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1.  Antenatal depression case-finding by community health workers in South Africa: feasibility of a mobile phone application 
Archives of women's mental health  2014;17(5):423-431.
Randomised controlled trials conducted in resource-limited settings have shown that once women with depressed mood are evaluated by specialists and referred for treatment, lay health workers can be trained to effectively administer psychological treatments. We sought to determine the extent to which community health workers could also be trained to conduct case finding using short and ultra-short screening instruments programmed into mobile phones.
Pregnant, Xhosa-speaking women were recruited independently in two cross-sectional studies (N=1,144 and N=361) conducted in Khayelitsha, South Africa and assessed for antenatal depression. In the smaller study, community health workers with no training in human subjects research were trained to administer the Edinburgh Postnatal Depression Scale (EPDS) during the routine course of their community-based outreach. We compared the operating characteristics of 4 short and ultra-short versions of the EPDS with the criterion standard of probable depression, defined as an EPDS-10 ≥13.
The prevalence of probable depression (475/1144 [42%] and 165/361 [46%]) was consistent across both samples. The 2-item subscale demonstrated poor internal consistency (Cronbach’s α ranged from 0.55-0.58). All 4 subscales demonstrated excellent discrimination, with area under the receiver operating characteristic curve (AUC) values ranging from 0.91-0.99. Maximal discrimination was observed for the 7-item depressive symptoms subscale: at the conventional screening threshold of ≥10, it had 0.97 sensitivity and 0.76 specificity for detecting probable antenatal depression.
The comparability of the findings across the two studies suggests that it is feasible to use community health workers to conduct case finding for antenatal depression.
PMCID: PMC4167933  PMID: 24682529
antenatal depression; case finding; South Africa
2.  Missed Opportunities along the Prevention of Mother-to-Child Transmission Services Cascade in South Africa: Uptake, Determinants, and Attributable Risk (the SAPMTCTE) 
PLoS ONE  2015;10(7):e0132425.
We examined uptake of prevention of mother-to-child HIV transmission (PMTCT) services, predictors of missed opportunities, and infant HIV transmission attributable to missed opportunities along the PMTCT cascade across South Africa.
A cross-sectional survey was conducted among 4–8 week old infants receiving first immunisations in 580 nationally representative public health facilities in 2010. This included maternal interviews and testing infants’ dried blood spots for HIV. A weighted analysis was performed to assess uptake of antenatal and perinatal PMTCT services along the PMTCT cascade (namely: maternal HIV testing, CD4 count test/result, and receiving maternal and infant antiretroviral treatment) and predictors of dropout. The population attributable fraction associated with dropouts at each service point are estimated.
Of 9,803 mothers included, 31.7% were HIV-positive as identified by reactive infant antibody tests. Of these 80.4% received some form of maternal and infant antiretroviral treatment. More than a third (34.9%) of mothers dropped out from one or more steps in the PMTCT service cascade. In a multivariable analysis, the following characteristics were associated with increased dropout from the PMTCT cascade: adolescent (<20 years) mothers, low socioeconomic score, low education level, primiparous mothers, delayed first antenatal visit, homebirth, and non-disclosure of HIV status. Adolescent mothers were twice (adjusted odds ratio: 2.2, 95% confidence interval: 1.5–3.3) as likely to be unaware of their HIV-positive status and had a significantly higher rate (85.2%) of unplanned pregnancies compared to adults aged ≥20 years (55.5%, p = 0.0001). A third (33.8%) of infant HIV infections were attributable to dropout in one or more steps in the cascade.
A third of transmissions attributable to missed opportunities of PMTCT services can be prevented by optimizing the uptake of PMTCT services. Identified risk factors for low PMTCT service uptake should be addressed through health facility and community-level interventions, including raising awareness, promoting women education, adolescent focused interventions, and strengthening linkages/referral-system between communities and health facilities.
PMCID: PMC4492960  PMID: 26147598
3.  Community-based prenatal screening for postpartum depression in a South African township 
To assess the feasibility of using community health workers to administer short or ultra-short screening instruments during routine community-based prenatal outreach for detecting probable depression at 12 weeks postpartum.
During pregnancy and at 12 weeks postpartum, the 10-item Edinburgh Postnatal Depression Scale (EPDS-10) was administered to 249 Xhosa-speaking black African women living in Khayelitsha, South Africa. We compared the operating characteristics of the prenatal EPDS-10, as well as 4 short and ultra-short subscales, with the criterion standard of probable postpartum depression.
