tag:theconversation.com,2011:/ca-fr/topics/maternal-and-child-health-31897/articlesMaternal and child health – La Conversation2023-07-18T07:34:37Ztag:theconversation.com,2011:article/2081442023-07-18T07:34:37Z2023-07-18T07:34:37ZMalnutrition in South Africa: how one community wants resources to be spent<figure><img src="https://images.theconversation.com/files/535329/original/file-20230703-269585-e1naed.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Proposed solutions to malnutrition included providing school breakfast. </span> <span class="attribution"><span class="source">Richard van der Spuy/Shutterstock</span></span></figcaption></figure><p>South Africa has persistently high rates of <a href="https://ci.uct.ac.za/sites/default/files/content_migration/health_uct_ac_za/533/files/CG2020_ch1_slow%2520violence%2520of%2520malnutrition.pdf">hunger and malnutrition</a> among mothers and children. More than a quarter – <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf#page=213">27%</a> – of children under five are stunted and <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf#page=219">61%</a> of children are iron-deficient. <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf#page=332">Sixty-nine percent</a> of women of reproductive age are overweight or obese, and 31% are iron-deficient.</p>
<p>These figures paint a worrying picture. They suggest gaps in the country’s <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf">evidence-based</a> nutrition policies and services. </p>
<p>One way to accelerate progress on malnutrition is through engaging with the people who are directly affected by policies. </p>
<p>South Africa’s health system strategy does include <a href="https://www.health.gov.za/wp-content/uploads/2020/11/depthealthstrategicplanfinal2020-21to2024-25-1.pdf">public consultation</a>. But public participation is mostly limited to public meetings once a policy has already been drafted. This leaves little opportunity for substantial revisions. The lack of meaningful public engagement is also evident in how funds for mother and child nutrition are allocated. <a href="http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742018000300016">Decisions are left to policy makers</a> and there’s little input from people on the ground. </p>
<p>Only by understanding what communities consider important can policies respond to the actual needs of individuals.</p>
<p>We are a group of social scientists at the University of the Witwatersrand who have been exploring approaches for public engagement. We designed a study that puts communities into the shoes of policy makers. We asked community members which programmes they would prioritise if they were given a limited health budget.</p>
<p>The <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-023-15761-1#ref-CR14">respondents</a> in Soweto, an urban township in South Africa with constrained resources, didn’t focus much on health system programmes. They put more emphasis on the underlying causes of malnutrition. To help mothers and children be well nourished they proposed: providing school breakfast; paid maternity leave; improved food safety; and establishing community gardens and clubs.</p>
<p>This article presents one approach for public engagement. We suggest policy makers, researchers and funders consider programmes that communities view as essential for improving mother-and-child nutrition.</p>
<h2>The study</h2>
<p>To engage communities, we modified an exercise called <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-023-15761-1#ref-CR14">CHAT (Choosing All Together)</a>. CHAT is a simulation exercise, something like a board game. It offers a practical way to involve the public in making healthcare decisions. It seeks to show not only which programmes people prioritise, using a limited budget, but the values (assumptions, beliefs or perspectives) those priorities are based on.</p>
<p>Our research team modified CHAT specifically for the context of Soweto. Members of the community were invited to select a package of programmes they saw as priorities to improve mother-and-child nutrition. Fifty-four adult men and women volunteered to part take in the exercise. As with policy makers in real life, they had to make difficult decisions around what to include in their package of programmes, what to leave out (given a limited budget), and why. The volunteers had to discuss and debate their choices to convince one another why one programme would be better for the community than another.</p>
<p>Participants worked together in small groups and they could select from 14 programmes. Five programmes were “nutrition-specific” (directly influenced the immediate causes of malnutrition) and delivered through the healthcare system (pregnancy supplements). Nine programmes were “nutrition-sensitive” (addressed the underlying causes of nutrition), and accessed in non-health sectors (extended paid maternity leave).</p>
<h2>The outcomes</h2>
<p>Community members’ top three priorities were:</p>
<ul>
<li><p>the provision of school breakfast </p></li>
<li><p>extending paid maternity leave to six months and to those in informal employment </p></li>
<li><p>ensuring that food sold by street vendors and served in schools and creches was prepared in a safe and hygienic way. </p></li>
</ul>
<p>Affordable healthy food, help in finding jobs, and community gardens were other programmes the participants considered important to improve their community’s mother-and-child nutrition.</p>
<blockquote>
<p>I think community gardens can help everyone. To be able to, if you want to, grow vegetables and sell them to people, to be able to get money and teach children and other older people to do gardening.</p>
</blockquote>
<p>The community’s choices reflect the values of fairness, equity, social justice and children’s well-being. Participants showed a willingness to consider other viewpoints and reflect on the consequences of their choices for the entire community. </p>
<p>Programmes that would interrupt the intergenerational cycle of poverty were important. These included freeing up disposable income by growing more of their own food, enhancing their self-reliance overall – which could also uplift the neediest among them – and reducing their dependence on social welfare.</p>
<p>In the South African context of astronomical rates of unemployment (<a href="https://www.statssa.gov.za/?p=15407">more than 60%</a> among young adults), solutions like establishing community gardens represented paths to livelihoods, socio-economic empowerment, and supporting the neediest in the community. </p>
<h2>Translating public engagement into action</h2>
<p>Public engagement is entrenched in the constitution and in various policy documents. But there are gaps. Even where public engagement has occurred it has had very little impact on policy making.</p>
<p>For South Africa to uphold its <a href="https://www.health.gov.za/wp-content/uploads/2020/11/depthealthstrategicplanfinal2020-21to2024-25-1.pdf">commitment</a> to equity in healthcare, engaging the public on ethical and social values should be part of a systematic process of setting priorities in government.</p>
<p>Addressing malnutrition will also require coordinated actions across many sectors. Our findings show that not all potential solutions (such as community gardens and extended maternity leave) would fall to the already overburdened health system. </p>
<p>The <a href="https://www.nutritionsociety.co.za/wp-content/uploads/2021/02/National-Food-and-Nutrition-Security-Plan-2018-2023.pdf">South African National Food and Nutrition Security Plan 2018-2023</a> already has cross-sectoral coordination as an objective, via the establishment of a multisectoral advisory council to oversee alignment of policies, and coordinate and implement programmes. Integrating public engagement, through using tools like CHAT, could complement such efforts.</p><img src="https://counter.theconversation.com/content/208144/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Agnes Erzse receives funding from the SAMRC/Wits Centre for Health Economics and Decision Science, PRICELESS, University of Witwatersrand School of Public Health, Faculty of Health Sciences, Johannesburg South Africa (23108).</span></em></p><p class="fine-print"><em><span>Aviva Tugendhaft receives funding from The SAMRC/Wits Centre for Health Economics and Decision Science, PRICELESS, University of Witwatersrand School of Public Health, Faculty of Health Sciences, Johannesburg South Africa (23108).</span></em></p>Failing to understand what communities consider important greatly diminishes the responsiveness of policies to the actual needs of individuals.Agnes Erzse, Researcher, SAMRC/Centre for Health Economics and Decision Science- PRICELESS SA, University of the WitwatersrandAviva Tugendhaft, Senior Researcher, SA MRC Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, Wits School of Public Health, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2029772023-04-19T14:16:04Z2023-04-19T14:16:04ZRahima Moosa: South Africa’s only mother and child hospital is falling apart - a veteran doctor reflects on why<figure><img src="https://images.theconversation.com/files/520758/original/file-20230413-28-483g5a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source"> Papi Morake/ Gallo Images via Getty Images</span></span></figcaption></figure><p><em>South Africa’s health ombudsman <a href="https://healthombud.org.za/wp-content/uploads/2023/03/Investigation-Report-into-allegations-against-Rahima-Moosa-Mother-and-Child.pdf">recently published</a> the findings of an investigation into Rahima Moosa Mother and Child Hospital. The investigation followed the publication of a <a href="https://www.news24.com/news24/SouthAfrica/News/watch-pregnant-women-sleeping-on-the-floor-at-joburg-hospital-20220402?s=08">video</a> showing pregnant women lying on the hospital floor, as well as complaints by patients’ family members. The ombudsman’s investigation produced shocking findings, including severe overcrowding and staff shortages at the facility. There haven’t been any substantial upgrades to the hospital since it was built 80 years ago.</em> </p>
<p><em>Laetitia Rispel has been researching health policy and systems for over 20 years. She asked <a href="https://www.thepresidency.gov.za/national-orders/recipient/prof-yosuf-%E2%80%9Cjoe%E2%80%9D-veriava">Professor Emeritus Yosuf “Joe” Veriava</a> – who has been involved in South Africa’s healthcare system for more than half a century and is a recipient of the Order of Luthuli in silver for his contribution to the medical profession in South Africa – about the report.</em></p>
<hr>
<p><strong>Laetitia Rispel:</strong> What did you find most disturbing about the report? Who should be held accountable? </p>
<p><strong>Yosuf Veriava:</strong> I spent most of my student or training years there in the late 1960s. Seeing the problems that are occurring now is very sad. </p>
<p>What I found particularly disturbing is the failure in providing appropriate, effective and efficient leadership. </p>
<p>At first glance I thought the only person to blame was the CEO. But the Gauteng provincial department of health is just as responsible. The department was involved in the appointment of the CEO. It was also the department that gave the CEO permission to work from home. I find this very problematic because the CEO of a hospital cannot work from home. The CEO could be needed at any time during working hours.</p>
<p>The CEO herself should be held responsible. And the Gauteng department of health must take some responsibility.</p>
<p><strong>Laetitia Rispel:</strong> In your opinion, what factors have contributed to the hospital’s current state?</p>
<p><strong>Yosuf Veriava:</strong> There are many. </p>
<p>First of all, it is the heavy patient burden. The hospital has a <a href="https://healthombud.org.za/wp-content/uploads/2023/03/Investigation-Report-into-allegations-against-Rahima-Moosa-Mother-and-Child.pdf#page=18">large catchment area</a>. And within it, many of the people are of a lower social economic group and clearly their disease profile is not of the best. </p>
<p>This is the only mother and child hospital in South Africa, providing care for a very large number of women and children. In theory the hospital should be treasured, but the large patient numbers and high burden of care have a negative impact on the hospital.</p>
<p>Rahima Moosa Hospital delivers around 15,000 babies every year, which is the second highest number of babies in the country after Chris Hani Baragwanath Hospital (which is known as <a href="https://www.chrishanibaragwanathhospital.co.za/">Africa’s biggest hospital</a>). But the total staff complement is 1,200, and health professionals (doctors, nurses, pharmacists and rehabilitation therapists) account for 65% (780). Hence, the staff-to-patient ratio is low, even when compared to hospitals of a similar size. </p>
<p>Another aspect is the age of the hospital. The hospital <a href="https://www.youtube.com/watch?v=OYDhTpC6V-w">is as old</a> as I am – 80.</p>
<p>When I was at Coronation (the hospital’s old name) it was in reasonable shape. Not as good as the hospitals catering for white patients. But it was well kept. </p>
<p>When you have such an old hospital, there is a natural process of decay and this was not catered for. This points to the public works department failing to keep up with the decaying processes, and the maintenance of the hospital. </p>
<p><strong>Laetitia Rispel:</strong> What should be done to turn the situation around?</p>
<p><strong>Yosuf Veriava:</strong> It is the government that should be doing something about sorting this out. There are in fact recommendations that come out of the ombud’s report. These need immediate attention. </p>
<p>There have been concerns about public sector hospitals in general. And there have been various types of interventions.</p>
<p>In 2013, when I was professor emeritus of medicine at the University of the Witwatersrand, I was involved in a legal intervention to make a difference. We wanted to take the then health minister, Dr Aaron Motsoaledi, to court to compel him to take action. </p>
<p>While we were trying to bring the challenge to court, the minister said we should have discussions. These were held with the university as well as the minister’s office. The discussions resulted in an agreement on a turnaround strategy.</p>
<p>While this was positive and helped sort out the university-linked hospitals, it did nothing for the other state hospitals. </p>
<p>The other hospitals have received quite a bit of <a href="https://www.iol.co.za/pretoria-news/news/disturbing-number-of-public-hospital-patients-have-died-due-to-negligence-e623f9b9-4801-446f-af91-51246800ae77">publicity</a>.</p>
<p>There have been other attempts at interventions. One includes the drawing up of the <a href="https://www.gov.za/speeches/president-cyril-ramaphosa-signing-presidential-health-compact-25-jul-2019-0000">Presidential Health Compact</a>. While there was a lot of hype about the meeting with the president and the health compact, nothing much has happened and the hospitals remain the way they were. </p>
<p>So things get raised, but we don’t have any action. </p>
<p><strong>Laetitia Rispel:</strong> What should be done to ensure a capable and functional public healthcare system in South Africa?</p>
<p><strong>Yosuf Veriava:</strong> We can sort out all the hospitals. But the outcomes aren’t just going to improve suddenly.</p>
<p>Without sorting out the marked inequity in our country we will not make any major gains in improving health outcomes. There are many experts who believe that without sorting out various social and economic determinants we won’t have a very healthy society. So that’s the first point to make.</p>
<p>We are sending students to Cuba to try to facilitate the establishment of a health system based on primary healthcare. But our infrastructure here is not conducive to that. Hence, we should improve the primary healthcare system to cater for illnesses that can be seen at that level, which would take some of the extreme load from public sector hospitals.</p>
<p>We can look at improving hospitals but we also need to look at how to improve health outcomes.</p><img src="https://counter.theconversation.com/content/202977/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laetitia Rispel holds a SARChI Chair at Wits University and receives funding from the National Research Foundation.
</span></em></p>Rahima Moosa Hospital caters for a very large number of women and children. The large patient numbers and high burden of care have a negative impact on the hospital.Laetitia Rispel, Professor of Public Health and DST/NRF Research Chair., University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1943852023-04-12T13:39:30Z2023-04-12T13:39:30ZCommunity health workers in Ethiopia set out to promote health - in the process they’ve empowered girls in other ways too<figure><img src="https://images.theconversation.com/files/518999/original/file-20230403-20-caez98.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/gpforeducation/11173162025/in/album-72157637696837414/"> GPE/Midastouch</a></span></figcaption></figure><p>Ethiopia has made significant progress in supporting gender equality and girls’ empowerment. Rates of child marriage and teenage pregnancy have <a href="https://data.unicef.org/resources/child-marriage-in-ethiopia/">decreased</a> substantially. Access to sexual and reproductive health services has <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-022-01434-6">increased</a>. There has also been progress in the education sector. School attendance rates at all levels have risen, and the gender gap in enrolment is <a href="https://www.unicef.org/ethiopia/media/2811/file/Gender%20Equality,%20Women%27s%20empowerment%20and%20child%20wellbeing%20in%20Ethiopia.pdf#page=15#">narrowing</a>. </p>
<p>Despite these positive trends, inequalities and entrenched patriarchal norms remain. Adolescent girls and young women in Ethiopia continue to face challenges, especially in rural areas. For example, the national rates of child marriage remain among the highest in Africa. Data from 2016 estimated that 58% of girls and 9% of boys were <a href="https://www.dhsprogram.com/pubs/pdf/FR328/FR328.pdf#page=101">married before the age of 18</a>. Improvements in education attainment for adolescent girls also remain sluggish. Only 15% of women have completed <a href="https://www.unicef.org/ethiopia/media/2811/file/Gender%20Equality,%20Women%27s%20empowerment%20and%20child%20wellbeing%20in%20Ethiopia.pdf#page=41">secondary or higher education</a>. For men, the figure is 23%. </p>
<p>Ethiopia is one of the <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-022-01445-3#:%7E:text=Ethiopia%20has%20the%20second%2Dlargest,people%20aged%2010%E2%80%9324%20years.">youngest</a> and <a href="https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/wpp2022_summary_of_results.pdf#page=9">fastest</a> growing populations in the world. Gender equality is critical for enabling young people to reach their full potential. Achieving this will require addressing gender attitudes and norms that are linked to early marriage and childbearing, and are a barrier to girls education.</p>
<p>The country has a national community health programme which aims to increase the availability of basic health services and promote healthy lifestyles. To do this, it uses community outreach activities, including household visits. Policymakers have been keen to understand more about its impacts on adolescent health and well-being as this could guide further efforts to improve the programme. </p>
<p>Our <a href="https://www.sciencedirect.com/science/article/pii/S1054139X22004189?via%3Dihub">study</a> looked at the association between this health extension programme and 12 indicators of adolescent health and well-being. The programme focuses primarily on disease prevention and health promotion. However, our findings suggest that household visits from health extension workers have had a measurable impact on multiple interconnected adolescent challenges beyond just health. </p>
<p>Household visits from health extension workers appear to reduce rates of child marriage, early pregnancy and school dropout. Impacts in these areas are important as they are likely to have long-term consequences. For example, delaying marriage and pregnancy promotes adolescent girls’ health and aspirations. Higher educational achievement also increases girls’ earning potential, and empowers their autonomy and decision-making.</p>
<h2>Health extension workers</h2>
<p>The <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-019-0470-1">health extension programme</a> was introduced in 2003. It is delivered by local health extension workers, who are mostly young women. They are recruited from the community based on their ability to speak the local language and completion of general secondary education. </p>
<p>The health extension workers promote routine medical check-ups at the local health post. They also use door-to-door household visits to educate families around health issues including family planning, youth reproductive health and child marriage. The programme has become a flagship intervention.</p>
<p>Many families in Ethiopia still place a high value on marriage and motherhood, especially in rural communities. The legal age of marriage is 18. However, child marriage and early pregnancy remain prevalent nationwide. The government <a href="https://www.unicef.org/ethiopia/reports/national-costed-roadmap-ending-child-marriage-and-fgmc">aims</a> to eliminate child marriage by 2025. Our study indicates that the health extension programme is likely to <a href="https://www.unicef.org/ethiopia/reports/national-costed-roadmap-ending-child-marriage-and-fgmc">play an important part</a> in achieving this. </p>
<p>Our research suggests that household visits from health extension workers are linked to significantly lower risks of child marriage, early pregnancy and school dropout. According to our study, receiving household visits from health extension workers is associated with a 70% reduction in the probability of child marriage, 75% reduction in the probability of early pregnancy, and 63% increase in the probability of being enrolled in education. There were also measured improvements in adolescent girls’ literacy and numeracy scores.</p>
<p>Our findings, along with <a href="https://www.unicef.org/ethiopia/reports/what-works-tackle-child-marriage-ethiopia">other research</a> by UNICEF and the Overseas Development Institute, suggest these effects are likely to be produced by health extension workers talking to families about the risks of child marriage and early pregnancy and the benefits of girls education. Health extension workers can modify families’ expectations for girls to marry early, and their reluctance to invest in girls’ secondary education.</p>
<p>Health extension workers are also able to monitor family preparations for marriage. They can intervene in cases where the bride is younger than the legal age of 18.</p>
<p>The workers are not just improving adolescent health. They are transforming adolescent girls’ opportunities to pursue their own aspirations for education, employment and family. </p>
<h2>The next steps</h2>
<p>Our research highlights areas for further work, particularly around adolescent girls’ sexual and reproductive health rights. This remains a taboo issue among some communities where it’s believed that access to modern contraception will promote promiscuity. Our study found no evidence that household visits from health extension workers had addressed common misconceptions among adolescent girls around fertility and preventing sexually transmitted infections.</p>
<p>There are still social barriers that prevent girls from getting information, services and support, and that foster misinformation around modern contraception.</p>
<p>One promising initiative is Adolescents 360’s Smart Start <a href="https://a360learninghub.org/open-source/adaptive-implementation/the-case-of-smart-start-in-ethiopia/">intervention</a> in Ethiopia. It works with young girls and the health extension program to deliver contraceptive programming. </p>
<p>For the last two years, Ethiopia has faced the COVID-19 <a href="https://pubmed.ncbi.nlm.nih.gov/35995265/">pandemic</a>, <a href="https://www.unfpa.org/press/women-tigray-need-immediate-support-race-against-time-save-lives#:%7E:text=New%20York%2C%2028%20May%202021%20-%20In%20the,civilians%2C%20including%20sexual%20violence%2C%20continue%20to%20be%20reported.">conflict</a> in the northern part of the country, and widespread <a href="https://www.theguardian.com/society/2022/apr/30/ethiopian-drought-leading-to-dramatic-increase-in-child-marriage-unicef-warns">drought</a>. All these events have disrupted the delivery of healthcare services, closed schools and heightened the needs of adolescents. </p>
<p>In the process, these crises may have reinforced discriminatory gender roles. So work remains for health extension workers to address cultural and attitudinal barriers that hold back adolescent girls’ education. </p>
<p><em>Dessalew Emaway, a public health practitioner, and Silinganisiwe Dzumbunu, a doctoral student with the University of Cape Town’s Centre for Social Science Research, contributed to this article and the original research it’s based on.</em>
<em>Click <a href="https://www.jahonline.org/article/S1054-139X(22)00418-9/fulltext">here</a> to access the original research this article is based on.</em></p><img src="https://counter.theconversation.com/content/194385/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Health extension workers in Ethiopia have had a measurable impact on interconnected challenges such as child marriage, teenage pregnancy, and school dropout.William Rudgard, Senior Postdoc, University of OxfordSilinganisiwe Dzumbunu, PhD Candidate , University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1946432022-12-01T02:46:43Z2022-12-01T02:46:43ZWhy do nurse home visits stop a few weeks after giving birth? Extending them to 2 years benefits the whole family<figure><img src="https://images.theconversation.com/files/498167/original/file-20221130-26-xgedg.jpg?ixlib=rb-1.1.0&rect=35%2C17%2C5955%2C3970&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/mother-with-baby-in-arms-7282407/">Pexels/Sarah Chai</a></span></figcaption></figure><p>Bringing home a new baby can be one of the most exciting and stressful times in your life. A nurse might visit a couple of times, then other than routine check-ups at the nurse’s office, you’re largely on your own. </p>
<p>Some people have a particularly hard time with a new baby because the challenges of parenting come on top of existing adversity, such as financial hardship, or poor physical or mental health. </p>
<p>Experiencing adversity from when a baby is conceived can affect the child’s <a href="https://www.rch.org.au/uploadedFiles/Main/Content/ccchdev/CCCH-The-First-Thousand-Days-An-Evidence-Paper-Summary-September-2017.pdf">health and development</a> as they grow older. So rather than stopping nurse visits a week or two after bringing a new baby home, we investigated whether extending these visits from pregnancy until children turned two made a difference. </p>
<p>The nurse visits focused on areas fundamental for children’s development: how a parent cares for and responds to their child, and their home environment. </p>
<p>We found home visits with nurses helps parenting and family relationships, and women’s mental health, wellbeing and confidence.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1380610832485154816"}"></div></p>
<h2>What happens when the nurse visits?</h2>
<p>Sustained nurse home visiting provides intensive services in a family’s home during pregnancy and the first two years of the child’s life. During this time, the child’s brain develops more rapidly than any other time in their life. </p>
<hr>
<p>
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<strong>
Read more:
<a href="https://theconversation.com/how-do-i-know-if-my-child-is-developing-normally-129137">How do I know if my child is developing normally?</a>
</strong>
</em>
</p>
<hr>
<p>International studies of sustained nurse home visiting programs show <a href="https://onlinelibrary.wiley.com/doi/10.1111/jan.14576">they can help families</a> with parenting, children’s behaviour and academic skills. However, most have only measured impacts up to when children turn three. </p>
<p>Programs differ depending on how they work to support families. They generally engage highly-trained nurses who can listen without judgement, offer practical, evidence-informed advice, and remind parents they’re doing a good job.</p>
<h2>Our study</h2>
<p>Our randomised controlled trial of <a href="https://www.rch.org.au/ccch/research-projects/right-at-home/">right@home</a> is Australia’s longest and largest trial of nurse home-visiting, starting in 2013. </p>
<p>The program supports parents with evidence-based techniques that promote parenting that responds to the child’s needs, safe homes, regular routines, and children’s learning and language development. The program starts in pregnancy and offers 25 home visits (60-90 minutes each) with a specially trained nurse until the children turn two. </p>
<p>The right@home program was designed for delivery through Australia’s existing child and family health nursing services, which are free for families with children from birth to school age. These existing services typically offer a handful of appointments (of around 20-40 minutes) that mostly take place in local clinics. Some also offer more intensive services.</p>
<figure class="align-center ">
<img alt="Toddler reads from a board book" src="https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498181/original/file-20221130-16-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Existing nurse services only offer a handful of appointments from birth to school age.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/u0zTce7KNlY">Unsplash/Stephen Andrews</a></span>
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<p>We invited women into the right@home study if they were experiencing two or more factors that can make it more difficult to parent. These include having low social support, poor physical or emotional health, or no household employment. We found <a href="https://onlinelibrary.wiley.com/doi/10.1111/jpc.13860">almost 40%</a> of pregnant women experienced at least two of these factors. </p>
<p>In total, 722 women and families living across Victoria and Tasmania took part in the study. Half were randomly allocated (like tossing a coin) to receive the right@home program and half received their local child and family health nursing service. </p>
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<h2>What did we find?</h2>
<p>Researchers who were separate to the nurse teams interviewed the families twice a year (one at home and one by phone) until children started school. </p>
<p>When the right@home program ended (at children’s second birthdays), the evaluation showed it <a href="https://doi.org/10.1542/peds.2018-1206">offered benefits</a> over and above the usual services. Parents had more confidence and skills in caring for their children, responding sensitively and providing a nurturing and stimulating home. </p>
<p>This pattern <a href="https://publications.aap.org/pediatrics/article/147/2/e2020025361/77055/Nurse-Home-Visiting-and-Maternal-Mental-Health-3">continued</a>. At three years, parents who received the right@home program reported benefits to their mental health, wellbeing, and self-confidence. </p>
<figure class="align-center ">
<img alt="Parents snuggle their newborn baby" src="https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498176/original/file-20221130-14-qnisxd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Nurses can remind new parents they’re doing a good job.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/cheerful-young-multiethnic-parents-admiring-sleeping-baby-on-bed-6392952/">Pexels/William Fortunato</a></span>
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<p>Our latest paper, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0277773">published in PLOS ONE</a>, shows that right@home offered lasting impacts to four and five years, which is two and three years after the program ended. </p>
<p>Some 5-10% more families had regular mealtimes, bedtimes and bedtime routines by the time the children turned five.</p>
<p>Around 9% more women reported very good health and parenting confidence. The proportions of women experiencing stress, and emotional abuse from an intimate partner were 7% and 11% lower, respectively. </p>
<p>There were additional benefits for children’s and women’s mental health, parenting, and women’s wellbeing, quality of life and relationship with their child. These impacts were evident for families regardless of where they lived across the seven regional and metropolitan areas in the two states.</p>
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<h2>Levelling the playing field for kids</h2>
<p>A goal of the program is to address the challenging circumstances that disrupt parenting and affect children’s health and development.</p>
<p>If Australia did this, and provided support according to need, we could reduce children’s poor developmental outcomes by <a href="https://doi.org/10.1093/ije/dyy087">50%-70%</a>.</p>
<p>Providing equitable support is especially important as we <a href="https://bmjpaedsopen.bmj.com/content/6/1/e001390">emerge from the COVID pandemic</a>, which has <a href="https://doi.org/10.5694/mja2.51368">disproportionately affected</a> families already experiencing adversity. </p>
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<img alt="Mother wipes ice cream from her daughter's chin" src="https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=377&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=377&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=377&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=474&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=474&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498372/original/file-20221201-16-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=474&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Greater early support boosts mothers’ mental wellbeing.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/attentive-asian-mother-cleaning-face-of-cute-daughter-5094378/">Kamaji Ogino/Pexels</a></span>
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<p>Almost no other public health program delivered during the early years has evidence of such a broad range of gains. </p>
<p><a href="https://bmjopen.bmj.com/content/11/12/e052156">Our economic evaluation</a> of right@home at three years showed delivering these benefits through the right@home program costs A$7,700 extra per family compared with the usual service.</p>
<p>Research from the US shows the benefits of <a href="http://www.wsipp.wa.gov/BenefitCost/Program/35">similar programs</a> accrue for families and taxpayers over a child’s lifetime, producing positive returns on investment, from improved mental health and more employment, among other benefits.</p>
<p>Australia is fortunate to have nationwide child and family health nursing services. These are the perfect platform for delivering an extended program like right@home. When so few programs make a difference for families experiencing adversity, we should maximise the reach of those that do.</p>
<p><em>Diana Harris, Lead for Knowledge Translation at the Australian Research Alliance for Children & Youth, coauthored this article.</em></p>
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<img src="https://counter.theconversation.com/content/194643/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>right@home is supported by the state governments of Victoria and Tasmania, the Ian Potter Foundation, Sabemo Trust, Sidney Myer fund, the Vincent Fairfax Family Foundation, and the National Health and Medical Research Council (NHMRC, 1079148). The MCRI administered the research grant for the study and provided infrastructural support to its staff but played no role in the conduct or analysis of the trial. Research at the MCRI is supported by the Victorian Government's Operational Infrastructure Support Program. SG was supported by NHMRC Practitioner Fellowship (1155290).
