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Background: Posttraumatic stress disorder (PTSD) is a serious and debilitating disorder that can develop following exposure to a traumatic event. Where parents develop PTSD, it may have an impact on their parenting role. Objective: The objective was to review the existing evidence base on parental PTSD, examining whether parental PTSD has an impact on key parenting domains. Method: A comprehensive web-based search identified 27 quantitative studies that examined parental PTSD in relation to parenting domains. Results: Several parenting domains were investigated including: parenting satisfaction, parenting stress, the parent–child relationship, and specific parenting practices. Sample sizes ranged from 19 to 3931 parents. A range of parental traumas were investigated, including traumatic birth experiences, military trauma, and intimate partner violence. Findings indicated associations between parental PTSD and several domains of parenting, but there were inconsistencies across studies. Conclusions: Findings suggested that parental PTSD is associated with impaired functioning across a number of parenting domains, including increased levels of parenting stress, lower parenting satisfaction, less optimal parent–child relationships, and more frequent use of negative parenting practices, such as overt hostility and controlling behaviours. However, methodological limitations across the literature as a whole limited the potential to infer causal impacts of PTSD on parenting. Further study is also needed to advance our current understanding around the impact of different trauma types on parenting domains. [ABSTRACT FROM AUTHOR]

Objectives: To assess the use and timing of scheduled cesareans and other categories of cesarean delivery and the prevalence of neonatal morbidity among cesareans in Oregon before and after the implementation of Oregon's statewide policy limiting elective early deliveries.Data Sources: Oregon vital statistics records, 2008-2013.Study Design: Retrospective cohort study, with multivariable logistic regression, regression controlling for time trends, and interrupted time series analyses, to compare the odds of different categories of cesarean delivery and the odds of neonatal morbidity pre- and postpolicy.Data Collection/extraction Methods: We analyzed vital statistics data on all term births in Oregon (2008-2013), excluding births in 2011.Principal Findings: The odds of early-term scheduled cesareans decreased postpolicy (adjusted odds ratio [aOR], 0.70; 95 percent confidence interval [CI], 0.66-0.74). In the postpolicy period, there were mixed findings regarding assisted neonatal ventilation and neonatal intensive care unit admission, with regression models indicating higher postpolicy odds in some categories, but lower postpolicy odds after controlling for time trends.Conclusions: Oregon's hard stop policy limiting elective early-term cesarean delivery was associated with lower odds of cesarean delivery in the category of women who were targeted by the policy; more research is needed on impact of such policies on neonatal outcomes. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented in which the authors discuss various articles published within the issue on such topics as the co-morbid epidemics of HIV and non-communicable diseases, HIV prevention, and prophylaxis for HIV prevention (PrEP).

Anxiety is highly prevalent in many populations; however, the burden of anxiety disorders amongst pregnant women in low-resource settings is not well documented. We investigated the prevalence and predictors of antenatal anxiety disorders amongst low-income women living with psychosocial adversity. Pregnant women were recruited from an urban, primary level clinic in Cape Town, South Africa. The Mini-International Neuropsychiatric Interview diagnostic interview assessed prevalence of anxiety disorders. Four self-report questionnaires measured psychosocial characteristics. Logistic regression models explored demographic and socioeconomic characteristics, psychosocial risk factors and psychiatric comorbidity as predictors for anxiety disorders. Amongst 376 participants, the prevalence of any anxiety disorder was 23%. Although 11% of all women had post-traumatic stress disorder, 18% of the total sample was diagnosed with other anxiety disorders. Multivariable analysis revealed several predictors for anxiety including a history of mental health problems (adjusted odds ratio [AOR] 4.11; 95% confidence interval (CI) 2.03-8.32), Major depressive episode (MDE) diagnosis (AOR 3.83; CI 1.99-7.31), multigravidity (AOR 2.87; CI 1.17-7.07), food insecurity (AOR 2.57; CI 1.48-4.46), unplanned and unwanted pregnancy (AOR 2.14; CI 1.11-4.15), pregnancy loss (AOR 2.10; CI 1.19-3.75) and experience of threatening life events (AOR 1.30; CI 1.04-1.57). Increased perceived social support appeared to reduce the risk for antenatal anxiety (AOR 0.95; CI 0.91-0.99). A range of antenatal anxiety disorders are prevalent amongst pregnant women living in low-resource settings. Women who experience psychosocial adversity may be exposed to multiple risk factors, which render them vulnerable to developing antenatal anxiety disorders. [ABSTRACT FROM AUTHOR]

In light of South Africa's high prenatal HIV prevalence and infant mortality rate, a cluster randomized controlled trial was conducted to evaluate an intervention called Philani+, which used community health workers (known as Mentor Mothers) to deliver pre- and postnatal home visits in Cape Town, South Africa, to improve maternal and child health. We assessed the costs and benefits of this intervention and made comparisons with other scenarios that depicted increased capacity and provision of nurse-delivered care. The recurrent cost of the twenty-four-month intervention was US$80,001. The major health outcomes analyzed were differences in the proportion of infants who were low birthweight, stunted, and suboptimally breastfed between intervention and control groups. Each case of low birthweight averted cost US$2,397; of stunted growth, US$2,454; and of suboptimal breastfeeding, US$1,618. Employment of community health workers was cost saving compared to that of nurses. Philani+ improved child health at a relatively low cost, considering the health system costs associated with low birthweight and undemutrition. The model could be suitable for replication in low-resource settings to improve child health in other countries. [ABSTRACT FROM AUTHOR]

Background: Concurrent epidemics of HIV, depression, alcohol abuse, and partner violence threaten maternal and child health (MCH) in South Africa. Although home visiting has been repeatedly demonstrated efficacious in research evaluations, efficacy disappears when programs are scaled broadly. In this cluster randomized controlled trial (RCT), we examine whether the benefits of ongoing accountability and supervision within an existing government funded and implemented community health workers (CHW) home visiting program ensure the effectiveness of home visiting.Methods/design: In the deeply rural, Eastern Cape of South Africa, CHW will be hired by the government and will be initially trained by the Philani Programme to conduct home visits with all pregnant mothers and their children until the children are 2 years old. Eight clinics will be randomized to receive either (1) the Accountable Care Condition in which additional monitoring and accountability systems that Philani routinely uses are implemented (4 clinics, 16 CHW, 450 households); or (2) a Standard Care Condition of initial Philani training, but with supervision and monitoring being delivered by local government structures and systems (4 clinics, 21 CHW, 450 households). In the Accountable Care Condition areas, the CHW's mobile phone reports, which are time-location stamped, will be monitored and data-informed supervision will be provided, as well as monitoring growth, medical adherence, mental health, and alcohol use outcomes. Interviewers will independently assess outcomes at pregnancy at 3, 6, 15, and 24 months post-birth. The primary outcome will be a composite score of documenting maternal HIV/TB testing, linkage to care, treatment adherence and retention, as well as child physical growth, cognitive functioning, and child behavior and developmental milestones.Discussion: The proposed cluster RCT will evaluate whether routinely implementing supervision and accountability procedures and monitoring CHWs' over time will improve MCH outcomes over the first 2 years of life.Trial Registration: ClinicalTrials.gov registration #NCT02957799 , registered on October 26, 2016. [ABSTRACT FROM AUTHOR]

