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      Iron/folic acid supplementation during pregnancy prevents neonatal and under-five mortality in Pakistan: propensity score matched sample from two Pakistan Demographic and Health Surveys

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          Abstract

          Background

          Several epidemiological studies from low- and middle-income countries have reported a protective effect of maternal antenatal iron/folic acid (IFA) on childhood mortality.

          Objective

          The current study aimed to evaluate the effect of maternal antenatal IFA supplementation on childhood mortality in Pakistan.

          Design

          A propensity score–matched sample of 8,512 infants live-born within the 5 years prior to interview was selected from the pooled data of two Pakistan Demographic and Health Surveys (2006/07 and 2012/13). The primary outcomes were childhood mortality indicators and the main exposure variable was maternal antenatal IFA supplementation. Post-matched analyses used Cox proportional hazards regression and adjusted for 16 potential confounders.

          Results

          Maternal antenatal IFA supplementation significantly reduced the adjusted risk of death on day 0 by 33% [adjusted hazard ratio (aHR)=0.67, 95% confidence interval (95% CI) 0.48–0.94], during the neonatal period by 29% (aHR=0.71, 95% CI 0.57–0.88), and for under-fives by 27% (aHR=0.73, 95% CI 0.60–0.89). When IFA was initiated in the first 4 months of pregnancy, the adjusted risk of neonatal and under-five deaths was significantly reduced by 35 and 33%, respectively. Twenty percent of under-five deaths were attributable to non-initiation of IFA in the first 4 months of pregnancy. With universal initiation of IFA in the first 4 months of pregnancy, 80,300 under-five deaths could be prevented annually in Pakistan.

          Conclusions

          Maternal antenatal IFA supplementation significantly reduced neonatal and under-five deaths in Pakistan. Earlier initiation of supplements in pregnancy was associated with a greater prevention of neonatal and under-five deaths.

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          Most cited references41

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          Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India.

          Using data from India, we estimate the relationship between household wealth and children's school enrollment. We proxy wealth by constructing a linear index from asset ownership indicators, using principal-components analysis to derive weights. In Indian data this index is robust to the assets included, and produces internally coherent results. State-level results correspond well to independent data on per capita output and poverty. To validate the method and to show that the asset index predicts enrollments as accurately as expenditures, or more so, we use data sets from Indonesia, Pakistan, and Nepal that contain information on both expenditures and assets. The results show large, variable wealth gaps in children's enrollment across Indian states. On average a "rich" child is 31 percentage points more likely to be enrolled than a "poor" child, but this gap varies from only 4.6 percentage points in Kerala to 38.2 in Uttar Pradesh and 42.6 in Bihar.
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            Anemia and iron deficiency: effects on pregnancy outcome.

            This article reviews current knowledge of the effects of maternal anemia and iron deficiency on pregnancy outcome. A considerable amount of information remains to be learned about the benefits of maternal iron supplementation on the health and iron status of the mother and her child during pregnancy and postpartum. Current knowledge indicates that iron deficiency anemia in pregnancy is a risk factor for preterm delivery and subsequent low birth weight, and possibly for inferior neonatal health. Data are inadequate to determine the extent to which maternal anemia might contribute to maternal mortality. Even for women who enter pregnancy with reasonable iron stores, iron supplements improve iron status during pregnancy and for a considerable length of time postpartum, thus providing some protection against iron deficiency in the subsequent pregnancy. Mounting evidence indicates that maternal iron deficiency in pregnancy reduces fetal iron stores, perhaps well into the first year of life. This deserves further exploration because of the tendency of infants to develop iron deficiency anemia and because of the documented adverse consequences of this condition on infant development. The weight of evidence supports the advisability of routine iron supplementation during pregnancy.
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              The role of conceptual frameworks in epidemiological analysis: a hierarchical approach.

              This paper discusses appropriate strategies for multivariate data analysis in epidemiological studies. In studies where determinants of disease are sought, it is suggested that the complex hierarchical inter-relationships between these determinants are best managed through the use of conceptual frameworks. Failure to take these aspects into consideration is common in the epidemiological literature and leads to underestimation of the effects of distal determinants. An example of this analytical approach, which is not based purely on statistical associations, is given for assessing determinants of mortality due to diarrhoea in children. Conceptual frameworks provide guidance for the use of multivariate techniques and aid the interpretation of their results in the light of social and biological knowledge.
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                Author and article information

                Journal
                Glob Health Action
                Glob Health Action
                GHA
                Global Health Action
                Co-Action Publishing
                1654-9716
                1654-9880
                11 February 2016
                2016
                : 9
                : 10.3402/gha.v9.29621
                Affiliations
                [1 ]United Nations Office for Project Services, Islamabad, Pakistan
                [2 ]Sydney School of Public Health, University of Sydney, Sydney, Australia
                Author notes
                [* ]Correspondence to: Yasir B. Nisar, Program Health and Monitoring and Evaluation Specialist, United Nations Office for Project Services (UNOPS), Plot No 5-11, UN Compound, Islamabad, Pakistan, Email: drbin01@ 123456hotmail.com

                Responsible Editor: Stig Wall, Umeå University, Sweden.

                Article
                29621
                10.3402/gha.v9.29621
                4752592
                26873178
                bd5b357f-b32b-46b5-8051-cca5d1076095
                © 2016 Yasir B. Nisar and Michael J. Dibley

                This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

                History
                : 03 September 2015
                : 04 January 2016
                : 20 January 2016
                Categories
                Original Article

                Health & Social care
                propensity score,antenatal care,iron/folic acid supplements,mortality,neonatal,under-five

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