Background/Project Description: There is a growing interest in the contribution of late preterm (34 – 36 week gestational age (GA)) birth to neonatal morbidity and mortality. Late preterm infants have an increased incidence of both respiratory and non- respiratory complications over the first year of life. Rates of prematurity as well as morbidity/mortality in infancy are higher in lower socioeconomic status (SES) groups but how GA and SES interact is relatively unexplored. Methods/Participant Population: A retrospective cohort study was undertaken utilizing anonymized data housed at the Manitoba Centre for Health Policy (MCHP). A population-based cohort of infants born at 34 to 41 weeks of GA was assembled; individual and area-level income information was used to develop SES groups. Outcomes studied included diagnoses received during the birth hospitalisation, neonatal and post-neonatal admissions. Regression models were constructed to explore the effects of GA and SES as well as control for multiple perinatal variables. Appropriate approvals and safeguards for data privacy were maintained. Results: GA and SES exerted a gradient effect on morbidity, which persisted after controlling for multiple confounding variables. The effect of GA was strongest during the birth hospitalisation but persisted throughout the first year with increased morbidity evident with each week of decreasing GA. The detrimental association of low SES with morbidity increased in effect size throughout the first year surpassing that of GA for post-neonatal admissions. An interaction effect of maternal diabetes, respiratory morbidity and SES was suggested and merits further investigation. Neonatal stays of 3 days or longer negated the association of GA with readmission within the first 28 days; in addition shorter stay infants had the highest risks of readmission at 37 weeks as compared to the late preterm gestations. Conclusions: The consistent associations between poverty, prematurity and morbidity require both further study and attention. Attention to the neonatal health of both late preterm and term infants is important due to their large numbers and population impact. The added risk of poverty merits urgent and multifaceted interventions to lay the groundwork for healthy childhood and long-term success.

Background/Project Description: There is a growing interest in the contribution of late preterm (34 – 36 week gestational age (GA)) birth to neonatal morbidity and mortality. Late preterm infants have an increased incidence of both respiratory and non- respiratory complications over the first year of life. Rates of prematurity as well as morbidity/mortality in infancy are higher in lower socioeconomic status (SES) groups but how GA and SES interact is relatively unexplored. Methods/Participant Population: A retrospective cohort study was undertaken utilizing anonymized data housed at the Manitoba Centre for Health Policy (MCHP). A population-based cohort of infants born at 34 to 41 weeks of GA was assembled; individual and area-level income information was used to develop SES groups. Outcomes studied included diagnoses received during the birth hospitalisation, neonatal and post-neonatal admissions. Regression models were constructed to explore the effects of GA and SES as well as control for multiple perinatal variables. Appropriate approvals and safeguards for data privacy were maintained. Results: GA and SES exerted a gradient effect on morbidity, which persisted after controlling for multiple confounding variables. The effect of GA was strongest during the birth hospitalisation but persisted throughout the first year with increased morbidity evident with each week of decreasing GA. The detrimental association of low SES with morbidity increased in effect size throughout the first year surpassing that of GA for post-neonatal admissions. An interaction effect of maternal diabetes, respiratory morbidity and SES was suggested and merits further investigation. Neonatal stays of 3 days or longer negated the association of GA with readmission within the first 28 days; in addition shorter stay infants had the highest risks of readmission at 37 weeks as compared to the late preterm gestations. Conclusions: The consistent associations between poverty, prematurity and morbidity require both further study and attention. Attention to the neonatal health of both late preterm and term infants is important due to their large numbers and population impact. The added risk of poverty merits urgent and multifaceted interventions to lay the groundwork for healthy childhood and long-term success.

Background: Peru has increased substantially its domestic public expenditure in maternal and child health. Peruvian departments are heterogeneous in contextual and geographic factors, underlining the importance of disaggregated expenditure analysis up to the district level. We aimed to assess possible district level factors influencing public expenditure on reproductive, maternal, neonatal and child health (RMNCH) in Peru. Methods: We performed an ecological study in 24 departments, with specific RMNCH expenditure indicators as outcomes, and covariates of different hierarchical dimensions as predictors. To account for the influence of variables included in the different dimensions over time and across departments, we chose a stepwise multilevel mixed-effects regression model, with department-year as the unit of analysis. Results: Public expenditure increased in all departments, particularly for maternal-neonatal and child health activities, with a different pace across departments. The multilevel analysis did not reveal consistently influential factors, except for previous year expenditure on reproductive and maternal-neonatal health. Our findings may be explained by a combination of inertial expenditure, a results-based budgeting approach to increase expenditure efficiency and effectiveness, and by a mixed-effects decentralization process. Sample size, interactions and collinearity cannot be ruled out completely. Conclusions: Public district-level RMNCH expenditure has increased remarkably in Peru. Evidence on underlying factors influencing such trends warrants further research, most likely through a combination of quantitative and qualitative approaches. / This work was funded through a sub-grant from the U.S. Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn and Child Survival grant from the Bill & Melinda Gates Foundation, and through a sub-grant from the Partnership for Maternal, Newborn & Child Health. / Revisión por pares / Revisión por pares