The “right@home” sustained nurse home visiting trial is a research collaboration between the Australian Research Alliance for Children and Youth (ARACY); the Translational Research and Social Innovation (TReSI) Group at Western Sydney University; and the Centre for Community Child Health (CCCH), which is a department of The Royal Children's Hospital and a research group of Murdoch Children’s Research Institute. Ownership of the right@home implementation and support license, which is purchased by Australian state governments for roll out for fidelity support, is shared between institutes.</span></em></p><p class="fine-print"><em><span>The MECSH home visiting program upon which right@home is based is trademarked and licenced by Western Sydney University and was developed by UNSW Australia. Western Sydney University is a member of the right@home consortium that receives funding from Australian state governments to support the implementation of the program. Western Sydney University also licenses the MECSH program to government and non-government providers of home visiting services in the UK and USA. </span></em></p><p class="fine-print"><em><span>Sharon Goldfeld receives funding from ARC and NHMRC.</span></em></p>Extending visits from nurses who can listen without judgement and offer practical, evidence-informed advice helps new parents who are experiencing adversity.Anna Price, The Erdi Foundation Child Health Equity (COVID-19) Scholar, Centre for Community Child Health | Honorary, Department of Paediatrics, University of Melbourne | Team Leader / Senior Research Officer, Murdoch Children's Research InstituteLynn Kemp, Director of the Translational Research and Social Innovation group, School of Nursing and Midwifery, Western Sydney UniversitySharon Goldfeld, Director, Center for Community Child Health Royal Children's Hospital; Professor, Department of Paediatrics, University of Melbourne; Theme Director Population Health, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1938072022-11-30T13:39:31Z2022-11-30T13:39:31ZPregnancy is a genetic battlefield – how conflicts of interest pit mom’s and dad’s genes against each other<figure><img src="https://images.theconversation.com/files/497774/original/file-20221128-20372-q68nv3.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2059%2C1454&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Paternal and maternal genes drive fetal development in different directions.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/hacking-baby-embryo-decoding-the-dna-of-royalty-free-illustration/1125420175">Valentina Kruchinina/iStock via Getty Images</a></span></figcaption></figure><p>Baby showers. Babymoons. Baby-arrival parties. There are many opportunities to celebrate the 40-week transition to parenthood. Often, these celebrations implicitly assume that pregnancy is cooperative and mutually beneficial to both the parent and the fetus. But this belief obscures a more interesting truth about pregnancy – the mother and the fetus may not be peacefully coexisting in the same body at all.</p>
<p>At the most fundamental level, there is a conflict between the interests of the parent and fetus. While this may sound like the beginning of a thriller, this <a href="https://doi.org/10.1086/418300">genetic conflict</a> is a normal part of pregnancy, leading to typical growth and development both during pregnancy and across an individual’s lifetime – something <a href="https://scholar.google.com/citations?user=YBPxHqkAAAAJ&hl=en&oi=ao">my research</a> focuses on. </p>
<p>However, even though genetic conflict is normal during pregnancy, it can play a role in pregnancy complications and developmental disorders when left unchecked.</p>
<h2>What is genetic conflict?</h2>
<p>Pregnancy is generally thought of as a period when a new individual is created from a unified blend of genes from their parents. But this is not quite right. </p>
<p>The genes a fetus gets from each parent carry slightly different instructions for development. This means there are contrasting and sometimes conflicting blueprints for how to build the new individual. Conflict over <a href="https://doi.org/10.1016/0168-9525(91)90230-N">which blueprint to follow</a> for fetal growth and development is the essence of the genetic conflict that occurs during pregnancy.</p>
<p>Moms have to use their bodies to help the fetus grow during pregnancy while dads don’t. This means that the genes the fetus inherits from mom have to not only provide for the current fetus, but also try to keep mom alive and healthy and make sure there are resources left over for a potential future pregnancy. These reserves include both biological resources like glucose, protein, iron and calcium, as well as the time and energy needed to help her children after birth as they grow and develop.</p>
<p>Dad’s genes don’t have this same pressure because they don’t use their bodies to help the fetus grow during pregnancy. A dad’s genes, then, don’t need to ensure that anyone other than the current fetus thrives.</p>
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<figcaption><span class="caption">Pregnancy transforms every organ in the body.</span></figcaption>
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<p>To better understand this situation, pretend that all of the resources a mom can give her children come in the form of a <a href="https://cir.nii.ac.jp/crid/1570854174915527168">milkshake</a>. Once the milkshake runs out, mom has nothing left to give her children. Maternal genes, therefore, want each child to drink only as much as they need to grow and develop. This ensures that the milkshake can be “shared” across all current and future children. </p>
<p>Paternal genes, on the other hand, have no such guarantee of representation in this mother’s other children – the father of the current child may not be the father of the mother’s potential future children. This lack of guaranteed genetic representation means there is no pressure on the father to “share” the milkshake. The best strategy when it comes to paternal genes, then, is for the fetus to drink as much of the milkshake as they can.</p>
<p>These two strategies play a figurative game of tug of war throughout pregnancy. Both sides are trying to pull fetal development slightly more toward their side. Paternal genes encourage the fetus to grow and develop quickly and take more resources, while maternal genes encourage the fetus to grow and use only what’s necessary for proper development. Conflict over how deeply the <a href="https://doi.org/10.1016/0168-9525(91)90230-N">embryo implants</a> in the uterus and how quickly the <a href="https://doi.org/10.1016/j.placenta.2012.05.002">placenta</a> and <a href="https://doi.org/10.1016/j.placenta.2005.07.004">fetus</a> grow are just a few areas where researchers have documented this tug of war during pregnancy.</p>
<p>The milkshake problem helps researchers determine where to look for genetic conflict by simplifying where trade-offs may take place during pregnancy. Because fetal growth is at the heart of genetic conflict, researchers have focused on processes where conflict over resource transfers from mother to fetus can be observed. These investigations have found that the placenta, a fetal organ responsible for all resource transfers during pregnancy, is <a href="https://www.hup.harvard.edu/catalog.php?isbn=9780674027220">dominated by paternally-expressed genes</a>. It releases paternally-derived <a href="https://doi.org/10.1038/ng0593-98">insulin-like growth factors</a> that make mom less sensitive to her own insulin and hormones that <a href="https://doi.org/10.1093/humrep/16.1.13">increase maternal blood pressure</a>, both of which ultimately increase the amount of resources the fetus can use to grow during pregnancy but have the potential to harm the mother’s health.</p>
<h2>Genetic conflict and pregnancy complications</h2>
<p>If genetic conflict goes uncontrolled, it can cause <a href="https://doi.org/10.1086/418300">pregnancy complications</a> for the mother and <a href="https://doi.org/10.1002/ajhb.10150">developmental disorders</a> for the child. In fact, there is a growing consensus among researchers that some of the most well-known pregnancy complications like <a href="https://doi.org/10.1126/science.1111726">preeclampsia</a>, <a href="https://doi.org/10.1007/978-3-319-19650-3_3044">gestational diabetes</a>, <a href="https://doi.org/10.1016/j.semcdb.2022.01.007">miscarriages</a> and <a href="https://doi.org/10.1093/aje/kwp325">preterm births</a> may best be explained by unchecked genetic conflict.</p>
<p>Despite the potential role that genetic conflict plays in pregnancy complications, current medical treatments are reactive rather than proactive. A pregnant person must <a href="https://www.mayoclinic.org/diseases-conditions/preeclampsia/diagnosis-treatment/drc-20355751">show signs of experiencing complications</a> before medical interventions and treatments can take place. </p>
<p>Knowing how unchecked genetic conflict contributes to pregnancy complications could provide researchers another way to develop treatments that are proactive and, ideally, preventive. However, there are currently no treatments for pregnancy complications that consider genetic conflict. Though <a href="https://doi.org/10.2337%2Fdb19-0798">gestational diabetes</a> can be attributed to underlying genetic conflict, a pregnant person must present with elevated blood sugar levels before doctors can treat underlying conflict over insulin production and blood sugar.</p>
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<figcaption><span class="caption">Pregnancy during the COVID-19 pandemic has been challenging for many.</span></figcaption>
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<p>The experiences of pregnant people during the COVID-19 pandemic provide an example of why more research on genetic conflict is needed. During the pandemic, doctors saw both a dramatic decrease in the number of <a href="http://dx.doi.org/10.1136/archdischild-2020-319990">preterm births</a> as well as an increase in the number of <a href="https://doi.org/10.1001/jama.2020.12746">stillbirths and miscarriages</a>. Both types of complications are influenced by genetic conflict, but the reasons behind these opposing trends are unclear.</p>
<p>As a woman who was pregnant early in the pandemic, my pregnancy was scary and stressful, spent at home away from the pressures of “normal” life. More research on the complex process of pregnancy and genetic conflict’s role in complications could help researchers better understand how the changes brought by the pandemic produced such wildly different pregnancy outcomes.</p><img src="https://counter.theconversation.com/content/193807/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jessica D. Ayers does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Genetic conflict may play a role in pregnancy complications, such as preeclampsia and gestational diabetes, as well as developmental disorders.Jessica D. Ayers, Assistant Professor of Psychological Science, Boise State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1892362022-09-28T14:37:10Z2022-09-28T14:37:10ZObesity is on the rise among South African women – a risk to maternal and child health<figure><img src="https://images.theconversation.com/files/484034/original/file-20220912-12-v49dqu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Obesity in adults has <a href="https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight">nearly tripled</a> between 1975 and 2016 across the world. The World Health Organization <a href="https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight">estimated</a> that by 2016, about 1.9 billion adults worldwide were overweight. More than 650 million of these adults were obese. These represent about 39% and 13% of the world’s adult population, respectively. </p>
<p>Women bear a disproportionately higher burden of obesity. In 2016, it was <a href="https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight">estimated</a> that 15% of the world’s women and 11% of men were obese. </p>
<p>Overweight and obesity are burgeoning health issues in sub-Saharan Africa – particularly South Africa, with a significantly high burden of overweight and obesity.</p>
<p>In our <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-12601-6">recent research</a> we looked at the prevalence of overweight and obesity among women of childbearing age in South Africa. Earlier studies published in <a href="https://hsrc.ac.za/uploads/pageNews/72/SANHANES-launch%20edition%20(online%20version).pdf">2013</a>, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0107471">2014</a> and <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf">2019</a> (including a government report) show the prevalence of overweight and obesity at one single point in time. But there is a dearth of studies looking at trend data on overweight and obesity prevalence among women of childbearing age, including socioeconomic determinants.</p>
<p>Obesity leads to a number of <a href="https://www.ajol.info/index.php/ijmbr/article/view/133171">maternal and child health problems</a>. These include infertility, miscarriage, babies having congenital abnormalities and other adverse obstetric outcomes. Women who are super-obese experience <a href="https://www.ajol.info/index.php/sajog/article/view/108616/98414">more pregnancy complications</a> (hypertension, pre-eclampsia and surgical complications) than those who are morbidly obese. Noncommunicable diseases associated with obesity are among the <a href="http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742016000500013">top causes of death</a> in the country. </p>
<h2>Overweight and obesity</h2>
<p><a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-12601-6">Our study</a> looked at nationally representative data on the prevalence and determinants of overweight and obesity in South African women aged 15 to 49 who were not pregnant. It covered the period 1998 to 2017.</p>
<p>The study found a rise in the prevalence of overweight (from 51.3% to 60%) and obesity (from 24.7% to 35.2%) between 1998 and 2017.</p>
<p>There are a number of factors behind the rising trend of overweight and obesity in women of childbearing age in South Africa. These include rapid economic development since the new democracy in 1994, urbanisation, and the increased number of women in the labour force. </p>
<p>Working women tend to have low-energy expending jobs. And mobility is less energy-intensive because of shorter commutes and the use of motorised transport. Long working hours make it difficult for many women to prepare healthy meals. In addition, processed food is more widely accessible. Also, the wider living environment may act as a barrier to physical activity. High crime levels in communities can lead to safety concerns that prevent women from being physically active.</p>
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<p>Factors associated with being overweight and obese were: increased age; self-identifying with the black African population group; higher educational attainment; residing in an urban area; and belonging to wealthier socioeconomic quintiles. Current smokers had decreased odds of being overweight and obese.</p>
<p>The prevalence of obesity in South Africa is high relative to that documented in other countries (except for urban Egypt). Rates of overweight and obesity documented in the <a href="https://link.springer.com/content/pdf/10.1007%2Fs10995-008-0340-6.pdf">US</a>, <a href="https://www.cambridge.org/core/services/aop-cambridge-core/content/view/84DE7B5E812AA66BB028039B058C6E69/S1368980004000618a.pdf/div-class-title-anthropometry-of-women-of-childbearing-age-in-morocco-body-composition-and-prevalence-of-overweight-and-obesity-div.pdf">Morocco</a> and <a href="https://bmjopen.bmj.com/content/7/10/e017344">urban sub-Saharan Africa</a> vary between 10% and 32%. </p>
<p>Our findings show that South Africa is off-track with meeting targets it set in 2013 for reducing overweight and obesity levels. The initial goal was to get levels down <a href="https://extranet.who.int/ncdccs/Data/ZAF_B3_NCDs_STRAT_PLAN_1_29_1_3%5B2%5D.pdf">10 percentage points by 2020</a>.</p>
<p>Given that by <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-12601-6">2017</a> the levels of overweight and obesity were still at 60% and 35.2%, respectively, it is clear from this research that more needs to be done. </p>
<h2>Recommendations</h2>
<p>The current tax on sugar-sweetened beverages is an example of the government’s commitment to fighting obesity in South Africa. However, the rising prevalence of overweight and obesity among women of childbearing age reported in this research means the government needs to complement this tax with other interventions. </p>
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Read more:
<a href="https://theconversation.com/new-research-shows-south-africas-levy-on-sugar-sweetened-drinks-is-having-an-impact-158320">New research shows South Africa's levy on sugar-sweetened drinks is having an impact</a>
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<p>The government should run sensitisation and awareness-raising campaigns and programmes targeting certain groups of women. There is a need to focus on women who are older, who self-identify as black African, with higher educational attainment, who live in urban areas, and who are relatively wealthy. </p>
<p>In addition, the interests of the food industry that contribute to the rise in overweight and obesity need to be regulated. And investments must be made by the government to promote healthy lifestyles and safety in urban communities. At an individual level, women need to have healthy lifestyles and be physically active. This will help to reverse or restrain the rise in overweight and obesity.</p><img src="https://counter.theconversation.com/content/189236/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mweete D. Nglazi received funding from the South African Medical Research Council (SAMRC) through its Division of Research Capacity Development under the National Health Scholarship Programme from funding received from the Public Health Enhancement Fund/South African National Department of Health. The content hereof is the author’s sole responsibility and does not necessarily represent the official views of the SAMRC. The funder had no role in writing the article.</span></em></p><p class="fine-print"><em><span>John Ele-Ojo Ataguba does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Obesity leads to a number of maternal and child health problems.Mweete D. Nglazi, PhD graduate, University of Cape TownJohn Ele-Ojo Ataguba, Senior Lecturer in the Health Economics Unit, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1811142022-05-11T13:35:08Z2022-05-11T13:35:08ZHow South Africa is integrating COVID into routine care for mothers and babies<figure><img src="https://images.theconversation.com/files/461015/original/file-20220503-20-co3b7u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Policies to stop the spread of COVID disadvantaged mothers and newborns. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>COVID-19 has had a direct impact on maternal mortality. </p>
<p>Pregnant women are not at an increased risk of becoming infected with SARS-CoV-2. But <a href="https://www.samrc.ac.za/sites/default/files/attachments/2021-03-31/SA%20report_Covid-19_2020%20pregnancy%20vs%202019_Provinces_Service%20use_Pattison%20etal_Mar21.pdf">data</a> show they are at higher risk of severe COVID-19 disease. This is especially the case in the last 12 weeks of pregnancy, and this is <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnant-people.html">still the case</a> two years into the pandemic. </p>
<p>In South Africa, this risk equated to an additional 16 COVID-19-related maternal deaths per 100,000 live births, compared to maternal deaths in uninfected women. This mortality rate is similar to that of disorders related to high blood pressure in pregnancy. As in other populations, pregnant women with high blood pressure, diabetes and obesity are at higher risk of severe COVID-19. </p>
<p>The indirect effects of the pandemic have been equally devastating. </p>
<p>The onset of the COVID-19 pandemic was marked by widespread fear and uncertainty. Worried about getting infected, people were reluctant to visit <a href="https://www.hst.org.za/publications/District%20Health%20Barometers/DHB%202019-20%20Complete%20Book.pdf">healthcare facilities</a>. As a result, the use of routine but critical services declined. These services include family planning, antenatal and postnatal care, childhood immunisations, growth monitoring and nutrition services, and other care for sick and malnourished children. </p>
<p>Between <a href="https://journals.co.za/doi/pdf/10.7196/SAMJ.2021.v111i8.15786#page=2">February and April 2020</a> family planning rates dropped by around 35% and immunisation coverage by around 25%. The <a href="https://journals.co.za/doi/pdf/10.7196/SAMJ.2021.v111i8.15786">health system</a> was significantly hindered due to staff being sick, isolated, quarantined, redeployed or suffering from burnout or other <a href="https://www.researchgate.net/publication/316683892_A_conceptual_framework_and_intervention_approach_for_addressing_intimate_partner_violence_in_pregnancy">mental health issues</a>. </p>
<p>Gains that had been made in some key areas of maternal and newborn health before the pandemic also suffered. Women were not allowed to have <a href="https://www.sciencedirect.com/science/article/pii/S1871519221001542?via%3Dihub">birth companions present</a> at the time of delivery. Kangaroo mother care for premature babies was halted in some settings. And some <a href="https://www.sciencedirect.com/science/article/pii/S1871519221001542?via%3Dihub">mothers were separated</a> from their newborns due to COVID-19 rules and restrictions. The narrow focus on COVID-19 also set back many <a href="https://www.hst.org.za/publications/District%20Health%20Barometers/DHB%202019-20%20Complete%20Book.pdf">other health programmes</a>, including HIV and TB care. </p>
<p>Two years down the line, South Africa has reached what many believe to be a <a href="https://theconversation.com/new-covid-data-south-africa-has-arrived-at-the-recovery-stage-of-the-pandemic-177933">turning point</a> in the pandemic. Around <a href="https://pubmed.ncbi.nlm.nih.gov/35196424/">80%</a> of the population has immunity, whether by previous infection or vaccination or a combination thereof. In addition, most of the COVID-related restrictions have been removed. </p>
<p>Mitigating current COVID-19 risks, while minimising indirect harm, requires careful risk-benefit analysis and clear and practical guidance. It’s in this light that the National Department of Health has published <a href="https://www.knowledgehub.org.za/system/files/elibdownloads/2022-04/COVID-19%20Guideline%2004%2004%202022%20digital%20v2.pdf">new guidelines</a> for the care of mothers and newborns in the context of the ever-present threat of COVID-19. The guidelines incorporate new scientific and operational evidence. The aim is to ensure that clinical care for mothers, babies and children during the pandemic remains relevant, practical and evidence-based. </p>
<h2>Back to basics</h2>
<p>The main themes are the integration of COVID-19 care into routine maternal and childcare services, non-separation of mother-baby pairs (as a rule rather than the exception), vaccination against COVID-19 (as applicable), non-pharmaceutical interventions for infection prevention and control, respectful maternity care, and support for maternal and healthcare workers’ mental health.</p>
<p>Separation of the mother-infant pair negatively affects breastfeeding, bonding, and <a href="https://www.who.int/publications/i/item/9241590351">kangaroo mother care</a>. Kangaroo mother care is a method of caring for preterm infants which involves the infants being carried, usually by the mother, with skin-to-skin contact. The practice was stopped in some settings to prevent COVID-19 infections and outbreaks. The new guidelines focus on enabling a mother to breastfeed her infant and practise skin-to-skin contact, even in the context of COVID-19 infection and even if the baby requires admission to the neonatal unit. </p>
<p>COVID-19 vaccination has been <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2789947">shown</a> to protect mothers from severe disease and death. The guidelines recommend that vaccination be provided as part of routine antenatal care to all pregnant women, their partners and planned birth companions. They can choose to opt out. </p>
<p>Vaccination also provides <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2789947">antibody protection</a> to the <a href="https://jamanetwork.com/journals/jama/article-abstract/2788986#:%7E:text=This%20study%20found%20that%20the,SARS%2DCoV%2D2%20infection.">newborn baby</a>. And it minimises risks should mothers or caregivers need to be accommodated in wards or hospital lodger facilities. </p>
<p>Non-pharmaceutical interventions (including mask-wearing, social distancing, handwashing and improved ventilation) remain the mainstay of infection <a href="https://www.researchgate.net/publication/356115250_Judicious_use_of_personal_protective_equipment_to_prevent_the_spread_of_COVID-19_in_maternity_units">prevention and control</a>. These interventions will protect healthcare workers, pregnant women, their newborns and their partners. Care can be provided safely while still allowing birth companions to participate in the memorable experience of childbirth and mothers to breastfeed and bond with their infants. </p>
<p>The heightened awareness of non-pharmaceutical interventions is likely to have a positive spinoff on the transmission of other common conditions such as TB, respiratory syncytial virus and other hospital-acquired infections.</p>
<p>Healthcare workers and pregnant women are at higher risk for mental health disorders. Pregnant women are also more vulnerable to social risks such as gender-based violence, which require close attention and individualised <a href="https://pubmed.ncbi.nlm.nih.gov/32489190/">interventions</a>. The guidelines facilitate screening, identification and care for mental health conditions, gender-based violence, grief and bereavement, addictions, and adolescent pregnancies. They provide several practical tools to encourage empathetic engagement, helpful communication and respectful maternity care.</p>
<h2>Way forward</h2>
<p>South Africa, and the world at large, is starting to come to terms with the <a href="https://www.nature.com/articles/d41586-022-00057-y">fact</a> that COVID-19 will probably be around for a while. COVID-19 therefore needs to be managed as part of a comprehensive package of maternal and child health services. </p>
<p>We believe that these new guidelines provide an important step towards including COVID-19 in routine maternal and child health services, providing staff at clinics and hospitals with a roadmap into the future.</p><img src="https://counter.theconversation.com/content/181114/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeannette Wessels is affiliated with the Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies of the University of Pretoria. The Centre received funding from UNICEF to cover staff time to assist the National Department of Health with the writing of the Maternal, Neonatal and Child COVID-19 guidelines.</span></em></p><p class="fine-print"><em><span>Ute Feucht is affiliated with the Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies of the University of Pretoria. The Centre received funding from UNICEF to cover staff time to assist the National Department of Health with the writing of the Maternal, Neonatal and Child COVID-19 guidelines.</span></em></p>The direct effects of COVID-19 disease on pregnant women, newborns and children are acknowledged. But the indirect effects of the pandemic have been equally devastating.Jeannette Wessels, Researcher, Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, University of PretoriaUte Feucht, Associate Professor in Paediatrics, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1687472021-09-28T06:54:57Z2021-09-28T06:54:57ZTake care with paracetamol when pregnant — but don’t let pain or fever go unchecked<figure><img src="https://images.theconversation.com/files/423465/original/file-20210928-13-6txwri.jpg?ixlib=rb-1.1.0&rect=19%2C6%2C4219%2C2815&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/pregnancy-people-health-care-concept-260nw-1015659301.jpg">Shutterstock</a></span></figcaption></figure><p>Pregnancy comes with aches and pains and heightened anxiety about what we put into the body. </p>
<p>A new article published in <a href="https://www.nature.com/articles/s41574-021-00553-7">Nature Reviews Endocrinology</a> has urged caution around taking paracetamol during pregnancy. The paper is a “consensus statement” that brings together analysis by a panel of experts who looked at evidence from human and animal studies of paracetamol use in pregnancy. </p>
