Well-baby Clinics Research Articles

Stress Assessment in Parents of Children With Autism Spectrum Disorder: A Prospective Case-Control Study.

Autism spectrum disorder (ASD) is a disorder that is manageable but has no cure. Therefore, it is associated with parental stress, which is often not given importance. Early identification and holistic management of children with ASD are needed. This prospective case-control study, conducted over 18 months, included 111 newly diagnosed autism cases (ages 2-9) from the Child Development Clinic at Shri Mahant Indiresh Hospital, Dehradun, India, diagnosed as per the International Clinical Epidemiology Network (INCLEN) criteria (DSM-V). Controls were 99 typically developing children from a well-baby clinic. Data collection involved administering the Autism Parenting Stress Scale and a predesigned questionnaire to both cases and controls. Parents with psychiatric or mental health issues were excluded. Parents of children with autism exhibited significantly higher stress scores compared to parents of typically developing children. In our study, out of a total of 210 subjects, 52.9% were diagnosed with autism, while 47.1% were controls.Cases were analyzed based on household and socioeconomic background. It was found that 94.6% of the cases showed significant stress levels. ASDsignificantly impacts parental stress, particularly among families from higher socioeconomic backgrounds and metropolitan areas. This study emphasizes the need for targeted support and interventions to address elevated stress levels and improve family dynamics, especially for parents of higher-functioning children.

Socioeconomic Factors and Clinical Characteristics Associated with Age at Autism Spectrum Disorder Diagnosis

Objective: Investigate factors influencing autism spectrum disorder (ASD) diagnosis in children under and over 36 months, and determine the average age for ASD diagnosis at Charoenkrung Pracharak Hospital, Bangkok, Thailand, after implementing ASD screening. Materials and Methods: A retrospective cross-sectional study of 252 children with ASD aged 1-15 years from 2014 to 2023, classified into ≤36 months (n=104) and >36 months (n=148) at diagnosis. Demographic, clinical data and child/family factors were analyzed using multivariate regression analysis. Results: Mean age at ASD diagnosis was 44.77 ± 19.91 months. Attending well-baby clinics (aOR 2.64, p=0.038), higher family income ≥ 814 US dollars per month (aOR 2.33, p=0.020), and higher parental education (aOR 3.43, p=0.011) were significantly associated with diagnosis before 36 months. Hyperactivity as the main complaint (aOR 0.07, p=0.001) and global developmental delay/intellectual disability (aOR 0.45, p=0.023) predicted later diagnosis. Child’s gender, being an only child, sibling order, and parental age had no significant impact. Conclusion: Over half of all ASD diagnoses occurred after age 3, with an average age around 44 months. Regular attendance in well-child clinics allowing ASD screening, and higher socioeconomic status and parental education facilitated earlier diagnosis. In contrast, concerns about hyperactivity and global developmental delay often lead to delayed ASD assessment. Enhancing awareness of ASD among families with limited resources can promote timely diagnosis and access to intervention.

Iron and Vitamin A Status of Children Aged 0 to 36 Months in Thulamela Municipality, Vhembe District, South Africa.

Objective: The present study assessed the iron and Vitamin A status of children aged 0 to 36 months in Thulamela municipality, Vhembe District. Methods: A cross-sectional study was conducted among 250 children aged 0 to 36 months attending well-baby clinic services with their mothers. Convenience sampling was used to select study participants, and simple random sampling was used to choose clinics. Data were gathered via a questionnaire administered by the researcher and field workers from August to September 2019. Standard techniques were used to measure body weight and height. In addition, serum retinol, haemoglobin, iron, ferritin, transferrin saturation, and transferrin levels were also assessed. Information on dietary diversity was gathered through a 24 h dietary recall. Results: The prevalence of underweight, wasting, and stunting was 3.6%, 2%, and 9.2%, respectively. Using serum retinol <10 µg/dL, 22% of children had vitamin A deficiency. The prevalence of anaemia was 53.6%, while 13.1% of children had iron deficiency anaemia when using serum ferritin of less than 12 μg/dL. Most children (90.8%) had an inadequate dietary diversity score, while 9.2% had sufficient dietary diversity. The most consumed food groups were grains, roots and tubers, vitamin A rich fruits and vegetable, and flesh foods. A higher percentage (44%) of children with low iron ferritin were underweight compared to those with normal iron ferritin (df = 1, p-value = 0.007). Conclusion: Iron, anaemia, and vitamin A deficiencies, accompanied by a high prevalence of stunting, were common among children in Thulamela Municipality. Thus, improving nutritional status in this area is a critical need.