Introduction: Short- and long-term health outcomes of children stem from their first 1000 days of development (3 months prior to conception to 2 years postpartum). Research shows a correlation between poor maternal nutrition and adverse birth outcomes. Various factors such as human breast milk (HBM), gut microbiome (GM), and body mass index (BMI) correlate with nutrition. The purpose of this study was to determine if maternal factors such as BMI impact preterm infant microbiome and short chain fatty acid (SCFA) profiles. Methods: Sample Collection: In order to understand the effect of maternal health factors on neonatal GM, deidentified stool samples were collected from the NICU at the MUSC and were utilized for GM and SCFA analysis at ETSU. Microbiome Analysis: GM analysis was performed on stool samples using the Qiagen QIAmp PowerFecal Pro DNA Kit. DNA was sequenced using Amplicon sequence of the 16s rRNA region with a modified Klindworth et al method. GM was analyzed using CLC Genomics Workbench v. 23 where Alpha diversity indexes were calculated with the Abundance Analysis tool and the Beta diversity (inter-sample diversity) was calculated using the weighted Unifrac metric. Short Chain Fatty Acid Analysis: The stool samples were subjected to SCFA extraction and analysis via a modified Schwiertz et al. method. Results: Significance was observed between the groups in microbiome for; C-section (yes, no), gestation (<28, 28-32, 33-36 weeks), week of sample collection (1, 2, 3, 4, >4 weeks), and maternal BMI + antibiotics (no antibiotics + normal, overweight, or obese BMI and antibiotics + normal, overweight, or obese BMI). Significance was detected between the groups in fecal fermentation for; recreational drug use (use, no use), preeclampsia (preeclamptic, not), sepsis evaluation (yes, no), week of sample collection (1, 2, 3, 4, >4 weeks), and Fenton measurements for birth length, birth weight, and occipital frontal circumference (small, average, large for gestational age). Conclusions: These results provide valuable insights into the various maternal and neonatal factors on the GM and SCFA profiles of preterm infants, which can have implications for their overall health and development. It is possible for future adverse health outcomes of premature neonates to be attenuated through HBM ingested and GM.

Thesis (M.S.)--University of Michigan, 1976.

Thesis (M.S.)--University of Michigan, 1976.

Master of Public Health - MPH / Introduction: Despite the progress that Zambia has made in reducing its maternal mortality ratio from 649 to 398 per 100,000 live births between 1996 and 2013/14, the country did not meet the Millennium Development Goal 5a target, of reducing the maternal mortality ratio by 75% (i.e. to a ratio of 162 per 100,000 live births) by the end of 2015. Thus, as is the case with many other countries, considerable challenges still remain in relation to reducing maternal mortality in Zambia. According to Zambia's Roadmap for Accelerating Reduction of Maternal, Newborn and Child Mortality (2013-2016), the continuum of care for reproductive and maternal, newborn, and child health includes integrated service delivery for mothers and children across these various time periods, and also across place: within the home, the community, and in health facilities. In this regard, a referral system plays a key role in linking the various levels at which care is provided, and the different types of services offered at these levels. In the urban district of Lusaka, Zambia, all complicated pregnancy-related cases received by health centres or clinics are referred to either Levy Mwanawasa General Hospital, or the University Teaching Hospital. However, it appears that at present those working at the primary level of care, who make such referrals up to these higher levels of care, receive no feedback on the outcome of their referrals; there are also few counter-referrals to the respective clinics in the district. With limited communication to the primary level of care, and with no formal handover of patients back to the clinics by the tertiary level institutions, it is difficult to ensure that the required continuum of care for the referred mothers and their children, post-delivery, has been established within the district. This explorative study aimed therefore to identify the strengths and weaknesses of the maternity-related referral system currently operating between primary and tertiary levels of health care in the district, and to consider how the system might be strengthened so as to support a stronger continuum of care with respect to maternal and neonatal health. Methods: Using a descriptive qualitative research approach, stakeholders involved in the planning, delivery and/or oversight of maternal and neonatal health services in the district were purposively sampled and asked to voluntarily participate in the study. Prior to all the interviews, after being informed about the study, and receiving information sheets to read through, participants were required to give informed consent. Their experiences and opinions regarding referrals and counter-referrals were collected through a series of 23 individual, semi-structured interviews. A Thematic Analysis approach was used to analyse data in this study. Ethics approval was first obtained from the Senate Research Committee, University of the Western Cape and thereafter from the Excellence in Research Ethics and Science Converge Ethical Review Board in Zambia, before proceeding with the study. Clearance was also obtained from the Ministry of Health, the Lusaka District Health Management Team and the University Teaching Hospital to facilitate entry into the health facilities. Findings: The study found that, in practice, the referral system for maternity and neonatal health does exist and is generally – but not optimally - functional in the Lusaka District. However, challenges were noted that included the fact that the district’s maternity referral system has not been revised since it was first developed in the 1980s and is not available in a comprehensive set of guidelines or standard operational procedures which explicitly outline the reasons for referral and the related referral steps and mechanisms. In addition, the referral forms currently in use in the district have not been standardised and appear to be inconsistently used by the different facilities. Interviewees reported that there were limitations in terms of the number of, and availability of ambulances, and that there was also an inadequate number of trained midwives. Limitations on the health service's infrastructure, namely, the physical space that is available, the number of delivery beds, and the limited supply of equipment place an additional burden on the staff working at both the primary and tertiary level. Conclusion: Overall, the study recommends that further research – possibly in the form of a baseline audit – be conducted so as to develop a more detailed and/or operational assessment of the actual rather than the reported level of functionality of the district's maternity referral system. Specific recommendations are also proposed for the various stakeholders who are critical role players in the referral system, namely, the clinics, the University Teaching Hospital, the Lusaka District Health Management Team, the Provincial Health Office, the Ministry of Health and Cooperating Partners.