"Good ethics start with good facts" wrote John Lantos and William Meadow in a 2009 editorial addressing periviability controversies - debates that continue to generate lively discussion amongst neonatologists, obstetricians, ethicists, and families (1). How do we best promote shared decision making with pregnant women who, through no fault of their own, might deliver an extremely premature infant? Unfortunately, the recent "A Different View" in this journal by Dr. Patrick Marmion regarding periviability issues in general, and specifically our shared decision making model at Providence St. Vincent Medical Center (PSVMC) in Portland, OR, is decidedly short on facts and is regrettably inflammatory (2). We appreciate the opportunity to respectfully clarify our bioethical foundation and periviability dialogue framework with the hope of promoting reasoned dialogue and understanding. This article is protected by copyright. All rights reserved. [ABSTRACT FROM AUTHOR]

Background: There is a growing body of literature outlining the promise of mobile information and communication technologies to improve healthcare in resource-constrained contexts. Methods: We reviewed the literature related to mobile information and communication technologies which aim to improve healthcare in resource-constrained contexts, in order to glean general observations regarding the state of mHealth in high-income countries (HIC) and low- and middle-income countries (LMIC). Results: mHealth interventions in LMIC often differ substantively from those in HIC, with the former being simpler, delivered through a single digital component (an SMS as opposed to a mobile phone application, or ‘app’), and, as a result, targeting only one of the many factors which impact on the activation (or deactivation) of the target behaviour. Almost as a rule, LMIC mHealth interventions lack an explicit theory of change. Conclusion: We highlight the necessity, when designing mHealth interventions, of having a theory of change that encompasses multiple salient perspectives pertaining to human behaviour. To address this need, we explore whether the concept of Life History Strategy could provide the mHealth field with a useful theory of change. Life History Strategy Theory may be particularly useful in understanding some of the problems, paradoxes, and limitations of mHealth interventions found in LMIC. Specifically, this theory illuminates questions regarding ‘light-weight’ programmes which solely provide information, reminders, and other virtual ‘nudges’ that may have limited impact on behaviours governed by extrinsic structural factors. [ABSTRACT FROM PUBLISHER]

Intimate partner violence (IPV) experienced by pregnant and post-partum women has negative health effects for women, as well as the foetus, and the new-born child. In this study we sought to assess the prevalence and factors associated with recent IPV amongst post-partum women in one clinic in eThekwini Municipality, South Africa, and explore the relationship between IPV, depression and functional limitations/disabilities. Past 12 month IPV-victimisation was 10.55%. Logistic regression modelled relationships between IPV, functional limitations, depressive symptoms, socio-economic measures, and sexual relationship power. In logistic regression models, overall severity of functional limitations were not associated with IPV-victimisation when treated as a continuous overall score. In this model relationship power (aOR0.22, p = 0.001) and depressive symptoms (aOR1.26, p = 0.001) were significant. When the different functional limitations were separated out in a second model, significant factors were relationship power (aOR0.20, p = 0.001), depressive symptoms (aOR1.20, p = 0.011) and mobility limitations (aOR2.96, p = 0.024). The study emphasises that not all functional limitations are associated with IPV-experience, that depression and disability while overlapping can also be considered different drivers of vulnerability, and that women’s experience of IPV is not dependent on pregnancy specific factors, but rather wider social factors that all women experience. [ABSTRACT FROM AUTHOR]

This study introduces a peri-urban context of poverty to the study of child development in Africa in contrast to the more typical assessments in middle-class and rural contexts. Spot observations were used to assess universal caregiving behaviors toward seventy-six 3-month-old infants. Results show that middle-class infants experienced distal parenting behaviors instantiated by mothers, whereas rural children experienced proximal parenting practices in interactions with others. Infants growing up in poverty had mothers and other caretakers involved at mostly low levels. They experienced low levels of body contact, body stimulation, and object stimulation, and high levels of face-to-face positions. The study indicates that caregiving in the context of poverty does not necessarily follow familiar pathways and needs to be contextualized accordingly. [ABSTRACT FROM AUTHOR]

In addition to its contribution to child mortality, HIV/AIDS has a substantial impact on the psychosocial well-being of children. We conducted a systematic review to identify studies that assess the effectiveness of interventions developed to improve the psychosocial well-being of children affected by HIV/AIDS, published between January 2008 and February 2016. Studies were eligible for the review if they included children under the age of 18 years, who had lost a parent to HIV/AIDS, were living with a parent with HIV/AIDS, or were vulnerable because of other factors and living in communities of high HIV/AIDS prevalence. Studies documented any intervention to improve the psychosocial well-being of children including psychological, psychosocial, medical, and social interventions, with psychological and/or social factors as outcomes. We identified 17 interventions to improve the psychosocial well-being of children affected by HIV/AIDS. Of these, 16 studies took place in 8 different low- and middle-income countries (LMIC), and 6 in Southern and Eastern Africa. Of the total, 15 showed some significant benefits of the intervention, while 2 showed no difference to psychosocial outcomes. The content of interventions, dosage and length of follow-up varied substantially between studies. There were few studies on children under 7 years and several focused mostly on girls. Due to the variability between interventions, it was not possible to make consolidated recommendations for programming based on the results of this review. However, we note that efforts to improve evaluation of interventions to improve the psychosocial well-being of children affected by HIV/AIDS have resulted in a number of new studies which met the inclusion criteria for the review. Most were research projects and not evaluations of existing services. We call for increased partnerships between policymakers, practitioners, and researchers in order to design evaluation studies that can feed into the growing evidence base. [ABSTRACT FROM AUTHOR]

A considerable body of evidence suggests that early caregiving may affect the short-term functioning and longer term development of the hypothalamic–pituitary–adrenocortical axis. Despite this, most research to date has been cross-sectional in nature or restricted to relatively short-term longitudinal follow-ups. More important, there is a paucity of research on the role of caregiving in low- and middle-income countries, where the protective effects of high-quality care in buffering the child's developing stress regulation systems may be crucial. In this paper, we report findings from a longitudinal study (N = 232) conducted in an impoverished periurban settlement in Cape Town, South Africa. We measured caregiving sensitivity and security of attachment in infancy and followed children up at age 13 years, when we conducted assessments of hypothalamus–pituitary–adrenocortical axis reactivity, as indexed by salivary cortisol during the Trier Social Stress Test. The findings indicated that insecure attachment was predictive of reduced cortisol responses to social stress, particularly in boys, and that attachment status moderated the impact of contextual adversity on stress responses: secure children in highly adverse circumstances did not show the blunted cortisol response shown by their insecure counterparts. Some evidence was found that sensitivity of care in infancy was also associated with cortisol reactivity, but in this case, insensitivity was associated with heightened cortisol reactivity, and only for girls. The discussion focuses on the potentially important role of caregiving in the long-term calibration of the stress system and the need to better understand the social and biological mechanisms shaping the stress response across development in low- and middle-income countries. [ABSTRACT FROM PUBLISHER]