Maternal micronutrient biomarkers and risk of non-syndromic cleft lip/palate: A case-control study.

This case-control study investigated the associations between maternal plasma vitamin B12, homocysteine, and red blood cell (RBC) folate levels and the risk of cleft lip with or without cleft palate (CL/P) in offspring. The study compared 94 mothers and children with non-syndromic CL/P from a teaching hospital in Thailand to 94 mother-infant controls from local well-baby clinics, frequency-matched by birth date and mother's education. Data included anthropometric measurements, blood sample analyses, and a questionnaire. Odds ratios (ORs) and 95% confidence intervals (CIs) estimated the associations through multiple logistic regression, adjusting for confounders. Mothers with higher plasma vitamin B12 levels had a lower risk of having a child with CL/P compared to those in the lowest quartile. This association was more pronounced among mothers without a family history of orofacial clefts and those who were not underweight. Conversely, elevated homocysteine levels, a marker of impaired B vitamin metabolism, increased the risk of CL/P. No association was found between RBC folate and CL/P. Higher maternal vitamin B12 levels are associated with a reduced risk of CL/P, while elevated homocysteine levels may increase the risk.

A Novel “Well Baby Clinic Service” Mobile Application: User Requirement Assessment and App Development

Abstract Background Utilization of under 5 year old child health care services in Egypt is considered low, the highest proportion of well-baby visits is mainly for immunization in the first two years of age. Parents may rely upon the internet and mobile applications (apps) for support in handling day to day parenting situations. mHealth (Mobile Health) interventions have the potential to be a useful and low-cost way to disseminate information about proper nutrition, can be used to monitor children’s growth using the official charts of World Health Organization, also can help in accessing vaccine-related information and recommended immunization schedules. Objectives To assess needs and requirements for a new comprehensive well-baby clinic mobile app. Also, to develop a mobile app prototype covering all well baby clinic service components which are: Physical growth, Developmental milestones, Immunizations, Nutrition and Safety &amp; emergency measures. Methods This work is done over two phases. In Exploratory phase, we assessed the need for the new app by performing bibliographic review of previous mHealth interventions in child-care field, market search of the available related apps and an online survey to assess the need and expectations of the new app. In preparatory phase, we developed the novel well baby clinic app that constituted all well baby clinic services for children’s health monitoring which are: Physical growth, Developmental milestones, Immunizations, Nutrition and Safety &amp; emergency measures relying on evidence-based information and honoring data safety. Results 13 Arabic apps were downloaded and extracted for review. All of these apps (100%∼13/13) were in the form of written articles that offered no interactive features for parents. All offered general health education not tailored according to the status of the child. None of them were developed by a university or a certified health organization. Almost all of them (92.3%∼12/13) were commercial apps as they included ads. Our online survey on 374 mothers showed that almost all of them (97.5%) reported the need of a new app to regularly follow their children’s health. They also reported the need of nutrition, developmental milestones and physical growth services in the app. We developed “Sehhat Tefly” app constituting caregiver information, child sociodemographic characteristics and the 6 previously mentioned services, it also included health education videos and a conclusive report section. Conclusion After vigorous review of literature, market search and user requirement assessment, apps reviewed didn’t provide any comprehensive approach to well-baby clinic services on a scientific basis. Upon market requirement for child m-health, we developed “Sehhat Tefly” app. The full potential of this app is yet to be defined. Further studies are needed to assess accessibility and usability of the app and to explore difficulties and barriers faced by users in different services.

Barriers to Achieving the Recommended Duration of Breastfeeding in Women Visiting the Well-Baby Clinic of King Abdulaziz University Hospital: A Cross-Sectional Study

Barriers to Achieving the Recommended Duration of Breastfeeding in Women Visiting the Well-Baby Clinic of King Abdulaziz University Hospital: A Cross-Sectional Study

Integration of cervical cancer screening into healthcare facilities in low- and middle-income countries: A scoping review.

