Search

Background: The PRECISE (PREgnancy Care Integrating translational Science, Everywhere) Network is a new and broadly-based group of research scientists and health advocates based in the UK, Africa and North America. Methods: This paper describes the protocol that underpins the clinical research activity of the Network, so that the investigators, and broader global health community, can have access to 'deep phenotyping' (social determinants of health, demographic and clinical parameters, placental biology and agnostic discovery biology) of women as they advance through pregnancy to the end of the puerperium, whether those pregnancies have normal outcomes or are complicated by one/more of the placental disorders of pregnancy (pregnancy hypertension, fetal growth restriction and stillbirth). Our clinical sites are in The Gambia (Farafenni), Kenya (Kilifi County), and Mozambique (Maputo Province). In each country, 50 non-pregnant women of reproductive age will be recruited each month for 1 year, to provide a final national sample size of 600; these women will provide culturally-, ethnically-, seasonally- and spatially-relevant control data with which to compare women with normal and complicated pregnancies. Between the three countries we will recruit ≈10,000 unselected pregnant women over 2 years. An estimated 1500 women will experience one/more placental complications over the same epoch. Importantly, as we will have accurate gestational age dating using the TraCer device, we will be able to discriminate between fetal growth restriction and preterm birth. Recruitment and follow-up will be primarily facility-based and will include women booking for antenatal care, subsequent visits in the third trimester, at time-of-disease, when relevant, during/immediately after birth and 6 weeks after birth. Conclusions: To accelerate progress towards the women's and children's health-relevant Sustainable Development Goals, we need to understand how a variety of social, chronic disease, biomarker and pregnancy-specific determinants health interact to result in either a resilient or a compromised pregnancy for either mother or fetus/newborn, or both. This protocol has been designed to create such a depth of understanding. We are seeking funding to maintain the cohort to better understand the implications of pregnancy complications for both maternal and child health. [ABSTRACT FROM AUTHOR]

Background: A community’s cultural beliefs, attitudes and discourse can affect their responses in surveys. Knowledge of these cultural factors and how to comply with them or adjust for them during data collection can improve data quality. Objective: This study describes implications of features of Gambian culture related to women’s reproductive health, and mortality, when collecting data in surveys. Methods: 13 in-depth interviews of female interviewers and a focus group discussion among male interviewers were conducted in two rural health and demographic surveillance systems as well as three key informant interviews in three regions in The Gambia. Results: From the fieldworker’s viewpoint, questions relating to reproduction were best asked by women as culturally pregnancies should be concealed, and menstruation is considered a sensitive topic. Gambians were reluctant to speak about decedents and the Fula did not like to be counted, potentially affecting estimation of mortality. Asking about siblings proved problematic among the Fula and Serahule communities. Proposals made to overcome these challenges were that culturally-appropriate metaphors and symbols should be used to discuss sensitive matters and to enumerating births/deaths singly instead of collecting summary totals, which had threatening connotations. This was as opposed to training interviewers to ask standardised and precise verbatim questions. Contribution: This paper presents indigenous Gambian solutions by fieldworkers to culturally sensitive topics when collecting pregnancy outcomes and mortality data in demographic and health surveys. For researchers collecting maternal mortality data, it highlights the potential shortcomings of the sibling history methodology. [ABSTRACT FROM AUTHOR]

Background We investigated whether adding community scheduled malaria screening and treatment (CSST) with artemether-lumefantrine by community health workers (CHWs) to standard intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) would improve maternal and infant health. Methods In this 2-arm cluster-randomized, controlled trial, villages in Burkina Faso, The Gambia, and Benin were randomized to receive CSST plus IPTp-SP or IPTp-SP alone. CHWs in the intervention arm performed monthly CSST during pregnancy. At each contact, filter paper and blood slides were collected, and at delivery, a placental biopsy was collected. Primary and secondary endpoints were the prevalence of placental malaria, maternal anemia, maternal peripheral infection, low birth weight, antenatal clinic (ANC) attendance, and IPTp-SP coverage. Results Malaria infection was detected at least once for 3.8% women in The Gambia, 16.9% in Benin, and 31.6% in Burkina Faso. There was no difference between study arms in terms of placenta malaria after adjusting for birth season, parity, and IPTp-SP doses (adjusted odds ratio, 1.06 [95% confidence interval,.78–1.44]; P =.72). No difference between the study arms was found for peripheral maternal infection, anemia, and adverse pregnancy outcomes. ANC attendance was significantly higher in the intervention arm in Burkina Faso but not in The Gambia and Benin. Increasing number of IPTp-SP doses was associated with a significantly lower risk of placenta malaria, anemia at delivery, and low birth weight. Conclusions Adding CSST to existing IPTp-SP strategies did not reduce malaria in pregnancy. Increasing the number of IPTp-SP doses given during pregnancy is a priority. Clinical Trials Registration NCT01941264; ISRCTN37259296. [ABSTRACT FROM AUTHOR]