Seventy-nine (31.7%) women were assessed as having probable postpartum depression. A prenatal EPDS-10 score of 13 or higher had 0.67 sensitivity and 0.67 specificity for detecting probable postpartum depression. Briefer subscales performed similarly.
Community health workers successfully conducted community-based screening for depression in a resource-limited setting using short or ultra-short screening instruments. However, overall feasibility was limited because prenatal screening failed to accurately predict probable depression during the postpartum period.
PMCID: PMC4053501  PMID: 24786139
Postpartum depression; Screening; Sub-Saharan Africa
4.  First population-level effectiveness evaluation of a national programme to prevent HIV transmission from mother to child, South Africa 
There is a paucity of data on the national population-level effectiveness of preventing mother-to-child transmission (PMTCT) programmes in high-HIV-prevalence, resource-limited settings. We assessed national PMTCT impact in South Africa (SA), 2010.
A facility-based survey was conducted using a stratified multistage, cluster sampling design. A nationally representative sample of 10 178 infants aged 4–8 weeks was recruited from 565 clinics. Data collection included caregiver interviews, record reviews and infant dried blood spots to identify HIV-exposed infants (HEI) and HIV-infected infants. During analysis, self-reported antiretroviral (ARV) use was categorised: 1a: triple ARV treatment; 1b: azidothymidine >10 weeks; 2a: azidothymidine ≤10 weeks; 2b: incomplete ARV prophylaxis; 3a: no antenatal ARV and 3b: missing ARV information. Findings were adjusted for non-response, survey design and weighted for live-birth distributions.
Nationally, 32% of live infants were HEI; early mother-to-child transmission (MTCT) was 3.5% (95% CI 2.9% to 4.1%). In total 29.4% HEI were born to mothers on triple ARV treatment (category 1a) 55.6% on prophylaxis (1b, 2a, 2b), 9.5% received no antenatal ARV (3a) and 5.5% had missing ARV information (3b). Controlling for other factors groups, 1b and 2a had similar MTCT to 1a (Ref; adjusted OR (AOR) for 1b, 0.98, 0.52 to 1.83; and 2a, 1.31, 0.69 to 2.48). MTCT was higher in group 2b (AOR 3.68, 1.69 to 7.97). Within group 3a, early MTCT was highest among breastfeeding mothers 11.50% (4.67% to 18.33%) for exclusive breast feeding, 11.90% (7.45% to 16.35%) for mixed breast feeding, and 3.45% (0.53% to 6.35%) for no breast feeding). Antiretroviral therapy or >10 weeks prophylaxis negated this difference (MTCT 3.94%, 1.98% to 5.90%; 2.07%, 0.55% to 3.60% and 2.11%, 1.28% to 2.95%, respectively).
SA, a high-HIV-prevalence middle income country achieved <5% MTCT by 4–8 weeks post partum. The long-term impact on PMTCT on HIV-free survival needs urgent assessment.
PMCID: PMC4345523  PMID: 25371480
5.  From Joint Thinking to Joint Action: A Call to Action on Improving Water, Sanitation, and Hygiene for Maternal and Newborn Health 
PLoS Medicine  2014;11(12):e1001771.
Yael Velleman and colleagues argue for stronger integration between the water, sanitation, and hygiene (WASH) and maternal and newborn health sectors.
Please see later in the article for the Editors' Summary
PMCID: PMC4264687  PMID: 25502229
6.  Food insecurity and its association with co-occurring postnatal depression, hazardous drinking, and suicidality among women in peri-urban South Africa 
Journal of affective disorders  2013;150(2):460-465.
Although the public health impacts of food insecurity and depression on both maternal and child health are extensive, no studies have investigated the associations between food insecurity and postnatal depression or suicidality.
We interviewed 249 women three months after they had given birth and assessed food insecurity, postnatal depression symptom severity, suicide risk, and hazardous drinking. Multivariable Poisson regression models with robust standard errors were used to estimate the impact of food insecurity on psychosocial outcomes.
Food insecurity, probable depression, and hazardous drinking were highly prevalent and co-occurring. More than half of the women (149 [59.8%]) were severely food insecure, 79 (31.7%) women met screening criteria for probable depression, and 39 (15.7%) women met screening criteria for hazardous drinking. Nineteen (7.6%) women had significant suicidality, of whom 7 (2.8%) were classified as high risk. Each additional point on the food insecurity scale was associated with increased risks of probable depression (adjusted risk ratio [ARR], 1.05; 95% CI, 1.02–1.07), hazardous drinking (ARR, 1.04; 95% CI, 1.00–1.09), and suicidality (ARR, 1.12; 95% CI, 1.02–1.23). Evaluated at the means of the covariates, these estimated associations were large in magnitude.