Cervical cancer is a prevalent disease among women, especially in low- and middle-income countries (LMICs), where most deaths occur. Integrating cervical cancer screening services into healthcare facilities is essential in combating the disease. Thus, this review aims to map evidence related to integrating cervical cancer screening into existing primary care services and identify associated barriers and facilitators in LMICs. The scoping review employed a five-step framework as proposed by Arksey and O'Malley. Five databases (MEDLINE, Maternity Infant Care, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science) were systematically searched. Data were extracted, charted, synthesized, and summarised. A total of 28 original articles conducted in LMICs from 2000 to 2023 were included. Thirty-nine percent of the reviewed studies showed that cervical cancer screening (CCS) was integrated into HIV clinics. The rest of the papers revealed that CCS was integrated into existing reproductive and sexual health clinics, maternal and child health, family planning, well-baby clinics, maternal health clinics, gynecology outpatient departments, and sexually transmitted infections clinics. The cost-effectiveness of integrated services, promotion, and international initiatives were identified as facilitators while resource scarcity, lack of skilled staff, high client loads, lack of preventive oncology policy, territorial disputes, and lack of national guidelines were identified as barriers to the services. The evidence suggests that CCS can be integrated into healthcare facilities in LMICs, in various primary care services, including HIV clinics, reproductive and sexual health clinics, well-baby clinics, maternal health clinics, and gynecology OPDs. However, barriers include limited health system capacity, workload, waiting times, and lack of coordination. Addressing these gaps could strengthen the successful integration of CCS into primary care services and improve cervical cancer prevention and treatment outcomes.

Child behaviour is a main concern for parents of 3-year-olds.

The aim of this study was to describe parental concerns about child health and behaviour and their sociodemographic predictors in 3-year-olds, in relation to the national guidelines of well-baby clinics. The study included parents of 33 526 children in Stockholm who had completed a questionnaire prior to a routine visit to a well-baby clinic at age 3 years. Multivariate regression was used to analyse predictors for concerns. Child behaviour problems, defined as defiance and problem with adherence to daily routines, were the most common parental concerns (36.4%), with poor social skills and relations being second (21.8%). Regarding development, 9.6% had concerns about speech and 4.7% about motor development. Screen use (9.5%) and being underweight (6.3%) were other common parental concerns, while lifestyle concerns regarding physical activity and overweight were rare. Parents raised about twice as many concerns for first-born children compared with younger siblings. Child behaviour and developmental concerns were more frequent in families where the mother had primary education only and attended a well-baby clinic with a high Care Need Index. Parents' concerns reflected the national guidelines about child development and behaviour, but not its emphasis on a healthy lifestyle.

Determinants and Prevalence of Exclusive Breastfeeding Among Thai Muslim Mothers: A Cross-sectional Analysis

Exclusive breastfeeding is pivotal for the health and development of infants and offers numerous benefits to mothers. However, unique cultural beliefs and practices, particularly among Muslim communities, can significantly influence breastfeeding behaviors. This study sought to elucidate the factors influencing exclusive breastfeeding among Thai Muslim mothers. The sample was 168 postpartum Muslim mothers from well-baby clinics in southern Thailand, selected through multi-stage random sampling. Data were collected from June to December 2022 employing the Demographic Data Form, Infant Feeding Intentions Scale, Breastfeeding Knowledge Questionnaire, Iowa Infant Feeding Attitude Scale, Breastfeeding Self-Efficacy Scale -Short Form, Maternal Health Literacy Scale, Islamic Belief Scale, Exclusive Breastfeeding Social Support, and Breastfeeding Practices Questionnaire. Data were analyzed using descriptive statistics, Spearman rank’s correlation, and binary logistic regression analysis. The study found that the rate of exclusive breastfeeding among Thai Muslim mothers at six months postpartum was 54.8%. Notably, breastfeeding self-efficacy emerged as the sole predictor of exclusive breastfeeding, accounting for 11% of the variance in this practice. These findings underscore the critical role of breastfeeding self-efficacy in promoting exclusive breastfeeding. It is recommended that nurses and healthcare professionals develop culturally tailored support programs that enhance breastfeeding self-efficacy, aligned with Islamic beliefs, to improve breastfeeding practices among Muslim mothers.

Capacity and needs assessment of the implementation of the toddler oral health intervention at well-baby clinics.