<p>Paracetamol use during pregnancy may alter fetal development, say the authors, with long-lasting effects on child health. The authors call for improved education for health-care professionals and patients, less paracetamol use during pregnancy and further research.</p>
<h2>Alert but not alarmed</h2>
<p>At first glance, calls to minimise paracetamol use during pregnancy are alarming. For those who have taken paracetamol (commonly marketed in Australia as Panadol, Herron Paracetamol, Panamax, Chemist Own or Dymadon) during pregnancy, this could cause anxiety. </p>
<p>This new consensus statement calls for caution, but not concern. The proposed recommendations are largely consistent with <a href="https://www.nps.org.au/australian-prescriber/articles/analgesics-and-pain-relief-in-pregnancy-and-breastfeeding-1">current advice</a> provided to pregnant women in Australia. </p>
<p>With any medication in pregnancy, there needs to be a careful balance between treating a maternal condition and protecting the unborn. A trusted health care provider can help reach an informed decision. Paracetamol is no different. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="pill packet" src="https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/423469/original/file-20210928-19-r1l55t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Paracetamol is the active ingredient in hundreds of prescription and non-prescription medications.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/siegen-north-rhinewestphaliagermany-01-02-260nw-1633257661.jpg">Shutterstock</a></span>
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<h2>What are the concerns?</h2>
<p>Worldwide, <a href="https://academic.oup.com/ije/article/45/6/2009/2724482">more than 50% of pregnant women</a> use paracetamol to treat pain and/or fever. Paracetamol is the active ingredient in hundreds of prescription and non-prescription products. It has been widely regarded for many years as safe to use during pregnancy.</p>
<p>Some, but not all, observational studies in humans suggest paracetamol use during pregnancy may <a href="https://pubmed.ncbi.nlm.nih.gov/25851072/">alter fetal development</a>. The new statement notes that paracetamol has been linked to increased risk of certain <a href="https://www.nature.com/articles/%20s41574-021-00553-7">neurodevelopmental, reproductive and urogenital disorders</a>.</p>
<p>But these studies have limitations. Researchers have found it hard to distinguish the effects of paracetamol from the effects of underlying illness. And there are potential inaccuracies in recording the amount and timing of paracetamol use across an entire pregnancy as are highlighted in the accompanying <a href="https://www.nature.com/articles/s41574-021-00567-1">editorial</a>.</p>
<p>Possible risks of paracetamol use in pregnancy are supported by a number of animal studies, the authors say. For this reason, caution regarding paracetamol use has been advised until a definitive link can be proven or disproven.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1441082949965795336"}"></div></p>
<p>It’s worth noting the available evidence suggests any possible harms of paracetamol are likely to be dose-related. As highlighted by the review article, most increased risks have been linked with use in pregnancy for <a href="https://www.nature.com/articles/s41574-021-00553-7">more than two or four weeks</a>. Current evidence suggests limited risks to unborn babies when paracetamol is taken short term. </p>
<p>Timing is also important. Taking paracetamol during the first trimester has been linked to an increased risk of reproductive and urogenital disorders. Neurodevelopmental disorders have been linked to use in the second or third trimester. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/domperidone-can-boost-breast-milk-supply-heres-what-you-need-know-88648">Domperidone can boost breast milk supply – here's what you need know</a>
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<h2>When the benefits outweigh the risks</h2>
<p>The potential benefits of taking medication need to be weighed against any possible risks. Paracetamol is recognised as an important medication for treating pain and fever during pregnancy. </p>
<p>If left untreated, these conditions could harm the fetus or the pregnant person (the Nature <a href="https://www.nature.com/articles/s41574-021-00567-1">editorial</a> and <a href="https://www.nature.com/articles/s41574-021-00553-7">statement</a> say the expert advice is “relevant for all people who wish to become pregnant, including transgender individuals, non-binary people and intersex people”). </p>
<p>The review authors recognise the <a href="https://www.nature.com/articles/s41574-021-00553-7">potential benefits of paracetamol use</a> and note untreated pain has been linked to increased risks of depression or anxiety as well as hypertension during pregnancy. Fever in pregnancy is a risk factor for multiple neonatal and childhood disorders, including certain birth defects and miscarriage. There is evidence to suggest that use of paracetamol may reduce these risks. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/using-cannabis-during-pregnancy-could-be-bad-news-for-your-baby-new-research-140443">Using cannabis during pregnancy could be bad news for your baby: new research</a>
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<h2>What are the alternatives?</h2>
<p>The optimal management of pain or fever during pregnancy has not been well studied and treatment options remain limited. </p>
<p>Non-steroidal anti-inflammatory medications (such as ibuprofen) have been linked to <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.15510">miscarriage</a> when used in the first trimester, whereas use after 30 weeks’ gestation can negatively impact <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.15510">kidney and heart/lung function</a> in the fetus. For this reason non-steroidal anti-inflammatory medications are <a href="https://www.medicinesinpregnancy.org/Medicine--pregnancy/Ibuprofen/">best avoided</a> unless advised by a healthcare professional. The same goes for strong pain medications such as opioids, which should be <a href="https://www.nps.org.au/australian-prescriber/articles/analgesics-and-pain-relief-in-pregnancy-and-breastfeeding-1">reserved for the management of severe pain</a>. Paracetamol remains the best choice for the short-term treatment of pain and/or fever during pregnancy. </p>
<p>It is also important to identify the cause of the pain or fever, particularly during pregnancy. Discussions about paracetamol use can lead to further investigation, recommendations for non-medication treatments or the need for different medications. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="pregnant woman with sore back" src="https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/423468/original/file-20210928-26-1vj7zne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Safe options for pain management during pregnancy are limited.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/pregnant-woman-suffering-lower-back-260nw-786703240.jpg">Shutterstock</a></span>
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<strong>
Read more:
<a href="https://theconversation.com/weight-gain-during-pregnancy-how-much-is-too-much-89016">Weight gain during pregnancy: how much is too much?</a>
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<h2>The bottom line</h2>
<p>The new consensus statement does not alter existing recommendations regarding paracetamol use during pregnancy. But it does highlight the importance of thinking carefully before using any medications during pregnancy and raises greater awareness about how challenging making informed decisions about medication use can be. </p>
<p>Better evidence is needed to support decision-making during pregnancy and reduce unnecessary anxiety and concern.</p>
<p>Paracetamol use during pregnancy should be discussed with a health-care professional and used at the lowest effective dose for the shortest possible duration. Non-medication therapies for treating pain or fever should be tried before or in addition to paracetamol. When indicated, short-term use of paracetamol remains the safest medication for the treatment of pain and/or fever during pregnancy.</p><img src="https://counter.theconversation.com/content/168747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Luke Grzeskowiak receives funding from the Channel 7 Children's Research Foundation, The Hospital Research Foundation, and National Health and Medical Research Foundation</span></em></p><p class="fine-print"><em><span>Debra Kennedy is affiliated with MotherSafe, the NSW Statewide Medications in Pregnancy and Lactation Advisory Service at the Royal Hospital for Women. </span></em></p>A panel of experts has urged caution regarding paracetamol during pregnancy. But that doesn’t change current advice to discuss pain relief with your doctor or pharmacist.Luke Grzeskowiak, Channel 7 Children's Research Foundation Fellow in Medicines Use and Safety - Flinders University & South Australian Health & Medical Research Institute, Flinders UniversityDebra Kennedy, Senior lecturer, School of Women's and Children's Health, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1659722021-08-19T14:32:25Z2021-08-19T14:32:25ZHow to put women at the centre of Africa’s food systems<figure><img src="https://images.theconversation.com/files/416768/original/file-20210818-15-1vw3qk1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Providing child care facilities at markets, like this one in Abijan, Ivory Coast, could ease the burden on women traders.</span> <span class="attribution"><span class="source">EFE-EPA/ Legnan Koula</span></span></figcaption></figure><p>The number of hungry people in the world grew by a staggering 161 million people in <a href="https://sdgs.un.org/events/state-food-security-and-nutrition-world-2021-sofi-33052#:%7E:text=Background-,The%20State%20of%20Food%20Security%20and%20Nutrition%20in%20the%20World,and%20spread%20across%20the%20globe.">2020</a> to 811 million. More than one third of these people live in Africa. One of the main reasons for this increase is the COVID-19 pandemic, coupled with the cost of healthy diets and high levels of income inequality. </p>
<p>More concerted efforts are needed to address the problem of food security. Empowering women is often said to be the <a href="https://www.globalagriculture.org/whats-new/news/en/34251.html#:%7E:text=Empowering%20women%20and%20female%20farmers,improves%20food%20security%20and%20nutrition">key</a>. In the past, researchers have looked to their specific disciplines to suggest how women could be empowered to improve food security.</p>
<p><a href="https://www.wider.unu.edu/sites/default/files/wp2017-71.pdf">Some</a> have focused on increasing women’s income because women spend more of their income on household nutrition. <a href="https://link.springer.com/article/10.1007/s12571-020-01021-2">Others</a> have focused on providing women with nutrition education because women carry the primary responsibility for preparing food.</p>
<p>While these studies are valuable for improving food security and nutrition, we also need to consider what shapes women’s participation in different aspects of the food system.</p>
<p>Globally, <a href="http://www.fao.org/3/i7846e/i7846e.pdf">experts</a> are beginning to recognise that focusing on one aspect of food overlooks the trade-offs or sacrifices people make. For example, women’s economic empowerment may mean that they spend more time on economic activities, and less time preparing food. </p>
<p><a href="http://www.fao.org/3/i7846e/i7846e.pdf">Studies</a> have shown that as a result, many women rely on convenient fast foods to feed their families. This food is typically low in nutritional value. </p>
<p>The <a href="https://www.sciencedirect.com/science/article/pii/S0305750X18303115?via%3Dihub">need</a> to look at food in its entirety has put more attention on the concept of food systems. That includes the inputs used to produce food, its production, how it is transported and consumed, and the type of food that people choose to eat.</p>
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Read more:
<a href="https://theconversation.com/covid-19-recovery-is-a-chance-to-improve-the-african-food-system-139134">COVID-19 recovery is a chance to improve the African food system</a>
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<p>While some frameworks exist to describe food systems, we could not find one that considered these issues from a gender perspective. We aimed to develop a framework that could help show how to improve women’s participation in and benefit from all areas of the food system.</p>
<h2>Our study</h2>
<p>Our <a href="https://www.mdpi.com/2071-1050/13/15/8564/htm">study</a> enhanced an existing food systems framework by integrating a gender perspective. A food systems framework is a set of things you need to think about when looking for ways to make better food available to more people. </p>
<p>It helps us understand how things interact – making it easier to see how one intervention might negatively or positively influence another aspect or activity in the system. We chose to work on the Global Panel on Agriculture and Food Systems for Nutrition (<a href="http://www.glopan.org/sites/default/files/Global%20Panel%20Technical%20Brief%20Final.pdf">Glopan</a>) framework because it was user-friendly. Glopan is a global panel of experts on food security and nutrition. </p>
<p>This framework looks at agricultural production, market and trade systems, people’s ability to buy food, how to transform food, the types of food people are likely to consume and healthy diets. The framework does not integrate gender issues. </p>
<p>We studied 18 global and pan-African commitments – such as the <a href="https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf">Sustainable Development Goals</a> and <a href="https://au.int/en/agenda2063/overview">Africa Agenda 2063</a> – to identify gender policy actions that could be taken in each of the areas of the Glopan food systems. </p>
<p>We found that generally, there is a consensus in the documents on specific actions that can be taken to advance gender equality in the food system. Our study brings together these policy actions to provide a way of understanding how they fit together and interact.</p>
<p>We also found that governance and social systems constraints – that are not necessarily part of the food system, but affect men’s and women’s capacity to participate in the food system – need to be addressed. </p>
<p>For example, maternity leave policies are important to ensure that women can work without experiencing discrimination or pay cuts. Paternity leave is also important to challenge the idea that only women are responsible for child care.</p>
<p>We developed an <a href="https://www.mdpi.com/2071-1050/13/15/8564/htm">enhanced framework</a> that helps policy makers identify how gender can be integrated into parts of the food system. </p>
<h2>An enhanced framework</h2>
<p>The framework we developed is an initial step to understanding the interactions between existing policies and the potential trade-offs. For example, improving women’s access to markets might have implications for the amount of time they can spend at home. Limited time spent at home may reduce breastfeeding – which is critically important for children’s health. Policy makers might consider building daycare facilities close to markets to support women to breastfeed.</p>
<p>Many of the policy options proposed in our study are consistent with study findings across African agriculture and nutrition research. These show that women face constraints in access to land, services and markets. </p>
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Read more:
<a href="https://theconversation.com/food-security-in-african-cities-needs-a-fresh-approach-our-book-sets-out-the-issues-161373">Food security in African cities needs a fresh approach - our book sets out the issues</a>
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<p>Our framework proposes several priority actions for policymakers:</p>
<ul>
<li><p>Improving women’s access to markets and trade systems. An example would be daycare facilities near markets.</p></li>
<li><p>Improving women’s social protection. Social grants or food parcels are examples. </p></li>
<li><p>Improving women’s access to nutritious food. This makes an important difference to maternal and child health, particularly during pregnancy. </p></li>
</ul>
<h2>Unlocking food security</h2>
<p>One challenge our study identified was that globally, policies still overemphasise the role of women in agricultural production and diets. Their role in markets, consumer demand and consumer purchasing power is not as highly prioritised. </p>
<p>Women’s access to resources and services is also overemphasised, overlooking issues of control. For example, policies may promote women’s access to agricultural technologies. But cultural restrictions prevent women from using these technologies. </p>
<p>Eliminating hunger will require that research and policies empower women to participate effectively in the food system. Research or policies that focus on one discipline will not suffice to achieve this goal. It’s also essential to understand what gender policy actions can be taken.</p><img src="https://counter.theconversation.com/content/165972/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Mkandawire receives funding from the Global Challenges Research Fund through the African Research Universities Alliance – United Kingdom Research and Innovation partnership.</span></em></p><p class="fine-print"><em><span>Melody Mentz-Coetzee receives funding for the FSNet-Africa project through the Global Challenges Research Fund (GCRF) under the auspices of the United Kingdom Research and Innovation (UKRI) and African Research Universities Alliance (ARUA) partnership. </span></em></p>Globally, experts are beginning to recognise that focusing on one aspect of food overlooks the trade-offs or sacrifices people make.Elizabeth Mkandawire, Network and Research Manager: ARUA – UKRI GCRF FSNet Africa, University of PretoriaMelody Mentz-Coetzee, Senior Researcher FSNet-Africa, University of Pretoria, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1530212021-01-18T13:18:25Z2021-01-18T13:18:25ZFood and healthcare in war-torn Tigray: preliminary insights on what’s at stake<figure><img src="https://images.theconversation.com/files/378765/original/file-20210114-17-fkahpo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This image was taken at the Hawzien market in Tigray, two years before the war which has put millions in need of emergency food assistance. </span> <span class="attribution"><span class="source">Oscar Espinosa/Shutterstock</span></span></figcaption></figure><p>It is now over two months since a war broke out in <a href="https://theconversation.com/conflict-between-tigray-and-eritrea-the-long-standing-faultline-in-ethiopian-politics-151042">Tigray</a> between the regional government and the federal government of Ethiopia. The military hostilities have led to a sudden disruption in essential services and endangered the lives and wellbeing of around <a href="https://www.unicef.org/ethiopia/media/2351/file/Tigray%20region%20.pdf">6 million residents</a> and over 100,000 Eritrean refugees sheltered in the region. It’s estimated that <a href="https://nation.africa/kenya/news/africa/over-2m-displaced-by-tigray-conflict-3247500?s=03">2.2 million people</a> – close to a third of the regional population – have been internally displaced. At least <a href="https://www.unhcr.org/news/briefing/2021/1/5ff4316c4/unhcr-relocates-first-ethiopian-refugees-new-site-sudan.html?s=03">56,000 citizens</a>, mainly women and children, have already fled across the border to Sudan. </p>
<p>Information on significant loss of lives and property is <a href="https://www.theguardian.com/global-development/2020/dec/21/slaughtered-like-chickens-eritrea-heavily-involved-in-tigray-conflict-say-eyewitnesses">just beginning to emerge</a>.</p>
<p>It’s difficult to get a complete and accurate picture of the war or its effects on the ground. This is mainly due to a communication blackout and the disintegration of the existing health information system in most parts of the region. </p>
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Read more:
<a href="https://theconversation.com/tigray-conflict-sets-off-new-wave-of-refugees-in-a-region-still-grappling-with-earlier-crises-150392">Tigray conflict sets off new wave of refugees in a region still grappling with earlier crises</a>
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<p>However, as a health system researcher and academic who has been working in Tigray at Mekelle University since 2010, closely collaborated with the regional health bureau and understands the many healthcare challenges in the region before the war, I believe it is possible to provide a broad picture of the consequences of the war. </p>
<p>Besides, as experience <a href="https://international-review.icrc.org/sites/default/files/irrc-889-footer-rubenstein.pdf">elsewhere shows</a>, the health and wellbeing effects will go beyond the direct impact of war-related fatalities, and are likely to last for years after peace is fully restored.</p>
<h2>Before the war</h2>
<p>Tigray is one of the 10 regional states in Ethiopia and <a href="https://www.unicef.org/ethiopia/media/2351/file/Tigray%20region%20.pdf">the fifth most populated</a> in the country. Consistent economic growth has been recorded in the past three decades, <a href="https://www.unicef.org/ethiopia/media/2351/file/Tigray%20region%20.pdf">creating opportunities</a> for rapid poverty reduction and improvement in health and healthcare delivery.</p>
<p>Before the war, <a href="https://dhsprogram.com/pubs/pdf/PR120/PR120.pdf">94%</a> of women who gave birth in the five years preceding the survey received antenatal care. About 73% delivered in health facilities and 63% received post-natal care from a skilled provider in 2019. These contrast with the national averages of 74%, 48% and 33.8% respectively. </p>
<p>Similarly, the child mortality rate in Tigray <a href="https://www.unicef.org/ethiopia/media/2351/file/Tigray%20region%20.pdf">in 2016 was 59 per 1,000 live births</a>. The corresponding rate for Ethiopia was 67 deaths per 1,000 births. </p>
<p>At the heart of these success stories was a strong <a href="https://www.who.int/alliance-hpsr/projects/alliancehpsr_ethiopiaabridgedprimasys.pdf">primary healthcare system</a>, of which the community health extension workers were the backbone.</p>
<p>Nevertheless, the region still suffered from high levels of poverty, and key public health challenges remained. These included increasing incidence of <a href="https://www.internationalhealthpolicies.org/featured-article/meeting-old-demands-and-rising-to-new-challenges-revisiting-the-role-of-ethiopian-health-extension-workers-in-the-prevention-and-control-of-ncds-amid-covid-19/">non-communicable diseases</a>, low quality of healthcare and acute food insecurity. The poverty rate in Tigray was 27% compared to the national average of 23.5%. The food poverty rate in Tigray was also the highest of all regions, at <a href="https://www.unicef.org/ethiopia/media/2351/file/Tigray%20region%20.pdf">32.9%</a>. </p>
<p>The ongoing war is expected to worsen some of these challenges, while rolling back the progress made in other areas over the past decades.</p>
<h2>Potential health and healthcare consequences</h2>
<p>Access to food and healthcare – life essentials and the most basic human rights – are the first casualties of war. Road closures and movement restrictions continue to create barriers to people’s ability to access life essentials.</p>
<p>Food security has been hit hard. Disruption in banking and communication services prevents people from using the resources they have to meet their basic needs. This threatens household food security, and has put <a href="https://www.reuters.com/article/uk-ethiopia-conflict/almost-2-3-million-people-need-aid-in-ethiopias-tigray-u-n-report-idUSKBN29D1XF?s=03">4.5 million people</a> (half of whom are children) in need of emergency food assistance. </p>
<p>The problem is even more concerning given that as many as <a href="https://www.unicef.org/ethiopia/media/2351/file/Tigray%20region%20.pdf">9.2% or about 65,000 children under five years of age</a> in the region are already suffering from acute nutritional deficiency such as wasting. </p>
<p>Officials have disclosed that <a href="https://nation.africa/kenya/news/africa/over-2m-displaced-by-tigray-conflict-3247500?s=03">most health facilities</a> have been destroyed or looted during the war. Most ambulances in the region were <a href="https://www.youtube.com/watch?v=9o9UCMTpyMM&%3Bfeature=youtu.be">either lost or destroyed</a>. </p>
<p>A senior health official in the region <a href="https://www.ethioexplorer.com/news-tigray-region-interim-health-bureau-head-admits-civilian-deaths-in-battle-to-capture-mekelle-looting-of-hospitals-and-university/">reported</a> disruptions to medical supply chains, interruption of basic amenities (such as electricity), and the displacement of health system leaders and trained medical personnel, along with low morale among health workers. </p>
<p>Immunisation and availability of vaccines are also critically compromised, putting the lives of children and mothers in great danger. Vaccines already in store are also likely to be wasted due to cold chain breach resulting from electricity interruption. </p>
<p>Similarly, maternal health services such as antenatal, delivery and postnatal care have been interrupted. So have family planning services. </p>
<p>Another direct health effect of the war will be on infectious diseases. For example, a recent <a href="https://www.reuters.com/article/uk-ethiopia-conflict/almost-2-3-million-people-need-aid-in-ethiopias-tigray-u-n-report-idUSKBN29D1XF?s=03">UN report</a> indicated that the interruption of COVID-19 surveillance and control activities and overcrowded conditions in displacement settings is feared to have facilitated high COVID-19 community transmissions. </p>
<p>The interruptions or limited access to water, sanitation and hygiene services, both within facilities and at the population level, also pose health risks.</p>
<p>War disproportionately affects women and girls as they can be subjected to sexual violence and abuse. There have been <a href="https://www.reuters.com/article/us-ethiopia-conflict/ethiopian-women-raped-in-mekelle-says-soldier-idUSKBN29E0IH?s=03">reports</a> of women being raped in the capital city of Tigray, Mekelle. Such violence could be worse in rural and other towns of Tigray. Furthermore, the traumatic events of the past two months would undoubtedly result in mental health and psychosocial problems.</p>
<h2>Moving forward</h2>
<p>Urgent steps must be taken to mitigate the health and healthcare crisis in the region.</p>
<p>The primary focus should be on saving lives and providing care for the needy. This requires inter-related actions such as these:</p>
<ul>
<li><p>Urgent, sustained and unfettered humanitarian assistance should be extended to all families in the region. This includes immediate provision of ready-to-use therapeutic food for the treatment of child malnutrition.</p></li>
<li><p>Humanitarian organisations and health workers should provide care and assistance without interference.</p></li>
</ul>
<p>In addition, health service delivery needs to be restored. This requires re-stocking medical supplies; reconnecting basic amenities; mobilising domestic and international resources; and supporting local institutions, including civil societies and the community health system in the region.</p>
<p>Emergency COVID-19 surveillance and response operations must be strengthened by providing medical and other prevention supplies at the facility and community levels.</p>
<p>Lastly, mental health and psychosocial support services need to be established, or where they exist strengthened. In particular, serious consideration should be given to women and girls who experienced sexual violence.</p><img src="https://counter.theconversation.com/content/153021/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Azeb Gebresilassie Tesema does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The health and wellbeing effects will go beyond the direct impact of war-related fatalities, and are likely to last for years after peace is fully restored.Azeb Gebresilassie Tesema, Assistant Professor of Public Health, Mekelle University; Scientia PhD scholar, George Institute for Global Health, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1481242020-10-27T14:23:23Z2020-10-27T14:23:23ZHow to get Malawian men more involved in antenatal care - and why it matters<figure><img src="https://images.theconversation.com/files/365519/original/file-20201026-23-kznse9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Male involvement antenatal care helps with the uptake of services and retention in care of both the mother and her baby.</span> <span class="attribution"><span class="source">Marco Longari/AFP via Getty Images</span></span></figcaption></figure><p>When men are excluded from antenatal (prenatal) care, or only participate in a limited way, it’s a lost opportunity for the whole family. This exclusion is seen more in patriarchal societies. </p>