Background: The use of most anti-malarial medications is restricted during pregnancy, but two doses of sulphadoxine-pyrimethamine are recommended after the first trimester as intermittent preventive treatment in pregnancy (IPTp). In The Gambia, only 32% of women receive two doses and very little research has been conducted on women's awareness of drug safety during pregnancy. The objective of this paper was to assess whether rural Gambian women were aware of the importance of the timing of the two-dose IPT dose schedule and its relevance to drug safety. Methods: This was a qualitative study in which 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants were conducted. A generic qualitative approach was used to generate a theory as to why women might not participate in IPTp as recommended. Results: Although most women used calendar months to count their stage of pregnancy, these months did not correlate with their concept of foetal development. Foetal growth was described following Islamic tradition as water, clot, piece of meat and human being, although there was little consensus about the order or timing in which these stages occurred. Common signs and conditions of malaria were known. Women were anxious about miscarriage and recognized that some medicines should not be taken in the first trimester, but were urged by men and traditional birth attendants to attend for antenatal care in the first trimester to "start treatment." General knowledge about the purpose of pregnancy medications and when they should be taken was poor among both men and women. One important result was that women relied entirely on health workers to provide safe drugs, at the correct time. Conclusion: Women did not have relevant information to judge the safety and appropriate timing of pregnancy drugs, which made them over-reliant on health workers. They should be encouraged to date their own pregnancies in culturally relevant terms and to anticipate when and which medications they should receive. [ABSTRACT FROM AUTHOR]

Background: Malaria in pregnancy remains a major health threat in sub-Saharan Africa to both expectant mothers and their unborn children. To date, there have been very few studies focused on the out of pocket costs associated with seeking treatment for malaria during pregnancy. Methods: A cross-sectional survey was undertaken in Burkina Faso and The Gambia to estimate the direct and indirect costs associated with outpatient consultations (OP) and inpatient admissions (IP). Direct costs were broken down into medical (admission fees, drug charges, and laboratory fees), and non-medical (transportation and food). Indirect costs reflected time lost due to illness. In total, 220 pregnant women in Burkina Faso and 263 in The Gambia were interviewed about their treatment seeking decisions, expenditure, time use and financial support associated with each malaria episode. Results: In Burkina Faso 6.7% sought treatment elsewhere before their OP visits, and 27.1% before their IP visits. This compares to 1.3% for OP and 25.92% for IP in The Gambia. Once at the facility, the average direct costs (out of pocket) were 3.91US$ for an OP visit and 15.38US$ of an IP visit in Burkina Faso, and 0.80US$ for an OP visit and 9.19US$ for an IP visit in The Gambia. Inpatient direct costs were driven by drug costs (9.27US$) and transportation costs (2.72US$) in Burkina Faso and drug costs (3.44 US$) and food costs (3.44 US$) in The Gambia. Indirect costs of IP visits, valued as the opportunity cost of time lost due to the illness, were estimated at 11.85US$ in Burkina Faso and 4.07US$ in The Gambia. The difference across the two countries was mainly due to the longer time of hospitalization in Burkina Faso compared to The Gambia. In The Gambia, the vast majority of pregnant women reported receiving financial support from family members living abroad, most commonly siblings (65%). Conclusions: High malaria treatment costs are incurred by pregnant women in Burkina Faso and The Gambia. Beyond the medical costs of fees and drugs, costs in terms of transport, food and time are significant drivers. The role of remittances, particularly their effect on accessing health care, needs further investigation. [ABSTRACT FROM AUTHOR]