To conduct a capacity and needs assessment identifying important factors for the successful implementation of an oral health coach (OHC) at well-baby clinics. This Toddler Oral Health Intervention (TOHI) provides oral health promotion to parents to prevent early childhood caries. A two-round Delphi study was conducted with an expert panel consisting of OHCs and paediatric staff. The survey was based on the Consolidated Framework for Implementation Research (CFIR), consisting of 39 constructs divided over 5 domains: intervention characteristics (8), inner setting (14), outer setting (4), characteristics of individuals (5) and the process of implementation (8). Constructs relating to the inner setting, outer setting and implementation process were identified as essential. Availability of resources, information on how to execute or facilitate the intervention, and the integration of the intervention into existing work tasks were also essential. Alignment and partnership between OHCs and paediatric staff, along with the prioritization of parents' and children's needs were emphasized. A formally appointed internal implementation leader within each organization, capable of transferring their enthusiasm to the team, and regular meetings for progress and experience sharing were considered essential. Specific strategies are needed in the implementation phase to increase the adoption, implementation and maintenance of the TOHI, ultimately leading to improved oral health in children. This study provides valuable insights into important factors for implementation of an oral health intervention in a public health setting.

A knowledge, attitude and practices based study to know the awareness and acceptance of contraceptive methods in married couples coming to well-baby clinic of a tertiary care centre in Panvel, Maharashtra, India

Background: Family planning plays a major role in improving the financial, nutritional, educational, social well-being of a family as a unit. To study the level of knowledge, attitude and practices of various family planning methods in eligible couples. Methods: Prospective Qualitative study was carried out from June 2021 - December 2022 on data of 180 eligible couples selected randomly from Well-Baby Clinic, collected through pretested and validated standardized questionnaire. Sample size was estimated scientifically. Results were arrived by descriptive statistical tests and correlational statistics using software’s like excel, SPSS. Results: The level of knowledge of contraceptive methods was 89.44% for OC pills, 67.08% depot medroxyprogesterone, 97.22% condoms, 84.03%, IUCD, 93.56% for female and 98.04% for male sterilization. Overall acceptance of any type of contraception was 55%, most commonly used method being condoms i.e.78.49%, OC pills 12.90%, IUCD 6.35%, depot 1.37% and 45% were using natural methods. Major factors affecting acceptance were desire to have more children, hesitancy to seek, lack of knowledge, decision making power of a woman in the family. Conclusions: Since our research finds contraceptive acceptance at 55% much lower than state average, we look into components of gender dynamics and offer array of choices to couples so that a well informed choice free of gender bias is taken. Continuity of personalized and dignified couple counseling from preconceptional, antenatal to postnatal period is emphasized to increase contraceptive acceptance. We recommend well baby clinics as effective point of delivery for family welfare activities using gender sensitive cafe-teria approach.

An eight-year follow-up on auditory outcomes after neonatal hearing screening.

The aim of this study is to assess the neonatal click Auditory Brainstem Response (ABR) results in relation to the subsequently determined mean hearing loss (HL) over 1, 2 and 4 kHz, as well as over 2 and 4 kHz. Between 2004-2009, follow-up data were collected from Visual Reinforcement Audiometry (VRA) at 1 and 2 years and playaudiometry at 4 and 8 years of newborns who had failed neonatal hearing screening in the well-baby clinics and who had been referred to a single Speech and Hearing center. Hearing Level data were compared with ABR threshold-levels established during the first months of life. The Two One-Sided Tests equivalence procedure for paired means was applied, using a region of similarity equal to 10 dB. Initially, in 135 out of 172 children referred for diagnostic procedures hearing loss was confirmed in the neonatal period. In 106/135 of the HL children the eight-year follow-up was completed. Permanent conductive HL was established in 5/106 cases; the hearing thresholds were predominantly stable over time. Temporary conductive HL was found in 48/106 cases and the loss disappeared by 4 years of age at the latest. Sensorineural hearing loss (SNHL) was found in 53/106 cases, of which 13 were unilateral and 40 bilateral. ABR levels were equivalent (within a 10 dB range) to VRA levels at age 1 and 2 and play audiometry levels at age 4 and 8, both when VRA and play audiometry were averaged over both frequency ranges. Long term follow-up data of children with SNHL suggest that the initial click ABR level established in the first months of life, are equivalent to the hearing threshold measured at the age of 1, 2, 4 and 8 years for both mean frequency ranges. Click ABR can reliably be used as starting point for long-term hearing rehabilitation.