<p>Prenatal care services are traditionally <a href="https://pubmed.ncbi.nlm.nih.gov/24998152/">designed to serve women</a>. But <a href="https://pubmed.ncbi.nlm.nih.gov/20024733/">male involvement</a> provides an opportunity for their increased contributions both within the health system and at home. For example, getting fathers involved in the prevention of <a href="https://pubmed.ncbi.nlm.nih.gov/21985332/">mother-to-child transmission</a> of HIV is critical for the uptake of services and retention in care of the mother and baby. When men are involved there are <a href="https://pubmed.ncbi.nlm.nih.gov/21084999/">better outcomes</a> for their HIV exposed or infected children. It can also <a href="https://pubmed.ncbi.nlm.nih.gov/28809770/">afford the men access</a> to HIV and other sexually transmitted infections services.</p>
<p>But male involvement in maternal and child health services is <a href="https://pubmed.ncbi.nlm.nih.gov/31533839/">low</a> in diverse settings <a href="https://pubmed.ncbi.nlm.nih.gov/31159712/">globally</a>. </p>
<p>To get men involved, it’s necessary to understand what blocks or eases the way. The strategy should be contextually relevant too. </p>
<p>From 2013 to 2015, we conducted a research project in Malawi to explore this. The project was done in two phases. We first wanted to determine the barriers to men being more involved. Based on these <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-691">findings</a> we developed and tested an <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0119273">intervention</a> for better participation. This intervention comprised giving pregnant women an invitation card for their partners. </p>
<p>We found that men who received invitation cards to their partners’ appointments were more involved in the health services. We believe that scaling up the use of this invitation card system could encourage more male participation in Malawi and similar settings. </p>
<h2>Barriers and intervention</h2>
<p>In the first phase, we conducted an exploratory qualitative study to describe the barriers to and enablers of male involvement in antenatal healthcare. The <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-691">study</a> was done from December 2012 to January 2013 at a health centre in Blantyre, Malawi. We conducted six face-to-face interviews with healthcare workers and four focus group discussions with 18 men and 17 pregnant women attending the clinic. We also wanted to identify the relevance of, and strategies for, involving men in the prevention of mother-to-child transmission of HIV. </p>
<p>One of the barriers <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-691">we found</a> was that these services were offered in spaces that focus on mothers. The focus of the services team is on the pregnant woman and the pregnancy and rarely, if at all, on the male partner. History taking, physical examinations and diagnostic assessments centre on the woman. The health system does not offer male-friendly services in the antenatal care clinic. </p>
<p>Men generally perceive clinics as more women and child friendly. They may have concerns about services provided by female health workers, and their work schedules may not fit with the opening hours and long waiting times at clinics. The health system doesn’t have a clear strategy for involving men. We found that men mostly stay with their partners during the HIV counselling and testing session. For the rest of the antenatal care appointment they often <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-2999-8">wait for their partner outside</a>.</p>
<p>Our study further showed that men could be involved in <a href="https://www.tandfonline.com/doi/full/10.3402/gha.v6i0.22780">several ways</a>. These include participating in <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-2137-y">health education</a>, providing financial and material support for the delivery or making the decisions that help the expectant mother to use health services. </p>
<p>The most effective way to get men involved in our setting was to send an invitation card via their female partners, inviting them to attend the antenatal clinic. An invitation card was deemed respectful since it was more personal than having their partners extend an invitation verbally. </p>
<p>We tested an <a href="https://journals.plos.org/plosone/article/related?id=10.1371/journal.pone.0119273">intervention</a> in the second phase of our study: an <a href="https://doi.org/10.1371/journal.pone.0119273.s004">invitation card</a> to encourage men to come with the women for antenatal care. This study was done at two health centres in Blantyre. The message on the invitation card was informed by the results from our first phase. The men preferred the card not to mention HIV testing. </p>
<p>The study had an intervention and a control arm. In total, we recruited 462 pregnant women. Of these, 230 were in the intervention arm where they were given an invitation card to pass on to their partner. The women in our control arm were asked to invite their male partners verbally, which was standard practice at the time. All women were followed for six weeks and had two follow-up visits. We did not trace them to check what was happening, to avoid interfering with the intervention. </p>
<p>Our results showed that more women (65 of 230 or 28.26%) in the intervention returned with their partner at the next visit. But only 44 of 232 (18.97%) from the control arm came back with their partners. The differences observed were statistically significant. We concluded that an invitation card addressed to a male partner and passed on by his partner is an effective strategy for getting men more involved in services that aim to prevent mother-to-child transmission of HIV. </p>
<p>To our knowledge, this was the first time this health service innovation had been tried in the country.</p>
<p>We spoke to the women who showed up at the clinic without their partners after both kinds of invitation. Some <a href="https://www.panafrican-med-journal.com/content/article/25/229/full/">(17.3%)</a> said their partners weren’t interested; others <a href="https://www.panafrican-med-journal.com/content/article/25/229/full/">(81.8%) weren’t available</a>. </p>
<p>In subsequent <a href="https://pubmed.ncbi.nlm.nih.gov/30558572/">research</a> colleagues at South Lunzu and Mpemba health centers and Queen Elizabeth Central Hospital in Malawi were able to identify couples’ health education needs. These authors also found that couples who attended antenatal care together were more prepared for delivery compared to those where only the woman attended the antenatal care sessions. </p>
<h2>Our recommendations</h2>
<p>We recommend that an invitation card be used to invite male partners to attend antenatal care services.</p>
<p>There is a need to offer the services at hours and on days when men can attend as well. For instance, the services could be available over the weekend or later in the evening. The design and delivery of services should be done with men in mind.</p><img src="https://counter.theconversation.com/content/148124/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alinane Linda Nyondo-Mipando receives funding from Malawi government through University of Malawi where she works. This research was supported by the National Health Research Strengthening Capacity Initiative of Malawi and the Consortium for Advanced Research on Africa. The funders of this study had no role in the design of the study, analysis of the results, and preparation of the manuscript or decision to publish. Alinane Linda Nyondo-Mipando has no conflicts of interest to declare.</span></em></p><p class="fine-print"><em><span>Adamson S. Muula receives funding from the Malawi Government through a credit facility from the International Development Association (IDA); funding the African Centers of Excellence II (Project Number : ACEII 048
Credit Facility : IDA; Credit Number : P151847.
This research was also supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No--B 8606.R02), Sida (Grant No:54100029), the DELTAS Africa Initiative (Grant No: 107768/Z/15/Z). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) (Grant No: 107768/Z/15/Z) and the UK government, the statements made and views expressed are solely the responsibility of the authors.</span></em></p>Male involvement in prevention of mother-to-child transmission of HIV is key for the uptake of services and retention in care. When men are involved, HIV exposed or infected children do better.Alinane Linda Nyondo-Mipando, Lecturer in Health Systems and Policy, University of MalawiAdamson S. Muula, Professor of Epidemiology and Public Health, University of MalawiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1364242020-04-21T13:35:09Z2020-04-21T13:35:09ZAfrica can’t let maternity care slide during the coronavirus pandemic<figure><img src="https://images.theconversation.com/files/328372/original/file-20200416-192689-1aiush6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This pandemic could have adverse effects on pregnant women.</span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>Amid global commitments to defeat, or at least minimise, the pervasive effects of the COVID-19 <a href="https://www.linkedin.com/pulse/covid-19-leadership-africa-ethiopia-leading-way-jerene-md-phd-mba">pandemic</a>, the impact on the African continent remains unclear. African governments have <a href="https://time.com/5820658/cyril-ramaphosa-coronavirus-african-countries/">moved quickly</a> to mobilise resources and strengthen their emergency preparedness and response capacities.</p>
<p>But particular attention needs to be paid to the most vulnerable members of the population. There are ongoing discussions on pressing health issues including <a href="https://www.weforum.org/agenda/2020/04/covid-19-coronavirus-pandemic-hit-women-harder-than-men/">women’s health</a>.</p>
<p>More than <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/">two-thirds</a> of the world’s maternal deaths happen in sub-Saharan Africa. The <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/">leading cause</a> of maternal deaths is inadequate access to quality care during pregnancy or delivery or after birth.</p>
<p>The world has committed to improving maternal health through quality care. But the use of maternal health services in sub-Saharan Africa remains low. More than <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/">four-fifths</a> of all maternal deaths are directly linked to poor and inadequate maternity services during pregnancy and childbirth and six weeks after birth. </p>
<p>COVID-19 and measures put in place to curb its spread may worsen the already poor access to quality maternal health services in parts of the continent. For example, the ongoing transmission mitigation strategies such as <a href="https://ewn.co.za/2020/04/14/latest-covid-19-data-to-guide-govt-on-any-lockdown-extension">lockdown</a> and <a href="https://qz.com/africa/1836458/curfews-not-lockdowns-will-slow-covid-19-spread-in-africa/">curfews</a> may intensify the dire consequences brought on by the lack of access to quality health services and by pre-existing maternal health problems. And struggling health systems may not have adequate capacity and space to attend to these routine healthcare needs. </p>
<h2>Affected services</h2>
<p>The use of maternal health services including antenatal care, skilled delivery and postnatal care has a significant impact on the overall health of the mother. But health systems across the continent may not be able to handle the situation in the event of mass infections. </p>
<p>For instance, during the 2014 Ebola outbreak in West Africa, the World Health Organisation (WHO) <a href="https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/EbolaGuidanceReport.pdf?ua=1">suggested</a> that there was a significant reduction in maternal and newborn health care use. This was mainly due to stretched healthcare systems. Evidence of this is the absence of referrals for complicated cases. There was also less adherence to treatment protocols.</p>
<p>The WHO also warned that this could lead to poor maternal and newborn health unless backed by the provision of context-specific services. </p>
<p>Evidence from recent <a href="https://academic.oup.com/heapol/article/35/1/78/5614323">empirical</a> <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-018-0502-y">studies</a> from <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30078-5/fulltext">Guinea</a>, <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2016.00222/full">Liberia</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731846/">Sierra Leone</a> supports this. They showed a significant reduction in the uptake of essential maternal health services during the Ebola outbreak. This had persistent effects after the crisis ended. </p>
<p>Consequently, the outbreak <a href="https://www.nature.com/news/maternal-health-ebola-s-lasting-legacy-1.17036">pushed back</a> the positive strides that had been achieved in maternal health in the region.</p>
<h2>What women need</h2>
<p>Women in many African countries already have difficulty getting decent <a href="https://data.unicef.org/topic/maternal-health/antenatal-care/#methodology">pre- and postnatal care</a>. They face delays in getting appropriate medical help for a pregnancy-related emergency, reaching an appropriate facility and receiving adequate care when a facility is reached. </p>
<p>This, in turn, diminishes access to respectful, skilled, comprehensive and culturally appropriate maternal healthcare.</p>
<p>These weaknesses could be worsened by “staying at home and physical distancing” measures. And COVID-19 disruptions may lead to shortages in the supply chain for maternal life-saving medicines. This may specifically affect emergency pregnancy services, including deliveries that require critical care.</p>
<p>In addition, pregnancy aggravated or pre-existing conditions including poor access to nutrition may put pregnant mothers at more risk. </p>
<h2>The way forward</h2>
<p>The African context requires a unique approach to enhance maternal health during the COVID-19 crisis. Special efforts must be made to create awareness about which maternal health services are available – routinely and during lockdowns and curfews. </p>
<p>These may include strengthening media coverage to motivate mothers to access services, with all precautionary measures in place. Additional measures also need to be taken. For example, Kenya has <a href="http://www.health.go.ke/wp-content/uploads/2020/04/Community-Response-to-COVID-2019_1.docx.pdf">reviewed</a> community health volunteers’ work packages so that they are motivated to do home-to-home visits, provide counselling and identify mothers who need special care. This could be enhanced through referrals to the next level health facility. The country has also developed a <a href="http://www.health.go.ke/wp-content/uploads/2020/04/KENYA-COVID19-RMNH.pdf.pdf.pdf">practical guideline</a> to ensure the continuity of maternal and newborn services. </p>
<p>Initiatives like this need to be scaled up across the region. Health facilities must also make standby maternity rooms available to ensure that maternity care can be offered in safe conditions.</p>
<p>And positive lessons from the Ebola outbreak in West Africa could guide the ongoing efforts. For instance, a consortium of international organisations including the WHO, UNICEF and Save the Children made <a href="https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/EbolaGuidanceReport.pdf?ua=1">recommendations</a> to key stakeholders on what needed to be done differently to minimise the impact of the outbreak on maternal and newborn health. </p>
<p>The consortium developed <a href="https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/EbolaGuidanceReport.pdf?ua=1">guidelines</a> to identify, train and incentivise frontline health care workers – such as community health workers – to provide contexualised maternal and newborn healthcare services during pregnancy and childbirth and after birth.</p>
<p>The guidelines reiterated that the implementation of these initiatives needed to be backed by appropriate policy, supervision and monitoring and evaluation. Experiences from the implementation of these emergency response plans and mitigation strategies <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2016.00222/full">showed some positive results</a> in maternal and newborn health. </p>
<p>The Centers for Disease Control and Prevention also <a href="https://www.cdc.gov/vhf/ebola/clinicians/evd/pregnant-women.html">urged</a> special screening and care for vulnerable pregnant women. </p>
<p>These lessons should be applied by countries in sub-Saharan Africa managing their way through the coronavirus pandemic.</p>
<p><em>Carol Wainaina, Research Officer with APHRC, contributed to the writing of this article</em></p><img src="https://counter.theconversation.com/content/136424/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amanuel Abajobir does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Measures put in place to curb the spread of COVID-19 may worsen the already poor access to quality maternal health services in parts of the continent.Amanuel Abajobir, Postdoctoral Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1222802020-03-27T12:14:12Z2020-03-27T12:14:12ZScreen time that supports new parents and young kids can enhance family health<figure><img src="https://images.theconversation.com/files/323436/original/file-20200326-133027-10bwr7o.jpg?ixlib=rb-1.1.0&rect=0%2C307%2C4451%2C3351&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Babies don't come with instruction manuals... mobile health apps can help new parents.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/new-jersey-jersey-city-woman-texting-and-holding-royalty-free-image/525445885">Tetra Images via Getty Images</a></span></figcaption></figure><p>Screen time for little kids takes a lot of heat under normal conditions. The American Academy of Pediatrics’ official recommendations urge families to be <a href="https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/Children-and-Media-Tips.aspx">thoughtful and judicious about screen time</a> for youngsters from birth to age five. And there is evidence that too much technology can lead to <a href="https://theconversation.com/why-its-wrong-for-pediatricians-to-eliminate-daily-screen-time-recommendations-49408">loss of child development opportunities</a>.</p>
<p>But technology can also connect families to important parenting and educational opportunities, especially at a time when people are sheltering in place and avoiding health care facilities for all but the most pressing concerns. The current generation of parents are <a href="https://doi.org/10.1007/978-3-662-46590-5_2">digital natives</a> themselves, having grown up in an era when internet was readily accessible. They often prefer technological solutions for their families.</p>
<p>We are <a href="https://scholar.google.com/citations?hl=en&authuser=2&user=DQ0Q4ekAAAAJ">a professor of social work</a> and <a href="https://keck.usc.edu/faculty-search/ashwini-lakshmanan/">a neonatologist</a> interested in how using internet-supported technologies – including apps, voice and text messaging, videoconferencing and e-learning platforms – can ease the parenting burden and promote healthy development. Reducing burdens on parents and increasing access to parent support are vital elements in helping families raise healthy children.</p>
<h2>Trusted info within arm’s reach</h2>
<p>Users can access apps, websites and programs from their cellphones or computers to receive information about medical tests, screenings and how to make healthier choices.</p>
<p>Phone apps can put trusted medical information right into a parent’s hand. Users can skip the hassle of having to visit a clinic or class. Health care providers recommend free apps like <a href="http://nicu2home.com">NICU2Home</a>, Providence Hospital Systems’ <a href="https://www.providence.org/services/circle-app">Circle</a> and March of Dimes’ <a href="https://www.marchofdimes.org/nicufamilysupport/my-nicu-baby-app.aspx">My NICU Baby</a> to their patients as sources of tips and helpful videos about how to care for a baby. The apps can help do things like track breastfeeding sessions, baby’s sleep patterns and baby’s weight; teach medical terminology; and connect families to others with similar experiences.</p>
<p>App can also provide task lists that ease a family’s transition from hospital to home with a newborn. For example, these apps can tell families about to be discharged from a NICU what supplies and special equipment they will need to have at home to support their baby after leaving the hospital. Having access to this information in an app, rather than a paper handout from a doctor, means it can be easily accessed on demand and won’t get lost in the shuffle of family life.</p>
<figure>
<iframe src="https://player.vimeo.com/video/310900917" width="500" height="281" frameborder="0" webkitallowfullscreen="" mozallowfullscreen="" allowfullscreen=""></iframe>
<figcaption><span class="caption">Children’s Hospital Los Angeles produced the Baby Steps LA app to help patient families.</span></figcaption>
</figure>
<p>One of us (Dr. Lakshmanan) created the app Baby Steps LA to help families and children with special health care needs at Children’s Hospital Los Angeles. The app includes information about how social factors like housing, insurance and food security can influence health and offers related resources.</p>
<p>There are also several apps that focus on the importance of peer support groups and how important they can be <a href="https://doi.org/10.1097/NMC.0000000000000489">for new mothers</a>. </p>
<p>Cellphones can potentially help new parents, even without specific apps installed. One study found that new mothers who received text messages with tips about breastfeeding and child development while enrolled in the Supplemental Nutrition Program for Women, Infants, and Children breastfed their children <a href="https://doi.org/10.1111/mcn.12488">more consistently and for a longer period of time</a>. </p>
<p>Text messaging chatbots like <a href="https://redtri.com/parentspark-interactive-chatbox-teach-you-to-be-better-parent/">ParentSpark</a> use artificial intelligence and user patterns to respond to parents’ queries on topics like feeding and exercise, helping inform their choices and teach new strategies.</p>
<p>Families can even turn to <a href="https://www.ncbi.nlm.nih.gov/pubmed/18999101">video games to help prepare them</a> for discharge from the hospital or to learn about medical conditions.</p>
<h2>Connecting to live experts via screens</h2>
<p><a href="https://www.healthit.gov/faq/what-telehealth-how-telehealth-different-telemedicine">Telehealth</a> is an important option for families with young children, because it expands access to medical, mental health and developmental care options, especially in areas where there are limited numbers of specialty providers. Parents and their children can videoconference with experts, reducing time spent traveling and in waiting rooms.</p>
<p>The expansion of <a href="https://www.healthrecoverysolutions.com/blog/telehealth-autism-diagnosis">autism services on telehealth platforms</a> is a prime example of how this technology can meet the needs of families with young children. Families can access screening, early diagnosis, applied behavior analysis, speech language pathology, parent training and overall treatment planning from home by logging into a videoconferencing platform and speaking to a live provider.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/ExMZtrH1Jm4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Live suggestions via on-screen interactions can help with parenting.</span></figcaption>
</figure>
<p>Families can also access parent support and parent training, including developmental assessments, using telehealth. One of us (Dr. Traube) designed a service called <a href="https://pat.usc.edu">Virtual Home Visitation</a> that gives families direct access to a parenting coach who guides them through activities that support their child’s development using videochat technology.</p>
<p>These services can be difficult to find in local communities. But, through weekly screen interactions with a parenting coach, families can promote their child’s development, ensure any developmental delays are quickly identified and find intervention options early.</p>
<h2>Online content aimed at kids</h2>
<p>Plenty of research indicates that <a href="https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/Children-and-Media-Tips.aspx">young children should not</a> interact with video games or content to the exclusion of books or in the absence of an adult to coach them. </p>
<p>But thoughtfully built educational platforms can be a productive way for parents to use technology to support their child’s early learning. <a href="https://doi.org/10.1542/peds.2014-2251">When designed with child development research in mind</a>, content platforms offering games, e-books, and videos can help kids build motor, socio-emotional and cognitive skills, as well as help to reduce skill gaps in important foundational areas like color, letter and number recognition.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/323437/original/file-20200326-133001-1pfny1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/323437/original/file-20200326-133001-1pfny1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/323437/original/file-20200326-133001-1pfny1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/323437/original/file-20200326-133001-1pfny1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/323437/original/file-20200326-133001-1pfny1t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/323437/original/file-20200326-133001-1pfny1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/323437/original/file-20200326-133001-1pfny1t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/323437/original/file-20200326-133001-1pfny1t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A crucial component in young children’s screen time is a parent’s close involvement and supervision.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/man-boy-and-young-girl-sitting-on-a-grey-sofa-royalty-free-image/910586842">Mint Images via Getty Images</a></span>
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<p>For example, studies suggest that well-designed e-books can <a href="https://files.eric.ed.gov/fulltext/ED560635.pdf">support early literacy</a>. Thoughtful use of highlighting, or animating relevant parts of picture or text, and interactive features including dictionaries, word readouts or learning games can help with word learning and reading.</p>
<p>When parents assess e-learning platforms, they should <a href="https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/Children-and-Media-Tips.aspx">evaluate them on the basis</a> of whether they are engaging, actively involve the child, have meaningful content, and demonstrate or encourage social interaction. Organizations including <a href="https://pbskids.org/">Public Broadcasting Service</a> and <a href="https://www.sesamestreet.org/">Sesame Workshop</a> focus on early childhood and have invested a lot of research into developing trustworthy e-platforms.</p>
<p><a href="https://doi.org/10.1056/NEJMp1713180">Over two-thirds of Americans use mobile health applications</a> and the iTunes and Android app stores offer more than 165,000 of them. All of these technologies offer health care providers an opportunity to meet families where they are whenever they need us. Done right, they could lead to sustainable improvements in child health and development.</p>
<p>[<em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em>]</p><img src="https://counter.theconversation.com/content/122280/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dorian Traube receives funding from the Overdeck Family Foundation, Gary Community Investments, Parsons Foundation, and Queenscare Foundation. </span></em></p><p class="fine-print"><em><span>Ashwini Lakshmanan receives funding from the Sharon D. Lund foundation and the Zumberge Diversity and Inclusion Award. She previously received funding from the National Institutes of Health, the Packard foundation for Children's Health and the Confidence Foundation.</span></em></p>Mobile health apps, teleconferencing with experts and thoughtfully designed educational platforms can all help families during the chaotic and confusing early years.Dorian Traube, Associate Professor of Social Work, University of Southern CaliforniaAshwini Lakshmanan, Assistant Professor of Clinical Pediatrics, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1291372020-02-03T04:06:30Z2020-02-03T04:06:30ZHow do I know if my child is developing normally?<figure><img src="https://images.theconversation.com/files/312393/original/file-20200129-92949-t6qgpt.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/3-year-old-kid-playground-outdoor-151170449">from www.shutterstock.com</a></span></figcaption></figure><p>It’s your three year old’s birthday and he’s having a party with his day care friends. You watch as the other three year olds ask for more cake and answer questions about what they’re wearing. </p>