Abstract: This paper draws on ethnographic fieldwork with Gambian women who have experienced infertility and/or child mortality and who have consequently become kanyalengs. Kanyaleng kafoos are groups of women united by their reproductive difficulties whose bold public performances are designed to “beg God” for fertility and for children who will survive. I situate ’kanyalengs’ disrupted childbearing within a framework of stratified reproduction, which reveals the tensions between ongoing demands to meet norms of high fertility, women’s heavy burden of reproductive disease and the limits of a reproductive public health agenda narrowly focused on family planning and HIV prevention. To ameliorate these tensions, I call for an expansion of the sexual and reproductive health (SRH) agenda in Gambia to include RTI/STI prevention, diagnosis and management. This expansion reflects the goals set out by the Cairo International Conference on Population and Development for a broader approach to reproductive health, the productive potential of linkages between SRH and HIV prevention efforts, as well as the reproductive objectives of Gambian women and men. [Copyright &y& Elsevier]

Background: Infant DNA methylation profiles are associated with their mother's periconceptional nutritional status. DNA methylation relies on nutritional inputs for one-carbon metabolic pathways, including the efficient recycling of homocysteine. This randomised controlled trial in nonpregnant women in rural Gambia tests the efficacy of a novel nutritional supplement designed to improve one-carbon-related nutrient status by reducing plasma homocysteine, and assesses its potential future use in preconception trials.Methods and Findings: We designed a novel drink powder based on determinants of plasma homocysteine in the target population and tested it in a three-arm, randomised, controlled trial. Nonpregnant women aged between 18 and 45 from the West Kiang region of The Gambia were randomised in a 1:1:1 allocation to 12 weeks daily supplementation of either (a) a novel drink powder (4 g betaine, 800 μg folic acid, 5.2 μg vitamin B12, and 2.8 mg vitamin B2), (b) a widely used multiple micronutrient tablet (United Nations Multiple Micronutrient Preparation [UNIMMAP]) containing 15 micronutrients, or (c) no intervention. The trial was conducted between March and July 2018. Supplementation was observed daily. Fasted venepuncture samples were collected at baseline, midline (week 5), and endline (week 12) to measure plasma homocysteine. We used linear regression models to determine the difference in homocysteine between pairs of trial arms at midline and endline, adjusted for baseline homocysteine, age, and body mass index (BMI). Blood pressure and pulse were measured as secondary outcomes. Two hundred and ninety-eight eligible women were enrolled and randomised. Compliance was >97.8% for both interventions. At endline (our primary endpoint), the drink powder and UNIMMAP reduced mean plasma homocysteine by 23.6% (-29.5 to -17.1) and 15.5% (-21.2 to -9.4), respectively (both p < 0.001), compared with the controls. Compared with UNIMMAP, the drink powder reduced mean homocysteine by 8.8% (-15.8 to -1.2; p = 0.025). The effects were stronger at midline. There was no effect of either intervention on blood pressure or pulse compared with the control at endline. Self-reported adverse events (AEs) were similar in both intervention arms. There were two serious AEs reported over the trial duration, both in the drink powder arm, but judged to be unrelated to the intervention. Limitations of the study include the use of a single targeted metabolic outcome, homocysteine.Conclusions: The trial confirms that dietary supplements can influence metabolic pathways that we have shown in previous studies to predict offspring DNA methylation. Both supplements reduced homocysteine effectively and remain potential candidates for future epigenetic trials in pregnancy in rural Gambia.Trial Registration: Clinicaltrials.gov Reference NCT03431597. [ABSTRACT FROM AUTHOR]

Background: In The Gambia, national estimates of under-five mortality (U5M) were from censuses and multiple indicator cluster surveys (MICS). The country’s first demographic and health survey (DHS) conducted in 2013 provided empirical disaggregated national estimates of neonatal, post-neonatal and child mortality trends. Objective: To assess the consistency and accuracy of the estimates of U5M from the existing data sources and its age-specific components in rural Gambia and produce reliable up-to-date estimates. Methods: Available national data on under-five mortality from 2000 onwards were extracted. Additionally, data from two DHS regions were compared to those from two health and demographic surveillance systems (HDSS) located within them. Indirect and direct estimates from the data were compared and flexible parametric survival methods used to predict mortality rates for all empirical data points up to 2015. Findings: Internal consistency checks on data quality for indirect estimation of U5M suggest that the data were plausible at national level once information from women aged 15–19 years was excluded. The DHS and HDSS data used to make direct U5M estimates were plausible, however HDSS data were of better quality. For 2009–2013, the DHS estimates agreed well with the 2013 census and 2010 MICS reports of U5M but was less accurate about the early births of older women. The most recent estimates from the 2013 DHS, which refer to 2011–12, are an U5M rate of 54/1000 livebirths (95% CI: 43–64) and a neonatal mortality rate of 21/1000 livebirths (95% CI: 15–27), contributing almost 40% of U5M in The Gambia. The DHS showed that for the decade prior to the survey, child mortality dropped by 55% and neonatal mortality by 31%. This indicates the importance of neonatal mortality in The Gambia, and the need to focus on neonatal survival, while maintaining currently successful strategies to further reduce U5M. [ABSTRACT FROM AUTHOR]