The study is limited by lack of data on formal DSM-IV diagnoses of major depressive disorder, potential sample selection bias, and inability to assess the causal impact of food insecurity.
Food insecurity is strongly associated with postnatal depression, hazardous drinking, and suicidality. Programmes promoting food security for new may enhance overall psychological well-being in addition to improving nutritional status.
PMCID: PMC3762324  PMID: 23707034
Food insecurity; Postnatal depression; Suicide; South Africa
7.  Patient Experiences following Acute HIV Infection Diagnosis and Counseling in South Africa 
PLoS ONE  2014;9(8):e105459.
Individuals in the acute stage of HIV infection (AHI) have an elevated potential to transmit HIV and play a critical role in the growth of the epidemic. Routine identification and counseling of individuals during AHI could decrease transmission behavior during this key period. However, diagnosis of AHI may present challenges distinct from those experienced through diagnosis of established HIV infection. A study was conducted in a public youth clinic outside of Cape Town, South Africa, to identify and counsel individuals with acute stage HIV infection. In-depth interviews were conducted with patients following diagnosis. After counseling, patients were accepting of the testing regimen used to diagnose AHI. They used the knowledge of having been recently infected to identify the source of their infection, but did not retain or place importance on information regarding the increased ability to transmit HIV during the acute stage. Future interventions directed at the reduction of HIV transmission following diagnosis with AHI will need to find ways of making this information more salient, possibly through more culturally meaningful educational approaches.
PMCID: PMC4143263  PMID: 25153674
8.  Value of a mobile information system to improve quality of care by community health workers 
South African journal of information management  2013;15(1):10.4102/sajim.v15i1.528.
We will be unable to achieve sustained impact on health outcomes with community health worker (CHW)-based interventions unless we bridge the gap between small scale efficacy studies and large scale interventions. Effective strategies to support the management of CHWs are central to bridging the gap. Mobile phones are broadly available, particularly in low and middle income countries (LAMIC's), where the penetration rate approaches 100%. In this article we describe how mobile phones may be combined with mobile web-based technology to assist in the management of CHWs in two projects in South Africa.
This paper is a descriptive one, drawing lessons from two Randomised Controlled Trials (RCT's), outlining how a mobile phone information system can be utilized to enhance the quality of health interventions. We organized our comprehensive management and supervision system around a previously published management framework. The system is composed of mobile phones utilized by CHWs and a web-based interface utilized by CHW supervisors. Computerized algorithms were designed with intervention and assessment protocols to aid in the real-time supervision and management of CHWs.
CHWs used mobile phones to initiate intervention visits and trigger content to be delivered during the course of intervention visits. Supervisors used the web-based interface for real-time monitoring of the location, timing, and content of intervention visits. Additional real-time support was provided through direct support calls in the event of crises in the field.
Mobile phone-based information system platforms offer significant opportunities to improve CHW-delivered interventions. The extent to which these efficiency gains can be translated into realized health gains for communities is yet to be tested.
PMCID: PMC4137890  PMID: 25147730
Mobile phones; community health workers; supervision; management; scale up
9.  Costs of Promoting Exclusive Breastfeeding at Community Level in Three Sites in South Africa 
PLoS ONE  2014;9(1):e79784.
Community-based peer support has been shown to be effective in improving exclusive breastfeeding rates in a variety of settings.
We conducted a cost analysis of a community cluster randomised-controlled trial (Promise-EBF), aimed at promoting exclusive infant feeding in three sites in South Africa. The costs were considered from the perspective of health service providers. Peer supporters in this trial visited women to support exclusive infant feeding, once antenatally and four times postpartum.
The total economic cost of the Promise-EBF intervention was US$393 656, with average costs per woman and per visit of US$228 and US$52, respectively. The average costs per woman and visit in an operational ‘non research’ scenario were US$137 and US$32 per woman and visit, respectively. Investing in the promotion of exclusive infant feeding requires substantial financial commitment from policy makers. Extending the tasks of multi-skilled community health workers (CHWs) to include promoting exclusive infant feeding is a potential option for reducing these costs. In order to avoid efficiency losses, we recommend that the time requirements for delivering the promotion of exclusive infant feeding are considered when integrating it within the existing activities of CHWs.
This paper focuses on interventions for exclusive infant feeding, but its findings more generally illustrate the importance of documenting and quantifying factors that affect the feasibility and sustainability of community-based interventions, which are receiving increased focus in low income settings.
PMCID: PMC3888383  PMID: 24427264
10.  Child survival: a message of hope but a call for renewed commitment in UNICEF report 
Reproductive Health  2013;10:64.