Background: Clear recognition of the damaging effects of poverty on early childhood development has fueled an interest in interventions aimed at mitigating these harmful consequences. Psychosocial interventions aimed at alleviating the negative impacts of poverty on children are frequently shown to be of benefit, but effect sizes are typically small to moderate. However, averaging outcomes over an entire sample, as is typically done, could underestimate efficacy because weaker effects on less susceptible individuals would dilute estimation of effects on those more disposed to respond. This study investigates whether a genetic polymorphism of the serotonin transporter gene moderates susceptibility to a psychosocial intervention.Methods and Findings: We reanalyzed data from a randomized controlled trial of a home-visiting program delivered by community health workers in a black, isiXhosa-speaking population in Khayelitsha, South Africa. The intervention, designed to enhance maternal-infant attachment, began in the third trimester and continued until 6 mo postpartum. Implemented between April 1999 and February 2003, the intervention comprised 16 home visits delivered to 220 mother-infant dyads by specially trained community health workers. A control group of 229 mother-infant dyads did not receive the intervention. Security of maternal-infant attachment was the main outcome measured at infant age 18 mo. Compared to controls, infants in the intervention group were significantly more likely to be securely attached to their primary caregiver (odds ratio [OR] = 1.7, p = 0.029, 95% CI [1.06, 2.76], d = 0.29). After the trial, 162 intervention and 172 control group children were reenrolled in a follow-up study at 13 y of age (December 2012-June 2014). At this time, DNA collected from 279 children (134 intervention and 145 control) was genotyped for a common serotonin transporter polymorphism. There were both genetic data and attachment security data for 220 children (110 intervention and 110 control), of whom 40% (44 intervention and 45 control) carried at least one short allele of the serotonin transporter gene. For these 220 individuals, carrying at least one short allele of the serotonin transporter gene was associated with a 26% higher rate of attachment security relative to controls (OR = 3.86, p = 0.008, 95% CI [1.42, 10.51], d = 0.75), whereas there was a negligible (1%) difference in security between intervention and control group individuals carrying only the long allele (OR = 0.95, p = 0.89, 95% CI [0.45, 2.01], d = 0.03). Expressed in terms of absolute risk, for those with the short allele, the probability of secure attachment being observed in the intervention group was 84% (95% CI [73%, 95%]), compared to 58% (95% CI [43%, 72%]) in the control group. For those with two copies of the long allele, 70% (95% CI [59%, 81%]) were secure in the intervention group, compared to 71% (95% CI [60%, 82%]) of infants in the control group. Controlling for sex, maternal genotype, and indices of socioeconomic adversity (housing, employment, education, electricity, water) did not change these results. A limitation of this study is that we were only able to reenroll 49% of the original sample randomized to the intervention and control conditions. Attribution of the primary outcome to causal effects of intervention in the present subsample should therefore be treated with caution.Conclusions: When infant genotype for serotonin transporter polymorphism was taken into account, the effect size of a maternal-infant attachment intervention targeting impoverished pregnant women increased more than 2.5-fold when only short allele carriers were considered (from d = 0.29 for all individuals irrespective of genotype to d = 0.75) and decreased 10-fold when only those carrying two copies of the long allele were considered (from d = 0.29 for all individuals to d = 0.03). Genetic differential susceptibility means that averaging across all participants is a misleading index of efficacy. The study raises questions about how policy-makers deal with the challenge of balancing equity (equal treatment for all) and efficacy (treating only those whose genes render them likely to benefit) when implementing psychosocial interventions.Trial Registration: Current Controlled Trials ISRCTN25664149. [ABSTRACT FROM AUTHOR]

Introduction Children's understanding of HIV and death in epidemic regions is under-researched. We investigated children's death-related questions post maternal HIV-disclosure. Secondary aims examined characteristics associated with death-related questions and consequences for children's mental health. Methods HIV-infected mothers ( N = 281) were supported to disclose their HIV status to their children (6–10 years) in an uncontrolled pre-post intervention evaluation. Children's questions post-disclosure were collected by maternal report, 1–2 weeks post-disclosure. 61/281 children asked 88 death-related questions, which were analysed qualitatively. Logistic regression analyses examined characteristics associated with death-related questions. Using the parent-report Child Behaviour Checklist (CBCL), linear regression analysis examined differences in total CBCL problems by group, controlling for baseline. Results Children's questions were grouped into three themes: ‘ threats’ ; ‘implications’ and ‘clarifications’ . Children were most concerned about the threat of death, mother's survival, and prior family deaths. In multivariate analysis variables significantly associated with asking death-related questions included an absence of regular remittance to the mother ( AOR 0.25 [CI 0.10, 0.59] p = 0.002), mother reporting the child's initial reaction to disclosure being “frightened” ( AOR 6.57 [ CI 2.75, 15.70] p =<0.001) and level of disclosure (full/partial) to the child ( AOR 2.55 [ CI 1.28, 5.06] p = 0.008). Controlling for significant variables and baseline, all children showed improvements on the CBCL post-intervention; with no significant differences on total problems scores post-intervention (β -0.096 SE 1.366 t = -0.07 p = 0.944). Discussion The content of questions children asked following disclosure indicate some understanding of HIV and, for almost a third of children, its potential consequence for parental death. Level of maternal disclosure and stability of financial support to the family may facilitate or inhibit discussions about death post-disclosure. Communication about death did not have immediate negative consequences on child behaviour according to maternal report. Conclusion In sub-Saharan Africa, given exposure to death at young ages, meeting children's informational needs could increase their resilience. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the association of Oregon's hard-stop policy limiting early elective deliveries (before 39 weeks of gestation) and the rate of elective early-term inductions and cesarean deliveries and associated maternal-neonatal outcomes.Methods: This was a population-based retrospective cohort study of Oregon births between 2008 and 2013 using vital statistics data and multivariable logistic regression models. Our exposure was the Oregon hard-stop policy, defined as the time periods prepolicy (2008-2010) and postpolicy (2012-2013). We included all term or postterm, cephalic, nonanomalous, singleton deliveries (N=181,034 births). Our primary outcomes were induction of labor and cesarean delivery at 37 or 38 weeks of gestation without a documented indication on the birth certificate (ie, elective early term delivery). Secondary outcomes included neonatal intensive care unit admission, stillbirth, macrosomia, chorioamnionitis, and neonatal death.Results: The rate of elective inductions before 39 weeks of gestation declined from 4.0% in the prepolicy period to 2.5% during the postpolicy period (P<.001); a similar decline was observed for elective early-term cesarean deliveries (from 3.4% to 2.1%; P<.001). There was no change in neonatal intensive care unit admission, stillbirth, or assisted ventilation prepolicy and postpolicy, but chorioamnionitis did increase (from 1.2% to 2.2%, P<.001; adjusted odds ratio 1.94, 95% confidence interval 1.80-2.09).Conclusions: Oregon's statewide policy to limit elective early-term delivery was associated with a reduction in elective early-term deliveries, but no improvement in maternal or neonatal outcomes. [ABSTRACT FROM AUTHOR]

Background: The ability to regulate emotions is a key developmental achievement acquired during social interactions and associated with better behavioral and social outcomes. We examined the influence of culture on child emotion regulation (ER) and aggression and on early parenting practices, and the role of parenting in child ER. Methods: We assessed 48 mother-infant dyads from three cultures (1 UK, 2 South African) at infant age of 3 months for maternal sensitivity during face-to-face interactions and responses to infant distress during daily life, and at 2 years for child ER strategies and maternally reported aggression. Results: There were cultural differences in child ER, and these were associated with differences in levels of aggression. Maternal strategies in response to early infant distress also differed by culture and predicted later child ER. Maternal sensitivity during face-to-face interactions was not associated with culture and showed no clear relationship with child ER. Conclusion: Cultural differences in maternal responses to infant distress mediated differences in child ER that are, in turn, related to differences in child aggression. [ABSTRACT FROM AUTHOR]

