Children's Investment Fund Foundation Research Articles

National, regional, and global estimates of low birthweight in 2020, with trends from 2000: a systematic analysis

Low birthweight (LBW; <2500 g) is an important predictor of health outcomes throughout the life course. We aimed to update country, regional, and global estimates of LBW prevalence for 2020, with trends from 2000, to assess progress towards global targets to reduce LBW by 30% by 2030. For this systematic analysis, we searched population-based, nationally representative data on LBW from Jan 1, 2000, to Dec 31, 2020. Using 2042 administrative and survey datapoints from 158 countries and areas, we developed a Bayesian hierarchical regression model incorporating country-specific intercepts, time-varying covariates, non-linear time trends, and bias adjustments based on data quality. We also provided novel estimates by birthweight subgroups. An estimated 19·8 million (95% credible interval 18·4-21·7 million) or 14·7% (13·7-16·1) of liveborn newborns were LBW worldwide in 2020, compared with 22·1 million (20·7-23·9 million) and 16·6% (15·5-17·9) in 2000-an absolute reduction of 1·9 percentage points between 2000 and 2020. Using 2012 as the baseline, as this is when the Global Nutrition Target began, the estimated average annual rate of reduction from 2012 to 2020 was 0·3% worldwide, 0·85% in southern Asia, and 0·59% in sub-Saharan Africa. Nearly three-quarters of LBW births in 2020 occurred in these two regions: of 19 833 900 estimated LBW births worldwide, 8 817 000 (44·5%) were in southern Asia and 5 381 300 (27·1%) were in sub-Saharan Africa. Of 945 300 estimated LBW births in northern America, Australia and New Zealand, central Asia, and Europe, approximately 35·0% (323 700) weighed less than 2000 g: 5·8% (95% CI 5·2-6·4; 54 800 [95% CI 49 400-60 800]) weighed less than 1000 g, 9·0% (8·7-9·4; 85 400 [82 000-88 900]) weighed between 1000 g and 1499 g, and 19·4% (19·0-19·8; 183 500 [180 000-187 000]) weighed between 1500 g and 1999 g. Insufficient progress has occurred over the past two decades to meet the Global Nutrition Target of a 30% reduction in LBW between 2012 and 2030. Accelerating progress requires investments throughout the lifecycle focused on primary prevention, especially for adolescent girls and women living in the most affected countries. With increasing numbers of births in facilities and advancing electronic information systems, improvements in the quality and availability of administrative LBW data are also achievable. The Children's Investment Fund Foundation; the UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction; and the Bill & Melinda Gates Foundation.

Developing and validating an abortion care quality metric for facility and out-of-facility settings: an observational cohort study in Bangladesh, Ethiopia, and Nigeria

Despite progress in assuring provision of safe abortion, substantial disparities remain in quality of abortion care around the world. However, no consistent, valid, reliable method exists to routinely measure quality in abortion care across facility and out-of-facility settings, impeding learning and improvement. To address this need, the Abortion Service Quality Initiative developed the first global standard for measuring quality of abortion care in low-income and middle-income countries. This prospective cohort study was conducted in Bangladesh, Ethiopia, and Nigeria in 2020-2022. Participants included sites and providers offering abortion care, including health facilities, pharmacies, proprietary and patent medicine vendors (PPMVs), and hotlines, and clients aged 15-49 receiving abortion care from a selected site. 111 structure and process indicators were tested, which originated from a review of existing abortion quality indicators and from qualitative research to develop additional client-centred quality indicators. The indicators were tested against 12 clinical and client experience outcomes at the site-level (such as abortion-related deaths) and client-level (such as whether the client would recommend the service to a friend) that were expected to result from the abortion quality indicators. Indicators were selected for the final metric based on predictive validity assessed using Bayesian models to test associations between indicators and outcomes, content validity, and performance. We included 1915 abortion clients recruited from 131 sites offering abortion care across the three countries. Among the 111 indicators tested, 44 were associated with outcomes in Bayesian analyses and an additional 8 were recommended for inclusion by the study's Resource Group for face validity. These 52 indicators were evaluated on content validity, predictive validity, and performance, and 29 validated indicators were included in the final abortion care quality metric. The 29 validated indicators were feasibility tested among 53 clients and 24 providers from 9 facility sites in Ethiopia and 57 clients and 6 PPMVs from 9 PPMV sites in Nigeria. The median time required to complete each survey instrument indicated feasibility: 10min to complete the client exit survey, 16min to complete the provider survey, and 11min to complete the site checklist. Overall, the indicators performed well. However, all providers in the feasibility test failed two indicators of provider knowledge to competently complete the abortion procedure, and these indicators were subsequently revised to improve performance. This study provides 29 validated abortion care quality indicators to assess quality in facility, pharmacy, and hotline settings in low-income and middle-income countries. Future research should validate the Abortion Care Quality (ACQ) Tool in additional abortion care settings, such as telemedicine, online medication abortion (MA) sellers, and traditional abortion providers, and in other geographical and legal settings. The David and Lucile Packard Foundation and the Children's Investment Fund Foundation.

