadt, G. L. 2005; 19 (4): 323-331


    Verbal autopsy (VA) is used to ascertain cause-specific neonatal mortality using parental/familial recall. We sought to compare agreement between causes of death obtained from the VA by physician review vs. computer-based algorithms. Data were drawn from a cluster-randomised trial involving 4130 live-born infants and 167 neonatal deaths in the rural Sarlahi District of Nepal. We examined the agreement between causes ascertained by physician review and algorithm assignment by the kappa (kappa) statistic. We also compared responses to identical questions posed posthumously during neonatal VA interviews with those obtained during maternal interviews and clinical examinations regarding condition of newborns soon after birth. Physician reviewers assigned prematurity or acute lower respiratory infection (ALRI) as causes of 48% of neonatal deaths; 41% were assigned as uncertain. The algorithm approach assigned sepsis (52%), ALRI (31%), birth asphyxia (29%), and prematurity (24%) as the most common causes of neonatal death. Physician review and algorithm assignment of causes of death showed high kappa for prematurity (0.73), diarrhoea (0.81) and ALRI (0.68), but was low for congenital malformation (0.44), birth asphyxia (0.17) and sepsis (0.00). Sensitivity and specificity of VA interview questions varied by symptom, with positive predictive values ranging from 50% to 100%, when compared with maternal interviews and examinations of neonates soon after birth. Analysis of the VA data by physician review and computer-based algorithms yielded disparate results for some causes but not for others. We recommend an analysis technique that combines both methods, and further validation studies to improve performance of the VA for assigning causes of neonatal death.

    View details for Web of Science ID 000229782200009

    View details for PubMedID 15958155

  • Perianal lymphangioma circumscriptum mistaken for genital warts PEDIATRICS Darmstadt, G. L. 1996; 98 (3): 461-463

    View details for Web of Science ID A1996VF50600023

    View details for PubMedID 8784378

  • Clinical picture ARCHIVES OF FAMILY MEDICINE Darmstadt, G. L., Tunnessen, W. W. 1996; 5 (8): 437-438

    View details for Web of Science ID A1996VH34100001

    View details for PubMedID 8797543

  • IMPETIGO - AN OVERVIEW PEDIATRIC DERMATOLOGY Darmstadt, G. L., Lane, A. T. 1994; 11 (4): 293-303


    This article reviews in detail the pathogenesis, clinical characteristics and management of impetigo in children. Impetigo is the most common bacterial skin infection of children. Most cases of nonbullous impetigo and all cases of bullous impetigo are caused by Staphylococcus aureus. The remainder of cases of nonbullous impetigo are due to group A beta hemolytic streptococci (GABHS). GABHS colonize the skin directly by binding to sites on fibronectin that are exposed by trauma. In contrast, S. aureus colonizes the nasal epithelium first; from this reservoir, colonization of the skin occurs. Patients with recurrent impetigo should be evaluated for carriage of S. aureus. Superficial, localized impetigo may be treated successfully in more than 90% of cases with topical application of mupirocin ointment. Impetigo that is widespread or involves deeper tissues should be treated with a beta-lactamase-resistant oral antibiotic. The choice of antibiotics is affected by the local prevalence of resistance to erythromycin among strains of S. aureus, antibiotic cost and availability, and issues of compliance.

    View details for Web of Science ID A1994PY11400001

    View details for PubMedID 7899177

  • PROTEUS SYNDROME PEDIATRIC DERMATOLOGY Darmstadt, G. L., Lane, A. T. 1994; 11 (3): 222-226


    A 10-month-old girl had macrodactyly, facial and extremity hemihypertrophy, plantar cerebriform hyperplasia, a subcutaneous mass on the back, macrocephaly, and lumbar kyphosis. These findings were diagnostic of Proteus syndrome. The clinical features, etiology, management, and points of differential diagnosis are discussed.

    View details for Web of Science ID A1994PE28000005

    View details for PubMedID 7971556


    View details for Web of Science ID A1994ND42800012

    View details for PubMedID 8143012