Background: In low and middle-income countries (LMIC), common mental disorders affecting pregnant women receive low priority, despite their disabling effect on maternal functioning and negative impact on child health and development. We investigated the prevalence of risk factors for antenatal depression among women living in adversity in a low-resource, urban setting in Cape Town, South Africa.Methods: The MINI Neuropsychiatric Interview (MINI Plus) was used to measure the diagnostic prevalence of depression amongst women attending their first antenatal visit at a primary-level, community-based clinic. Demographic data were collected followed by administration of questionnaires to measure psychosocial risk. Analysis examined the association between diagnosis of depression and psychosocial risk variables, and logistic regression was used to investigate predictors for major depressive episode (MDE).Results: Among 376 women participating, the mean age was 26 years. The MINI-defined prevalence of MDE was 22%, with 50% of depressed women also expressing suicidality. MDE diagnosis was significantly associated with multiple socioeconomic and psychosocial risk factors, including a history of depression or anxiety, food insecurity, experience of threatening life events and perceived support from family.Limitations: The use of self-report measures may have led to recall bias. Retrospective collection of clinical data limited our ability to examine some known risk factors for mental distress.Conclusion: These findings confirm the high prevalence of MDE among pregnant women in LMIC settings. Rates of depression may be increased in settings where women are exposed to multiple risks. These risk factors should be considered when planning maternal mental health interventions. [ABSTRACT FROM AUTHOR]

Maternal depression, including antepartum and postpartum depression, is a neglected public health issue with potentially far-reaching effects on maternal and child health. We aimed to measure the burden of antepartum depression and identify risk factors among women in a peri-urban community in Swaziland. We conducted a cross-sectional study within the context of a community outreach peer support project involving 'Mentor Mothers'. We used of the Edinburgh Postnatal Depression Scale (EPDS) to screen women for depression during the third trimester of pregnancy, using a cut-off score of ≥13 to indicate depression. We also collected demographic and socioeconomic factors, and assessed the association of these factors with EPDS score using logistic regression models. A total of 1038 pregnant women were screened over a period of 9 months. Almost a quarter (22.7 %) had EPDS scores ≥13 and 41.2 % were HIV positive. A fifth, 17.5 % were teenagers and 73.7 % were unemployed. Depression was not associated with HIV status, age or employment status. However, women with multiple socioeconomic stressors were found to be more likely to score highly on the EPDS. Depression was common among pregnant women in the peri-urban areas of Swaziland. Screening for depression using the EPDS is feasible and can be included in the community health worker standard tool box as a way to improve early detection of depression and to highlight the importance of maternal mental health as a core public health concern. [ABSTRACT FROM AUTHOR]

Context: A robust evidence base is now emerging that indicates that treatment for depression and alcohol use disorders (AUD) delivered in low and middle-income countries (LMIC) can be effective. However, the coverage of services for these conditions in most LMIC settings remains unknown. Objective: To describe the methods of a repeat cross-sectional survey to determine changes in treatment contact coverage for probable depression and for probable AUD in four LMIC districts, and to present the baseline findings regarding treatment contact coverage. Methods: Population-based cross-sectional surveys with structured questionnaires, which included validated screening tools to identify probable cases. We defined contact coverage as being the proportion of cases who sought professional help in the past 12 months. Setting: Sodo District, Ethiopia; Sehore District, India; Chitwan District, Nepal; and Kamuli District, Uganda Participants: 8036 adults residing in these districts between May 2013 and May 2014 Main Outcome Measures: Treatment contact coverage was defined as having sought care from a specialist, generalist, or other health care provider for symptoms related to depression or AUD. Results: The proportion of adults who screened positive for depression over the past 12 months ranged from 11.2% in Nepal to 29.7% in India and treatment contact coverage over the past 12 months ranged between 8.1% in Nepal to 23.5% in India. In Ethiopia, lifetime contact coverage for probable depression was 23.7%. The proportion of adults who screened positive for AUD over the past 12 months ranged from 1.7% in Uganda to 13.9% in Ethiopia and treatment contact coverage over the past 12 months ranged from 2.8% in India to 5.1% in Nepal. In Ethiopia, lifetime contact coverage for probable AUD was 13.1%. Conclusions: Our findings are consistent with and contribute to the limited evidence base which indicates low treatment contact coverage for depression and for AUD in LMIC. The planned follow up surveys will be used to estimate the change in contact coverage coinciding with the implementation of district-level mental health care plans. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Defeating AIDS--Advancing Global Health" in the July 11, 2015 issue.

Community-based responses have a lengthy history. The ravages of HIV on family functioning has included a widespread community response. Although much funding has been invested in front line community-based organisations (CBO), there was no equal investment in evaluations. This study was set up to compare children aged 9–13 years old, randomly sampled from two South African provinces, who had not received CBO support over time (YC) with a group of similarly aged children who were CBO attenders (CCC). YC baseline refusal rate was 2.5% and retention rate was 97%. CCC baseline refusal rate was 0.7% and retention rate was 86.5%. 1848 children were included—446 CBO attenders compared to 1402 9–13 year olds drawn from a random sample of high-HIV prevalence areas. Data were gathered at baseline and 12–15 months follow-up. Standardised measures recorded demographics, violence and abuse, mental health, social and educational factors. Multivariate regression analyses revealed that children attending CBOs had lower odds of experiencing weekly domestic conflict between adults in their home (OR 0.17; 95% CI 0.09, 0.32), domestic violence (OR 0.22; 95% CI 0.08, 0.62), or abuse (OR 0.11; 95% CI 0.05, 0.25) at follow-up compared to participants without CBO contact. CBO attenders had lower odds of suicidal ideation (OR 0.41; 95% CI 0.18, 0.91), fewer depressive symptoms (B = -0.40; 95% CI -0.62, -0.17), less perceived stigma (B = -0.37; 95% CI -0.57, -0.18), fewer peer problems (B = -1.08; 95% CI -1.29, -0.86) and fewer conduct problems (B = -0.77; 95% CI -0.95, -0.60) at follow-up. In addition, CBO contact was associated with more prosocial behaviours at follow-up (B = 1.40; 95% CI 1.13, 1.67). No associations were observed between CBO contact and parental praise or post-traumatic symptoms. These results suggest that CBO exposure is associated with behavioural and mental health benefits for children over time. More severe psychopathology was not affected by attendance and may need more specialised input. [ABSTRACT FROM AUTHOR]

Aim: To determine whether, in an impoverished South African community, an intervention that benefitted infant attachment also benefitted cognitive development.Method: Pregnant females were randomized to intervention (n=220) and no-treatment control groups (n=229). The intervention was home-based parenting support for attachment, delivered until 6 months postpartum. At 18 months, infants were assessed on attachment and cognitive development (Bayley Scales Mental Development Index [MDI]) (n=127 intervention, n=136 control participants). Infant MDI was examined in relation to intervention, socio-economic risk, antenatal depression, and infant sex and attachment.Results: Overall, there was little effect of the intervention on MDI (p=0.094, d=0.20), but there was an interaction between intervention and risk (p=0.03, ηp2=0.02). MDI scores of infants of lower risk intervention group mothers were, on average, 4.84 points higher than those of other infants (p=0.002, d=0.41). Antenatal depression was not significant once intervention and risk were controlled (p=0.08); there was no association between infant MDI and either sex (p=0.41) or attachment (p=0.56).Interpretation: Parenting interventions for infant cognitive development may benefit from inclusion of specific components to support infant cognition beyond those that support attachment, and may be most effective for infants over 6 months. They may need augmentation with other input where adversity is extreme. [ABSTRACT FROM AUTHOR]

Background: The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care.Methods: The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness.Results: Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3-50 %) and alcohol consumption during pregnancy (5-51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community.Conclusions: It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services. [ABSTRACT FROM AUTHOR]