Donor aid mentioning newborns and stillbirths, 2002–19: an analysis of levels, trends, and equity

Global aid for reproductive, maternal, newborn, and child health has stagnated in recent years, and aid mentioning newborns or stillbirths has previously represented a very small proportion of aid for reproductive, maternal, newborn, and child health. Neonatal survival targets have been set by 78 countries, and stillbirth prevention targets have been set by 30 countries, to address the 4·4 million newborn deaths and stillbirths globally. We aimed to generate novel estimates of current levels of, and trends in, aid mentioning newborns and stillbirths over 2002-19, and to assess whether the amount of aid disbursed aligns with the associated mortality burden. For this analysis, we did a manual review and coding of the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System database from 2002 to 2019 using key search terms for aid mentioning newborns and stillbirths. We compared these findings with estimates of aid for reproductive, maternal, newborn, and child health for 2002-19 based on the Muskoka2 method. Findings are presented in 2019 US$ according to the OECD's Development Assistance Committee deflators, which account for variation in exchange rates and inflation in donor countries. We identified 21 957 unique records in the 2002-19 period. Aid mentioning newborns and stillbirths comprised approximately 10% ($1·6 billion) of reproductive, maternal, newborn, and child health funding overall in 2019 ($15·9 billion), with a small decrease in value between 2015 and 2019. 1284 (6%) of 21 957 records and 3·4% ($535 million) of their total value mentioned aid focused only on newborn health. Ten donors contributed 87% ($13·7 billion) of the total value of aid mentioning newborns and stillbirths during 2002-19. Aid mentioning newborns and stillbirths was inequitably allocated in the least developed countries (as defined by the UN), ranging from $18 per death in Angola to $1389 per death in Timor-Leste. Stillbirths were not mentioned in any funding in 2002-09, and they were only mentioned in 46 of 21 957 records in 2010-19, comprising $44·4 million of aid disbursed during this period. Aid mentioning newborns and stillbirths is poorly matched to their corresponding mortality burden (representing 10% of aid for reproductive, maternal, newborn, and child health overall, yet accounting for approximately 50% of mortality in children <5 years) and across recipient countries (with substantial variation in the amount of aid received per newborn death and stillbirth between countries with similar health and economic needs). Our findings indicate that aid needs to be better targeted to populations with the highest mortality burdens, creating greater potential for impact. John D and Catherine T MacArthur Foundation, Bill & Melinda Gates Foundation, ELMA Philanthropies, Children's Investment Fund Foundation UK, Lemelson Foundation, and Ting Tsung and Wei Fong Chao Foundation. For the French translation of the abstract see Supplementary Materials section.

National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis

Preterm birth is the leading cause of neonatal mortality and is associated with long-term physical, neurodevelopmental, and socioeconomic effects. This study updated national preterm birth rates and trends, plus novel estimates by gestational age subgroups, to inform progress towards global health goals and targets, and aimed to update country, regional, and global estimates of preterm birth for 2020 in addition to trends between 2010 and 2020. We systematically searched population-based, nationally representative data on preterm birth from Jan 1, 2010, to Dec 31, 2020 and study data (26 March-14 April, 2021) for countries and areas with no national-level data. The analysis included 679 data points (86% nationally representative administrative data [582 of 679 data points]) from 103 countries and areas (62% of countries and areas having nationally representative administrative data [64 of 103 data points]). A Bayesian hierarchical regression was used for estimating country-level preterm rates, which incoporated country-specific intercepts, low birthweight as a covariate, non-linear time trends, and bias adjustments based on a data quality categorisation, and other indicators such as method of gestational age estimation. An estimated 13·4 million (95% credible interval [CrI] 12·3-15·2 million) newborn babies were born preterm (<37 weeks) in 2020 (9·9% of all births [95% CrI 9·1-11·2]) compared with 13·8 million (12·7-15·5 million) in 2010 (9·8% of all births [9·0-11·0]) worldwide. The global annual rate of reduction was estimated at -0·14% from 2010 to 2020. In total, 55·6% of total livebirths are in southern Asia (26·8% [36 099 000 of 134 767 000]) and sub-Saharan Africa (28·7% [38 819 300 of 134 767 000]), yet these two regions accounted for approximately 65% (8 692 000 of 13 376 200) of all preterm births globally in 2020. Of the 33 countries and areas in the highest data quality category, none were in southern Asia or sub-Saharan Africa compared with 94% (30 of 32 countries) in high-income countries and areas. Worldwide from 2010 to 2020, approximately 15% of all preterm births occurred at less than 32 weeks of gestation, requiring more neonatal care (<28 weeks: 4·2%, 95% CI 3·1-5·0, 567 800 [410 200-663 200 newborn babies]); 28-32 weeks: 10·4% [9·5-10·6], 1 392 500 [1 274 800-1 422 600 newborn babies]). There has been no measurable change in preterm birth rates over the last decade at global level. Despite increasing facility birth rates and substantial focus on routine health data systems, there remain many missed opportunities to improve preterm birth data. Gaps in national routine data for preterm birth are most marked in regions of southern Asia and sub-Saharan Africa, which also have the highest estimated burden of preterm births. Countries need to prioritise programmatic investments to prevent preterm birth and to ensure evidence-based quality care when preterm birth occurs. Investments in improving data quality are crucial so that preterm birth data can be improved and used for action and accountability processes. The Children's Investment Fund Foundation and the UNDP, United Nations Population Fund-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Infection prevention and care bundles addressing health care-associated infections in neonatal care in low-middle income countries: a scoping review.