<p>But your child doesn’t say much, and what he does say is difficult to understand. He also isn’t really kicking the ball, using the slide or riding his new tricycle as well as the other kids. </p>
<p>You always thought he was quiet or shy. But is there something more happening? Is his behaviour normal? How concerned should you be?</p>
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Read more:
<a href="https://theconversation.com/whats-in-a-milestone-understanding-your-childs-development-50894">What’s in a milestone? Understanding your child’s development</a>
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<p>Delays in early child development are common. In Australia, <a href="https://www.aedc.gov.au/communities/findings-from-the-aedc">more than one in five</a> children starting school are behind where they should be in how they think, communicate, move, socialise or <a href="https://www.brighttomorrows.org.au/responding-to-emotions/">manage their emotions</a>.</p>
<p>Our <a href="https://www.tandfonline.com/doi/full/10.1080/09638288.2019.1707296">recently published research</a> looked at how we begin to notice delays in young children – what delays look like and what parents need to notice.</p>
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<figcaption><span class="caption">Seeking help early saved this baby’s sight (Raising Children Network)</span></figcaption>
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<h2>A niggle or an ‘aha’ moment?</h2>
<p>Noticing delays in a child’s development is not always an obvious “aha” moment, though it can be. </p>
<p>Big “aha” moments are more likely when there is a sudden change in a child. There could be something specific they should be doing but are not, such as responding to their name. Or there could be unexplained behaviours, like frequent temper tantrums sparked by seemingly nothing that take your child a long time to calm down from.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/no-i-dont-wanna-wahhhh-a-parents-guide-to-managing-tantrums-87175">'No, I don't wanna... wahhhh!' A parent's guide to managing tantrums</a>
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<p>But frequently a parent notices gradually – a niggle that grows over time. This can be a gut feeling or intuition that something isn’t quite right. These niggles can be confusing and make you second-guess yourself – “maybe it’s nothing, but …”. Yet these niggles are compelling enough to make you worry. </p>
<p>Our research found both “aha” moments and niggles were often signs of real developmental delays. And generally knowing about child development and comparing your child to others of a similar age led parents to notice something wasn’t quite right.</p>
<h2>What’s normal?</h2>
<p>Knowing what normal looks like and remembering that normal is a range helps us to begin to identify when a child is developing differently. For example, knowing three-year olds use sentences of <a href="https://raisingchildren.net.au/toddlers/development/development-tracker-1-3-years/2-3-years">three to five words</a> can help to understand their language development.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/is-my-child-being-too-clingy-and-how-can-i-help-115372">Is my child being too clingy and how can I help?</a>
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<p>But where do we get this knowledge from? While social media and parenting sites have their place, beware the rabbit hole of <a href="https://www.sciencedirect.com/science/article/pii/S0747563218300463">conflicting and even judgemental information</a> online. </p>
<p>Stick to sources like the <a href="https://raisingchildren.net.au">Raising Children Network</a> website, which provides best-practice, well-researched information across different ages and areas of development.</p>
<h2>Comparing with other kids</h2>
<p>Comparing your child’s development with other children’s can also help. For example, if most other children at the party speak in sentences while your child is using single words and gestures, it is easier to pick up on the difference. </p>
<p>However, rather than relying on signs from a single party, seeing your child with a variety of other children as well as in different settings is best. This helps gain a full picture of your child. </p>
<p>Remember all children develop differently and being a little behind does not necessarily <a href="https://raisingchildren.net.au/toddlers/development/language-development/language-delay">equal delay</a>. But this may flag something to watch. </p>
<p>Play, particularly play with others, is <a href="https://pediatrics.aappublications.org/content/119/1/182%20">fundamental to child development</a>. It is even enshrined in the United Nations <a href="https://www.unicef.org.au/Upload/UNICEF/Media/Our%20work/childfriendlycrc.pdf">Convention on the Rights of the Child</a>.</p>
<p>Play also provides a chance to compare your child with others. This could be watching how your child plays with siblings, neighbours or friends’ children at the park or at <a href="https://playgroupaustralia.org.au/">playgroup</a>.</p>
<h2>Now, I’m concerned. What should I do?</h2>
<p>So if you would like a little more information or to talk to someone about your child, what can you do? If you are in Australia, maternal and child health services across each state and territory offer a schedule of appointments to check in with your child’s health and development. </p>
<p>For example, Western Australia operates under the <a href="https://ww2.health.wa.gov.au/%7E/media/Files/Corporate/general%20documents/CACH/CAH-010029_Purple_book_FNL.pdf">Purple Book</a> scheme and provide checks at eight weeks, four months, 12 months, two years, and when your child enters school. </p>
<p>You can also make appointments outside these set times by contacting your local child health centre if you have concerns; there is no need to wait until your child hits one of these ages. </p>
<p>Child health centres also often offer drop-in sessions as well as group sessions for parenting support and advice. </p>
<p><a href="https://raisingchildren.net.au/grown-ups/services-support/about-services-support/helplines">Parent helplines</a>, such as <a href="https://www.parentline.com.au/">Parentline</a> in Queensland and the Northern Territory, offer tips and opportunities to confidentially talk through any concerns. You can also talk to your GP.</p>
<p>So trust those niggles, watch out for “aha” moments, learn how children develop and embrace opportunities to see your child with others. Even if you are a little uncertain, talk to someone. Sharing your concerns with someone is never a waste of anyone’s time – because maybe it’s nothing, but what if it’s not? </p>
<hr>
<p><em>More information about maternal and child health services in your state or territory is available: <a href="https://health.act.gov.au/services-and-programs/women-youth-and-children/maternal-and-child-health-mach">ACT</a>, <a href="https://nt.gov.au/wellbeing/pregnancy-birthing-and-child-health/baby-child-assessments-clinics">NT</a>, <a href="https://www.health.nsw.gov.au/kidsfamilies/MCFhealth/Pages/child-family-health-faqs.aspx#faq2">NSW</a>, <a href="https://www.childrens.health.qld.gov.au/chq/our-services/community-health-services/child-health-service/">Qld</a>, <a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/Public+Content/SA+Health+Internet/Health+services/Parenting+and+child+health+services/">SA</a>, <a href="https://www.dhhs.tas.gov.au/service_information/services_files/child_health_centres">Tas</a>, <a href="https://www.betterhealth.vic.gov.au/health/healthyliving/maternal-and-child-health-services">Vic</a> and <a href="https://cahs.health.wa.gov.au/our-services/community-health/child-health">WA</a>.</em></p>
<p><em>More information about child development is also available on the Raising Children Network <a href="https://raisingchildren.net.au/guides/first-1000-days/development/baby-development">website</a>.</em></p><img src="https://counter.theconversation.com/content/129137/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Belinda Cuomo is affiliated with Curtin University (employee). She received PhD support funding from CoLab/the Minderoo Foundation and an Australian Government Research Training Program (RTP) Scholarship.</span></em></p><p class="fine-print"><em><span>Annette Joosten is affiliated with Australian Catholic University (employee); Member of the Australian Occupational Therapy Association. </span></em></p><p class="fine-print"><em><span>Sharmila Vaz is affiliated with Curtin University (employee). </span></em></p>It’s easy to worry if your child doesn’t seem to be developing as quickly as their playmates. But trust your ‘niggles’ and watch out for ‘aha’ moments. Our research shows they’re often right.Belinda Cuomo, Lecturer and PhD Candidate, Occupational Therapy, Curtin UniversityAnnette Joosten, Associate Professor, Occupational Therapy, Australian Catholic UniversitySharmila Vaz, Senior research fellow, School of Occupational Therapy and Social Work, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1266872019-12-11T18:53:26Z2019-12-11T18:53:26ZDiabetes and pregnancy can be a tricky (but achievable) mix: 6 things to think about if you want a baby and 1 if you don’t<figure><img src="https://images.theconversation.com/files/303927/original/file-20191127-112512-1f0qfds.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C991%2C658&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A successful pregnancy if you have diabetes comes down to planning and making sure you have the right health-care team behind you.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-tests-gestational-diabetes-by-1565040010">from www.shutterstock.com</a></span></figcaption></figure><p>The number of people with diabetes is expected to increase from <a href="https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html">463 million in 2019 to 700 million by 2045 globally</a>. So more women with diabetes will be having babies in the future.</p>
<p>If you have diabetes, here’s how to have the best chance of a safe and successful pregnancy, and to give your baby the best start in life. </p>
<p>Alternatively, if you have diabetes and want to avoid pregnancy, here’s what to think about when it comes to contraception.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-diabetes-11842">Explainer: what is diabetes?</a>
</strong>
</em>
</p>
<hr>
<h2>Why are women with diabetes and their babies at greater risk?</h2>
<p>Women with diabetes have an <a href="https://dmsjournal.biomedcentral.com/articles/10.1186/1758-5996-4-41">increased risk</a> of pregnancy complications, particularly if they’re among the <a href="https://care.diabetesjournals.org/content/27/suppl_1/s76.full-text.pdf">more than 60%</a> whose pregnancies are unplanned.</p>
<p>Harm can be to the mother, <a href="https://www.ajog.org/article/S0002-9378(00)70225-0/fulltext">such as preeclampsia</a>, where her blood pressure increases, her body swells and her liver and kidneys may be damaged. If left untreated, preeclampsia can lead to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4317712/pdf/nihms658214.pdf">seizures and loss of mother and baby</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-pre-eclampsia-and-how-does-it-affect-mums-and-babies-97781">Explainer: what is pre-eclampsia, and how does it affect mums and babies?</a>
</strong>
</em>
</p>
<hr>
<p>Pregnancy can also affect the mother’s diabetes directly, from changes in how her body uses insulin. </p>
<p>Early in pregnancy, women may become more sensitive to insulin and be more likely to have extremely low blood sugar levels (<a href="https://www.nature.com/articles/nrendo.2014.170">become</a> <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1464-5491.2012.03604.x">hypoglycaemic</a>), severe enough to lose consciousness.</p>
<p>Later in pregnancy, hormones released from the placenta make the body more resistant to insulin, which can make controlling her blood glucose <a href="https://insights.ovid.com/pubmed?pmid=17982337">much more difficult</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/305112/original/file-20191204-70184-15d80nf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Babies are at a greater risk of malformations due to sub-optimal levels of glucose they may be exposed to in the womb.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-rendered-medically-accurate-illustration-fetus-1482584390?src=0c4a42c3-cfd0-47b8-bc56-ccd8736197c3-1-28&studio=1">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Babies are also at <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-6-30">higher risk</a> <a href="https://link.springer.com/article/10.1007%2Fs00125-013-3108-5">of malformations</a>, such as congenital heart defects and central nervous system defects, because of the mother’s <a href="https://care.diabetesjournals.org/content/30/7/1920.long">sub-optimal blood glucose levels</a>. </p>
<p>If higher blood glucose levels continue or the mother has extreme blood glucose levels, <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-6-30">this may lead to</a> miscarriage, stillbirth or the baby dying shortly after birth.</p>
<p>So it’s no wonder the childbearing years can be daunting.</p>
<p>Here are some tips from the <a href="https://www.mja.com.au/system/files/issues/183_07_031005/mce10281_fm.pdf">Australasian Diabetes in Pregnancy Society</a> on contraception, pre-pregnancy care and antenatal care.</p>
<h2>1. Think about contraception early, even if you want a baby</h2>
<p>Are you planning to become pregnant? If “yes”, then contraception is important to make sure you’re ready for pregnancy, and when it happens, there’s the greatest chance of a healthy baby (see point 2). If “no” and you are sexually active, or soon will be, then you also need effective contraception.</p>
<p>So, start discussing contraception early in your childbearing years, ideally before you become sexually active. You can do this either through your diabetes team or your regular health-care provider.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/305316/original/file-20191205-16528-1o0k5g2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Long-acting reversible contraception, like this intrauterine device, is recommended for women with diabetes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-intrauterine-device-on-blue-background-731018869">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Long-acting reversible contraception (for instance, intrauterine devices or implants) are strongly recommended as these have the <a href="https://theconversation.com/few-australian-women-use-long-acting-contraceptives-despite-their-advantages-44896">lowest failure risk</a> and minimal, if any, impact on your diabetes.</p>
<p>Some oral contraceptives are less effective than long-acting reversible contraception and can lead you to gain weight (which <a href="https://www.tandfonline.com/doi/abs/10.1080/07315724.2003.10719316?journalCode=uacn20">can impact</a> how well your diabetes is managed). Weight gain may also increase your risk factors for heart disease, and <a href="https://www.health.gov.au/sites/default/files/pregnancy-care-guidelines_0.pdf">increases the risk</a> of pregnancy complications, such as having a large baby.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/few-australian-women-use-long-acting-contraceptives-despite-their-advantages-44896">Few Australian women use long-acting contraceptives, despite their advantages</a>
</strong>
</em>
</p>
<hr>
<h2>2. If you want a baby, find a pre-pregnancy diabetes management service</h2>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/30322376">pre-pregnancy diabetes management service</a> is a one-stop-shop that looks after your pre-pregnancy care including contraception (see point 1) to make sure the time for conception is right for you.</p>
<p>Using one of these services <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-792">has been shown to reduce the risk</a> of your baby being malformed by 75% or dying before or at birth by 66% compared to those that do not receive such pre-pregnancy care.</p>
<p>So ask your health-care provider if there is a service like this in your area, and if there is, ask for a referral well before trying to conceive.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-psychological-support-can-help-people-living-with-diabetes-10647">How psychological support can help people living with diabetes</a>
</strong>
</em>
</p>
<hr>
<p>At a pre-pregnancy diabetes service, you will get advice and support on all aspects of diabetes from a multidisciplinary team including: a diabetes specialist, a diabetes educator and dietitian, linked with obstetric or gynaecology services.</p>
<p>This includes the impact pregnancy can have on diabetes complications; the impact of diabetes on your baby and pregnancy outcomes; miscarriage and IVF; folic acid supplementation (see point 5); and medication safety (see point 6).</p>
<p>But these services are not available in all areas. Before our diabetes contraception and pre-pregnancy service <a href="https://www.ncbi.nlm.nih.gov/pubmed/30322376">opened in 2018</a>, few clinics in NSW specialised in diabetes pre-pregnancy care.</p>
<h2>3. Choose the right health-care provider for your pregnancy</h2>
<p>Once you know you’re pregnant, ask your GP to refer you to a diabetes specialist team of health-care professionals experienced in managing diabetes in pregnancy. This team will work with an obstetric team. </p>
<p>Such a <a href="https://www.mja.com.au/system/files/issues/183_07_031005/mce10281_fm.pdf">multi-disciplinary</a> approach means endocrinologists, obstetricians trained in high-risk pregnancy care, dietitians and diabetes educators, among others, will be looking after you.</p>
<p>Early referral is essential, preferably before eight weeks gestation. This is to allow your insulin to be carefully managed to avoid uncontrolled changes in glucose that, as mentioned earlier, can affect you and your baby.</p>
<p>Every woman should have access to diabetes specialist services through a hospital, but in rural and remote areas this may be some distance away. </p>
<p>Although there may be some telehealth options, it is important that ongoing management and particularly the birth are planned with that diabetes specialist team as soon as possible. Your GP will need to refer you.</p>
<h2>4. Keep healthy glucose levels before and during pregnancy</h2>
<p>Whichever health professional or team of health professionals looks after you, <a href="https://care.diabetesjournals.org/content/19/5/514">maintaining your blood glucose levels</a> within range as much as possible before and during pregnancy is vital.</p>
<p>It helps women with diabetes fall pregnant safely, reducing the chance of miscarriage. If you are using IVF, fewer miscarriages will mean fewer rounds of IVF.</p>
<p>Healthy glucose levels also provide a growing baby an environment where it will flourish, reducing the chances of pregnancy complications.</p>
<p>So, when monitoring your blood glucose <a href="https://www.mja.com.au/system/files/issues/183_07_031005/mce10281_fm.pdf">aim for</a>:</p>
<ul>
<li>fasting blood glucose level, 4-5.5 mmol/L</li>
<li>one hour after eating level, less than 8.0 mmol/L, and </li>
<li>two hours after eating, less than 7 mmol/L. </li>
</ul>
<p>Naturally, these may need to be higher if hypoglycaemia is a problem.</p>
<p>If you have type 1 diabetes and are planning pregnancy, are pregnant or have very recently had a baby, you now have access to a <a href="https://www.ndss.com.au/living-with-diabetes/managing-diabetes/continuous-glucose-monitoring/">free glucose sensor</a>, a wearable device that monitors your glucose continuously. With this device, you should aim to be within <a href="https://care.diabetesjournals.org/content/early/2019/06/07/dci19-0028">3.5-7.8mmol/L more than 70% of the day</a>.</p>
<p>At present there is not enough evidence to support using a continuous glucose monitoring during pregnancy if you have type 2 diabetes. But glucose monitoring remains very important before breakfast and after meals.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-is-it-safe-to-express-milk-before-giving-birth-78399">Health Check: is it safe to express milk before giving birth?</a>
</strong>
</em>
</p>
<hr>
<h2>5. Take a high-dose folate supplement</h2>
<p>Pregnant women with diabetes are recommended to take a <a href="https://www.mja.com.au/system/files/issues/183_07_031005/mce10281_fm.pdf">high dose of folate</a> (5 milligrams daily, as opposed to <a href="https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/red-book/preventive-activities-prior-to-pregnancy#ref-num-14">0.4-0.5 milligrams</a> in women without diabetes.</p>
<p>That’s because the risk of having a baby with a neural tube defect <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(01)07104-5/fulltext">is raised</a> in women with diabetes.</p>
<p>So if your health-care professional doesn’t raise this, mention it yourself and buy a folate supplement from your local pharmacy.</p>
<h2>6. Ask about your medications</h2>
<p>It’s important to talk to your health-care provider as soon as you know you are pregnant so they can advise whether it is safe to continue taking your existing diabetes medication.</p>
<p>Insulin does not cross the placenta and is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984914/pdf/13300_2018_Article_411.pdf">the preferred medication</a>, if required. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-metformin-the-diabetes-drug-developed-from-french-lilac-64430">Weekly Dose: metformin, the diabetes drug developed from French lilac</a>
</strong>
</em>
</p>
<hr>
<p>Metformin does not cause malformations but does cross the placenta. It’s used <a href="https://www.mja.com.au/system/files/issues/180_09_030504/sim10814_fm.pdf">where the benefits</a> from improved glucose control outweigh any possible theoretical long-term risks to the baby. </p>
<p>Other oral medications to lower blood glucose are generally not approved for use during pregnancy.</p>
<hr>
<p><em>If you have diabetes and want to know more about pregnancy or avoiding pregnancy, resources are available from the <a href="https://www.adips.org/">Australasian Diabetes in Pregnancy Society</a>, <a href="https://www.diabetesaustralia.com.au/pregnancy">Diabetes Australia</a> and our <a href="https://www.westernsydney.edu.au/domtru/projects/dcapp">Diabetes Contraception and Pre-pregnancy Program</a>. Information is also available from the government’s health-care advisory service <a href="https://www.pregnancybirthbaby.org.au/diabetes-during-pregnancy">Pregnancy, Birth and Baby</a> and <a href="https://www.ndss.com.au/about-diabetes/pregnancy/resources/">National Diabetes Services Scheme</a>.</em></p><img src="https://counter.theconversation.com/content/126687/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Freya MacMillan was involved in the development of the Diabetes Contraception and Pre-Pregnancy Program in South Western Sydney and is currently involved in the evaluation and improvement of this service. She receives funding from South Western Sydney Primary Health Network and South Western Sydney Local Health District for this work.</span></em></p><p class="fine-print"><em><span>David Simmons is affiliated with Western Sydney University (WSU), South Western Sydney Local Health District (SWSLHD) and Maridulu Budyari Gumal (Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)) and the WSU/SWSLHD Diabetes Obesity Metabolism Translational Research Unit that have work underway to reduce the risk of malformations and other pregnancy complications among women with diabetes</span></em></p><p class="fine-print"><em><span>Tinashe Dune receives funding from the Australian Research Council and has recieved fundng from the Department of Family and Community Services. Dr Dune is involved in the evaluation of the Diabetes Contraception and Pre-Pregnancy Program in South Western Sydney. She is Director of the Secretariat for African Women Australia, a not-for-profit incorporated association which aims to raise the profile and voices of African women in Australia.</span></em></p>Women with diabetes are at high risk of pregnancy complications. But there is a lot women can do to have a healthy pregnancy and a healthy baby.Freya MacMillan, Senior Lecturer in Interprofessional Health Science, Western Sydney UniversityDavid Simmons, Professor of Medicine Western Sydney University, Head of Department Endocrinology, Campbelltown Hospital, Western Sydney UniversityTinashe Dune, Senior Lecturer in Interprofessional Health Sciences, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1286342019-12-11T12:57:51Z2019-12-11T12:57:51ZHow South Africa can build a child-centred health care system<figure><img src="https://images.theconversation.com/files/306094/original/file-20191210-95130-812jgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Child health care remains uneven in South Africa and varies between provinces and districts.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>It is more than 20 years since the South African constitution first guaranteed children’s “right to basic health care services”. This is part of a broader commitment to ensure children’s rights to optimal survival, health and development. The question is how close South Africa is to realising these rights in practice. </p>
<p>We address this issue in a <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2019/CG2019%20-%20%281%29%20Prioritising%20child%20and%20adolescent%20health.pdf">chapter</a> of the <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2019/ChildGauge_2019_final_print%20%28sm%29.pdf">South African Child Gauge 2019</a> report. </p>
<p>Unlike adults’ right to health, children’s right to basic health care services is not subject to progressive realisation. Children should therefore be prioritised within the health care system. Yet the state has still not defined an essential package of health care services for children. This makes it difficult to determine what they are entitled to and what the state should be held accountable for. </p>
<p>Without a defined package, there’s a danger that the drive for efficiencies and cost saving may result in a limited basket of care that doesn’t address the complex needs of children. This is particularly true for those with chronic (long term) health conditions. </p>
<p>This essential package of care needs to be supported by a set of norms and standards. These need to specify the infrastructure, equipment, medicines and staff needed to meet the unique needs of children and adolescents. A clear package will also make explicit how health care establishments need to be equipped. These would include neonatal and paediatric wards as well as emergency medical services and primary health care services, where children currently have to compete for attention with sick and injured adults. </p>
<p>In other facets of the health system, too, budgets, building of infrastructure and medicine supplies need to consider children’s unique needs. </p>
<p>A child rights approach to health requires health professionals to treat children and their caregivers with respect and communicate effectively. Health care providers also need to build children’s and adolescents’ capacity to take responsibility for their own health and include them in decision making. </p>
<p>These fundamental shifts in the balance of power between adult and child, doctor and patient have been found to relieve pain and suffering. They also improve diagnosis, compliance with treatment, patient satisfaction and health outcomes. </p>
<h2>Training health workers</h2>
<p>The United Nations Committee on the Rights of Child has called for children’s rights to be integrated in the curriculum and performance criteria of all professionals working with children. These include health and allied professionals, teachers and social workers. The aim is to ensure that they are better attuned to children’s needs and rights. </p>
<p>For example, the <a href="http://www.lincare.co.za/?m=2019">LinCARE</a> programme, where a team of health workers provides mother and child health care in Limpopo province, aims to reduce neonatal mortality. It does this by improving the quality of care during pregnancy and labour. The programme is aimed at ensuring that all women have a positive pregnancy and birth experience. It includes antenatal classes and ensures that women have practical and emotional support from a birth companion and kind, respectful and technically competent clinical staff.</p>
<p>As part of current preparation for a <a href="http://www.health.gov.za/index.php/nhi">national health insurance</a> system, which is aimed at extending universal health care to all South Africans, bolstering the primary health care system offers three opportunities to strengthen the child health workforce and improve the quality of care: </p>