Objective: To analyse the effect of community-based counselling on feeding patterns during the first 12 weeks after birth, and to study whether the effect differs by maternal HIV status, educational level or household wealth.Design: Cluster-randomized trial with fifteen clusters in each arm to evaluate an integrated package providing two pregnancy and five postnatal home visits delivered by community health workers. Infant feeding data were collected using 24 h recall of nineteen food and fluid items.Setting: A township near Durban, South Africa.Subjects: Pregnant women (1894 intervention and 2243 control) aged 17 years or more.Results: Twelve weeks after birth, 1629 (intervention) and 1865 (control) mother-infant pairs were available for analysis. Socio-economic conditions differed slightly across intervention groups, which were considered in the analyses. There was no effect on early initiation of breast-feeding. At 12 weeks of age the intervention doubled exclusive breast-feeding (OR=2·29; 95 % CI 1·80, 2·92), increased exclusive formula-feeding (OR=1·70; 95 % CI 1·28, 2·27), increased predominant breast-feeding (OR=1·71; 95 % CI 1·34, 2·19), decreased mixed formula-feeding (OR=0·68; 95 % CI 0·55, 0·83) and decreased mixed breast-feeding (OR=0·54; 95 % CI 0·44, 0·67). The effect on exclusive breast-feeding at 12 weeks was stronger among HIV-negative mothers than HIV-positive mothers (P=0·01), while the effect on mixed formula-feeding was significant only among HIV-positive mothers (P=0·03). The effect on exclusive feeding was not different by household wealth or maternal education levels.Conclusions: A perinatal intervention package delivered by community health workers was effective in increasing exclusive breast-feeding, exclusive formula-feeding and decreasing mixed feeding. [ABSTRACT FROM AUTHOR]

Background: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose.Methods: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries.Results: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge.Conclusions: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs. [ABSTRACT FROM AUTHOR]

The article presents a study which showed that cell-free deoxyribonucleic acid (cfDNA) testing for fetal trisonomy is more effective than standard screening during the first-trimester of pregnancy in routine prenatal populations. Topics include the study's respondents which comprised of pregnant women presenting for aneuploidy screening, and the higher sensitivity of cfDNA testing for trisomy 21 when compared with standard screening in measuring nuchal translucency and biochemical analytes.

Background Maternal depression carries a major public health burden for mothers and their infants, yet there is a substantial treatment gap for this condition in low-resourced regions such as sub- Saharan Africa. To address this treatment gap, the strategy of "task sharing" has been proposed, involving the delivery of interventions by non-specialist health workers trained and supervised by specialists in routine healthcare delivery systems. Several psychological interventions have shown benefit in treating maternal depression, but few have been rigorously evaluated using a task sharing approach. The proposed trial will be the first randomised controlled trial (RCT) evaluating a task sharing model of delivering care for women with maternal depression in sub-Saharan Africa. The objective of this RCT is to determine the effectiveness and cost-effectiveness of a task sharing counseling intervention for maternal depression in South Africa. Methods/Design The study is an individual-level two-arm RCT. A total of 420 depressed pregnant women will be recruited from two ante-natal clinics in a low-income township area of Cape Town, using the Edinburgh Postnatal Depression Scale to screen for depression; 210 women will be randomly allocated to each of the intervention and control arms. The intervention group will be given six sessions of basic counseling over a period of 3 to 4 months, provided by trained community health workers (CHW)s. The control group will receive three monthly phone calls from a CHW trained to conduct phone calls but not basic counseling. The primary outcome measure is the 17-Item Hamilton Depression Rating Scale (HDRS-17). The outcome measures will be applied at the baseline assessment, and at three follow-up points: 1 month before delivery, and 3 and 12 months after delivery. The primary analysis will be by intention-to-treat and secondary analyses will be on a per protocol population. The primary outcome measure will be analyzed using linear regression adjusting for baseline symptom severity measured using the HDRS-17. Discussion The findings of this trial can provide policy makers with evidence regarding the effectiveness and cost-effectiveness of structured psychological interventions for maternal depression delivered by appropriately trained and supervised non-specialist CHWs in sub- Saharan Africa. Trial registration Clinical Trials (ClinicalTrials.gov): NCT01977326, registered on 24/10/2013; Pan African Clinical Trials Registry (www.pactr.org): PACTR201403000676264, registered on 11/10/2013. [ABSTRACT FROM AUTHOR]

Paraprofessional home visitors trained to improve multiple outcomes (HIV, alcohol, infant health and malnutrition) have been shown to benefit mothers and children over 18 months in a cluster randomised controlled trial. These longitudinal analyses examine the mechanisms which influence child outcomes at 18 months post-birth in Cape Town, South Africa. The results were evaluated using structural equation modelling, specifically examining the mediating effects of prior maternal behaviours and a home visiting intervention post-birth. Twelve matched pairs of neighbourhoods were randomised within pairs to: (1) the control condition, receiving comprehensive health care at community primary health care clinics (n = 12 neighbourhoods;n = 594 pregnant women), or (2) the Philani Intervention Program, which provided home visits by trained, paraprofessional community health workers, here called Mentor Mothers, in addition to clinic care (n = 12 neighbourhoods;n = 644 pregnant women). Recruitment of all pregnant neighbourhood women was high (98%) with 88% reassessed at 6 months and 84% at 18 months. Infants’ growth and diarrhoea episodes were examined at 18 months in response to the intervention condition, breastfeeding, alcohol use, social support and low birth weight, controlling for HIV status and previous history of risk. We found that randomisation to the intervention was associated with a significantly lower number of recent diarrhoea episodes and increased rates and duration of breastfeeding. Across both the intervention and control conditions, mothers who used alcohol during pregnancy and had low birth weight infants were significantly less likely to have infants with normal growth patterns, whereas social support was associated with better growth. HIV infection was significantly associated with poor growth and less breastfeeding. Women with more risk factors had significantly smaller social support networks. The relationships among initial and sustained maternal risk behaviours and the buffering impact of home visits and social support are demonstrated in these analyses. [ABSTRACT FROM PUBLISHER]

Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs. [ABSTRACT FROM AUTHOR]

Objective: This is a secondary analysis examining neighborhood factors predicting high rates of child resilience in South African Township neighborhoods.Methods: A population cohort of South African pregnant women (98%; n = 1238), were recruited and assessed across five years with high follow-up rates (83-96%). Resilient children were identified based on consistently meeting global standards for growth, cognitive functioning, and behavior. Community infrastructure, maternal risks, and caretaking behaviors were examined based on neighborhood as predictors of childhood resilience.Results: The rate of resilient children varied significantly by neighborhood (9.5% to 27%). Mothers living in high prevalence neighborhoods (HPN) compared to low prevalence neighborhoods (LPN) were older and more likely be living with three or more people in formal housing with access to water and electricity. In the HPN, resilient children had more food security and were less likely to have mothers with depressed mood. Migration to rural areas occurred more frequently among resilient compared to non-resilient children in the HPN.Conclusion: This study applies a novel measure of resilience that is multidimensional and longitudinally defined. Living in formal housing with consistent access to food was associated with resilience. Migration to rural areas among families living in HPN suggests that rural areas could be protective.Trial Registration: ClinicalTrials.gov registration #NCT00996528. [ABSTRACT FROM AUTHOR]

• Living in a safe community, attending community-based organisations, food security and being in receipt of caregiver monitoring and praise showed accelerating effects for numerous outcomes related to the sustainable development goals. • Additive effects for combined interventions were relatively robust for mental health outcomes; school-factors require further research. • Existing interventions could be utilised or new ones devised to improve accelerator access. • Community-based organisations may be well-placed to deliver accelerating services to those most vulnerable. [ABSTRACT FROM AUTHOR]