SummaryBackgroundHealth care-associated infections (HCAI) in neonatal units in low- and middle-income countries (LMIC) are a major cause of mortality. This scoping review aimed to synthesise published literature on infection prevention and care bundles addressing neonatal HCAI in LMICs and to construct a Classification Framework for their components (elements).MethodsFive electronic databases were searched between January 2001 and July 2020. A mixed-methods approach was applied: qualitative content analysis was used to build a classification framework to categorise bundle elements and the contents of the classification groups were then described quantitatively.Findings3619 records were screened, with 44 eligible studies identified. The bundle element Classification Framework created involved: (1) Primary prevention, (2) Detection, (3) Case management, and Implementation (3 + I). The 44 studies included 56 care bundles with 295 elements that were then classified. Primary prevention elements (128, 43%) predominated of which 71 (55%) focused on central line catheters and mechanical ventilators. Only 12 elements (4%) were related to detection. A further 75 (25%) elements addressed case management and 66 (88%) of these aimed at outbreak control.InterpretationThe 3 + I Classification Framework was a feasible approach to reporting and synthesising research for infection-relevant bundled interventions in neonatal units. A shift towards the use in infection prevention and care bundles of primary prevention elements focused on the neonate and on commonly used hospital devices in LMIC (e.g., self-inflating bags, suctioning equipment) would be valuable to reduce HCAI transmission. Detection elements were a major gap.FundingThis work was made possible in part by the John D. and Catherine T. MacArthur Foundation, the Bill & Melinda Gates Foundation, ELMA Philanthropies, The Children's Investment Fund Foundation UK, The Lemelson Foundation, and the Ting Tsung and Wei Fong Chao Foundation under agreements to William Marsh Rice University. The project leading to these results has also received the support of a fellowship from the “la Caixa” Foundation (ID 100010434). The fellowship code is LCF/BQ/EU19/11710040. EJAF is an Academic Clinical Fellow whose salary is funded by the UK National Institute for Health Research (NIHR). NES receives a Research Training Program Scholarship (Australian Commonwealth Government).

Assessment of the validity of the measurement of newborn and maternal health-care coverage in hospitals (EN-BIRTH): an observational study

Progress in reducing maternal and neonatal deaths and stillbirths is impeded by data gaps, especially regarding coverage and quality of care in hospitals. We aimed to assess the validity of indicators of maternal and newborn health-care coverage around the time of birth in survey data and routine facility register data. Every Newborn-BIRTH Indicators Research Tracking in Hospitals was an observational study in five hospitals in Bangladesh, Nepal, and Tanzania. We included women and their newborn babies who consented on admission to hospital. Exclusion critiera at admission were no fetal heartbeat heard or imminent birth. For coverage of uterotonics to prevent post-partum haemorrhage, early initiation of breastfeeding (within 1 h), neonatal bag-mask ventilation, kangaroo mother care (KMC), and antibiotics for clinically defined neonatal infection (sepsis, pneumonia, or meningitis), we collected time-stamped, direct observation or case note verification data as gold standard. We compared data reported via hospital exit surveys and via hospital registers to the gold standard, pooled using random effects meta-analysis. We calculated population-level validity ratios (measured coverage to observed coverage) plus individual-level validity metrics. We observed 23 471 births and 840 mother-baby KMC pairs, and verified the case notes of 1015 admitted newborn babies regarding antibiotic treatment. Exit-survey-reported coverage for KMC was 99·9% (95% CI 98·3-100) compared with observed coverage of 100% (99·9-100), but exit surveys underestimated coverage for uterotonics (84·7% [79·1-89·5]) vs 99·4% [98·7-99·8] observed), bag-mask ventilation (0·8% [0·4-1·4]) vs 4·4% [1·9-8·1]), and antibiotics for neonatal infection (74·7% [55·3-90·1] vs 96·4% [94·0-98·6] observed). Early breastfeeding coverage was overestimated in exit surveys (53·2% [39·4-66·8) vs 10·9% [3·8-21·0] observed). "Don't know" responses concerning clinical interventions were more common in the exit survey after caesarean birth. Register data underestimated coverage of uterotonics (77·9% [37·8-99·5] vs 99·2% [98·6-99·7] observed), bag-mask ventilation (4·3% [2·1-7·3] vs 5·1% [2·0-9·6] observed), KMC (92·9% [84·2-98·5] vs 100% [99·9-100] observed), and overestimated early breastfeeding (85·9% (58·1-99·6) vs 12·5% [4·6-23·6] observed). Inter-hospital heterogeneity was higher for register-recorded coverage than for exit survey report. Even with the same register design, accuracy varied between hospitals. Coverage indicators for newborn and maternal health care in exit surveys had low accuracy for specific clinical interventions, except for self-report of KMC, which had high sensitivity after admission to a KMC ward or corner and could be considered for further assessment. Hospital register design and completion are less standardised than surveys, resulting in variable data quality, with good validity for the best performing sites. Because approximately 80% of births worldwide take place in facilities, standardising register design and information systems has the potential to sustainably improve the quality of data on care at birth. Children's Investment Fund Foundation and Swedish Research Council.