Identifying and developing strategies for implementation of a guided internet- and mobile-based infant sleep intervention in well-baby and community mental health clinics using group concept mapping

BackgroundThis study aimed to identify strategies for the implementation of a guided internet- and mobile-based intervention (IMI) for infant sleep problems (“Sleep Well, Little Sweetheart”) in well-baby and community mental health clinics.Study designWe used group concept mapping, a two-phased mixed methods approach, conducted as a two-day workshop in each clinic. We recruited 20 participants from four clinics and collected sorting and rating data for implementation strategies based on the Expert Recommendations for Implementing Change taxonomy and brainstorming sessions. Data were analyzed using descriptive statistics, multidimensional scaling, and hierarchical cluster analysis to create cluster maps, laddergrams, and Go-Zone graphs. Participants were presented with the results and discussed and interpreted the findings at each of the clinics in spring 2022.ResultsParticipants identified 10 clusters of strategies, of which Training, Embedding and Coherence, User Involvement and Participation, and Clinician Support and Implementation Counseling were rated as most important and feasible. Economy and Funding and Interactive and Interdisciplinary Collaboration were rated significantly lower on importance and feasibility compared to many of the clusters (all ps < 0.05). There was a correlation between the importance and feasibility ratings (r =.62, p =.004).ConclusionsThe use of group concept mapping made it possible to efficiently examine well-baby and community clinics’ perspectives on complex issues, and to acquire specific knowledge to allow for the planning and prioritization of strategies for implementation. These results suggest areas of priority for the implementation of IMIs related to infant sleep problems.Trial registrationThe study was pre-registered at Open Science Framework (www.osf.io/emct8).

Screening of children attending well baby clinic for risk of autism using modified checklist for autism in toddlers in a pediatric tertiary care Centre in Chennai

Background: Autism spectrum disorder is a common neurodevelopmental disorder with core deficits in social communication, interaction, and restrictive/repetitive behavior. Early intervention provides opportunity for good functional outcome. The study aimed to screen children attending well baby clinic for risk of autism using modified checklist for autism in toddlers (MCHAT) questionnaire. Methods: This descriptive cross-sectional study was conducted on 302 children attending the pediatric well baby clinic. The children aged 16-30 months who met the inclusion criteria were screened for risk of autism using MCHAT. Results: 20 out of 302 children failed the MCHAT screening, 6.6% of the children were found to be at risk of autism. Boys: girls’ ratio was 2:1. Advanced parental age and higher socioeconomic status were found to have significant association with the risk of autism. 70% of children in the at-risk group were first born, 70% of children who failed the MCHAT screen were from a nuclear family. Conclusions: All toddlers attending the well-baby clinic should be screened for autism by pediatricians. MCHAT is a simple easy to use validated tool to screen for autism in a busy pediatric OPD. Timely referral for comprehensive assessment and intervention can help to improve the outcome in children with autism.

Timing, reasons, and predictors for first dental visits among children seen at two university hospitals.

Dental caries is the most common chronic childhood disease. The recommended age for the first dental visit (FDV) is 1 year, yet a minority of children visit before the age of 3 years. The aim of the study was to estimate the patterns of and predictors for dental visits among a sample of children. Parents of children between the ages of 6 months and 18 years, who attended the paediatric dentistry clinics and the well-baby clinics, were recruited. A validated questionnaire was used to collect data. Logistic regression was utilized to assess the predictors of ever visiting a dentist. The mean age at FDV was 5.8 ± 2.1 years. Parents' belief of not needing to see a dentist was the most common barrier to visiting a dentist (33%). Among the reasons for FDV, caries and pain were the most common (45% and 20%, respectively). Predictors of ever visiting a dentist were children who are not an only child and children of parents who visited a dentist themselves. Children visited the dentist at an age older than that recommended, and the reasons for FDV were mainly caries and its consequences.