The low rates of child literacy in South Africa are cause for considerable concern. Research from the developed world shows that parental sharing of picture books with infants and young children is beneficial for child language and cognitive development, as well as literacy skills. We conducted a pilot study to examine whether such benefits might extend to an impoverished community in South Africa, by evaluating the impact of training mothers in book sharing with their 14-18 month old infants. Seventeen mothers received book sharing training; and 13 mothers did not, but instead received a comparison training in toy play. We assessed the mothers' behavior during both book sharing and toy play before and after training, and we also assessed infant attention and language. Mothers receiving book sharing training engaged well with it, and they also benefited from it; thus, compared to the comparison group mothers, they became more sensitive, more facilitating, and more elaborative with their infants during book sharing, and they also became more sensitive to their infants during toy play. In addition, infants whose mothers received the book sharing training showed greater benefits than the comparison group infants in both their attention and language. Training in book sharing for families living in conditions of marked socio-economic adversity in South Africa has the potential to be of considerable benefit to child developmental progress. A large scale controlled trial is required to confirm this. [ABSTRACT FROM AUTHOR]

Background: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. Methods: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. Results: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. Conclusions: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care. [ABSTRACT FROM AUTHOR]

Objective: We evaluate the effect of clinic-based support by HIV-positive Peer Mentors, in addition to standard clinic care, on maternal and infant well-being among Women Living with HIV (WLH) from pregnancy through the infant's first year of life. Methods: In a cluster randomized controlled trial in KwaZulu-Natal, South Africa, eight clinics were randomized for pregnant WLH to receive either: a Standard Care condition (SC; 4 clinics; n = 656 WLH); or an Enhanced Intervention (EI; 4 clinics; n = 544 WLH). WLH in the EI were invited to attend four antenatal and four postnatal meetings led by HIV-positive Peer Mentors, in addition to SC. WLH were recruited during pregnancy, and at least two post-birth assessment interviews were completed by 57% of WLH at 1.5, 6 or 12 months. EI's effect was ascertained on 19 measures of maternal and infant well-being using random effects regressions to control for clinic clustering. A binomial test for correlated outcomes evaluated EI's overall efficacy. Findings: WLH attended an average of 4.1 sessions (SD = 2.0); 13% did not attend any sessions. Significant overall benefits were found in EI compared to SC using the binomial test. Secondarily, over time, WLH in the EI reported significantly fewer depressive symptoms and fewer underweight infants than WLH in the SC condition. EI WLH were significantly more likely to use one feeding method for six months and exclusively breastfeed their infants for at least 6 months. Conclusions: WLH benefit by support from HIV-positive Peer Mentors, even though EI participation was partial, with incomplete follow-up rates from 6–12 months. Trial Registration: ClinicalTrials.gov NCT00972699 [ABSTRACT FROM AUTHOR]

Breastfeeding is widely endorsed as the optimal strategy for feeding newborns and young infants, as well as improving child survival and achieving Millennium Development Goal 4. Exclusive breastfeeding ( EBF) for the first 6 months of life is rarely practised in South Africa. Following the 2010 World Health Organization ( WHO) infant feeding recommendations ( EBF for HIV-positive mothers with maternal or infant antiretroviral treatment), South Africa adopted breastfeeding promotion as a National Infant Feeding Strategy and removed free formula milk from the Prevention of Mother-to- Child Transmission of HIV programme. This study aimed to explore the perceptions of mothers and household members at community level regarding the value they placed on formula feeding and circumstances that drive the practice in a peri-urban community. We conducted in-depth interviews with HIV-positive and HIV-negative mothers in a community-randomised trial ( Good Start III). Focus group discussions were held with grandmothers, fathers and teenage mothers. Data were analysed using thematic analysis. The following themes were identified; inadequate involvement of teenage mothers; grandmothers who become replacement mothers; fear of failing to practise EBF for 6 months; partners as formula providers and costly formula milk leading to risky feeding practices. The new South African Infant Feeding Strategy needs to address the gaps in key health messages and develop community-orientated programmes with a focus on teenage mothers. These should encourage the involvement of grandmothers and fathers in decision-making about infant feeding so that they can support EBF for optimal child survival. [ABSTRACT FROM AUTHOR]

Reducing alcohol use during pregnancy is a pressing public health priority in Sub-Saharan Africa, but insight into the factors that influence prenatal drinking practices is lacking. This study investigated perceptions of, and motivations for, alcohol consumption during pregnancy and associated practices in a rural district of Lesotho. A combination of purposive and snowball sampling methods were used to identify pregnant women and mothers with young children from the general community, as well as from alcohol-serving venues. Between September 2016 and March 2017, a trained data collector conducted in-depth interviews with 40 women on reasons why pregnant women drink, what they know about the risk of drinking alcohol during pregnancy, and perceptions of women who drink during pregnancy. Sixty-five percent of women (n = 26) reported that they consumed alcohol during pregnancy. Findings were clustered into four themes: 1) alcohol use in daily and cultural life; 2) alcohol as relief from stress and hunger; 3) alcohol's effect on the baby; and 4) access to information about alcohol consumption. Our data suggest that alcohol use was a prominent feature of daily life and a key part of traditional events and ceremonies. Other than potentially harming the baby through falling on their stomachs while inebriated, women did not mention other risks associated with prenatal alcohol use. Rather, there were prominent beliefs that drinking alcohol – home-brewed alcohol in particular – had cleansing or protective benefits for the baby. Experiences of food insecurity were prominent, and women reported that alcohol helped curb their hunger and allowed them to save food to give to their children. Within this context of chronic poverty and food insecurity, alcohol use during pregnancy will continue to represent a valid, though tragic choice if the structural conditions and current social arrangements that facilitate prenatal alcohol use remain unchanged. • Women consumed alcohol during pregnancy as a source of relief from stress and poverty. • Experiences of food insecurity were prominent, and alcohol helped curb women's hunger. • Drinking alcohol was a key part of social and traditional events, facilitating prenatal alcohol use. • Consuming alcohol during pregnancy was perceived as beneficial and perceptions of risk was minimal. [ABSTRACT FROM AUTHOR]

Recognition of high rates of common mental disorders in many resource-constrained contexts has indicated the need for routine screening of patients attending public health facilities. Screening may facilitate entry into community level psychiatric services for those identified as disordered. Yet, screening instruments will need to ensure high specificity so as to minimise expenditures on treating false positives. Task shifting of screening activities to primary health care staff and lay workers in low income settings may hold some population-level advantages, including greater population coverage, more efficient deployment of health care staff, and the reduction of stigma if specific conditions are met. [ABSTRACT FROM PUBLISHER]