A recent UNICEF report Committing to Child Survival: A Promise Renewed Progress Report 2013 presents a comprehensive analysis of levels and trends in child mortality and progress towards MDG 4. The global under-five mortality rate has been cut nearly in half (47%) since 1990. However, during this same period, 216 million children are estimated to have died before their fifth birthday. Most of these deaths were from leading infectious diseases such as pneumonia, diarrhoea or malaria, or were caused by preventable neonatal causes such as those related to intra-partum complications. The highest mortality rates in the world are observed in low-income countries in sub-Saharan Africa and South Asia. Sub-Saharan Africa faces a particular challenge in that it not only has the highest under-five mortality in the world but it also has the fastest population growth. Progress is possible, however, and sharp reductions in child mortality have been observed at all levels of national income and in all regions. Some of the world’s poorest countries in terms of national income have made the strongest gains in child survival. Within countries, new analysis suggests that disparities in under-five mortality between the richest and the poorest households have declined in most regions of the world, with the exception of Sub-Saharan Africa. Furthermore, under-five mortality rates have fallen even among the poorest households in all regions. The report highlights the growing importance of neonatal deaths; roughly 44% of global under-five deaths — now 2.9 million a year — occur during the neonatal period, with up to 50% dying during their first day of life and yet over two-thirds of these deaths are preventable without intensive care. The report stresses how a continuum of care approach across the whole life cycle is the most powerful way of understanding and accelerating further progress.
PMCID: PMC3866945  PMID: 24325885
Child mortality; Under-five mortality; Neonatal mortality; A Promise Renewed
11.  Addressing health systems strengthening through an health equity lens 
BMC Health Services Research  2013;13(Suppl 2):S13.
PMCID: PMC3668237  PMID: 23819874
12.  Pathways of care-seeking during fatal infant illnesses in under-resourced South African settings 
The purpose of this study was to examine care-seeking during fatal infant illnesses in under-resourced South African settings to inform potential strategies for reducing infant mortality. We interviewed 22 caregivers of deceased infants in a rural community and 28 in an urban township. We also interviewed seven local leaders and 12 health providers to ascertain opinions about factors contributing to infant death.
Despite the availability of free public health services in these settings, many caregivers utilised multiple sources of care including allopathic, indigenous and home treatments. Urban caregivers reported up to eight points of care while rural caregivers reported up to four points of care. The specific pathways taken and combinations of care varied, but many caregivers used other types of care shortly after presenting at public services, indicating dissatisfaction with the care they received. Many infants died despite caregivers’ considerable efforts, pointing to critical deficiencies in the system of care serving these families. Initiatives that aim to improve assessment, management and referral practices by both allopathic and traditional providers (for example, through training and improved collaboration), and caregiver recognition of infant danger signs may reduce the high rate of infant death in these settings.
PMCID: PMC3254810  PMID: 22136954
Infant mortality; Health care seeking behaviour; South Africa; Qualitative research
13.  Optimizing community case management strategies to achieve equitable reduction of childhood pneumonia mortality: An application of Equitable Impact Sensitive Tool (EQUIST) in five low– and middle–income countries 
Journal of Global Health  2012;2(2):020402.
The aim of this study was to populate the Equitable Impact Sensitive Tool (EQUIST) framework with all necessary data and conduct the first implementation of EQUIST in studying cost–effectiveness of community case management of childhood pneumonia in 5 low– and middle–income countries with relation to equity impact.
Wealth quintile–specific data were gathered or modelled for all contributory determinants of the EQUIST framework, namely: under–five mortality rate, cost of intervention, intervention effectiveness, current coverage of intervention and relative disease distribution. These were then combined statistically to calculate the final outcome of the EQUIST model for community case management of childhood pneumonia: US$ per life saved, in several different approaches to scaling–up.
The current ‘mainstream’ approach to scaling–up of interventions is never the most cost–effective. Community–case management appears to strongly support an ‘equity–promoting’ approach to scaling–up, displaying the highest levels of cost–effectiveness in interventions targeted at the poorest quintile of each study country, although absolute cost differences vary by context.
The relationship between cost–effectiveness and equity impact is complex, with many determinants to consider. One important way to increase intervention cost–effectiveness in poorer quintiles is to improve the efficiency and quality of delivery. More data are needed in all areas to increase the accuracy of EQUIST–based estimates.