Advances in technology have lowered the limits of viability in premature births to 24 weeks of gestation. This brought forth a new population of children, who are born 3-4 months early and spent considerable amounts of time in neonatal intensive care unit (NICU), instead of sterile environment of mother’s womb. Besides, other problems associated with prematurity, these children often undergo invasive procedures resulting in mucosal inflammation and/ or injury by feeding tubes, endotracheal tubes, and prolonged IV catheter. To test whether “ex-preemie-infants” were different than “term-infants” with regard to their immunity, preterm infants (< 32 weeks) and term infants (control) at the corrected age of 9-12 months were analyzed for their resting and stimulated immune responses. Preterm infants had a significant Th1 skewed response, higher number of activated and functionally competent T cells compared to term infants. The critical role of neonatal environmental exposure on immune system development is imminent; nevertheless detailed mechanistic studies on pathways are warranted.

Advances in technology have lowered the limits of viability in premature births to 24 weeks of gestation. This brought forth a new population of children, who are born 3-4 months early and spent considerable amounts of time in neonatal intensive care unit (NICU), instead of sterile environment of mother’s womb. Besides, other problems associated with prematurity, these children often undergo invasive procedures resulting in mucosal inflammation and/ or injury by feeding tubes, endotracheal tubes, and prolonged IV catheter. To test whether “ex-preemie-infants” were different than “term-infants” with regard to their immunity, preterm infants (< 32 weeks) and term infants (control) at the corrected age of 9-12 months were analyzed for their resting and stimulated immune responses. Preterm infants had a significant Th1 skewed response, higher number of activated and functionally competent T cells compared to term infants. The critical role of neonatal environmental exposure on immune system development is imminent; nevertheless detailed mechanistic studies on pathways are warranted.

This research examined two interrelated issues relevant to maternal and neonatal health in Pakistan, namely, the rising rates of C-section delivery and low rates of exclusive breastfeeding. By using the Andersen's health behavioral model to frame two empirical studies, the data from the Pakistan Demographic and Health Survey (PDHS) 2012-13 was used. The first empirical study examined the correlation between place of delivery and the odds of cesarean section in Pakistan. Not all Pakistani women have an equal chance of delivering at a health facility where C-section delivery takes place; therefore, the study modeled mode of delivery as a two-step process. In the first step, place of delivery was a function of medical indications and various sociodemographic and community factors. Women who delivered at a health facility were included in the second step, where C-section was a function of medical indications and type of facility (private, public). It is found that women who delivered at a private health facility were more likely to have a C-section, even after controlling for the effects of medical/clinical factors, which is concerning. Findings suggest that the private maternal health sector in Pakistan may be over-medicalizing childbirth. The second study examined this paradox of low exclusive breastfeeding in Pakistan, taking into account not only individual-level characteristics of the child and parents, but also place and mode of delivery, sociocultural factors, and community composition. The sample consisted of 1,044 children 0-5 months old, currently living with their mothers. Binary logistic regressions of exclusive and predominant breastfeeding found women who delivered vaginally, whether at home or health care facility were more likely than mothers who delivered via C-section to predominantly breastfeed their infant, and that mothers who delivered vaginally at a health care facility were more likely than their peers who delivered via C-section to exclusively breastfeed their infants. Collectively, the findings of both empirical studies suggest that private maternal health care services in Pakistan may be facilitating medically unnecessary C-sections, either for profit making or time management. An extended and integrated policy regarding medically unnecessary C-section delivery and low rates of exclusive breastfeeding is needed in Pakistan to address both issues together effectively.