Unravelling the Mystery of Arterial Tortuosity Syndrome: A Case Report of an Unexpected Rare Diagnosis in a Well-Baby Clinic at a Primary Care Center in Qatar

A case of Arterial Tortuosity Syndrome (ATS) is a rare autosomal recessive genetic disorder characterized by significant alterations in the structure and function of the arterial system. Mutations in the SLC2A10 gene, responsible for encoding the transporter protein GLUT10, lead to the development of ATS. Keywords: Arterial Tortuosity Syndrome, case report, well baby clinic, Qatar

Integrated health system intervention aimed at reducing type 2 diabetes risk in women after gestational diabetes in South Africa (IINDIAGO): a randomised controlled trial protocol

IntroductionSouth Africa has a high prevalence of gestational diabetes mellitus (GDM; 15%) and many of these women (48%) progress to type 2 diabetes mellitus (T2DM) within 5 years post partum....

Knowledge, Attitude, and Practice among Parents toward Early Childhood Development in Belagavi City: A Cross-sectional Study

Context: As the educational levels and socioeconomic status of parents are low in developing countries, providing knowledge about early childhood development (ECD), the importance of early stimulation, proper caregiving practices, and ensuring the quality of the home environment through an integrated intervention is critical. In this situation, it is also critical to consider and assess the parental facts, attitudes, and practices before devising any intervention strategy. Hence, the current study intended to assess the knowledge, attitude, and practice of parents in ECD. Materials and Methods: An observational study was conducted in Belagavi City on 200 parents of children between the age group of 0 and 5 years. A structured questionnaire was used to assess the knowledge, attitude, and practice of the parents about ECD visiting the well-baby clinic and pediatric outpatient department of a tertiary care hospital. Statistical Analysis: For the test of significance, Chi-square and multiple liner regression analysis were used to find out the relationship between factors and to find the dependency status between dependent and independent variables. Results: In knowledge, P = 0.001 indicated significant knowledge of parents about the ECD, providing a strong understanding of their child’s development. The parents frequently paid attention to their children’s behavior, indicating that they had a positive attitude toward their children’s growth with a significant P = 0.001, and in the practice part, P = 0.001 indicated good significant practice of parents by frequently performing home learning techniques. Conclusion: The present study concluded that parents exhibit significant knowledge, positive attitudes, and effective practices regarding child development for children aged 0 to 5 years.

Infant screen media and child development: A prospective community study.

The current study examined longitudinal associations between early screen media exposure (assessed at 6, 12, and 24months) and the child's motor and language/communication development at the ages of 24 and 36months. We also aimed to study whether these associations varied by socioeconomic status (SES). Participants were 179 parent-infant dyads, recruited from well-baby clinic services during routine visits. Child development measures included standardized measures of developmental milestones as assessed by professionals and referral data to child developmental centers. Both measures were retrieved from the official health maintenance organization records by an expert in child development. Results indicated that screen exposure at 6 and 12months was associated with a higher risk for language/communication deficits at 36months in children with moderate or high SES but not in children with low SES. Our findings are consistent with existing literature demonstrating cross-sectional and longitudinal associations between early screen exposure and language development deficits. Given that media use practices and motivations vary among families from different backgrounds, further investigation of the interaction between SES and screen exposure is needed.

Healthy lifestyle practices: Evidence from clinic attending mothers in the northern province, Sri Lanka

Healthy lifestyles are known to reduce noncommunicable disease-related mortalities and morbidities. Public health initiatives should encourage healthier lifestyles to prevent the risk of noncommunicable diseases. This study aimed to determine healthy lifestyle practices and their associated factors among clinic-attending mothers (mothers attending antenatal clinics, postnatal clinics, well-baby clinics, family planning clinics, well-women clinics, and polyclinics) in the Chavakachcheri Medical Officer of Health (MOH) area. We conducted a clinic-based cross-sectional study in 19 centers covering 28 Public Health Midwives (PHM) areas. Healthy lifestyle practices, such as regular exercise, consumption of recommended servings of fruits and vegetables, measuring their own BMI, and average salt consumption, were poor. In the multivariate analysis, we found only three factors that had higher odds of affecting healthy lifestyle practices that were statistically significant: attributes of higher level of perceptions about healthy lifestyle practices (AOR = 4.36, 1.32–14.39), participating in Mothers’ Support Groups (AOR = 7.97, 2.17–29.27) and BMI value of < 23 kg/m2 (AOR = 4.47, 1.35–14.73). Effective targeted healthy lifestyle-related educational programs instead of regular training during clinic visits and promoting participation in peer groups at the community level may benefit clinic-attending mothers.