Patterns of individual non-treatment during multiple rounds of mass drug administration for control of soil-transmitted helminths in the TUMIKIA trial, Kenya: a secondary longitudinal analysis

SummaryBackgroundFew studies have been done of patterns of treatment during mass drug administration (MDA) to control neglected tropical diseases. We used routinely collected individual-level treatment records that had been collated for the Tuangamize Minyoo Kenya Imarisha Afya (Swahili for Eradicate Worms in Kenya for Better Health [TUMIKIA]) trial, done in coastal Kenya from 2015 to 2017. In this analysis we estimate the extent of and factors associated with the same individuals not being treated over multiple rounds of MDA, which we term systematic non-treatment.MethodsWe linked the baseline population of the TUMIKIA trial randomly assigned to receive biannual community-wide MDA for soil-transmitted helminthiasis to longitudinal records on receipt of treatment in any of the four treatment rounds of the study. We fitted logistic regression models to estimate the association of non-treatment in a given round with non-treatment in the previous round, controlling for identified predictors of non-treatment. We also used multinomial logistic regression to identify factors associated with part or no treatment versus complete treatment.Findings36 327 participants were included in our analysis: 16 236 children aged 2–14 years and 20 091 adults aged 15 years or older. The odds of having no treatment recorded was higher if a participant was not treated during the previous round of MDA (adjusted odds ratio [OR] 3·60, 95% CI 3·08–4·20 for children and 5·58, 5·01–6·21 for adults). For children, school attendance and rural residence reduced the odds of receiving part or no treatment, whereas odds were increased by least poor socioeconomic status and living in an urban or periurban household. Women had higher odds than men of receiving part or no treatment. However, when those with pregnancy or childbirth in the previous 2 weeks were excluded, women became more likely to receive complete treatment. Adults aged 20–25 years were the age group with the highest odds of receiving part (OR 1·41, 95% CI 1·22–1·63) or no treatment (OR 1·81, 95% CI 1·53–2·14).InterpretationNon-treatment was associated with specific sociodemographic groups and characteristics and did not occcur at random. This finding has important implications for MDA programme effectiveness, the relevance of which will intensify as disease prevalence decreases and infections become increasingly clustered.FundingBill & Melinda Gates Foundation, Joint Global Health Trials Scheme of the Medical Research Council, UK Department for International Development, Wellcome Trust, Children's Investment Fund Foundation, and London Centre for Neglected Tropical Diseases.

Testing the Impact of Layered Health and Nutrition Interventions in Rajasthan, India: Baseline Findings on Birthweight

Abstract Objectives The Children's Investment Fund Foundation (CIFF) in partnership with the Government of Rajasthan seeks to reduce prevalence of low birthweight through multi-faceted interventions to strengthen existing delivery of services during pregnancy continuing into early childhood. We employed a quasi-experimental matched case design with matching at district, block, and sub-center level to enable a difference-in-difference estimation of impact of the interventions at endline. Methods We conducted a retrospective baseline survey of mothers with children under three years in 2018 to assess prevalence of low birthweight in six districts of Rajasthan. Primary household survey data was collected on 8583 mothers with children under the age of three years and 2406 currently pregnant women. Birthweight records of 5702 children under three years were collected from public facilities where the children were reported to be delivered by the mothers surveyed. Results Matching facility birthweight records of children born to mothers in the sample confirmed heaping of data, consistent with studies from developing countries that rely on administrative or secondary sources of birthweight records. We observed heaping of birthweight readings around multiples of 500 gms; 23% of the new-borns weighed 2.5 kgs and 19% weighed 3 kgs. Possible reasons for misreporting include malfunctioning or mis calibrated spring scales, manual data entry errors in the labor room registers, poor knowledge of optimal weighing practices and misclassification of low birthweight new-borns as normal birthweight. Conclusions Concerns with reliance on facility records for the key impact indicator have highlighted the need for standardisation of birthweight measurement at public delivery facilities. All public delivery facilities in the evaluation's treatment and control areas will receive digital weighing scales in labor rooms, along with training and mentoring of labor room staff based on a standardised protocol. This has implications for endline assessment of impact - average birthweight (continuous variable) will be used as the primary outcome for difference-in-difference impact estimation at endline. Changes in prevalence of low birthweight will only be tested using endline sample conditional on baseline equivalence. Funding Sources Children's Investment Fund Foundation.