<ul>
<li><p>Community health workers play a central role in bringing health care services close to home, particularly for children living in poor or remote households. It’s therefore encouraging to see the national department of health’s commitment to employing them and paying them the minimum wage. This should improve supervision and support and ensure greater continuity of care between community-based services and health care facilities. </p></li>
<li><p>School health teams are another essential ingredient of the child system, helping to screen older children and address barriers to learning. Yet coverage reaches only one third of pupils in their first year of schooling and 20% of grade 8 learners. Its effectiveness is compromised by the shortage of health and other social service professionals, such as social workers, oral hygienists and dentists, psychologists, physiotherapists, speech and language therapists and occupational therapists.</p></li>
<li><p>Finally, district clinical specialist teams provide essential leadership for child and adolescent health at district level. For example, neonatal mortality has dropped by 30% in districts where there are paediatricians and paediatric nurses, yet less than half of specialist teams have a full paediatric team.</p></li>
</ul>
<h2>What needs to be done</h2>
<p>The progress for child health has been uneven in South Africa with significant variation between provinces and districts. For example, immunisation varied from 90% in Mpumalanga to 69% in the Eastern Cape – signalling persistent inequities in access and coverage of care.</p>
<p>Given these challenges, greater investment is needed to strengthen systems and build a workforce for child and adolescent health. National health insurance provides an important opportunity to ensure universal health coverage and financial risk protection for the poor, as well as to improve the quality of care. </p>
<p>This requires leadership for child health at every level of the health care system – from individual encounters with children and their families, to ensuring that child health is adequately represented on key decision-making structures that will decide how resources are allocated.</p>
<p>Very importantly, it requires that the health sector works with and alongside other sectors. Interventions such as sufficient good quality food, good quality education, safe water and sanitation, good housing, safe roads and safe communities can significantly promote the health and well-being of children.</p>
<p><em>The South African Child Gauge 2019 report is published by the Children’s Institute at the University of Cape Town. The theme of the 2019 issue – “Child and adolescent health: leave no one behind” – is a call to prioritise child and adolescent health and put children at the heart of the health care system.</em> </p>
<p><em>Lori Lake, a co-editor of the Child Gauge report, also contributed to this article.</em></p><img src="https://counter.theconversation.com/content/128634/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maylene Shung-King does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Children’s right to health is paramount: here’s what needs to be done to build a child-centred health care system.Maylene Shung-King, Professor, Health Policy, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1271672019-12-10T13:57:16Z2019-12-10T13:57:16ZFat-shaming pregnant women isn’t just mean, it’s harmful<figure><img src="https://images.theconversation.com/files/305078/original/file-20191204-70122-7pl9td.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5742%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Criticizing pregnant women about their weight can be bad for them and their babies.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-man-holding-weigh-scale-pointing-1371144845">kzenan/Shutterstock.com</a></span></figcaption></figure><p>December is considered the most fertile month, a time when there’s the <a href="https://www.telegraph.co.uk/men/relationships/11285849/Happy-Conception-Day-Its-the-most-fertile-day-of-the-year.html">greatest likelihood that children will be conceived</a>. Some experts even pinpoint Dec. 11 as the most fertile day.</p>
<p>But in the lead up to giving birth and in the time after bringing home their new additions, many women may experience an unwelcome surprise. Family, friends and even bystanders are all too quick to comment on – and often criticize – an expectant or new mother’s weight.</p>
<p>This shaming can include judging a mother-to-be for her weight before becoming pregnant; the weight she gains over pregnancy; and the weight she doesn’t lose after having the baby. Weight stigma like this is potentially a very real threat to maternal health.</p>
<p>Outside the realm of pregnancy, research shows that <a href="https://doi.org/10.1016/j.appet.2014.06.108">experiencing weight stigma is stressful and harmful</a>. For instance, it is associated with various <a href="https://doi.org/10.1007/s13679-015-0153-z">health consequences, including weight gain, heightened cortisol and inflammation, and unhealthy or disordered eating</a>. Despite this, little research has examined weight stigma’s effects on pregnant and postpartum women. </p>
<p>As a <a href="https://www.wpi.edu/people/faculty/acrodriguez">health psychologist studying weight stigma and its consequences</a>, I see pregnancy as an important new avenue for research. This is because, in the context of pregnancy, the consequences may be multiplied by two. Stress that affects a pregnant woman might <a href="https://doi.org/10.1111/j.1467-8624.2009.01385.x">harm her unborn child as well</a>.</p>
<h2>Do pregnant women actually get shamed for their weight?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/305079/original/file-20191204-70167-tc78y9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/305079/original/file-20191204-70167-tc78y9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/305079/original/file-20191204-70167-tc78y9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/305079/original/file-20191204-70167-tc78y9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/305079/original/file-20191204-70167-tc78y9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/305079/original/file-20191204-70167-tc78y9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/305079/original/file-20191204-70167-tc78y9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Friends and family often try to monitor what a pregnant woman eats.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/gorgeous-pregnant-woman-eating-happy-yogurt-120818578">Federico Marcicano/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>The short answer – yes! My recent research suggests that nearly two-thirds of pregnant and postpartum women <a href="https://doi.org/10.1037/sah0000191">experience some form of weight stigma</a>. In one study, 501 pregnant and postpartum women reported experiencing weight stigma from multiple people and places. </p>
<p>For instance, 21% indicated they had experienced it from immediate family. One woman said, “A good number of my family told me that I shouldn’t be ‘trying’ to get pregnant because I’m too heavy after they found out I was expecting.” Nearly 25% reported feeling stigmatized by the media. Also, 33% said they experienced weight stigma in the media, an example being, “society treats overweight pregnant women as less than.” </p>
<p>Health care providers were another common source. One woman shared, “One doctor told me I was terrible for getting pregnant at my weight … I was setting up my baby to fail.” </p>
<p>Moreover, these types of experiences didn’t just happen for heavy mothers. Women of all weights experienced some form of weight stigma. </p>
<h2>What’s the big deal?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/305080/original/file-20191204-70101-1ua0z3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/305080/original/file-20191204-70101-1ua0z3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=359&fit=crop&dpr=1 600w, https://images.theconversation.com/files/305080/original/file-20191204-70101-1ua0z3v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=359&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/305080/original/file-20191204-70101-1ua0z3v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=359&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/305080/original/file-20191204-70101-1ua0z3v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=451&fit=crop&dpr=1 754w, https://images.theconversation.com/files/305080/original/file-20191204-70101-1ua0z3v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=451&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/305080/original/file-20191204-70101-1ua0z3v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=451&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Weight shaming has been linked to increased postpartum depression in women, an often serious illness.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/wornout-mother-crying-baby-13318426">Aspen Studio/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>There’s a <a href="https://doi.org/10.1080/21604851.2014.889491">widely held concern that heavy women are unhealthy and have unhealthy pregnancies</a>, so many think we need to intervene on weight. My research, however, suggests that we should also be very concerned about weight stigma directed at pregnant and postpartum women. </p>
<p>For instance, in that same sample of 501 women, <a href="https://doi.org/10.1016/j.socscimed.2019.112401">having experienced weight stigma</a> was related to more symptoms of depression (both during and after pregnancy), dieting in unhealthy ways, more emotional eating behavior, and feeling stressed out. Among postpartum moms, weight stigma was also related to keeping on their baby weight. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/tacBOfYA2FM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The author discusses her research on weight stigma during pregnancy.</span></figcaption>
</figure>
<p>In another sample, I similarly found that experiencing weight-based discrimination during pregnancy was associated with <a href="https://doi.org/10.1037/hea0000711">gaining more weight throughout the pregnancy</a>. It also predicted more symptoms of postpartum depression and retaining baby weight in the first year after having the baby. </p>
<p>All these findings took into account a woman’s actual weight. It is not just that heavier moms tend to be more depressed or to eat in unhealthy ways. These relationships emerged regardless of a woman’s weight before becoming pregnant. So whether or not weight is a great indicator of health – which I argue it is not – making a pregnant or postpartum woman feel bad about her weight could be very harmful to her well-being.</p>
<h2>Shifting the conversation</h2>
<p>Being pregnant doesn’t suddenly make it any less uncomfortable for someone to comment on your weight (or to touch your stomach). So as the year comes to a close, you might consider a new kind of New Year’s resolution. If your partner, friend, sister, neighbor or colleague is pregnant, be mindful in how you talk to her about her weight. Or better yet, maybe don’t even mention weight. </p>
<p>If we want healthy babies, that begins with healthy mothers. We all have a role to play in that insofar as we can avoid weight shaming.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/127167/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Angela Incollingo Rodriguez does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Fat shaming is harmful to all women, but pregnant women face a particular danger. Shaming affects not only their health but also that of their children.Angela Incollingo Rodriguez, Assistant professor of Psychology, Worcester Polytechnic InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1244402019-11-28T14:12:09Z2019-11-28T14:12:09ZHow better information will reduce maternal and child deaths<figure><img src="https://images.theconversation.com/files/303972/original/file-20191127-112489-1lq8c8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Countries need to have the capacity to interrogate their health data to address maternal and child health challenges.</span> <span class="attribution"><span class="source">APHRC</span></span></figcaption></figure><p><em>At least two-thirds of all annual maternal and child deaths worldwide occur in sub-Saharan Africa. Despite recent improvements, significant inequities persist across countries and regions and within countries. An initiative by the <a href="https://aphrc.org/">African Population and Health Research Centre</a>, <a href="http://countdown2030.org">Countdown to 2030</a>, seeks to accelerate coverage and access to reproductive, maternal, newborn, child, and adolescents’ health and nutrition services by providing evidence that informs decision making for policy, programming and financing. Cheikh Mbacke Faye explains.</em></p>
<p><strong>Why the focus on maternal and child health?</strong></p>
<p>There has been substantial progress in reducing maternal and child deaths globally. This is due to increased investment in good infrastructure, the use of vaccines and other factors. Between 1990 and 2015, maternal and under-five mortality <a href="https://data.unicef.org/resources/trends-maternal-mortality-2000-2017/">declined</a> by 44% and 58% respectively globally. But maternal mortality remains unacceptably high, especially in developing countries. At least <a href="https://data.unicef.org/topic/maternal-health/maternal-mortality/">two-thirds of all annual maternal and child deaths worldwide</a> occur in sub-Saharan Africa. </p>
<p><strong>How does the Countdown 2030 initiative hope to change this?</strong></p>
<p>This initiative aims to equip country health data experts to provide deep analyses of inequalities from existing data sources such as the District Health Information System and the Demographic Health Surveys. Evidence like this should help improve equity in maternal and child health as <a href="https://www.who.int/sdg/targets/en/">stipulated</a> in the Sustainable Development Goals. The overall aim is to reach all populations with essential health services of good quality. </p>
<p>The analysis aims to show the inequities by sub-national level, socioeconomic status and the rural-urban divide. When governments have evidence, they are better placed to develop policies and programmes that provide equitable coverage of effective health interventions for women, children and adolescents. The project is anchored on the use of evidence to promote increased coverage and access to reproductive, maternal, newborn, child, and adolescents’ health and nutrition services to all people. </p>
<p>For example, in Uganda, working with Makerere University School of Public Health, we did an analysis to understand the rate of under-five mortality in different regions of Uganda. The analysis identified the six regions in Uganda with the highest child mortality rates. This evidence was shared at a meeting in Kampala with stakeholders in government and civil society organisations to facilitate a discussion of health system challenges in these regions. </p>
<p>In addition, the initiative seeks to ensure that disadvantaged groups are not left behind. This is because inequities in access and coverage of reproductive health and nutrition services for these target groups persist. Knowing the inequities is the first step to identifying the challenges and how to address them. </p>
<p><strong>How do you plan to bring change in just over a decade?</strong> </p>
<p>Strengthening the evidence base and country analytical capacity is key. Countries need to have the capacity to interrogate properly the health data that is collected. Investigating what the data means will lead to its use in informing targeted action to address maternal and child health challenges. </p>
<p>The initiative is, therefore, training health data specialists at country level. They are trained on which analyses to do, how to do them and how to share the evidence. As a result, it is expected that there will be more demand for evidence. On top of this, the institutions with data analysis capacity will be considered as technical partners of government. Other actors can provide evidence on a needs basis. </p>
<p>This evidence can inform decision making for policy, programming and financing. Already <a href="http://countdown2030.org/country-and-regional-networks/country-profiles">country analyses</a> have revealed the disparities in the coverage between the poor and wealthy, those living in urban and rural areas, and other strata. </p>
<p>The initiative is also highlighting the data collected in interesting ways that are easy to read, understand and use. These include equity profiles, country profiles and dashboards that are accessible for free. </p>
<p>Related to this are technical analyses and support for countries to define priority areas and activities for their participation and funding through the Global Financing Facility. This brings together partners focusing on women, children and adolescents to agree on priorities and country-led plans to implement. It is a catalyst for domestic financing as country funding commitments are matched through Trust Fund grants by the World Bank. </p>
<p>The initiative collaborates with the facility at country level to ensure priorities are informed by evidence. </p>
<p>The other element is building national capacity for the collection, quality assessment, analysis and use of data related to their policies and programmes. For example, the initiative trains people in each country to collect, analyse and share the data in consistent and useful ways to inform decision making for women’s children and adolescents’ health.</p>
<p>Finally, the initiative will support decision makers, civil society representatives, governments and advocates with evidence for effective advocacy efforts.</p>
<p><strong>What are the measures of success?</strong></p>
<p>At the top level is the creation of global public tools like country profiles. They help the monitoring and measurement of coverage, quality and equity. </p>
<p>At the regional level, the initiative is enhancing cross-country learning and sharing of best practices. It is also enhancing regional networks and multi-country monitoring, learning and evaluation. This will make it easier for regions and countries to track their progress in enhancing equity in the health outcomes of women, children and adolescents. </p>
<p>At national level, strengthened country-led data analysis and generation of evidence can be used to inform decision making for policy and programming. This will mean that countries will have more relevant information to plan and make effective decisions to address health system challenges. </p>
<p>Finally, improved communication and use of evidence on progress and performance will make it easier for anyone to see what progress is being made in preventing maternal, child and adolescent deaths.</p><img src="https://counter.theconversation.com/content/124440/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When governments have evidence, they are better placed to develop health policies and programmes.Cheikh Mbacke Faye, Associate Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1207972019-07-30T14:40:41Z2019-07-30T14:40:41ZSouth Africa’s healthcare system can’t afford to ignore migration<figure><img src="https://images.theconversation.com/files/286062/original/file-20190729-43136-136qa3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Musina, a border town in South Africa's Limpopo province. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Reflecting global trends, most migration in South Africa is internal – people moving between the country’s different provinces. South Africa is also home to a much smaller population of foreign-born migrants, mostly from countries that are part of the South African Development Community, who make up about <a href="http://www.statssa.gov.za/census/census_2011/census_products/Census_2011_Census_in_brief.pdf">4%</a> of the total population.</p>
<p>Both internal migrants moving within the borders of the country and international migrants face <a href="https://www.csvr.org.za/images/brief_8_migration.pdf">daily stresses</a> associated with the challenges of moving to a new area, seeking work, struggling to access safe housing and a secure livelihood, and – in some cases – feeling alone and without social support. </p>
<p>Both groups of migrants also face particular challenges when it comes to accessing healthcare. In the South African context this is exacerbated by <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60951-X/fulltext">historical disparities and a poorly functioning public healthcare system</a>. </p>
<p>On top of this, the country is grappling with what’s known as the <a href="https://pmg.org.za/committee-meeting/22198/">quadruple burden of disease</a> – maternal, newborn and child health; HIV and tuberculosis (TB); non-communicable diseases; and violence and injury.</p>
<p>Population movements have implications for all four groups of disease meaning that migration needs to be considered in the development and implementation of all <a href="https://journals.co.za/content/journal/10520/EJC-c80eeea50">health system responses</a>. </p>
<p>The problem is that the public health system isn’t engaging adequately with the movement of either internal South African migrants or foreign-born migrants. This <a href="https://www.hst.org.za/publications/South%20African%20Health%20Reviews/9_Towards%20a%20migration%20aware%20health%20system%20in%20South%20Africa_a%20strategic%20opportunity%20to%20address%20health%20inequity.pdf">affects everyone</a>. </p>
<p>For example, efforts to control communicable diseases are undermined by the fact that the movement of people makes it hard for the health system – in its current form – to keep track of people’s medical records. Follow-up appointments are easily missed, and drug regimens may not be completed. The result is that the whole population is placed at an increased risk of acquiring a communicable disease.</p>
<h2>The challenges</h2>
<p>One major challenge is that South Africa’s healthcare facilities are unable to <a href="https://www.hst.org.za/publications/South%20African%20Health%20Reviews/9_Towards%20a%20migration%20aware%20health%20system%20in%20South%20Africa_a%20strategic%20opportunity%20to%20address%20health%20inequity.pdf">access health records of people moving</a> within the country. </p>
<p>The result is that clerks and healthcare providers are forced to spend time trying to trace client records. Very often they can’t, and have to open a new file and begin the process again. Not only does this take up time, but it also means that the needs of all who migrate are compromised. </p>
<p>This has implications for accessing testing and treatment. Migrants struggle to continue treatment and care because health facilities in different locations are not linked, and – for those moving into and out of South Africa – treatment regimens across the region differ. </p>
<p>In the case of TB and HIV, long treatment regimens are needed and there’s a risk of treatment being disrupted due to migration. This has implications for resistance and – in the case of HIV – increasing the risk of onward transmission.</p>
<p>The consequences are dire for patients, as well as the broader population. </p>
<p>Tied to this is the fact that migrants may find themselves living and working in environments in which they are at <a href="https://www.tandfonline.com/doi/full/10.1080/03768350500253153">higher risk of acquiring HIV</a> than the general population. These include commercial farms, mining communities and urban informal settlements. In the context of migrant labour, many people work in dangerous and exploitative conditions, that are associated with occupational health risks including injuries linked to working in the mining and agricultural sectors.</p>
<p>Another challenge relates to antenatal care and childbirth. Many South African women living in urban areas choose to return to their rural homes to deliver their babies. This can lead to a chain of events that affect both the mother and the child. For example, women may miss antenatal care visits because they’ve moved away from the first clinic they visited. Then after the baby is born, it can mean that their babies aren’t entered into the vaccination system when they return to the city. </p>
<p>The movement of people also makes it hard for the country’s health system to respond to non-communicable diseases like heart disease and diabetes. These too require long-term, chronic treatment and support. </p>
<p>Added to this is the fact that migrants face <a href="https://reliefweb.int/report/south-africa/south-africa-launches-plan-combat-xenophobia-and-racism">multiple forms of violence</a>. For foreign nationals, various forms of structural, physical, and verbal xenophobic violence are persistent. </p>
<p>Some international migrants may be undocumented and experience further stress due to fear of arrest, detention and deportation. This is further coupled with xenophobic violence – and the fear of violence – which negatively affects migrants’ <a href="https://csvr.org.za/images/brief_8_migration.pdf">mental and psychosocial well being</a>.</p>
<p>People seeking asylum based on <a href="https://journals.sagepub.com/doi/full/10.1177/000203971805300105">sexual orientation or gender identity</a> are also likely to experience violence in South Africa. </p>
<h2>The next steps</h2>
<p>South Africa’s health system needs to engage with migration. Developing a <a href="https://www.hst.org.za/publications/South%20African%20Health%20Reviews/9_Towards%20a%20migration%20aware%20health%20system%20in%20South%20Africa_a%20strategic%20opportunity%20to%20address%20health%20inequity.pdf">migration-aware health system</a> will support the improvement of health for all in South Africa. </p>
<p>A migration-aware health system must have population movement embedded as a central concern in the design of policies and interventions. </p>
<p>South Africa could learn from the experiences of Sri Lanka. In 2010, the government of Sri Lanka commissioned a <a href="https://publications.iom.int/books/migration-health-research-advance-evidence-based-policy-and-practice-sri-lanka">study</a> to explore health impacts of inbound, outbound, and internal migrant flows. The study included the families left behind by migrants and contributed to the formulation of a <a href="http://srilanka.iom.int/iom/?q=pbn/national-migration-health-policy-launched-sri-lanka">National Migration Health Policy</a> and national action plan. </p>
<p>Such an approach requires input from <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32855-1/fulltext">all sectors of society</a> including government, academia and civil society. Sri Lanka developed a <a href="https://www.thelancet.com/action/showPdf?pii=S0140-6736%2818%2932855-1">national migration and health research commission</a> and provided opportunities for engagement between researchers, communities and policy makers. This led to evidence-informed interventions to support the health of different migrant groups. </p>
<p>By establishing a national migration and health task team, South Africa could develop a similar approach that engages with internal and international migration.</p><img src="https://counter.theconversation.com/content/120797/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jo Vearey receives funding from the Wellcome Trust.</span></em></p><p class="fine-print"><em><span>Stephen Tollman receives funding from the SAMRC, Dept of Science and Technology SA, National Institutes of Health USA, UK Medical Research Council, and (previously) Wellcome Trust UK. He is affiliated with the SA Population Research Infrastructure Network (SAPRIN) and INDEPTH Network of population-based health and socio-demographic information systems. </span></em></p><p class="fine-print"><em><span>Sasha Frade does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It’s difficult to keep track of the medical records of patients on the move and some may be lost to follow-up, presenting further public health challenges and population-wide risks.Sasha Frade, Sasha Frade is a PhD student, as well as an Associate Lecturer, in the Demography and Population Studies, University of the WitwatersrandJo Vearey, Associate Professor, University of the WitwatersrandStephen Tollman, Director: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1094772019-02-13T11:40:19Z2019-02-13T11:40:19ZBabies with healthier diets are more active and sleep better - new findings<figure><img src="https://images.theconversation.com/files/257988/original/file-20190208-174894-bci5wx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Learning to climb.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cute-baby-bad-room-213820711?src=1GdJUWXWdazRjY5dIRS5MQ-1-18">Zsolt Biczo/Shutterstock</a></span></figcaption></figure><p>Physical activity is important at all stages of life. It prevents obesity, improves well-being and reduces the risk of many chronic conditions, such as heart disease, arthritis and diabetes. Evidence shows that being active at a young age tracks into adulthood, and that physical activity behaviours adopted when young are likely to <a href="https://www.ncbi.nlm.nih.gov/pubmed/25074589">carry through life</a>. And now our <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/ijpo.12512">study</a> of babies’ activity levels has shown how different factors, including sleep and diet, link together to improve baby health from the day they are born.</p>