Background: Globally, 40% of the 7.6 million deaths of children under five every year occur in the neonatal period (first 28 days after birth). Increased and earlier recognition of illness facilitated by community health workers (CHWs), coupled with effective referral systems can result in better child health outcomes. This model has not been tested in a peri-urban poor setting in Africa, or in a high HIV context. Methods: The Good Start Saving Newborn Lives (SNL) study (ISRCTN41046462) conducted in Umlazi, KwaZulu- Natal, was a community randomized trial to assess the effect of an integrated home visit package delivered to mothers by CHWs during pregnancy and post-delivery on uptake of PMTCT interventions and appropriate newborn care practices. CHWs were trained to refer babies with illnesses or identified danger signs. The aim of this sub-study was to assess the effectiveness of this referral system by describing CHW referral completion rates as well as mothers' health-care seeking practices. Interviews were conducted using a structured questionnaire with all mothers whose babies had been referred by a CHW since the start of the SNL trial. Descriptive analysis was conducted to describe referral completion and health seeking behaviour of mothers. Results: Of the 2423 women enrolled in the SNL study, 148 sick infants were referred between June 2008 and June 2010. 62% of referrals occurred during the first 4 weeks of life and 22% between birth and 2 weeks of age. Almost all mothers (95%) completed the referral as advised by CHWs. Difficulty breathing, rash and redness/discharge around the cord accounted for the highest number of referrals (26%, 19% and 17% respectively). Only16% of health workers gave written feedback on the outcome of the referral to the referring CHW. Conclusions: We found high compliance with CHW referral of sick babies in an urban South African township. This suggests that CHWs can play a significant role, within community outreach teams, to improve newborn health and reduce child mortality. This supports the current primary health care re-engineering process being undertaken by the South African National Department of Health which involves the establishment of family health worker teams including CHWs. [ABSTRACT FROM AUTHOR]

The article presents a case study which describes a step-wise primary care model for pregnant women under the Perinatal Mental Health Project (PMHP) in South Africa. It is inferred that 90 percent of women receiving antenatal care were offered with mental health screening. It highlights the feasibility of the stepped care approach in the delivery of mental health services at the primary care level.

Abstract: Background: HIV-positive pregnant women who drink put their children at risk of both HIV and fetal alcohol spectrum disorders. The province of KwaZulu-Natal (KZN) has the highest prevalence of HIV in South Africa, but has not before been considered an area of high alcohol consumption among women. This paper analyzes a large sample of HIV+ pregnant women in KZN to examine alcohol consumption in that population. Methods: Data came from assessments of women enrolled in Prevention of Mother-To-Child Transmission programs at 8 clinics in KZN. Descriptive statistics and logistic regressions were used to examine the prevalence and correlates of alcohol consumption and binge drinking. Results: Of 1201 women assessed, 18% reported drinking during pregnancy, and 67% of drinkers usually binged when drinking (had 3+ drinks in one sitting). Over one-third of drinkers binged twice a month or more. Women living in urban and peri-urban locations were more likely to drink, as were those with indicators of higher economic status and greater social engagement. Married women were less likely to drink, while women who had poorer mental health, used tobacco, or had a greater history of sexual risk-taking were more likely to drink. Conclusion: Health care workers in KZN should be aware that pregnant women who drink are likely to do so at a level that is dangerous for their babies. Some factors associated with drinking indicate social/environmental influences that need to be counteracted by greater dissemination of information about the dangers of drinking, and greater support for abstinence or moderation. [Copyright &y& Elsevier]

Background: Pregnant women living with HIV (WLH) face daily challenges maintaining their own and their babies' health and mental health. Standard Prevention of Maternal to Child Transmission (PMTCT) programs are not designed to address these challenges. Methods/Design: As part of a cluster randomized controlled trial, WLH are invited to attend four antenatal and four postnatal small group sessions led by a peer WLH (a Peer Mentor). The WLH and their babies are assessed during pregnancy and at one week, six months, and twelve months post-birth. Mobile phones are used to collect routine information, complete questionnaires and remain in contact with participants over time. Pregnant WLH (N = 1200) are randomly assigned by clinic (N = 8 clinics) to an intervention program, called Masihambisane (n = 4 clinics, n = 600 WLH) or a standard care PMTCT control condition (n = 4 clinics; n = 600 WLH). Discussion: Data collection with cellular phones are innovative and effective in low-resource settings. Standard PMTCT programs are not designed to address the daily challenges faced by WLH; Peer Mentors may be useful in supporting WLH to cope with these challenges. Trial registration: ClinicalTrials.gov registration # NCT00972699. [ABSTRACT FROM AUTHOR]

Background: Chronicity and severity of early exposure to maternal common mental disorders (CMD) has been associated with poorer infant development in high-income countries. In low- and middle-income countries (LAMICs), perinatal CMD is inconsistently associated with infant development, but the impact of severity and persistence has not been examined. Methods: A nested population-based cohort of 258 pregnant women was identified from the Perinatal Maternal Mental Disorder in Ethiopia (P-MaMiE) study, and 194 (75.2%) were successfully followed up until the infants were 12 months of age. Maternal CMD was measured in pregnancy and at two and 12 months postnatal using the WHO Self-Reporting Questionnaire, validated for use in this setting. Infant outcomes were evaluated using the Bayley Scales of Infant Development. Results: Antenatal maternal CMD symptoms were associated with poorer infant motor development ( ... -0.20; 95% CI: -0.37 to -0.03), but this became non-significant after adjusting for confounders. Postnatal CMD symptoms were not associated with any domain of infant development. There was evidence of a dose-response relationship between the number of time-points at which the mother had high levels of CMD symptoms (SRQ = 6) and impaired infant motor development ( ... = -0.80; 95%CI -2.24, 0.65 for ante- or postnatal CMD only, ... = -4.19; 95% CI -8.60, 0.21 for ante- and postnatal CMD, compared to no CMD; test-for-trend χ²13.08(1), p < 0.001). Although this association became non-significant in the fully adjusted model, the ... coefficients were unchanged indicating that the relationship was not confounded. In multivariable analyses, lower socio-economic status and lower infant weight-for-age were associated with significantly lower scores on both motor and cognitive developmental scales. Maternal experience of physical violence was significantly associated with impaired cognitive development. Conclusions: The study supports the hypothesis that it is the accumulation of risk exposures across time rather than early exposure to maternal CMD per se that is more likely to affect child development. Further investigation of the impact of chronicity of maternal CMD upon child development in LAMICs is indicated. In the Ethiopian setting, poverty, interpersonal violence and infant undernutrition should be targets for interventions to reduce the loss of child developmental potential. [ABSTRACT FROM AUTHOR]

Background: Child undernutrition is a major public health problem in low income countries. Prospective studies of predictors of infant growth in rural low-income country settings are relatively scarce but vital to guide intervention efforts. Methods: A population-based sample of 1065 women in the third trimester of pregnancy was recruited from the demographic surveillance site (DSS) in Butajira, south-central Ethiopia, and followed up until the infants were one year of age. After standardising infant weight and length using the 2006 WHO child growth standard, a cut-off of two standard deviations below the mean defined the prevalence of stunting (length-for-age <-2), underweight (weight-for-age <-2) and wasting (weight-for-length <-2). Results: The prevalence of infant undernutrition was high at 6 months (21.7% underweight, 26.7% stunted and 16.7% wasted) and at 12 months of age (21.2% underweight, 48.1% stunted, and 8.4% wasted). Significant and consistent predictors of infant undernutrition in both logistic and linear multiple regression models were male gender, low birth weight, poor maternal nutritional status, poor household sanitary facilities and living in a rural residence. Compared to girls, boys had twice the odds of being underweight (OR = 2.00; 95%CI: 1.39, 2.86) at 6 months, and being stunted at 6 months (OR = 2.38, 95%CI: 1.69, 3.33) and at 12 months of age (OR = 2.08, 95%CI: 1.59, 2.89). Infant undernutrition at 6 and 12 months of age was not associated with infant feeding practices in the first two months of life. Conclusion: There was a high prevalence of undernutrition in the first year of infancy in this rural Ethiopia population, with significant gender imbalance. Our prospective study highlighted the importance of prenatal maternal nutritional status and household sanitary facilities as potential targets for intervention. [ABSTRACT FROM AUTHOR]