Introduction: In many Sub-Saharan African countries, women with infertility search relentlessly for treatment. Guided by the Partners for Applied Social Sciences model for health seeking behaviour and access to care research, this study aims to understand the health seeking behaviour of women with infertility in the West Coast region of The Gambia and the influence of aetiological beliefs on health seeking paths. Methodology: A qualitative approach was used to generate both primary and secondary data for thematic analysis. The data collection methods included in-depth interviews (36), observations (18), informal conversations (42), group discussion (7) and made use of pile-sorting exercises. Sources of secondary data included government and non-governmental reports and media outputs. Results: The health seeking approaches of women living in both rural and urban areas were extremely complex and dynamic, with women reporting that they looked for biomedical treatment as well as seeking indigenous treatment provided by local healers, sacred places and kanyaleng groups. While treatment choice was related to the perceived aetiology of infertility, it was also strongly influenced by the perceived effectiveness of the treatment available and the duration of the fertility problems. Other relevant factors were the affordability, accessibility and availability of treatment and respondents’ family and social networks, whereby access to the biomedical health sector was strongly influenced by people’s socio-economic background. Conclusion: On the basis of this analysis and our wider research in the area, we see a need for health authorities to further invest in providing information and counselling on issues related to infertility prevention and treatment. The availability of locally applicable guidelines for the management of infertility for both men and women at all levels of the health system would facilitate such work. In addition, the public sphere should provide more space for alternative forms of social identity for both men and women. [ABSTRACT FROM AUTHOR]

The article discusses various papers published within the issue including topics concerning nutrition in early life, cognitive functioning and nutrition supplementation provided throughout pregnancy.

Although a low serum folate concentration is a useful biomarker of pure folate deficiency, the presence of vitamin B12 deficiency or hemolysis or both in individuals with low folate status predictably raises serum folate levels. Therefore, in resourcelimited settings where dietary folate deficiency can coexist with vitamin B12 deficiency or malaria or both, the serum folate concentration can range from normal to high, leading to serious underestimation of tissue folate status. This review traces the genesis of an inappropriate overreliance on the serum folate concentration to rule out folate deficiency in vulnerable populations of women and children. Of significance, without due consideration of a chronically inadequate dietary folate intake, authors of influential studies have likely wrongly judged these populations to have an adequate folate status. Through repetition, this error has led to a dangerous entry into the contemporary medical literature that folate deficiency is rare in women and children. As a consequence, many millions of under-resourced women and children with mild to moderate tissue folate deficiency may have been deprived of folate replacement. This review uses historical documents to challenge earlier conclusions and re-emphasizes the need for contextual integration of clinical information in resource-limited settings. [ABSTRACT FROM AUTHOR]

Background: The high rate of maternal mortality reported in The Gambia is influenced by many factors, such as difficulties in accessing quality healthcare and facilities. In addition, socio-cultural practices in rural areas may limit the resources available to pregnant women, resulting in adverse health consequences. The aim of this study is to depict the gender dynamics in a rural Gambian context by exploring the social and cultural factors affecting maternal health. Methods and Findings: Five focus group discussions that included 50 participants (aged 15–30 years, with at least one child) and six in-depth interviews with traditional birth attendants were conducted to explore perceptions of maternal health issues among rural women. The discussion was facilitated by guides focusing on issues such as how the women perceived their own physical health during pregnancy, difficulties in keeping themselves healthy, and health-related problems during pregnancy and delivery. The data resulting from the discussion was transcribed verbatim and investigated using a qualitative thematic analysis. In general, rural Gambian women did not enjoy privileges in their households when they were pregnant. The duties expected of them required pregnant women to endure heavy workloads, with limited opportunities for sick leave and almost nonexistent resources to access prenatal care. The division of labor between men and women in the household was such that women often engaged in non-remunerable field work with few economic resources, and their household duties during pregnancy were not alleviated by either their husbands or the other members of polygamous households. At the time of delivery, the decision to receive care by trained personnel was often beyond the women’s control, resulting in birth-related complications. Conclusions: Our findings suggest that despite women’s multiple roles in the household, their positions are quite unfavorable. The high maternal morbidity and mortality rate in The Gambia is related to practices associated with gender inequality. [ABSTRACT FROM AUTHOR]