Randomised comparison of two household survey modules for measuring stillbirths and neonatal deaths in five countries: the Every Newborn-INDEPTH study

An estimated 5·1 million stillbirths and neonatal deaths occur annually. Household surveys, most notably the Demographic and Health Survey (DHS), run in more than 90 countries and are the main data source from the highest burden regions, but data-quality concerns remain. We aimed to compare two questionnaires: a full birth history module with additional questions on pregnancy losses (FBH+; the current DHS standard) and a full pregnancy history module (FPH), which collects information on all livebirths, stillbirths, miscarriages, and neonatal deaths. Women residing in five Health and Demographic Surveillance System sites within the INDEPTH Network (Bandim in Guinea-Bissau, Dabat in Ethiopia, IgangaMayuge in Uganda, Matlab in Bangladesh, and Kintampo in Ghana) were randomly assigned (individually) to be interviewed using either FBH+ or FPH between July 28, 2017, and Aug 13, 2018. The primary outcomes were stillbirths and neonatal deaths in the 5 years before the survey interview (measured by stillbirth rate [SBR] and neonatal mortality rate [NMR]) and mean time taken to complete the maternity history section of the questionnaire. We also assessed between-site heterogeneity. This study is registered with the Research Registry, 4720. 69 176 women were allocated to be interviewed by either FBH+ (n=34 805) or FPH (n=34 371). The mean time taken to complete FPH (10·5 min) was longer than for FBH+ (9·1 min; p<0·0001). Using FPH, the estimated SBR was 17·4 per 1000 total births, 21% (95% CI -10 to 62) higher than with FBH+ (15·2 per 1000 total births; p=0·20) in the 5 years preceding the survey interview. There was strong evidence of between-site heterogeneity (I2=80·9%; p<0·0001), with SBR higher for FPH than for FBH+ in four of five sites. The estimated NMR did not differ between modules (FPH 25·1 per 1000 livebirths vs FBH+ 25·4 per 1000 livebirths), with no evidence of between-site heterogeneity (I2=0·7%; p=0·40). FPH takes an average of 1·4 min longer to complete than does FBH+, but has the potential to increase reporting of stillbirths in high burden contexts. The between-site heterogeneity we found might reflect variations in interviewer training and survey implementation, emphasising the importance of interviewer skills, training, and consistent implementation in data quality. Children's Investment Fund Foundation.

National, regional, and worldwide estimates of low birthweight in 2015, with trends from 2000: a systematic analysis

SummaryBackgroundLow birthweight (LBW) of less than 2500 g is an important marker of maternal and fetal health, predicting mortality, stunting, and adult-onset chronic conditions. Global nutrition targets set at the World Health Assembly in 2012 include an ambitious 30% reduction in LBW prevalence between 2012 and 2025. Estimates to track progress towards this target are lacking; with this analysis, we aim to assist in setting a baseline against which to assess progress towards the achievement of the World Health Assembly targets.MethodsWe sought to identify all available LBW input data for livebirths for the years 2000–16. We considered population-based national or nationally representative datasets for inclusion if they contained information on birthweight or LBW prevalence for livebirths. A new method for survey adjustment was developed and used. For 57 countries with higher quality time-series data, we smoothed country-reported trends in birthweight data by use of B-spline regression. For all other countries, we estimated LBW prevalence and trends by use of a restricted maximum likelihood approach with country-level random effects. Uncertainty ranges were obtained through bootstrapping. Results were summed at the regional and worldwide level.FindingsWe collated 1447 country-years of birthweight data (281 million births) for 148 countries of 195 UN member states (47 countries had no data meeting inclusion criteria). The estimated worldwide LBW prevalence in 2015 was 14·6% (uncertainty range [UR] 12·4–17·1) compared with 17·5% (14·1–21·3) in 2000 (average annual reduction rate [AARR] 1·23%). In 2015, an estimated 20·5 million (UR 17·4–24·0 million) livebirths were LBW, 91% from low-and-middle income countries, mainly southern Asia (48%) and sub-Saharan Africa (24%).InterpretationAlthough these estimates suggest some progress in reducing LBW between 2000 and 2015, achieving the 2·74% AARR required between 2012 and 2025 to meet the global nutrition target will require more than doubling progress, involving both improved measurement and programme investments to address the causes of LBW throughout the lifecycle.FundingBill & Melinda Gates Foundation, The Children's Investment Fund Foundation, United Nations Children's Fund (UNICEF), and WHO.

Effects, equity, and cost of school-based and community-wide treatment strategies for soil-transmitted helminths in Kenya: a cluster-randomised controlled trial

SummaryBackgroundSchool-based deworming programmes can reduce morbidity attributable to soil-transmitted helminths in children but do not interrupt transmission in the wider community. We assessed the effects of alternative mass treatment strategies on community soil-transmitted helminth infection.MethodsIn this cluster-randomised controlled trial, 120 community units (clusters) serving 150 000 households in Kenya were randomly assigned (1:1:1) to receive albendazole through annual school-based treatment targeting 2–14 year olds or annual or biannual community-wide treatment targeting all ages. The primary outcome was community hookworm prevalence, assessed at 12 and 24 months through repeat cross-sectional surveys. Secondary outcomes were Ascaris lumbricoides and Trichuris trichiura prevalence, infection intensity of each soil-transmitted helminth species, and treatment coverage and costs. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02397772.FindingsAfter 24 months, prevalence of hookworm changed from 18·6% (95% CI 13·9–23·2) to 13·8% (10·5–17·0) in the annual school-based treatment group, 17·9% (13·7–22·1) to 8·0% (6·0–10·1) in the annual community-wide treatment group, and 20·6% (15·8–25·5) to 6·2% (4·9–7·5) in the biannual community-wide treatment group. Relative to annual school-based treatment, the risk ratio for annual community-wide treatment was 0·59 (95% CI 0·42–0·83; p<0·001) and for biannual community-wide treatment was 0·46 (0·33–0·63; p<0·001). More modest reductions in risk were observed after 12 months. Risk ratios were similar across demographic and socioeconomic subgroups after 24 months. No adverse events related to albendazole were reported.InterpretationCommunity-wide treatment was more effective in reducing hookworm prevalence and intensity than school-based treatment, with little additional benefit of treating every 6 months, and was shown to be remarkably equitable in coverage and effects.FundingBill & Melinda Gates Foundation, the Joint Global Health Trials Scheme of the Medical Research Council, the UK Department for International Development, the Wellcome Trust, and the Children's Investment Fund Foundation.