PMCID: PMC3529311  PMID: 23289077
14.  Why do families still not receive the child support grant in South Africa? A longitudinal analysis of a cohort of families across South Africa 
Child cash transfers are increasingly recognised for their potential to reduce poverty and improve health outcomes. South Africa‘s child support grant (CSG) constitutes the largest cash transfer in the continent. No studies have been conducted to look at factors associated with successful receipt of the CSG. This paper reports findings on factors associated with CSG receipt in three settings in South Africa (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal).
This study used longitudinal data from a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding by peer-counsellors in South Africa ( NCT00397150). 1148 mother-infant pairs were enrolled in the study and data on the CSG were collected at infant age 6, 12, 24 weeks and 18–24 months. A stratified cox proportional hazards regression model was fitted to the data to investigate factors associated with CSG receipt.
Uptake of the CSG amongst eligible children at a median age of 22 months was 62% in Paarl, 64% in Rietvlei and 60% in Umlazi. Possessing a birth certificate was found to be the strongest predictor of CSG receipt (HR 3.1, 95% CI: 2.4 -4.1). Other factors also found to be independently associated with CSG receipt were an HIV-positive mother (HR 1.2, 95% CI: 1.0-1.4) and a household income below R1100 (HR1.7, 95% CI: 1.1 -2.6).
Receipt of the CSG was sub optimal amongst eligible children showing administrative requirements such as possessing a birth certificate to be a serious barrier to access. In the spirit of promoting and protecting children’s rights, more efforts are needed to improve and ease access to this cash transfer program.
PMCID: PMC3534520  PMID: 23088827
15.  Early cessation of breastfeeding amongst women in South Africa: an area needing urgent attention to improve child health 
BMC Pediatrics  2012;12:105.
Breastfeeding is a critical component of interventions to reduce child mortality. Exclusive breastfeeding practice is extremely low in South Africa and there has been no improvement in this over the past ten years largely due to fears of HIV transmission. Early cessation of breastfeeding has been found to have negative effects on child morbidity and survival in several studies in Africa. This paper reports on determinants of early breastfeeding cessation among women in South Africa.
This is a sub group analysis of a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding in three South African sites (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal) between 2006 and 2008 ( no: NCT00397150). Infant feeding recall of 22 food and fluid items was collected at 3, 6, 12 and 24 weeks postpartum. Women’s experiences of breast health problems were also collected at the same time points. 999 women who ever breastfed were included in the analysis. Univariable and multivariable logistic regression analysis adjusting for site, arm and cluster, was performed to determine predictors of stopping breastfeeding by 12 weeks postpartum.
By 12 weeks postpartum, 20% of HIV-negative women and 40% of HIV-positive women had stopped all breastfeeding. About a third of women introduced other fluids, most commonly formula milk, within the first 3 days after birth. Antenatal intention not to breastfeed and being undecided about how to feed were most strongly associated with stopping breastfeeding by 12 weeks (Adjusted odds ratio, AOR 5.6, 95% CI 3.4 – 9.5 and AOR 4.1, 95% CI 1.6 – 10.8, respectively). Also important was self-reported breast health problems associated with a 3-fold risk of stopping breastfeeding (AOR 3.1, 95%CI 1.7 – 5.7) and the mother having her own income doubled the risk of stopping breastfeeding (AOR 1.9, 95% CI 1.3 – 2.8).
Early cessation of breastfeeding is common amongst both HIV-negative and positive women in South Africa. There is an urgent need to improve antenatal breastfeeding counselling taking into account the challenges faced by working women as well as early postnatal lactation support to prevent breast health problems.
PMCID: PMC3441849  PMID: 22827969
16.  Social, economic, political and health system and program determinants of child mortality reduction in China between 1990 and 2006: A systematic analysis 
Journal of Global Health  2012;2(1):010405.
Between 1990 and 2006, China reduced its under-five mortality rate (U5MR) from 64.6 to 20.6 per 1000 live births and achieved the fourth United Nation’s Millennium Development Goal nine years ahead of target. This study explores the contribution of social, economic and political determinants, health system and policy determinants, and health programmes and interventions to this success.
For each of the years between 1990 and 2006, we obtained an estimate of U5MR for 30 Chinese provinces from the annual China Health Statistics Yearbook. For each year, we also obtained data describing the status of 8 social, 10 economic, 2 political, 9 health system and policy, and six health programmes and intervention indicators for each province. These government data are not of the same quality as some other health information sources in modern China, such as articles with primary research data available in Chinese National Knowledge Infrastructure (CNKI) and Wan Fang databases, or Chinese Maternal and Child Mortality Surveillance system. Still, the comparison of relative changes in underlying indicators with the undisputed strong general trend of childhood mortality reduction over 17 years should still capture the main effects at the macro-level. We used multivariate random effect regression models to determine the effect of 35 indicators individually and 5 constructs defined by factor analysis (reflecting effects of social, economic, political, health systems and policy, and health programmes) on the reduction of U5MR in China.
