The survival and nutritional status of children in relation to aspects of maternal health : follow-up studies in rural Uganda

Background: Low income countries continue to experience high under-five mortality and a high prevalence of protein energy malnutrition (PEM) among surviving children. There is lack of empirical data for accurate tracking of child survival and for determining the consequences of early childhood PEM on future health and education.

Main aim: To assess under–five mortality trends and associated factors to inform the design of child survival interventions, and also examine the impact of childhood PEM on future adolescent health and schooling among survivors in a rural population in Uganda.

Methods: Four studies were nested in the Kyamulibwa Health and Demographic Surveillance Site in southwestern Uganda. In study 1, prospective data collected between 2002 and 2012 were extracted for 10,118 children under the age of five years and used to estimate age-specific mortality rates using the synthetic cohort life-table method. Calendar year-specific hazard rates and risk factors were explored by Cox regression. In study II, women of reproductive age were enrolled and stillbirth rates were compared using i) 12 months recall of pregnancy outcome (n= 1800) (method 1) and ii) lifetime recall (method 2) and associated risk factors were explored. In study III, 1054 children followed to adolescence were categorised as stunted/wasted, recovered, deteriorated and normal after three nutritional assessments between 1999 and 2011. Mean blood pressures and schooling years achieved measured in 2011 were compared in the 4 groups. In study IV, a pragmatic trial, involving registration of pregnancies and delivering stage-of-pregnancy-specific text message (SMS) via community health workers to pregnant women in 13 intervention villages (n=262) compared with pregnant women in control villages (n=263) with no intervention. Place of birth (home or health facility) was the main outcome.

Results: Under-five mortality was 92 per 1000 live births. Overall mortality declined by 33% between 2002 and 2012 with the highest decline observed in the post-neonatal period. Early neonatal mortality did not change. Stillbirth rates differed by method of estimation; 26.2/1000 births versus 13.8/1000 births respectively by methods 1 and 2. No decline in stillbirth rates was observed. Under-five mortality increased with decreasing child age, HIV infection of the child, a birth interval <1 year, having an unmarried mother, a maternal parity >4 and a home delivery. Stillbirth risk increased with maternal age and reduced with increasing parity. In study III, wasting was negatively associated with systolic blood pressure (-7.90 95%CI [-14.52,-1.28], p= 0.02) and diastolic blood pressure (-3.92, 95%CI [-7.42, -0.38], p= 0.03) among surviving children. Recovery from wasting was positively associated with diastolic blood pressure (1.93, 95%CI (0.11, 3.74] p=0.04). Both stunting and wasting regardless of recovery were negatively associated with school achievement. In study IV, the SMS intervention was associated with lower odds of homebirths [AOR=0.38, 95%CI (0.15-0.97)]. Home births were associated with muslim religion [AOR= 4.0, 95%CI (1.72-9.34)], primary or no maternal education [AOR= 2.51, 95%CI (1.00-6.35)] and health facility distance ≥ 2 km [AOR= 2.26, 95%CI (0.95-5.40)].

Conclusions: Survival of children in rural Uganda is improving, and could improve further with increased uptake of family planning and facility births. Promoting community health workers‘ role in improving child survival through use of mobile phones for delivering tailored messages to mothers is a potential strategy that could be scaled up in rural communities.

List of scientific papers

I. Gershim Asiki, Robert Newton, Lena Marions, Janet Seeley, Anatoli Kamali, and Lars Smedman. The Impact of Maternal Factors on Mortality Rates among Children under the Age of Five Years in a Rural Ugandan Population between 2002 and 2012. Acta Paediatrica. (2015).
https://doi.org/10.1111/apa.13252

II. Gershim Asiki, Kathy Baisley, Robert Newton, Lena Marions, Janet Seeley, Anatoli Kamali, and Lars Smedman. Adverse Pregnancy Outcomes in Rural Uganda (1996–2013): Trends and Associated Factors from Serial Cross Sectional Surveys. BMC pregnancy and childbirth. 15 (2015), 1.
https://doi.org/10.1186/s12884-015-0708-8

III. Gershim Asiki, Robert Newton, Lena Marions, Anatoli Kamali, Lars Smedman. The effect of childhood protein energy malnutrition on adolescent health and school achievement in rural south-western Uganda: a prospective cohort study. [Submitted]

IV. Gershim Asiki, Robert Newton, Leonard Kibirige, Anatoli Kamali, Lena Marions, Lars Smedman. Feasibility of using smartphones by village health workers for pregnancy registration and effectiveness of mobile phone text messages on reduction of homebirths: a pragmatic trial in rural Uganda. [Submitted]