Getting Treatment and Care Services Right for Children and Adolescents to Reach High Viral Suppression.

In August 2014, PEPFAR and the Children's Investment Fund Foundation launched the Accelerating Children's HIV/AIDS Treatment (ACT) initiative with the aim of doubling the number of children on antiretroviral treatment in 9 African countries. Increasing rates of pretreatment drug resistance and use of suboptimal treatment regimens and formulations result in poor adherence and high rates of viral failure. Supporting adherence and ensuring appropriate treatment monitoring are needed to maximize duration of first-line treatment and enable timely sequencing to subsequent lines of antiretroviral treatment. Although timely antiretroviral treatment is the core of clinical care for infants, children and adolescents living with HIV, ensuring a broader package of biomedical and non-biomedical interventions is also required to address highly prevalent comorbidities among children living with HIV. Providing such a comprehensive package has been challenging for health care workers who lack the necessary skills and confidence to care for pediatric populations. Efforts to simplify clinical management and specific training and mentorship are needed to address these challenges. In this article, we review the progress made during the ACT initiative and the persistent challenges in achieving and maintaining virological suppression across the age spectrum. We identify innovations needed to build on the success of the ACT initiative. Despite the challenges, achieving high levels of virological suppression in children and adolescents is possible. The complexity of pediatric HIV treatment can be offset as antiretroviral regimens become more effective, tolerable, and easier to prescribe and administer. Meanwhile, basic programmatic elements to address comorbidities as well as support health care workers remain critical. In this article we review the progress made through the ACT initiative, as well as identify innovations needed to address persistent challenges to viral suppression across the age spectrum.

Strategies for Identifying and Linking HIV-Infected Infants, Children, and Adolescents to HIV Treatment Services in Resource Limited Settings.

Many children living with HIV in resource-limited settings remain undiagnosed and at risk for HIV-related mortality and morbidity. This article describes 5 key strategies for strengthening HIV case finding and linkage to treatment for infants, children, and adolescents. These strategies result from lessons learned during the Accelerating Children's HIV/AIDS Treatment Initiative, a public-private partnership between the President's Emergency Plan for AIDS Relief (PEPFAR) and the Children's Investment Fund Foundation (CIFF). The 5 strategies include (1) implementing a targeted mix of HIV case finding approaches (eg, provider-initiated testing and counseling within health facilities, optimization of early infant diagnosis, index family testing, and integration of HIV testing within key population and orphan and vulnerable children programs); (2) addressing the unique needs of adolescents; (3) collecting and using data for program improvement; (4) fostering a supportive political and community environment; and (5) investing in health system-strengthening activities. Continued advocacy and global investments are required to eliminate AIDS-related deaths among children and adolescents.

ACTing in Partnership to Accelerate Impact.

Partnership between funders plays a vital role in tackling the AIDS epidemic and can help partners deliver "more than the sum of their parts." But how do partnerships form? How is value leveraged and maximized? How can partnerships achieve policy change? This article addresses these questions through the example of the Accelerating Children's HIV/AIDS Treatment Initiative, an ambitious $200 million public private partnership with a goal of doubling the number of children living with HIV on treatment in 9 priority African countries over a 2-year period. It describes how the partnership formed between the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Children's Investment Fund Foundation (CIFF), and the differing styles, vision, and resources each organization contributed. It also gives examples of policy influence at global level and policy change at national level. Finally, the article considers whether working in partnership was more or less effective than independent funding, with reflections on the value and challenges of collaboration.

Sustainability and Accelerating Children's HIV/AIDS Treatment (ACT) Initiative: Lessons for the Next Treatment Surge.

The Accelerating Children's HIV/AIDS Treatment (ACT) Initiative was an ambitious joint donor initiative to increase the number of HIV-positive children and adolescents on treatment over a 2-year period from 2014 to 2016. The funding was provided by the US Government's President's Emergency Plan for AIDS Relief (PEPFAR) and the private Children's Investment Fund Foundation (CIFF). Great gains were achieved across the 9 ACT focus countries in pediatric treatment coverage. This article assesses the status of sustainability in the ACT countries after the pediatric treatment surge using PEPFAR sustainability data and a CIFF independent evaluation of sustainability. Although a focus on treatment is critical for pediatric HIV and HIV broadly, there is also a need to support the host country ability to maintain the progress gained once donor funds and initiatives transition. It uses the case of the ACT Initiative to argue that although surge activities are successful in rapidly scaling treatment results, there are concerns related to the health system's ability to maintain the progress along the full cascade. It shares important lessons for planning for and management of transition to support future donor efforts in pediatric HIV, overall HIV programming, and broader global health initiatives.