In the univariate regression applied with a one-year time lag, social determinants of health construct showed the strongest crude association with U5MR reduction (R2 = 0.74), followed by the constructs for health programmes and interventions (R2 = 0.65), economic (R2 = 0.47), political (R2 = 0.28) and health system and policy determinants (R2 = 0.26), respectively. Similarly, when multivariate regression was applied with a one-year time lag, the social determinants construct showed the strongest effect (beta = 11.79, P < 0.0001), followed by the construct for political factors (beta = 4.24, P < 0.0001) and health programmes and interventions (beta = −3.45, P < 0.0001). The 5 studied constructs accounted for about 80% of variability in U5MR reduction across provinces over the 17-year period.
Vertical intervention programs, health systems strengthening or economic growth alone may all fail to achieve the desired reduction in child mortality when improvement of the key social determinants of health is lagging behind. To accelerate progress toward MDG4, low- and middle-income countries should undertake appropriate efforts to promote maternal education, reduce fertility rates, integrate minority populations and improve access to clean water and safe sanitation. A cross-sectoral approach seems most likely to have the greatest impact on U5MR.
PMCID: PMC3484751  PMID: 23198134
17.  Understanding the determinants of the complex interplay between cost-effectiveness and equitable impact in maternal and child mortality reduction 
Journal of Global Health  2012;2(1):010406.
One of the most unexpected outcomes arising from the efforts towards maternal and child mortality reduction is that all too often the objective success has been coupled with increased inequity in the population. The aim of this study is to analyze the determinants of the complex interplay between cost-effectiveness and equity and suggest strategies that will promote an impact on mortality that reduce population child health inequities.
We developed a conceptual framework that exposes the nature of the links between the five key determinants that need to be taken into account when planning equitable impact. These determinants are: (i) efficiency of intervention scale-up (requires knowledge of differential increase in cost of intervention scale-up by equity strata in the population); (ii) effectiveness of intervention (requires understanding of differential effectiveness of interventions by equity strata in the population); (iii) the impact on mortality (requires knowledge of differential mortality levels by equity strata, and understanding the differences in cause composition of overall mortality in different equity strata); (iv) cost-effectiveness (compares the initial cost and the resulting impact on mortality); (v) equity structure of the population. The framework is presented visually as a four-quadrant graph.
We use the proposed framework to demonstrate why the relationship between cost-effectiveness and equitable impact of an intervention cannot be intuitively predicted or easily planned. The relationships between the five determinants are complex, often nonlinear, context-specific and intervention-specific. We demonstrate that there will be instances when an equity-promoting approach, ie, trying to reach for the poorest and excluded in the population with health interventions, will also be the most cost-effective approach. However, there will be cases in which this will be entirely unfeasible, and where equity-neutral or even inequity-promoting approaches may be substantially more cost-effective. In those cases, investments into health system development among the poorest that would increase the quality and reduce the cost of intervention delivery would be required before intervention scale-up is planned.
The relationships between the most important determinants of cost-effectiveness and equitable impact of health interventions used to reduce maternal and child mortality are highly complex, and the effect on equity cannot be predicted intuitively, or by using simple linear models.
PMCID: PMC3484756  PMID: 23198135
19.  Infant feeding practices at routine PMTCT sites, South Africa: results of a prospective observational study amongst HIV exposed and unexposed infants - birth to 9 months 
We sought to investigate infant feeding practices amongst HIV-positive and -negative mothers (0-9 months postpartum) and describe the association between infant feeding practices and HIV-free survival.
Infant feeding data from a prospective observational cohort study conducted at three (of 18) purposively-selected routine South African PMTCT sites, 2002-2003, were analysed. Infant feeding data (previous 4 days) were gathered during home visits at 3, 5, 7, 9, 12, 16, 20, 24, 28, 32 and 36 weeks postpartum. Four feeding groups were of interest, namely exclusive breastfeeding, mixed breastfeeding, exclusive formula feeding and mixed formula feeding. Cox proportional hazards models were fitted to investigate associations between feeding practices (0-12 weeks) and infant HIV-free survival.