<p>For our research project, we tracked the physical activity of 141 12-month-old infants (77 boys and 64 girls) using accelerometers, which they wore on their ankles for a week. We looked at how active the children were during the day and at night. Then we compared the different characteristics of the most and least active children. This involved using the accelerometer data, information that we collected from measuring the infants at home – things like weight and diet diaries were included in this – and medical records from the mothers’ pregnancy, as well as the the infants’ own birth and GP records. </p>
<p>Overall, the research showed that getting the right start means that other healthy behaviours fall in to place more easily. Across the board we found that active babies are healthy, are of good weight and are born full term. In addition, the larger babies who had been born full term were more active. </p>
<p>We found that diet is an important factor when it comes to being an active child. The children who were breastfed (breastfeeding has been associated with <a href="https://www.ncbi.nlm.nih.gov/pubmed/22237059">higher fitness levels in childhood</a>) and those who ate more vegetables were more active. Infants who were less active had a more adult style diet, with juice rather than milk and adult crisps. </p>
<p>As well as improving their activity levels, healthy eating behaviours, such as having a higher vegetable intake, adopted at this age are <a href="https://www.bmj.com/content/348/bmj.g3256">likely to be carried through life</a> too. This, when combined with another finding that infants born prematurely, and who do not put on weight well after birth, move less, also suggests that preterm and low birthweight infants should be breastfed for longer, and that a healthy diet of milk and vegetables is even more important for them.</p>
<p>We also found that active babies sleep better than less active babies. Those infants who were active during the day woke up less at night, so they tended to sleep better – although they did move about in their sleep more. This suggests that encouraging activity could have a knock-on effect on improving other behaviours like good sleep practices. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/257989/original/file-20190208-174873-resqgg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/257989/original/file-20190208-174873-resqgg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/257989/original/file-20190208-174873-resqgg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/257989/original/file-20190208-174873-resqgg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/257989/original/file-20190208-174873-resqgg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/257989/original/file-20190208-174873-resqgg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/257989/original/file-20190208-174873-resqgg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nap time.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/one-year-old-baby-girl-sleeping-664478614?src=y_W4EoDSKqKRJXhvCYGwpg-1-5">Stephan Schlachter/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Boys are more active</h2>
<p>The data showed that boys are more active than girls in general, even at 12 months old. Although we are not sure if this is because boys are inherently more active than girls, or if parental behaviours encourage boys to be active, and that parents accept boisterous physical behaviours from boys but not from girls. </p>
<p>Given the link between early movement and physical activity later in life, this finding raises questions about how we address girls’ physical activity. Are girls inherently less active or are they taught to be less physical? Is a boy climbing the curtains just acceptable behaviour while we worry that a girl climbing will get hurt? Is it nature or nurture that makes girls less active than boys? </p>
<p>Though we can’t answer these questions solely based on this study, another recent project of ours has <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5274-3">highlighted the frustrations</a> girls feel towards activity through to their teenage years. Girls report there are many activities for boys but few for girls. But if girls are inherently different from boys in their activity rates, perhaps we should be tailoring activity for girls rather than assuming the want to do the same as boys. The finding from our study of infants gives more weight to the argument that we need to rethink our gendered perceptions of activity. </p>
<p>Risks for poor health cluster together in this study, but by tackling one, it could create a ripple effect of change. Improving infant diet means that they will be more active which has a knock-on effect for their sleep patterns too. And ultimately it can improve the infant’s physical fitness throughout life. Helping families with poor health behaviours from pregnancy could really improve overall health for the future infant.</p><img src="https://counter.theconversation.com/content/109477/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sinead Brophy works in Swansea University and through the university receives funding from Heath and Care Research Wales, MRC and ESRC</span></em></p><p class="fine-print"><em><span>Michaela James receives funding from the National Centre for Population Health and Wellbeing Research. </span></em></p><p class="fine-print"><em><span>Shang-Ming Zhou works with Swansea University. He receives funding from MRC, Health and Care Research Wales, China Social Science Foundation.</span></em></p>Encouraging your baby to be active can improve their health in other areas too.Sinead Brophy, Professor in Public Health Data Science, Swansea UniversityMichaela James, Research Assistant in Childhood Physical Activity, Swansea UniversityShang-Ming Zhou, Senior Lecturer in Health Data, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1044622018-12-11T23:22:33Z2018-12-11T23:22:33ZHow robots are helping doctors save lives in the Canadian North<figure><img src="https://images.theconversation.com/files/250040/original/file-20181211-76983-c6mhax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Remote presence technology enables a medic to perform an ultrasound at the scene of accident.</span> <span class="attribution"><span class="source">(University of Saskatchewan)</span>, <span class="license">Author provided</span></span></figcaption></figure><p>It is the middle of the winter and a six-month-old child is brought with acute respiratory distress to a nursing station in a remote community in the Canadian North. </p>
<p>The nurse realizes that the child is seriously ill and contacts a pediatric intensivist located in a tertiary care centre 900 kilometres away. The intensivist uses her tablet to activate <a href="https://phys.org/news/2013-01-fda-green-rp-vita-hospital-robot.html">a remote presence robot</a> installed in the nursing station and asks the robot to go to the assessment room. </p>
<p>The robot autonomously navigates the nursing station corridors and arrives at the assessment room two minutes later. With the help of the robot’s powerful cameras, the doctor “sees” the child and talks to the nurse and the parents to obtain the medical history. She uses the robot’s stethoscope to listen to the child’s chest, measures the child’s oxygen blood saturation with a <a href="https://www.hopkinsmedicine.org/healthlibrary/test_procedures/pulmonary/pulse_oximetry_92,p07754">pulse oximeter</a> and performs an electrocardiogram. </p>
<p>With the robot’s telestrator (an electronic device which enables the user to write and draw freehand over a video image) she helps the nurse to start an intravenous line and commences therapy to treat the child’s life-threatening condition. </p>
<p>This is not science fiction. This remote presence technology is currently in use in Saskatchewan, Canada — to provide care to acutely ill children living in remote Northern communities. </p>
<h2>Treating acutely ill children</h2>
<p>Advances in telecommunication, robotics, medical sensor technology and artificial intelligence (AI) have opened the door for solutions to the challenge of delivering remote, real-time health care to underserviced rural and remote populations. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/250044/original/file-20181211-76986-s7xlie.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/250044/original/file-20181211-76986-s7xlie.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/250044/original/file-20181211-76986-s7xlie.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/250044/original/file-20181211-76986-s7xlie.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/250044/original/file-20181211-76986-s7xlie.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/250044/original/file-20181211-76986-s7xlie.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/250044/original/file-20181211-76986-s7xlie.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A team uses a remote presence robot to see a patient in the emergency room.</span>
<span class="attribution"><span class="source">(University of Saskatchewan)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>In Saskatchewan, we have established a <a href="https://globalnews.ca/news/4102687/cant-access-a-doctor-a-robot-will-see-you-now/">remote medicine program</a> that focuses on the care of the most vulnerable populations — such as acutely ill children, pregnant women and the elderly.</p>
<p>We have demonstrated that with this technology about <a href="https://doi.org/10.1089/tmj.2017.0211">70 per cent of acutely ill children can be successfully treated in their own communities</a>. In similar communities without this technology, all acutely ill children need to be transported to a tertiary care centre. </p>
<p>We have also shown that this technology prevents delays in diagnosis and treatment and results in substantial savings to the health-care system.</p>
<h2>Prenatal ultrasounds for Indigenous women</h2>
<p>Remote communities often lack access to diagnostic ultrasonography services. This gap disproportionally affects Indigenous pregnant women in the Canadian North and results in increases in maternal and newborn morbidity and mortality. </p>
<p>We are pioneering the use of an innovative <a href="https://thestarphoenix.com/news/local-news/remote-presence-technology-improves-access-to-ultrasound-in-northern-sask">tele-robotic ultrasound system</a> that allows an expert sonographer to perform a diagnostic ultrasound study, in real time, in a distant location. </p>
<p>Research shows that robotic ultrasonography is <a href="https://doi.org/10.1002/jum.14619">comparable to standard sonography</a> and is accepted by most patients. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/zH7IFHjHIg4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>The first tele-robotic ultrasonography systems have been deployed to two northern Saskatchewan communities and are currently performing prenatal ultrasounds.</p>
<h2>Emergency room trauma assessment</h2>
<p><a href="https://doi.org/10.1503/cmaj.120223">Portable remote presence devices</a> that use available cellular networks could also be used in emergency situations, such as trauma assessment at the scene of an accident or transport of a victim to hospital. </p>
<p>For example, emergency physicians or trauma surgeons could perform real-time ultrasonography of the abdomen, thorax and heart in critically injured patients, identify life-threatening injuries and start life-saving treatment.</p>
<p>Wearable remote presence devices such a <a href="https://www.healthcare-informatics.com/blogs/david-raths/telemedicine/google-glass-isn-t-just-remote-scribes">Google Glass technology</a> are the next step in remote presence health care for underserviced populations. </p>
<p>For example, a local nurse and a specialist in a tertiary care centre thousand of kilometres away could assess together an acutely ill patient in an emergency room in a remote community through the nurse’s eyes. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/250043/original/file-20181211-76977-14l8wgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/250043/original/file-20181211-76977-14l8wgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/250043/original/file-20181211-76977-14l8wgu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/250043/original/file-20181211-76977-14l8wgu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/250043/original/file-20181211-76977-14l8wgu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/250043/original/file-20181211-76977-14l8wgu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/250043/original/file-20181211-76977-14l8wgu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A nurse examines a patient with Google Glass.</span>
<span class="attribution"><span class="source">(University of Saskatchewan)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Although remote presence technology may be applied initially to emergency situations in remote locations, its major impact may be in the delivery of primary health care. We can imagine the use of mobile remote presence devices by health professionals in a wide range of scenarios — from home-care visits to follow-up mental health sessions — in which access to medical expertise in real time would be just a computer click away.</p>
<h2>A paradigm shift in health-care delivery</h2>
<p>The current model of centralized health care, where the patient has to go to a hospital or a clinic to receive urgent or elective medical care, is inefficient and costly. Patients have to wait many hours in emergency rooms. Hospitals run at overcapacity. Delays in diagnosis and treatment cause poor outcomes or even death. </p>
<p>Underserviced rural and remote communities and the most vulnerable populations such as children and the elderly are the most affected by this centralized model.</p>
<p>Remote presence technologies have the potential to shift this — so that we can deliver medical care to a patient anywhere. In this decentralized model, patients requiring urgent or elective medical care will be seen, diagnosed and treated in their own communities or homes and patients requiring hospitalization will be triaged without delay.</p>
<p>This technology could have important applications in low-resource settings. Cellular network signals around the globe and rapidly increasing bandwidth will provide the telecommunication platform for a wide range of mobile applications. </p>
<p>Low-cost, dedicated remote-presence devices will increase access to medical expertise for anybody living in a geographical area with a cellphone signal. This access will be especially beneficial to people in developing countries where medical expertise is insufficient or not available.</p>
<p>The future of medical care is not in building more or bigger hospitals but in harnessing the power of technology to monitor and reach patients wherever they are — to preserve life, ensure wellness and speed up diagnosis and treatment.</p><img src="https://counter.theconversation.com/content/104462/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ivar Mendez receives funding from College of Medicine, University of Saskatchewan & Ministry of Health, Province of Saskatchewan. </span></em></p>A remote medicine program in Saskatchewan allows acutely ill children and pregnant women to be treated by specialist doctors, without leaving their communities.Ivar Mendez, Fred H. Wigmore Professor and Unified Head of the Department of Surgery, University of SaskatchewanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/944282018-06-05T13:44:43Z2018-06-05T13:44:43ZSuffering in silence: how Kenyan women live with profound childbirth injuries<figure><img src="https://images.theconversation.com/files/221387/original/file-20180601-142083-1j8anm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><a href="http://vc.bridgew.edu/cgi/viewcontent.cgi?article=1942&context=jiws">Sasha</a> is 22-years-old. She was married off when she was just nine and by the time she was 11, she was pregnant with her first child, and unprepared for childbirth. </p>
<p>So when labour came, in the middle of the night – in her geographically isolated village in rural Kenya – she was unaware of the painful fate awaiting her. </p>
<p>During childbirth, the baby’s head was too big to fit through Sasha’s pelvis, causing the baby to get stuck in her birthing canal. Traditional birth attendants tried their best to help Sasha but they were not skilled enough to handle the complications. She needed surgery, and quickly. But because she could not access emergency obstetric services, she spent the next six days trying to push out the baby that was stuck inside of her. </p>
<p>In the end, Sasha delivered a dead, rotten baby in macerated form. She was not only in grief of her lost child, but was also traumatised by her experience which left her with profound injuries and a double <a href="https://www.ncbi.nlm.nih.gov/pubmed/8873157">obstetric vaginal fistula</a>. </p>
<p>An obstetric vaginal fistula is a tear between a woman’s vagina and another body part – usually caused by obstructed or prolonged labour. It occurs when the baby’s head is trapped against the pelvic bone and cannot descend further. As the labour intensifies, the blood supply is cut and the surrounding tissues die. Shortly after the baby dies and labour continues until the baby is pushed out.</p>
<p>Across the world, there is an estimated <a href="https://www.booktopia.com.au/tears-for-my-sisters-l-lewis-wall/prod9781421424170.html">two million</a> women and girls just like Sasha who live with vaginal fistulas. There are up to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3937166/#B1">100 000 new cases each year</a>. In Kenya, at least 3000 new cases are reported annually but <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-13-56">research</a> shows that only 7.5% are treated.</p>
<p>But these statistics are bound to be grossly inaccurate
due to under-reporting, poor and non-existent data keeping in most African hospitals. This is made worse by women feeling internalised shame which keeps them from seeking help for their fistulas. It means that the magnitude of the problem on the continent is assumed to be much higher. </p>
<p>Sasha was one of the women I interviewed in <a href="https://www.springer.com/us/book/9789811305641">my research</a> which investigated how Kenyan women with fistulas negotiated the complexities of living with a body that leaks. This included the process of trying to get treatment as well as the journey to recovery from childbirth traumas that rendered their bodies abject, damaged and at times irreparable.</p>
<p>My research revealed a lack of resources and the structural challenges that prevent women from getting the help they need. This is particularly prevalent in remote areas, where access to health services is not available or is very limited.</p>
<p>It also reinforces what <a href="https://www.gfmer.ch/Medical_education_En/PGC_RH_2004/Obstetric_fistula_Kenya.htm">researchers</a> and <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/ajmw.2011.5.2.95">medical professionals</a> in Kenya have established over the years. </p>
<h2>Negotiating the challenges around fistula</h2>
<p>Kenya continues to face enormous challenges as far as dealing with vaginal fistula are concerned. The biggest is the lack of resources to treat fistulas along with a <a href="https://www.reuters.com/article/us-kenya-health-fistula/as-surgeries-triple-kenya-aims-to-end-shame-of-fistula-idUSKBN18L1DN">severe shortage of fistula surgeons</a>. By 2014, Kenya only had three internationally renowned fistula surgeons and less than 10 surgeons who could perform simple obstetric operations.</p>
<p>This has made it logistically impossible to treat all the women who seek treatment every year. It also means that many are left untreated for years adding to the ever increasing backlog.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women awaiting fistula surgery at the Gynocare Women’s and Fistula Hospital in Kenya, which is the only private facility which specifically treats fistulas for free.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/directrelief/11197145265/in/photolist-i4sibH-i4sXtH-9MdDUt-i4spDd-i4ta9P-i4sodN-i4sYRn-i4sp71-i4t9Yt-i4siDA-i4sk2B-i4t6AL-i4sidq-bsqR9F-9MgyxN-i4sg3e-i4seaM-bsqSpe-i4sfQR-i4tHbH-i4srtA-6YgpYi-i4tefW-i4sYja-i4sk2f-i4t5V8-i4tPb8-i4sozY-i4t6Tj-i4siBn-i4taUf-i4t7wo-i4t7M4-75QQSQ-i4tHVi-i4t5Ww-bVLPEU-i4tcgd-bm1xDN-bm1xCW-6YkrxW-byVqGZ-6YgrpP-6YgryX-i4tQUP-8gTYV2-6Ygqra-i4tezJ-i4t8RZ-i4sQ3o">Direct Relief/Flickr</a></span>
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</figure>
<p>But for most women with fistulas, the damage is not only physical, it’s also psychological. They negotiate rejection and social exclusion on a day-to-day basis which can have severe psychological consequences. This can be more destructive than the actual fistula.</p>
<p>The women I engaged with explained how their fistula diagnosis threatened their social and intimate lives. They explained how having a “leaking body” was constructed as being dirty, deviant and contaminated. </p>
<p>Many described that the way they went about their lives was primarily occupied with finding ways to protect themselves from being “outed” or shamed for the pungent smell that they carried with them.</p>
<p>Their stories revealed the structural and sociocultural challenges that explain why women in Kenya are at risk of developing vaginal fistulas and then having adequate treatment delayed or denied them. This is particularly prevalent in remote areas, where there are transport barriers, impassable roads, and limited or unavailable access to health services or emergency obstetric care. </p>
<h2>Responding to fistulas</h2>
<p>In the last decade, the Kenyan government has initiated a programme under which local health workers train traditional birth attendants working in remote areas to mitigate maternal casualties. But despite the fact that the training includes skills to manage birthing complications, some women require immediate medical intervention. </p>
<p>Kenya also rolled out other public health campaigns to end maternal deaths. One was the <a href="https://www.beyondzero.or.ke/official-launch-of-the-beyond-zero-campaign/">Beyond Zero campaign</a> which was initiated by Kenya’s First Lady, Margaret Kenyatta to raise funds and awareness on issues of safe delivery, and obstetric injuries that lead to vaginal fistulas. </p>
<p>Although the initiative was heavily <a href="https://www.pambazuka.org/food-health/beyond-zero-kenyan-first-lady%E2%80%99s-charity-can%E2%80%99t-cure-healthcare-neglect-and-theft">criticised</a> as an attempt to provide a quick fix to structural problems, it raised national awareness about vaginal fistulas and mobilised resources for free surgeries for women with the condition. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/better-maternal-care-in-africa-can-save-women-from-suffering-in-childbirth-59688">Better maternal care in Africa can save women from suffering in childbirth</a>
</strong>
</em>
</p>
<hr>
<p>The criticism reflects the importance of addressing the underlying causes of fistula. These causes have been summed by one of Kenya’s most renown fistula surgeons <a href="https://scholar.google.co.uk/citations?user=Cku3H4wAAAAJ&hl=en">Dr Weston Khisa</a>, who says</p>
<blockquote>
<p>Medically, fistula is caused by obstructed labour, but the underlying causes are obstructed transport, obstructed family planning, obstructed emergency care, and obstructed human rights.</p>
</blockquote>
<p>Ending fistulas means eradicating both cultural and structural obstacles that put women at risk of developing preventable tragedies such as fistulas. It requires a complete overhaul of health infrastructure in Kenya to ensure that maternal care and women’s reproductive health are prioritised – and that no woman has to lose her life while trying to give one.</p><img src="https://counter.theconversation.com/content/94428/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathomi Gatwiri PhD does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Each year an estimated 100 000 women have complications during childbirth which leave them with obstetric vaginal fistula.Kathomi Gatwiri PhD, Lecturer, Southern Cross UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/937922018-03-27T04:41:00Z2018-03-27T04:41:00ZStart resetting your kids’ body clocks before daylight saving ends – here’s how<figure><img src="https://images.theconversation.com/files/212112/original/file-20180327-188613-isbj4v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children need different amounts of sleep but should aim to wake feeling rested, without an alarm.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sweet-kid-sleeping-bed-time-tired-1040389855?src=I3De-Oaw4cLTjNKsoUuQ3g-1-8">Juninatt/shutterstock</a></span></figcaption></figure><p>Daylight saving time ends on Sunday morning, signalling an end to summer. It’s also a period of disruption for children and their parents as they adjust to the new time. </p>
<p>Although an hour doesn’t seem like a big jump, children who have <a href="https://www.ncbi.nlm.nih.gov/pubmed/20093054">as little as 30 minutes less sleep</a> than usual are more likely to have behavioural difficulties, lower attention, and increased social and emotional difficulties.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/regular-bed-times-as-important-for-kids-as-getting-enough-sleep-19396">Regular bed times as important for kids as getting enough sleep</a>
</strong>
</em>
</p>
<hr>
<p>Before we get into the tips, let’s revisit the science on the drivers behind sleep. </p>
<h2>How the body clocks work</h2>
<p>Like adults, children’s sleep is regulated by two systems. </p>
<p>First, the homeostatic process regulates how long and how deeply we sleep. Referred to as “sleep propensity”, children’s level of sleepiness is influenced by the length and quality of their last sleep, as well as the time since they last had a sleep. </p>
<p>Sleep is also influenced by each child’s own sleep needs. The <a href="https://www.sleephealthfoundation.org.au/public-information/fact-sheets-a-z/230-how-much-sleep-do-you-really-need.html">Australian Sleep Health Foundation</a> recommends the following:</p>
<p><iframe id="tFOi1" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/tFOi1/5/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>But how much sleep each child needs is different. While these recommendations provide a useful guide, there is <a href="https://www.researchgate.net/publication/282461895_Cross-sectional_sleep_thresholds_for_optimal_health_and_wellbeing_in_Australian_4-9-year-olds">no <em>ideal</em> sleep duration</a>. Children should be able to wake up feeling refreshed, without the help of an alarm.</p>
<p>The second sleep regulation system is our circadian rhythm, commonly referred to as our body clock. It controls when children sleep, and when they’re awake. Understanding how this system functions is important to understanding how to navigate the daylight savings period. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/keeping-time-how-our-circadian-rhythms-drive-us-17">Keeping time: how our circadian rhythms drive us</a>
</strong>
</em>
</p>
<hr>
<p>This system is controlled by environmental cues called zeitgebers. The most common of these is the light-dark cycle, which turns on and off the body’s production of the hormone <a href="http://www.smrv-journal.com/article/S1087-0792(04)00111-X/abstract">melatonin</a>. This hormone helps us initiate sleep after it is released by the body’s pineal gland. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/212116/original/file-20180327-188628-10vuw5e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/212116/original/file-20180327-188628-10vuw5e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/212116/original/file-20180327-188628-10vuw5e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/212116/original/file-20180327-188628-10vuw5e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/212116/original/file-20180327-188628-10vuw5e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/212116/original/file-20180327-188628-10vuw5e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/212116/original/file-20180327-188628-10vuw5e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Light makes kids less sleepy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-boy-pajama-reading-story-grandmother-1042840264?src=aqMjlZeKzpYjg7RVq1fKIg-2-1">Shutterstock/LumineImages</a></span>
</figcaption>
</figure>
<p>In the presence of light, the body’s production of melatonin stops or slows down and hence children are not sleepy; while the presence of darkness increases the production of melatonin, enabling you to go to sleep.</p>