Introduction: The potential benefits of Mass Drug Administration (MDA) for malaria elimination are being considered in several malaria endemic countries where a decline in malaria transmission has been reported. For this strategy to work, it is important that a large proportion of the target population participates, requiring an in-depth understanding of factors that may affect participation and adherence to MDA programs. Methodology: This social science study was ancillary to a one-round directly observed MDA campaign with dihydroartemisinin-piperaquine, carried out in 12 villages in rural Gambia between June and August 2014. The social science study employed a mixed-methods approach combining qualitative methods (participant observation and in-depth interviewing) and quantitative methods (structured follow-up interviews among non-participating and non-adhering community members). Results: Of 3942 people registered in the study villages, 67.9% adhered to the three consecutive daily doses. For the remaining villagers, 12.6% did not attend the screening, 3.5% was not eligible and 16% did not adhere to the treatment schedule. The main barriers for non-participation and adherence were long and short-term mobility of individuals and specific subgroups, perceived adverse drug reactions and rumors, inconveniences related to the logistics of MDA (e.g. waiting times) and the perceived lack of information about MDA. Conclusion: While, there was no fundamental resistance from the target communities, adherence was 67.9%. This shows the necessity of understanding local perceptions and barriers to increase its effectiveness. Moreover, certain of the constraining factors were socio-spatially clustered which might prove problematic since focal areas of residual malaria transmission may remain allowing malaria to spread to adjacent areas where transmission had been temporarily interrupted. [ABSTRACT FROM AUTHOR]

Objective. In sub-Saharan African countries, there are unique cultural factors and adverse physical conditions that contribute to women's experiences of pregnancy and birth. The objective of this study was to qualitatively explore women's experiences of pregnancy, childbirth, the postnatal period, and maternal psychological distress in The Gambia. Design and methods. Semi-structured interviews were carried out with 55 women who had given birth within the previous year. Results. Thematic analysis identified five themes: (1) transition to adulthood, (2) physical difficulties, (3) value of children in relation to others, (4) children as a strain, and (5) going through it alone. The results suggest that having a child is a defining point in women's lives associated with happiness and joy. However, women also described situations which could lead to unhappiness and distress in the perinatal period. A child conceived out of wedlock or a baby girl can be sources of distress because of negative cultural perceptions. The strain of having a child, particularly the additional financial burden, and minimal support from men were also a concern for women. Finally, women recognized the danger associated with delivery and expressed recurrent worries of complications during childbirth which could result in the death of them or the baby. Conclusions. Further research is needed to identify women vulnerable to psychological distress so that health services and target interventions can be developed accordingly. [ABSTRACT FROM AUTHOR]

A system to improve the management of emergencies during pregnancy, childbirth, infancy and childhood in a region of The Gambia (Brikama) with a population of approximately 250,000 has been developed. This was accomplished through formal partnership between the Gambian Ministry of Health, the World Health Organisation, Maternal Childhealth Advocacy International and the Advanced Life Support Group. Since October 2006, the hospital in Brikama has been renovated and equipped and more efficiently provided with emergency medicines. An emergency ambulance service now links the community with the hospital through a mobile telephone system. Health professionals from community to hospital have been trained in obstetric, neonatal and paediatric emergency management using skills' based education. The programme was evaluated in log books detailing individual resuscitations and by external assessment. The hospital now has constant water and electricity, a functioning operating theatre and emergency room; the maternity unit and children's wards have better emergency equipment and there is a more reliable supply of oxygen and emergency drugs, including misoprostol (for treating post partum haemorrhage) and magnesium sulphate (for severe pre-eclampsia). There is also a blood transfusion service. Countrywide, 217 doctors, nurses, and midwives have undergone accredited training in the provision of emergency maternal, newborn and child care, including for major trauma. 33 have received additional education through Generic Instructor Courses and 15 have reached full instructor status. 83 Traditional Birth Attendants and 48 Village Health Workers have been trained in the recognition and initial management of emergencies, including resuscitation of the newborn. Eleven and ten nurses underwent training in peri-operative nursing and anaesthetics respectively, to address the acute shortage required for emergency Caesarean section. Between May 2007 and March 2010, 109 patients, mostly pregnant mothers, were stabilised and transported to hospital by the new emergency ambulance service. 293 resuscitation attempts were documented in personal logbooks. A sustainable system for better managing emergencies has been established and is helping to negate the main obstacle impeding progress: the country's lack of available trained medical and nursing staff. However, insufficient attention was paid to improving staff morale and accommodation representing significant failings of the programme. [ABSTRACT FROM AUTHOR]