Six hundred and sixty five HIV-positive and 218 HIV-negative women were recruited antenatally and followed-up until 36 weeks postpartum. Amongst mothers who breastfed between 3 weeks and 6 months postpartum, significantly more HIV-positive mothers practiced exclusive breastfeeding compared with HIV-negative: at 3 weeks 130 (42%) versus 33 (17%) (p < 0.01); this dropped to 17 (11%) versus 1 (0.7%) by four months postpartum. Amongst mothers practicing mixed breastfeeding between 3 weeks and 6 months postpartum, significantly more HIV-negative mothers used commercially available breast milk substitutes (p < 0.02) and use of these peaked between 9 and 12 weeks. The probability of postnatal HIV or death was lowest amongst infants living in the best resourced site who avoided breastfeeding, and highest amongst infants living in the rural site who stopped breastfeeding early (mean and standard deviations: 10.7% ± 3% versus 46% ± 11%).
Although feeding practices were poor amongst HIV-positive and -negative mothers, HIV-positive mothers undertake safer infant feeding practices, possibly due to counseling provided through the routine PMTCT programme. The data on differences in infant outcome by feeding practice and site validate the WHO 2009 recommendations that site differences should guide feeding practices amongst HIV-positive mothers. Strong interventions are needed to promote exclusive breastfeeding (to 6 months) with continued breastfeeding thereafter amongst HIV-negative motherswho are still the majority of mothers even in high HIV prevalence setting like South Africa.
PMCID: PMC3348038  PMID: 22472507
PMTCT; HIV and Infant Feeding; Breastfeeding; HIV-free survival; Formula Feeding
20.  An effectiveness study of an integrated, community-based package for maternal, newborn, child and HIV care in South Africa: study protocol for a randomized controlled trial 
Trials  2011;12:236.
Progress towards MDG4 in South Africa will depend largely on scaling up effective prevention against mother to child transmission (PMTCT) of HIV and also addressing neonatal mortality. This imperative drives increasing focus on the neonatal period and particularly on the development and testing of appropriate models of sustainable, community-based care in South Africa in order to reach the poor. A number of key implementation gaps affecting progress have been identified. Implementation gaps for HIV prevention in neonates; implementation gaps for neonatal care especially home postnatal care; and implementation gaps for maternal mental health support. We have developed and are evaluating and costing an integrated and scaleable home visit package delivered by community health workers targeting pregnant and postnatal women and their newborns to provide essential maternal/newborn care as well as interventions for Prevention of Mother to Child Transmission (PMTCT) of HIV.
The trial is a cluster randomized controlled trial that is being implemented in Umlazi which is a peri-urban settlement with a total population of 1 million close to Durban in KwaZulu Natal, South Africa. The trial consists of 30 randomized clusters (15 in each arm). A baseline survey established the homogeneity of clusters and neither stratification nor matching was performed. Sample size was based on increasing HIV-free survival from 74% to 84%, and calculated to be 120 pregnant women per cluster. Primary outcomes are higher levels of HIV free survival and levels of exclusive and appropriate infant feeding at 12 weeks postnatally. The intervention is home based with community health workers delivering two antenatal visits, a postnatal visit within 48 hours of birth, and a further four visits during the first two months of the infants life. We are undertaking programmatic and cost effectiveness analysis to cost the intervention.
The question is not merely to develop an efficacious package but also to identify and test delivery strategies that enable scaling up, which requires effectiveness studies in a health systems context, adapting and testing Asian community-based studies in various African contexts.
Trial registration
PMCID: PMC3248873  PMID: 22044553
21.  Setting Research Priorities to Reduce Global Mortality from Childhood Pneumonia by 2015 
PLoS Medicine  2011;8(9):e1001099.
Igor Rudan and colleagues report the results of their consensus building exercise that identified health research priorities to help reduce child mortality from pneumonia.
PMCID: PMC3181228  PMID: 21980266
22.  Influences on Healthcare-seeking during Final Illnesses of Infants in Under-resourced South African Settings 
To examine how health caregivers in under-resourced South African settings select from among the healthcare alternatives available to them during the final illness of their infants, qualitative interviews were conducted with 39 caregivers of deceased infants in a rural community and an urban township. Nineteen local health providers and community leaders were also interviewed to ascertain opinions about local healthcare and other factors impacting healthcare-seeking choices. The framework analysis method guided qualitative analysis of data. Limited autonomy of caregivers in decision-making, lack of awareness of infant danger-signs, and identification of an externalizing cause of illness were important influences on healthcare-seeking during illnesses of infants in these settings. Health system factors relating to the performance of health workers and the accessibility and availability of services also influenced healthcare-seeking decisions. Although South African public-health services are free, the findings showed that poor families faced other financial constraints that impacted their access to healthcare. Often there was not one factor but a combination of factors occurring either concurrently or sequentially that determined whether, when, and from where outside healthcare was sought during final illnesses of infants. In addition to reducing health system barriers to healthcare, initiatives to improve timely and appropriate healthcare-seeking for sick infants must take into consideration ways to mitigate contextual problems, such as limited autonomy of caregivers in decision-making, and reconcile local explanatory models of childhood illnesses that may not encourage healthcare-seeking at allopathic services.