<p>To further aid sleep, children’s core temperature decreases in sync with the body clock. Bedrooms or pyjamas that are too hot may make it more difficult to get to sleep. </p>
<p>Our circadian rhythms are also synchronised to other external cues, such as the timing of meals, baths and alarm clocks. </p>
<h2>Sleep strategies</h2>
<p>The shift from daylight saving time will leave kids’ body clocks an hour “out of sync”, in a similar way to jetlag. They will need help shifting their body clocks. </p>
<p>There are some effective, <a href="https://www.ncbi.nlm.nih.gov/pubmed/21890825">evidence-based sleep strategies</a> to help your children transition more easily to the new time schedule, and to deal with issues that arise like refusing to go to bed, or rising too early. Here are four:</p>
<h2>1. Set a regular bedtime routine</h2>
<p>As our circadian rhythm synchronises to our environment, a consistent bedtime routine is important during the daylight savings period. </p>
<p>A bedtime routine should include a consistent pattern, which occurs for at least the 30 minutes before your child goes to bed. </p>
<p>Activities should be relaxing, enabling children to wind down. This could involve quiet reading together, bath time or talking as a family. It should also include all activities which your child may use as an excuse to come out of bed later, such as needing to go to the toilet, being hungry or thirsty, or wanting a cuddle. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/212118/original/file-20180327-188622-egkw6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/212118/original/file-20180327-188622-egkw6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/212118/original/file-20180327-188622-egkw6k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/212118/original/file-20180327-188622-egkw6k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/212118/original/file-20180327-188622-egkw6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/212118/original/file-20180327-188622-egkw6k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/212118/original/file-20180327-188622-egkw6k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Set aside around 30 minutes for the bedtime routine.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-girl-playing-tub-pink-cup-796873984?src=oTCSq8oNRRfULThww2Y2rQ-3-23">Swebbie/Shutterstock</a></span>
</figcaption>
</figure>
<p>Having a dimmed environment will also be helpful, to further enable the body to recognise it is sleep time through the production of melatonin. </p>
<h2>2. Shift your child’s body clock</h2>
<p>For some families, the daylight saving switchover provides an opportunity to change your child’s bedtime. </p>
<p>If turning the clock back an hour means your child’s body clock will be set to sleep at a more ideal time, then you may not need to do anything. If the new time isn’t ideal, then you will need to help your child adjust their body clock to the new time. </p>
<p>This will involve having your child go to bed 10 to 15 minutes later in slow increments. After each shift, let your child go to bed at that time for two to three nights so their internal body clocks adjust to the new routine. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-a-week-of-camping-resets-the-body-clock-16557">How a week of camping resets the body clock</a>
</strong>
</em>
</p>
<hr>
<p>Once they are able to fall asleep quickly at the new time, then shift it again until you reach your desired sleep time. It may be worth considering starting this process before daylight savings ends, as it can take a couple of weeks to adjust.</p>
<h2>3. Have a plan to deal with bedtime refusal</h2>
<p>It will be common for children to refuse to go to bed at their new bedtime, either by calling out or coming out of their bedrooms. If they call out, it’s best to ignore these requests and not to engage them in conversation. Your bedtime routine should have addressed many of the reasons they may have for wanting you to come in. </p>
<p>If you want, you could enable them a “free pass” each night, which they can redeem for one request. For this technique, a physical pass is best as it enables them to physically hold the pass and to hand it over to you once they have made their request.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/212111/original/file-20180327-188632-t238en.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/212111/original/file-20180327-188632-t238en.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/212111/original/file-20180327-188632-t238en.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/212111/original/file-20180327-188632-t238en.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/212111/original/file-20180327-188632-t238en.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/212111/original/file-20180327-188632-t238en.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/212111/original/file-20180327-188632-t238en.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Children often have an excuse for why they need to get up, which you can pre-empt.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/wzOyUkuLy7E">Jelleke Vanooteghem</a></span>
</figcaption>
</figure>
<p>If they do come out, it is best to return them immediately, but calmly, to their bed. Once again, try to make this engagement boring, so as not to encourage them to come out again. Don’t reprimand your child in any way, as this may upset them and make it difficult for them to settle for sleep. </p>
<p>Do this as many times as it takes until your child stays in bed. It might take many returns before your child stays in bed. If you use this option, you’ll have to be very patient.</p>
<h2>4. Combat early rising</h2>
<p>With the shift in daylight savings, children are likely to wake up an hour earlier until their body clock is able to shift. Young children find it difficult to stay in bed, when their body clocks indicate it is time to wake up. Once it is shifted, they should wake up at their regular wake time. </p>
<p>In the meantime, encourage your child to stay in their bedroom in the morning after they wake up. This is where a nightlight with a daytime function may be helpful, to help your child see when it is waking up time. </p>
<p>Before the clock tells them it is time to wake up, allow them to have quiet play in their room. This could be reading, drawing or playing with their toys.</p><img src="https://counter.theconversation.com/content/93792/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jon Quach receives funding from the Australian Research Council and National Health Medical Research Council. He is affiliated with Sleep Health Foundation. </span></em></p>The shift from daylight saving time will leave kids’ body clocks an hour “out of sync”, in a similar way to jet lag. Here are some evidence-based strategies to deal with this.Jon Quach, Postdoctoral researcher in child community health, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/886482018-03-15T01:05:25Z2018-03-15T01:05:25ZDomperidone can boost breast milk supply – here’s what you need know<figure><img src="https://images.theconversation.com/files/207973/original/file-20180227-140184-1i7z1zn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's not suitable for women with heart problems, but otherwise is a safe and effective option.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com">Alex Pasarelu</a></span></figcaption></figure><p>Breast milk is the <a href="https://www.ncbi.nlm.nih.gov/pubmed/19609306">best form of nutrition</a> for infants’ growth and development. But some women don’t produce enough milk to exclusively breastfeed their baby. </p>
<p>We don’t have good data on the proportion of women with breast milk supply issues, but it is a <a href="http://pediatrics.aappublications.org/content/131/3/e726.short">commonly reported</a> reason for stopping breastfeeding and/or starting formula. </p>
<p>For women who suspect they have low breast milk supply, the first thing to do is get some breastfeeding support. A <a href="https://thewomens.r.worldssl.net/images/uploads/downloadable-records/clinical-guidelines/infant-feeding-management-of-low-breast-milk-supply_160517.pdf">lactation consultant or other specialist</a> can provide practical help with attaching the infant on the breast, and guidance on strategies to stimulate supply, such as increasing the frequency of breastfeeds or using a breast pump.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/essays-on-health-australia-is-failing-new-parents-with-conflicting-advice-its-urgent-we-get-it-right-77943">Essays on health: Australia is failing new parents with conflicting advice – it's urgent we get it right</a>
</strong>
</em>
</p>
<hr>
<p>If the supply problem persists, you may be offered the prescription medication <a href="https://www.mja.com.au/journal/2014/201/5/pharmacological-management-low-milk-supply-domperidone-separating-fact-fiction">domperidone</a>. This is the most effective and <a href="http://cmajopen.ca/content/4/1/E13.full">commonly used</a> drug to boost milk supply. </p>
<h2>How does domperidone work?</h2>
<p>A key hormone involved in controlling breast milk production is prolactin. Domperidone works to raise levels of prolactin, which helps increase the production of breast milk.</p>
<p>Domperidone <a href="https://thewomens.r.worldssl.net/images/uploads/downloadable-records/clinical-guidelines/infant-feeding-management-of-low-breast-milk-supply_160517.pdf">is usually started</a> at a dose of 10 milligrams (one tablet) three times a day. Breast milk supply should start to improve within seven days and peak at two to four weeks. </p>
<p>If supply remains low, there is <a href="http://journals.sagepub.com/doi/abs/10.1177/0890334412438961">some evidence</a> – though weak – that doubling the dose may help. But this should only be done under careful <a href="https://www.mja.com.au/journal/2014/201/5/pharmacological-management-low-milk-supply-domperidone-separating-fact-fiction">medical supervision</a>. </p>
<p>Once adequate breast milk supply is reached, the dose should be slowly reduced to avoid a drop in milk production. </p>
<h2>How effective is it?</h2>
<p>Most <a href="http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.15177/abstract">studies</a> have investigated the effects of domperidone in mothers following preterm birth (birth at less than 37 weeks’ gestation) where their baby is admitted to a hospital neonatal unit. In these settings, domperidone was associated with a short-term increase in daily milk production of 90 millilitres per day.</p>
<p>We assume domperidone works just as well in mothers with a full-term birth, but there’s no evidence to prove this. </p>
<p>Also, there’s <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492930/">some evidence</a> domperidone may work better in some women than others. This means not all women taking domperidone will experience the same increase in breast milk volume. And some may get no benefit at all. </p>
<h2>What are the risks?</h2>
<p>Side effects are uncommon but include headaches, abdominal pain, dry mouth and, even less commonly, a rash or trouble sleeping. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gut-instinct-how-the-way-youre-born-and-fed-affect-your-immune-system-65104">Gut instinct: how the way you're born and fed affect your immune system</a>
</strong>
</em>
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<hr>
<p>Domperidone has received negative press in recent years because of concerns it can change the rhythm of the heart, a concept known as <a href="https://www.nps.org.au/australian-prescriber/articles/risk-assessment-of-drug-induced-qt-prolongation">QT prolongation</a>. By altering the rhythm of the heart, domperidone has the potential to cause a potentially life-threatening side effect known as ventricular arrhythmia, or rapid heart rate. </p>
<p>Previous studies have shown those at most risk from this rare side effect were male, older than 60 years of age, taking other medications that can also cause the same effect on the heart, or had a previous history of an abnormal heart rate. So the relevance of these concerns to young and otherwise healthy lactating women has been <a href="https://www.mja.com.au/journal/2014/201/5/pharmacological-management-low-milk-supply-domperidone-separating-fact-fiction">questioned</a>. </p>
<p>The cardiac safety of domperidone when used in breastfeeding has only been looked at in one study, from Canada. <a href="http://onlinelibrary.wiley.com/wol1/doi/10.1002/pds.4035/abstract">Researchers</a> investigated 45,163 women using domperidone in the six months after giving birth. A total of six women who took domperidone were hospitalised for ventricular arrhythmia (a rapid heart rate). This is 1.3 per 10,000 women. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/210233/original/file-20180314-131572-lycd29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/210233/original/file-20180314-131572-lycd29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/210233/original/file-20180314-131572-lycd29.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/210233/original/file-20180314-131572-lycd29.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/210233/original/file-20180314-131572-lycd29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/210233/original/file-20180314-131572-lycd29.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/210233/original/file-20180314-131572-lycd29.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">It’s difficult to know exactly how well domperidone boosts supply in women with full-term babies.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1044530980?src=ybK4AAnCVWU6RfTRLXaw-A-1-13&size=medium_jpg">Olga Vladimirova/Shutterstock</a></span>
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<p>Looking more closely into the study results, all cases of ventricular arrhythmia occurred in women who had a previous history of ventricular arrhythmia. Among 45,163 women using domperidone who had no previous history of ventricular arrhythmia, no cases were observed. </p>
<p>This study provides reassuring evidence of the safety of domperidone in women who have recently given birth, and also highlights the importance of women discussing any heart conditions with their doctor. </p>
<p>No side effects have been found in infants whose mothers use domperidone. The amount of domperidone found in breast milk is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492930/">extremely small</a>, with infants exposed to less than 0.02% of the total dose. </p>
<h2>What about metoclopramide?</h2>
<p>Domperidone belongs to the same family of medicines as metoclopramide and works in a similar way. But they have very different side effects. Metoclopramide can cause central nervous system side effects such as fatigue, irritability, or depression. </p>
<p>Side effects are much less likely with domperidone, so it’s the preferred medicine to boost breast milk supply.</p>
<h2>Are herbal medicines as good?</h2>
<p>In recent years, interest has grown in whether herbal medicines – such as fenugreek, milk thistle, blessed thistle and ginger – can boost milk supply. </p>
<p>Herbal medicines are popular because they can be purchased without the need to see a doctor and get a prescription. They may also seem safer and more “natural” than prescription medicines. </p>
<p>But the <a href="http://journals.sagepub.com/doi/abs/10.1177/0890334413477243">evidence</a> does not appear to match enthusiasm for their use. There is no good quality evidence these medicines work, with most supporting evidence coming from case reports or very low quality studies or those based on historical use. </p>
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Read more:
<a href="https://theconversation.com/breast-milk-banking-continues-an-ancient-human-tradition-and-can-save-lives-69351">Breast milk banking continues an ancient human tradition and can save lives</a>
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<p>There is, however, evidence they could cause <a href="https://www.nps.org.au/australian-prescriber/articles/drugs-affecting-milk-supply-during-lactation">side effects</a>, interact with other medicines, or interfere with other medical conditions.</p>
<p>While some women might find benefits in using herbal medicines, they should not be seen as an alternative to evidence-based treatments and should only be used after discussion with a health care professional.</p><img src="https://counter.theconversation.com/content/88648/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Domperidone raises levels of prolactin, which increases the production of breast milk. It’s safe for mothers and babies, but not all women will experience the same increase in milk volume.Luke Grzeskowiak, NHMRC Early Career Research Fellow – Robinson Research Institute, University of AdelaideLisa Amir, Associate Professor in Breastfeeding Research, La Trobe UniversityWendy Ingman, Associate Professor, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/887692017-12-07T05:41:39Z2017-12-07T05:41:39ZWhat is meningococcal disease and what are the options for vaccination?<figure><img src="https://images.theconversation.com/files/198090/original/file-20171207-31539-fgs9bf.jpg?ixlib=rb-1.1.0&rect=5%2C142%2C992%2C523&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children aged under two are at increased risk of meningococcal disease.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cute-little-boy-stting-on-mother-767951725?src=0popTvu1ZqoPELcl7VVUCQ-1-7">Shutterstock</a></span></figcaption></figure><p>As a medical researcher and parent of two teenagers there is one bug, <em>Neisseria meningitidis</em>, that really scares me. This is mainly because of the speed and severity of the infection it causes, called <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-fact-sheet.pdf">meningococcal disease</a>, and its predilection for infecting healthy adolescents and younger children. </p>
<p>Meningococcal is a rare but very serious infection that <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-fact-sheet.pdf">can lead to</a> blood poisoning (septicaemia) and/or brain infection (meningitis). </p>
<p>The initial symptoms can be vague and non-specific. This includes the sudden onset of fever and a rash. The rash can be either red-purple spots or bruises – detected by the classic <a href="http://www.meningococcal.org/the_rash.html">pushing-a-glass-on-the-skin test</a> to see if the rash goes away (and is therefore less likely to be meningococcal) – or a flat or raised non-specific rash. </p>
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Read more:
<a href="https://theconversation.com/explainer-whats-meningococcal-meningitis-and-what-are-the-signs-64170">Explainer: what's meningococcal meningitis and what are the signs?</a>
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<p>Other symptoms can be mistaken for disease like the flu and include headache, neck stiffness, reduced consciousness, muscle aches, joint pain, nausea and vomiting. If you are at all worried see your GP.</p>
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<a href="https://images.theconversation.com/files/198067/original/file-20171207-31532-t9o1bt.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/198067/original/file-20171207-31532-t9o1bt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/198067/original/file-20171207-31532-t9o1bt.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/198067/original/file-20171207-31532-t9o1bt.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/198067/original/file-20171207-31532-t9o1bt.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/198067/original/file-20171207-31532-t9o1bt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/198067/original/file-20171207-31532-t9o1bt.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/198067/original/file-20171207-31532-t9o1bt.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Symptoms of meningoccal disease can be vague and non-specific, or mistaken for other illnesses.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/291045173?src=X8ALwvwlKUCxgYFHvEroRQ-1-3&size=vector_eps">Shutterstock</a></span>
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<p>Once infected the <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-fact-sheet.pdf">death rate</a> is around 5–10%. About 10–30% of children and adolescents who survive the disease <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-fact-sheet.pdf">can develop permanent complications</a>, such as limb deformity, skin scarring, deafness and neurological deficits. </p>
<p>Early diagnosis and treatment with antibiotics can improve the patient’s outcomes but the disease can largely be prevented by vaccination.</p>
<h2>How common is meningococcal disease?</h2>
<p>Using differences in the surface “sugars” (polysaccharides) of the <em>Neisseria meningitidis</em> organism’s outer membrane capsule, we are able to classify the bacteria into serogroups (types), and each serogroup is given a letter of the alphabet, for example, A, B, C and so on. There are 13 different serogroups. </p>
<p>Globally, most meningococcal disease is caused by serogroups A, B, C, W and Y. These were chosen as the targets for vaccines. </p>
<p>The bug poses the greatest risk of infection in those people with immune system weaknesses. But healthy people in our community who are smokers, live in crowded living conditions, engage in intimate kissing with multiple partners (hence adolescents and young adults), and those with a recent or current viral respiratory infection are also targets.</p>
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Read more:
<a href="https://theconversation.com/health-check-which-vaccinations-should-i-get-as-an-adult-81400">Health Check: which vaccinations should I get as an adult?</a>
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<p>The burden of meningococcal disease fluctuates naturally over time. The rate declined from 2002 to 2013, but has been on the increase since 2014. </p>
<p>Serogroup C disease has become very rare (<a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-fact-sheet.pdf">accounting for only 1.2% of cases</a> in 2016) since the introduction of a free vaccine in 2003. </p>
<p>Serogroup B disease <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-fact-sheet.pdf">has been dominant until recently</a>, but has been naturally declining in most states and territories, even without widespread vaccination against this serogroup. </p>
<p>Serogroup W disease has increased since 2013. This is now the main cause of meningococcal disease in Australia, <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-fact-sheet.pdf">accounting for 44.7% of cases</a> in 2016. </p>
<p>Children aged under two years have the highest rates of meningococcal W and Y disease, followed by older adolescents. </p>
<h2>Vaccination options</h2>
<p>No single vaccine offers protection against all serogroups that cause meningococcal disease, but there are safe and effective vaccines that can protect against five serogroups (A,B,C,W,Y). The vaccines cover different serogroups and it does get confusing so here are the basics.</p>
<p>There are three types of meningococcal vaccines registered in Australia, which cover the following serogroups: </p>
<ul>
<li>Meningococcal C (MenC)</li>
<li>Meningococcal B (MenB) </li>
<li>Meningococcal A, C, W, Y (MenACWY). </li>
</ul>
<p>All these vaccines include “killed” parts of the bacteria in order to stimulate an immune response. This means if someone comes into contact with the bacteria, for example via kissing, then they already have immunity and don’t get the nasty disease. It’s not possible for the vaccine to cause meningococcal disease.</p>
<h2>Menigococcal C vaccine</h2>
<p>The MenC vaccine is given for free to all Australian infants at 12 months of age under our <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/national-immunisation-program-schedule">National Immunisation Program</a>. It’s given as a combination vaccine with the trade name Menitorix® and protects against meningococcal C and another bacteria called <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-hib"><em>Haemophilus influenzae</em> type b</a>.</p>
<p>The MenC vaccine has reduced the rate of meningoccocal C <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-fact-sheet.pdf">by 96%</a> since its introduction. </p>
<p>Although serogroup C disease is now not common, it’s not completely eradicated so get your child vaccinated at 12 months. </p>
<h2>Menigococcal B vaccine</h2>
<p>The <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-FAQ.pdf">MenB vaccine</a>, which has the trade name Bexsero®, is not on the national immunisation program and will cost you around A$95-150 per dose, depending on what your pharmacist or GP charges. It might be worth calling a few different pharmacies to check their price. </p>
<p>It’s strongly recommended for people who either have immune system weaknesses, work in environments where there’s a high chance of exposure (such as health care or laboratory workers), or live in close proximity to others (such as military recruits and those in boarding houses or residential accommodation). </p>
<p>Children, especially those aged under two, and adolescents aged 15 to 19 years are also at increased risk. </p>
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Read more:
<a href="https://theconversation.com/more-reason-to-use-meningococcal-b-vaccine-it-could-also-cut-the-clap-80739">More reason to use Meningococcal B vaccine – it could also cut the Clap</a>
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<p>The younger you start the MenB vaccine the more doses you need. If starting between six weeks to five months old, the child needs three doses* plus a booster dose at 12 months old; if over six months old, then two doses as a minimum and a booster dose depending on the age at which you started. Adolescents need two doses.</p>
<p>Infants should be given a medicine like paracetamol at the time of vaccination to reduce the chance of the vaccine causing a fever. </p>
<h2>Menigococcal ACWY vaccine</h2>
<p><a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-FAQ.pdf">Three vaccines</a> are available in Australia, which have the trade names of Menveo®, Menactra® and Nimenrix®. </p>
<p>Like the MenB vaccine, the number of doses needed depends on the age you start vaccinating (babies under six months need four doses; 7- to 11-month olds need two doses and 12-23 month olds need one or two doses (either one dose of Nimenrix® or two doses of Menveo®); and if started over two years, the child only needs one dose). Menveo® is the only vaccine registered for use in babies under one. </p>
<p>In all states except South Australia (where a MenB program is currently underway), MenACWY will be given to adolescents in years 11 and 12 via high school-based programs. This is in response to the recent emergence of MenW disease around parts of the country. </p>
<p>Parents wanting to vaccinate younger children will have to pay around A$55-90 per dose, depending on the brand you choose and what your pharmacist and GP charges. (Again, different pharmacies may have different prices).</p>
<h2>What should you get?</h2>
<p>The inevitable question parents ask is, “should I pay to get my child vaccinated against MenB and MenACWY?” </p>
<p>In an ideal world, the answer would be “give both vaccines”. If you or your child has immune system weaknesses then definitely <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-FAQ.pdf">go for both optional vaccines</a>.</p>
<p>Another way to answer would be to state what we know. We know both vaccines are effective against severe disease. We know they can be given on the same day safely. But we also know no vaccine is 100% effective, and a person may still become infected even after immunisation. </p>
<p>If you are very worried your child may have meningococcal disease, whether vaccinated or not, seek medical advice immediately.</p>
<p><em>Editor’s note: since this article was first published, the meningococcal ACWY (Nimenrix®) vaccine has been added to the <a href="https://beta.health.gov.au/health-topics/immunisation/immunisation-throughout-life/national-immunisation-program-schedule">National Immunisation Program Schedule</a> for children at 12 months. The vaccine will also be available for all adolescents aged 14-19 from April 2019.</em></p>
<p><em>*Correction: this article originally said adolescents needed one dose of the MenB vaccine, rather than two, and did not mention boosters.</em></p><img src="https://counter.theconversation.com/content/88769/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicholas Wood receives funding from the NHMRC. The CHildren's Hospital at Westmead has had GSK support for investigator-initiated studies in the past. </span></em></p>Meningococcal is a rare but very serious infection that can lead to blood poisoning and brain infection. But no single vaccine protects against all the strains.Nicholas Wood, Associate Professor, Discipline of Childhood and Adolescent Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.