Objectives Control of infectious diseases in developing countries often requires using drugs that are contraindicated during pregnancy. Avoiding inadvertent exposure to drugs involves women (a) recognising pregnancy early, (b) disclosing the pregnancy to health workers and (c) using medicines in an informed manner. We explored these factors to inform and improve the process by which health workers provide care and treatment to pregnant women. Design Qualitative study. Setting The Gambia. Population Rural women and men. Methods We conducted 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants (TBAs). Main outcome measure Pregnancy disclosure. Results Most women recognised early signs and symptoms of pregnancy and believed other people could easily do so. To avoid gossip, women hid their pregnancies and delayed antenatal care, even though husbands and TBAs insisted on attendance. Women acutely ill in early pregnancy hoped health workers would recognise pregnancy without explicit disclosure. Women said that they knew, and sought to avoid, some contraindicated drugs, but their knowledge was rudimentary. Health workers stressed the benefits, not the risks of prescribed drugs. Conclusions Despite public health and clinical benefits of preventing and treating pregnancy infections, women were ill informed and pressurised into taking drugs. These ethical issues should be more widely addressed. [ABSTRACT FROM AUTHOR]

Background: Antenatal care is widely established and provides an opportunity to inform and educate pregnant women about pregnancy, childbirth and care of the newborn. It is expected that this would assist the women in making choices that would contribute to good pregnancy outcome. We examined the provision of information and education in antenatal clinics from the perspective of pregnant women attending these clinics. Methods: A cross sectional survey of 457 pregnant women attending six urban and six rural antenatal clinics in the largest health division in The Gambia was undertaken. The women were interviewed using modified antenatal client exit interview and antenatal record review questionnaires from the WHO Safe Motherhood Needs Assessment kit. Differences between women attending urban and rural clinics were assessed using the Chi-square test. Relative risks with 95% confidence intervals are presented. Results: Ninety percent of those interviewed had attended the antenatal clinic more than once and 52% four or more times. Most pregnant women (70.5%) said they spent 3 minutes or less with the antenatal care provider. About 35% recalled they were informed or educated on diet and nutrition, 30.4% on care of the baby, 23.6% on family planning, 22.8% on place of birth and 19.3% on what to do if there was a complication. About 25% of pregnant women said they were given information about the progress of their pregnancy after consultation and only 12.8% asked their provider any question. Awareness of danger signs was low. The proportions of women that recognised signs of danger were 28.9% for anaemia, 24.6% for hypertension, 14.8% for haemorrhage, 12.9% for fever and 5% for puerperal sepsis. Prolonged labour was not recognised as a danger sign. Women attending rural antenatal clinics were 1.6 times more likely to recognise signs of anaemia and hypertension as indicative of danger compared to women attending urban antenatal clinics. Conclusion: Information, education and communication during antenatal care in the largest health division are poor. Pregnant women are ill-equipped to make appropriate choices especially when they are in danger. This contributes to the persistence of high maternal mortality ratios in the country. [ABSTRACT FROM AUTHOR]

We have developed a methodology for comparing the seasonal influences on two outcomes, when those influences may act cumulatively or instantaneously. We have used this to compare the seasonal pattern of intrauterine growth retardation (IUGR, as reflected by weight-for-gestational-age) and preterm delivery (as assessed by Dubowitz scoring) among 1718 infants born in rural Gambia. Both outcomes were analysed as binary variables: small-for-gestational-age (SGA, <10th centile of reference standard) and preterm (<37 weeks) respectively. Percentages of preterm and SGA babies show divergent seasonal patterns that might indicate separate aetiologies. However, seasonal effects influencing intrauterine growth are likely to be cumulative over the last few months of pregnancy. By modelling seasonality with truncated Fourier series we were able to deconvolve the underlying seasonal influences on fetal growth from the pattern for SGA. This enabled us to use seemingly unrelated biprobit regression to compare the underlying seasonal pattern of intrauterine growth with that governing the incidence of preterm delivery. We conclude that, if the seasonal factors affecting intrauterine growth operate over more than the last 2 months of pregnancy, then the seasonal patterns of the factors causing IUGR and preterm delivery are indistinguishable if the factors are assumed to trigger preterm delivery immediately, but differ if preterm delivery is assumed to be programmed by factors acting at conception. [ABSTRACT FROM AUTHOR]