PMCID: PMC3190369  PMID: 21957677
Healthcare; Healthcare-seeking behaviour; Infant mortality; Medicine, Traditional; Qualitative research; South Africa
23.  Do improvements in outreach, clinical, and family and community-based services predict improvements in child survival? An analysis of serial cross-sectional national surveys 
BMC Public Health  2011;11:456.
There are three main service delivery channels: clinical services, outreach, and family and community. To determine which delivery channels are associated with the greatest reductions in under-5 mortality rates (U5MR), we used data from sequential population-based surveys to examine the correlation between changes in coverage of clinical, outreach, and family and community services and in U5MR for 27 high-burden countries.
Household survey data were abstracted from serial surveys in 27 countries. Average annual changes (AAC) between the most recent and penultimate survey were calculated for under-five mortality rates and for 22 variables in the domains of clinical, outreach, and family- and community-based services. For all 27 countries and a subset of 19 African countries, we conducted principal component analysis to reduce the variables into a few components in each domain and applied linear regression to assess the correlation between changes in the principal components and changes in under-five mortality rates after controlling for multiple potential confounding factors.
AAC in under 5-mortality varied from 6.6% in Nepal to -0.9% in Kenya, with six of the 19 African countries all experiencing less than a 1% decline in mortality. The strongest correlation with reductions in U5MR was observed for access to clinical services (all countries: p = 0.02, r2 = 0.58; 19 African countries p < 0.001, r2 = 0.67). For outreach activities, AAC U5MR was significantly correlated with antenatal care and family planning services, while AAC in immunization services showed no association. In the family- and community services domain, improvements in breastfeeding were associated with significant changes in mortality in the 30 countries but not in the African subset; while in the African countries, nutritional status improvements were associated with a significant decline in mortality.
Our findings support the importance of increasing access to clinical services, certain outreach services and breastfeeding and, in Africa, of improving nutritional status. Integrated programs that emphasize these services may lead to substantial mortality declines.
PMCID: PMC3141447  PMID: 21658267
24.  The case for launch of an international DNA-based birth cohort study 
Journal of Global Health  2011;1(1):39-45.
The global health agenda beyond 2015 will inevitably need to broaden its focus from mortality reduction to the social determinants of deaths, growing inequities among children and mothers, and ensuring the sustainability of the progress made against the infectious diseases. New research tools, including technologies that enable high-throughput genetic and ‘-omics’ research, could be deployed for better understanding of the aetiology of maternal and child health problems. The research needed to address those challenges will require conceptually different studies than those used in the past. It should be guided by stringent ethical frameworks related to the emerging collections of biological specimens and other health related information. We will aim to establish an international birth cohort which should assist low- and middle-income countries to use emerging genomic research technologies to address the main problems in maternal and child health, which are still major contributors to the burden of disease globally.
PMCID: PMC3484746  PMID: 23198101
25.  Explaining household socio-economic related child health inequalities using multiple methods in three diverse settings in South Africa 
Despite free healthcare to pregnant women and children under the age of six, access to healthcare has failed to secure better child health outcomes amongst all children of the country. There is growing evidence of socioeconomic gradient on child health outcomes
The objectives of this study were to measure inequalities in child mortality, HIV transmission and vaccination coverage within a cohort of infants in South Africa. We also used the decomposition technique to identify the factors that contribute to the inequalities in these three child health outcomes. We used data from a prospective cohort study of mother-child pairs in three sites in South African. A relative index of household socio-economic status was developed using principal component analysis. This paper uses the concentration index to summarise inequalities in child mortality, HIV transmission and vaccination coverage.
We observed disparities in the availability of infrastructure between least poor and most poor families, and inequalities in all measured child health outcomes. Overall, 75 (8.5%) infants died between birth and 36 weeks. Infant mortality and HIV transmission was higher among the poorest families within the sample. Immunisation coverage was higher among the least poor. The inequalities were mainly due to the area of residence and socio-economic position.
This study provides evidence that socio-economic inequalities are highly prevalent within the relatively poor black population. Poor socio-economic position exposes infants to ill health. In addition, the use of immunisation services was lower in the poor households. These inequalities need to be explicitly addressed in future programme planning to improve child health for all South Africans.
PMCID: PMC3086829  PMID: 21463530

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