Effect of self-administration versus provider-administered injection of subcutaneous depot medroxyprogesterone acetate on continuation rates in Malawi: a randomised controlled trial.

Injectable contraceptives are popular in sub-Saharan Africa but have high discontinuation rates due partly to the need for provider-administered re-injection. We compared continuation rates of women who self-injected subcutaneous depot medroxyprogesterone acetate (DMPA-SC) and women who received DMPA-SC from a health-care provider, including community health workers (CHWs). We did an open-label randomised controlled trial based at six Ministry of Health clinics in rural Mangochi District, Malawi. Health-care providers recruited adult women who presented at the six clinics or to CHWs in rural communities in the clinic catchment areas. Participants received DMPA-SC and were randomised (1:1) to receive provider-administered injections or training in how to self-inject DMPA-SC. Randomisation was done via a computer-generated block randomisation schedule with block sizes of four, six, and eight and stratified by study site, generated by an independent statistician. Self-injectors administered the first injection under observation and were sent home with three doses, written instructions, and a calendar. The provider-administered group received a DMPA-SC injection and a calendar, and were asked to return for subsequent injections. Data collectors contacted participants after the 14-week re-injection window at 3, 6, and 9 months to collect continuation data. At 12 months after enrolment or early discontinuation, women had their final interview, which included pregnancy testing. The primary outcome was discontinuation of DMPA-SC, as assessed in the intention-to-treat population. We used Kaplan-Meier methods to estimate the probabilities of continuation and a log-rank test to compare groups. Safety was assessed in the as-treated population, which consisted only of participants who successfully received at least one DMPA-SC injection after randomisation. This trial is registered with ClinicalTrials.gov, number NCT02293694. This study lasted from Sept 17, 2015, to Feb 21, 2017. 731 women underwent randomisation, with 364 assigned to the self-administered group and 367 to the provider-administered group. One woman in the self-injection group withdrew at month 0. Treatment was discontinued by 99 women in the self-administered group and 199 women in the provider-administered group. The 12 month continuation rate was 73% in the self-injection group and 45% in the provider-administered group, giving an incidence rate ratio of 0·40 (95% CI 0·31-0·51; p<0·0001). Adverse events deemed to potentially be treatment-related were reported by ten women (20 events) in the self-administered group and 17 women (28 events) in the provider-administered group. Five serious adverse events were reported during the trial by four women; two events related to DMPA-SC (menorrhagia and anaemia requiring hospital admission) were reported by the same woman in the provider-administered group and resolved without sequelae. The other serious adverse events, including one death, were deemed to be unrelated to DMPA-SC. Women who self-injected DMPA-SC had significantly higher rates of continuation than those receiving provider-injected DMPA-SC. Community-based provision of injectable contraception for self-injection in low-resource settings seems to be safe and feasible. Self-administration of DMPA-SC should be made widely available. United States Agency for International Development and Children's Investment Fund Foundation.

Program Impact on Nutritional Status among Children Aged 6 to 24 Months in Rural Malawi: Findings from a Longitudinal Cohort Study

ObjectiveTo evaluate the 18‐month impact of a program providing a daily lipid‐based nutrient supplement (LNS) and social and behavior change communication (SBCC) to promote infant and young child feeding practices from 6–23 months, on undernutrition (stunting, wasting, and underweight) and linear‐ and ponderal growth [length‐for‐age z‐score (LAZ), weight‐for‐length (WLZ), weight‐for‐age (WAZ) z‐score] in rural Malawi.MethodsTwo cohorts of infants (n=348), aged 6–7 months, were enrolled in the program (n=176) and comparison (n=172) districts, respectively, and followed‐up at 12, 18, and 24 months of age. Child weight and length were taken at each visit and converted to z‐scores using the WHO child growth standards. Multilevel mixed‐effects linear regression models estimated the program impact on growth, accounting for within individual and village correlations, and adjusted for age, sex, and baseline nutritional status.ResultsPercentages of children stunted and wasted were comparable at enrollment in both districts: 42.4% and 1.5% (districts combined), but underweight was higher in the program district (15.4% vs. 6.5%;p&lt;0.01). A trend toward a higher LAZ emerged in the program district at 12 (+0.13 z;p=0.15) and 18 (+0.14 z; p=0.19) months of age, that was significant at 24 (+0.34 z; p=0.003) months. Similarly, significant program impact on WAZ was noted at 12 (+0.20 Z; p=0.03), continued at 18 months (+016 Z; p=0.08), and became larger at 24 months of age (+0.32 Z; p=0.003) in program over comparison district. No statistically significant differences between groups were notable for WLZ at any visit. Further, at 18 and 24 months of age, the percent of children underweight was lower by 8.3% (p=0.04) and 9.8% (p=0.02), respectively, in the program vs. comparison district. No significant reduction in the percent of children stunted or wasted between groups were found at any visit.ConclusionsFindings suggest that a daily provision of LNS and SBCC messaging from 6–23 months of age in rural Malawi may improve linear growth and underweight.Support or Funding InformationThis study was funded by the Children's Investment Fund Foundation, UK.