Background: Although maternal common mental disorder (CMD) appears to be a risk factor for infant undernutrition in South Asian countries, the position in sub-Saharan Africa (SSA) is unclear Methods: A population-based cohort of 1065 women, in the third trimester of pregnancy, was identified from the demographic surveillance site (DSS) in Butajira, to investigate the effect of maternal CMD on infant undernutrition in a predominantly rural Ethiopian population. Participants were interviewed at recruitment and at two months postpartum. Maternal CMD was measured using the locally validated Self-Reported Questionnaire (score of ≥ six indicating high levels of CMD). Infant anthropometry was recorded at six and twelve months of age. Result: The prevalence of CMD was 12% during pregnancy and 5% at the two month postnatal time-point. In bivariate analysis antenatal CMD which had resolved after delivery predicted underweight at twelve months (OR = 1.71; 95% CI: 1.05, 2.50). There were no other statistically significant differences in the prevalence of underweight or stunted infants in mothers with high levels of CMD compared to those with low levels. The associations between CMD and infant nutritional status were not significant after adjusting for pre-specified potential confounders. Conclusion: Our negative finding adds to the inconsistent picture emerging from SSA. The association between CMD and infant undernutrition might be modified by study methodology as well as degree of shared parenting among family members, making it difficult to extrapolate across low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Objective: The possibility of mother-to-child transmission (MTCT) of HIV through breast-feeding has focused attention on how best to support optimal feeding practices especially in low-resource and high-HIV settings, which characterizes most of sub-Saharan Africa. To identify strategic opportunities to minimize late postnatal HIV transmission, we undertook a review of selected country experiences on HIV and infant feeding, with the aims of documenting progress over the last few years and determining the main challenges and constraints. Design: Field teams conducted national-level interviews with key informants and visited a total of thirty-six facilities in twenty-one sites across the three countries - eighteen facilities in Malawi, eleven in Kenya and seven in Zambia. During these visits interviews were undertaken with key informants such as the district and facility management teams, programme coordinators and health workers. Setting: A rapid assessment of HIV and infant feeding counselling in Kenya, Malawi and Zambia, undertaken from February to May 2007. Results: Infant feeding counselling has, until now, been given low priority within programmes aimed at prevention of MTCT (PMTCT) of HIV. This is manifest in the lack of resources - human, financial and time - for infant feeding counselling, leading to widespread misunderstanding of the HIV transmission risks from breastfeeding. It has also resulted in lack of space and time for proper counselling, poor support and supervision, and very weak monitoring and evaluation of infant feeding. Finally, there are very few examples of linkages with community-based infant feeding interventions. However, all three countries have started to revise their feeding policies and strategies and there are signs of increased resources. Conclusions: In order to sustain this momentum it will be necessary to continue the advocacy with the HIV community and stress the importance of child survival - not just minimization of HIV transmission - and hence the need for integrating MTCT prevention. [ABSTRACT FROM AUTHOR]

The article presents a study on HIV prevalence and risk behaviors among heterosexual men with multiple sex partners in South Africa. A survey was conducted among men aged 18 years or older who reported having had sex with more than 1 female partner in the previous three months with the use of respondent-driven sampling. It concludes that studied men requires more targeted HIV surveillance and prevention interventions.

Objectives To examine the impact of antenatal psychosocial stressors, including maternal common mental disorders (CMD), upon low birth weight, stillbirth and neonatal mortality, and other perinatal outcomes in rural Ethiopia. Methods A population-based sample of 1065 pregnant women was assessed for symptoms of antenatal CMD (Self-Reporting Questionnaire-20: SRQ-20), stressful life events during pregnancy (List of Threatening Experiences: LTE) and worry about the forthcoming delivery. In a sub-sample of 654 women from six rural sub-districts, neonatal birth weight was measured on 521 (79.7%) singleton babies within 48 h of delivery. Information about other perinatal outcomes was obtained shortly after birth from the mother’s verbal report and via the Demographic Surveillance System. Results After adjusting for potential confounders, none of the psychosocial stressors were associated with lower mean birth weight, stillbirth or neonatal mortality. Increasing levels of antenatal CMD symptoms were associated both with prolonged labour (>24 h) (SRQ 1–5: RR 1.4; 95% CI 1.0–1.9, SRQ ≥ 6: RR 1.6; 95% CI 1.0–2.6) and delaying initiation of breast-feeding more than eight hours (SRQ 1–5: RR 1.4; 95% CI 0.8 to 2.4, SRQ ≥ 6: RR 2.8; 95% CI 1.3–6.1). Worry about delivery was also associated with labour longer than 24 h (RR 1.5; 95% CI 1.0–2.1). Conclusions This study provides preliminary evidence of important public health consequences of poor maternal mental health in low-income countries but does not replicate the strong association with low birth weight found in South Asia. [ABSTRACT FROM AUTHOR]

A Correction to this paper has been published: https://doi.org/10.1007/s00737-021-01122-7 [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the safety and immunogenicity of ZOSTAVAX administered concomitantly with inactivated influenza vaccine or sequentially in adults aged 50 and older. DESIGN: Randomized, blinded, placebo-controlled study. SETTING: Thirteen U.S. and seven European study sites. PARTICIPANTS: Three hundred eighty-two concomitantly, 380 sequentially vaccinated subjects. INTERVENTION: The concomitant vaccination group received influenza vaccine and ZOSTAVAX at separate injection sites on Day 1 and placebo at Week 4. The nonconcomitant vaccination group received influenza vaccine and placebo at separate injection sites on Day 1 and ZOSTAVAX at Week 4. MEASUREMENTS: Primary safety endpoints: vaccine-related serious adverse experiences (AEs) within 28 days postvaccination (PV); and diary card–prompted local and systemic AEs. Primary immunogenicity endpoints: geometric mean titer (GMT) and geometric mean fold rise (GMFR) from baseline of varicella-zoster virus (VZV) antibody (Ab) at 4 weeks PV according to glycoprotein enzyme-linked immunosorbent assay (gpELISA) and GMT of influenza Ab for the three vaccine strains (2005–2006 influenza season) at 4 weeks PV according to hemagglutination inhibition assay. Secondary immunogenicity endpoint: influenza seroconversion rates (SCRs). RESULTS: No serious AEs related to ZOSTAVAX were observed during the study. VZV Ab GMTs 4 weeks PV for the concomitant and sequential groups were 554 and 597 gpELISA U/mL, respectively. The estimated VZV Ab GMT ratio was 0.9 (95% confidence interval (CI)=0.8–1.0), indicating noninferior ( P<.001 for the null hypothesis of GMT ratio <0.67) responses. Estimated VZV Ab GMFR from baseline in the concomitant group was 2.1 (95% CI=2.0–2.3), indicating acceptable fold rise. Estimated GMT ratios (concomitant/sequential) for influenza strains A(H1N1), A(H3N2), and B were 0.9 (95% CI=0.8–1.1), 1.1 (95% CI=0.9–1.3), and 0.9 (95% CI=0.8–1.1), respectively, and SCRs were comparable across both groups, with more than 85% achieving titers of 1:40 or greater, meeting regulatory criteria. CONCLUSION: ZOSTAVAX and influenza vaccine given concomitantly are generally well tolerated in adults aged 50 and older. Ab responses were similar whether ZOSTAVAX and influenza vaccine were given concomitantly or sequentially. [ABSTRACT FROM AUTHOR]