Background: Host susceptibility to P.falciparum is critical for understanding malaria in pregnancy, its consequences for the mother and baby, and for improving malaria control in pregnant women. Yet host genetic factors which could influence placental malaria risk are little studied and there are no reports of the role of blood group polymorphisms on pregnancy outcomes in malaria endemic areas. This study analyses the association between ABO blood group phenotypes in relation to placental malaria pathology. Methods: A total of 198 mother/child pairs delivering in Banjul and the Kombo-St Mary District (The Gambia) were analysed. ABO blood group was measured by agglutination. Placental malaria parasites wee enumerated and the presence of malaria pigment noted. Birth anthropometry was recorded and placental weight. Maternal and infant haemoglobin was measured. Results: 89 (45%) subjects were primiparae and 110 (55%)multiparae. The ABO phenotype distribution was 38(A), 52(B), 6(AB) and 102(O). Placental histo-pathology showed active placental malaria in 74 (37%), past infection in 42 (21%) and no infection in 82 cases (41%). In primiparae blood group O was associated with a higher risk of active infection (OR = 2.99; 95% CI = 1.24- 7.25), and a lower risk of past infection (OR = 0.31, 0.10-1.01, p < 0.05). In multiparae the O phenotype was associated with reduced prevalence of active or past placental infection (OR = 0.45; 95% CI 0.21-0.98). The mean feto-placental weight ratio was significantly higher in multiparae with group O women compared to non-O phenotypes (5.74 vs 5.36; p = 0.04). Among primiparae with active placental infection, mean birth weight was higher in children of mothers with the O phenotype (p = 0.04). Conclusion: These results indicate that blood group O was significantly associated with increased placental malaria infection in primiparae and reduced risk of infection in multiparae. This parity related susceptibility was not present with other ABO phenotypes. Cell surface glycans, such as ABO and related antigens have special relevance in reproductive biology and could modulate specific cell interactions as those associated with the pathogenesis of placental malaria. [ABSTRACT FROM AUTHOR]

Background: Thymic size in early infancy predicts subsequent survival in low-income settings. The human thymus develops from early gestation, is most active in early life and is highly sensitive to malnutrition. Our objective was to test whether thymic size in infancy could be increased by maternal and/or infant nutritional supplementation.Methods: The Early Nutrition and Immune Development (ENID) Trial was a randomized 2 × 2 × 2 factorial, partially blinded trial of nutritional supplementation conducted in rural Gambia, West Africa. Pregnant women (N = 875) were randomized to four intervention groups (iron-folate (standard care), multiple micronutrients, protein energy or protein energy + multiple micronutrients at 'booking' (mean gestational age at enrolment = 13.6 weeks, range 8-20 weeks) until delivery. The iron-folate and multiple micronutrient arms were administered in tablet form and the protein energy arms as a lipid-based nutritional supplement. All intervention arms contained 60 mg iron and 400 μg folic acid per daily dose. From 24 to 52 weeks of age, infants from all groups were randomized to receive a daily lipid-based nutritional supplement, with or without additional micronutrients. Thymic size was assessed by ultrasonography at 1, 8, 24 and 52 weeks of infant age, and a volume-related thymic index calculated. Detailed data on infant growth, feeding status and morbidity were collected.Results: A total of 724 (82.7%) mother-infant pairs completed the trial to infant age 52 weeks. Thymic size in infancy was not significantly associated with maternal supplement group at any post-natal time point. Infants who received the daily LNS with additional micronutrients had a significantly larger thymic index at 52 weeks of age (equivalent to an 8.0% increase in thymic index [95% CI 2.89, 13.4], P = 0.002). No interaction was observed between maternal and infant supplement groups.Conclusions: A micronutrient-fortified lipid-based supplement given in the latter half of infancy increased thymic size, a key mediator of immune function. Improving the micronutrient status of infants from populations with marginal micronutrient status may improve immune development and survival.Trial Registration: ISRCTN registry (controlled-trials.com) Identifier: ISRCTN49285450. [ABSTRACT FROM AUTHOR]