Politics and leadership in global health delivery: lessons from South Africa's HIV and health insurance initiatives

Abstract Background South Africa's Health Minister Aaron Motsoaledi inherited an HIV epidemic and a weak public health system when he took office in 2009. His priorities were to establish a national programme to address HIV and to create a system of national health insurance (NHI) to increase access to affordable and high-quality health care. By 2015, Motsoaledi's work on HIV was considered as a success; however, work on the creation of NHI was stymied. Here, we aimed to compare the design, promotion, and implementation of the national HIV programme—a primarily vertical programme—with that of NHI, a horizontal programme. Methods In January and February, 2015, we conducted 20 semi-structured interviews in South Africa with government leaders, civil society, researchers, health-care practitioners, private insurers, and international non-governmental organisations. We analysed interviews and available quantitative data from government, academic, and industry sources and distilled key themes in two teaching cases. Findings We identified several key differences between the HIV programme and NHI efforts, including the role that leadership and politics play in health policy and care delivery; the effect of historical, economic, and cultural context on outcomes and leaders' ability to institute change; and the importance of strategy in planning and decision making. We noted both contextual barriers (such as public distrust of government) and catalysts (demand for HIV treatment) in the programmes. Furthermore, the approach used by the Minister of Health sometimes hindered programme success (for example, the exclusion of private insurers from NHI design) and sometimes enabled success (such as the engagement of civil society in the HIV response). For both programmes, the availability or absence of outcomes data affected the Minister's ability to advocate for change and to make strategic decisions about how to invest in health. Interpretation The comparison of South Africa's well known and effective HIV programme with its stalled NHI efforts—both led by the same person with very different results––sheds light on important considerations when approaching complex, large-scale change. Our analysis of the politics of health systems shows how explicit acknowledgement of the political nature of health will lead to more effective health promotion strategies and policies. Political leaders can either drive or hinder the implementation of evidence-based public health practices. Funding The Ministerial Leadership in Health Program of the Harvard TH Chan School of Public Health, and Children's Investment Fund Foundation (CIFF), UK.

Conducting Formative Research to Understand Patterns and Determinants of Small‐quantity LNS Utilization in Rural Malawi and Mozambique

ObjectiveTo understand household utilization of a 20‐gram, lipid‐based nutrient supplement (LNS) for children 6 – 23 monthsMethodsIn Malawi and Mozambique, we conducted home‐feeding trials with small‐quantity, LNS for 8 and 6 weeks, respectively. In‐depth interviews (n = 38), direct meal observations (n = 80), full‐day observations (n = 38), and spot checks of LNS supply (n = 23), were conducted (n = 35 in Malawi; n = 24 in Mozambique) as triangulation. We analyzed data drawing from Grounded Theory with Atlas.ti v7.0 and using basic statistics.ResultsThe LNS was utilized contrary to recommended use, with 50% of households in Malawi running out of stock early and 87% of households in Mozambique either over‐ or under‐using it. Salient patterns of LNS sharing occurred in three ways: 1) caregiver consumption of LNS, 2) caregiver sharing of LNS with children &gt;2 years, and 3) theft by older children due to lack of storage. In Mozambique, it was common for caregivers to not only provide &gt;1 LNS sachet to children 6 – 23 months, but also forget or not be permitted by husbands to provide it. In Malawi, caregivers often gave LNS leftovers to children &gt;2 years. LNS utilization was largely governed by rational decision making in line with core cultural values and as coping mechanisms in light of food insecurity, rather than a mere disregard for program guidelines.ConclusionInterventions need to address reasons behind household choices to over‐ or under‐use a small‐quantity LNS and utilize strategies to intervene at key behavioral decision points to maximize adherence.Funded by Children's Investment Fund Foundation

Water, Sanitation and Hygiene (WASH) and Breastfeeding Contribute to Child Stunting in Rural Malawi

Evidence linking water, sanitation and hygiene (WASH) to stunting has been mixed but constitutes a possibly important contributor to chronic undernutrition in low and middle income countries. Using cross‐sectional baseline data of an impact evaluation of a nutrition program targeted at reducing maternal and child undernutrition, we assessed the extent to which optimal WASH practices contribute to reduced odds of stunting (length‐for‐age z‐score &lt;‐2 SD) among children 6 to 24 months of age living in two rural districts of Malawi. We used multivariable logistic regression with robust standard error estimation to measure the relationship between stunting and a composite of six WASH indicators (measured as an unweighted score ranging from 0‐11, with scores of 0, 1 or 2 assigned for levels of optimal water source and treatment, sanitation facility and cleanliness, handwashing with soap, and safe disposal of child feces), controlling for potential health, dietary, and socioeconomic confounders. 53% of children were stunted in this population. The median (IQR) of the WASH score was 5.5 (4‐6). A high WASH score (蠅8) (OR=0.71, 95% CI 0.51‐1.00) and breastfeeding 蠅10 times per day in the last 7 days (OR=0.50, 95% CI 0.27‐0.92) were associated with a reduced odds of stunting in an adjusted analysis; diarrhea, child age, sex, and maternal education, were all significantly associated with stunting in this population. Integration of WASH and infant and young child feeding interventions in nutrition programs may contribute to reductions in stunting in Malawi. Funded by the Children's Investment Fund Foundation, UK.