International Journal of Epidemiology
Volume 44 Issue 6 December 2015
http://ije.oxfordjournals.org/content/current

.
Early Life
Institutional deliveries weakly associated with improved neonatal survival in developing countries: evidence from 192 Demographic and Health Surveys
Günther Fink*, Rebecca Ross and Kenneth Hill
Author Affiliations
Harvard T.H. Chan School of Public Health, Boston, MA, USA
Abstract
Background: Child and maternal mortality remain high in many developing countries. A principal strategy used in low- and middle-income countries is increasing the proportion of pregnancies delivered at facilities. Although this strategy is reasonable with high quality facilities, evidence for the protective effects of facility deliveries is mixed.
Methods: We pooled 1.47 million birth records collected by the Demographic and Health Surveys to estimate the association between institutional deliveries and early neonatal mortality. Subsample analysis and instrumental variable estimation were used to assess and correct the extent to which mortality differentials are biased by an increased likelihood of facility attendance for high-risk deliveries.
Results: No associations between institutional deliveries and early neonatal mortality were found in the pooled sample [adjusted odds ratio (aOR) 0.995, 95% confidence interval (CI) 0.966-1.025)]. When stratified by facility type, protective effects were found for private facilities (aOR 0.876, 95% CI 0.840-0.914), but not for public hospitals or health centres. Significant protective effects were found when past behaviour was used to eliminate selection bias generated by short-term responses to medical need (aOR 0.884, 95% CI 0.814-0.961). At the community and country levels, strong positive associations were found between early neonatal mortality among facility deliveries and the prevalence of institutional deliveries.
Conclusion: Facility deliveries have the potential to reduce early neonatal mortality in developing countries. The results presented suggest that the quality, utilization and protective effects of institutional deliveries vary widely across countries; major improvements in both utilization and quality of care will be needed to achieve further improvements in maternal and child health.

.

Effect of fortified complementary food supplementation on child growth in rural Bangladesh: a cluster-randomized trial
Parul Christian, Saijuddin Shaikh, Abu Ahmed Shamim, Sucheta Mehra, Lee Wu, Maithilee Mitra, Hasmot Ali, Rebecca D Merrill, Nuzhat Choudhury, Monira Parveen, Rachel D Fuli, Md Iqbal Hossain, Md Munirul Islam, Rolf Klemm, Kerry Schulze, Alain Labrique, Saskia de Pee,
Tahmeed Ahmed, and Keith P West, Jr
Author Affiliations
1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,
2JiVitA Project, Gaibandha, Bangladesh,
3Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Bangladesh, Mohakhali, Dhaka, Bangladesh,
4United Nations World Food Programme, IDB Bhaban, Dhaka, Bangladesh and
5Office of Nutrition Advisor, United Nations World Food Programme, Rome, Italy
Abstract
Background: Growth faltering in the first 2 years of life is high in South Asia where prevalence of stunting is estimated at 40–50%. Although nutrition counselling has shown modest benefits, few intervention trials of food supplementation exist showing improvements in growth and prevention of stunting.
Methods: A cluster-randomized controlled trial was conducted in rural Bangladesh to test the effect of two local, ready-to-use foods (chickpea and rice-lentil based) and a fortified blended food (wheat-soy-blend++, WSB++) compared with Plumpy’doz, all with nutrition counselling vs nutrition counselling alone (control) on outcomes of linear growth (length and length-for-age z-score, LAZ), stunting (LAZ < −2), weight-for-length z-score (WLZ) and wasting (WLZ < −2) in children 6–18 months of age. Children (n = 5536) were enrolled at 6 months of age and, in the food groups, provided with one of the allocated supplements daily for a year.
Results: Growth deceleration occurred from 6 to 18 months of age but deceleration in LAZ was lower (by 0.02–0.04/month) in the Plumpy’doz (P = 0.02), rice-lentil (< 0.01), and chickpea (< 0.01) groups relative to control, whereas WLZ decline was lower only in Plumpy’doz and chickpea groups. WSB++ did not impact on these outcomes. The prevalence of stunting was 44% at 18 months in the control group, but lower by 5–6% (P ≤ 0.01) in those receiving Plumpy’doz and chickpea. Mean length and LAZ at 18 months were higher by 0.27–0.30 cm and 0.07–0.10 (all P < 0.05), respectively, in all four food groups relative to the control.
Conclusions: In rural Bangladesh, small amounts of daily fortified complementary foods, provided for a year in addition to nutrition counselling, modestly increased linear growth and reduced stunting at 18 months of age.