United Nations Children's Fund Zambia

OBJECTIVE: Optimal utilization of maternal health-care services is associated with reduction of mortality and morbidity for both mothers and their neonates. However, deficiencies and disparity in the use of key maternal health services within most developing countries still persist. We examined patterns and predictors associated with the utilization of specific indicators for maternal health services among mothers living in the poorest and remote district populations of Zambia. METHODS: A cross-sectional baseline household survey was conducted in May 2012. A total of 551 mothers with children between the ages 0 and 5 months were sampled from 29 catchment areas in four rural and remote districts of Zambia using the lot quality assurance sampling method. Using multilevel modeling, we accounted for individual- and community-level factors associated with utilization of maternal health-care services, with a focus on antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC). RESULTS: Utilization rates of focused ANC, SBA, and PNC within 48 h were 30, 37, and 28%, respectively. The mother's ability to take an HIV test and receiving test results and uptake of intermittent preventive treatment for malaria were positive predictors of focused ANC. Receiving ANC at least once from skilled personnel was a significant predictor of SBA and PNC within 48 h after delivery. Women who live in centralized rural areas were more likely to use SBA than those living in remote rural areas. CONCLUSION: Utilization of maternal health services by mothers living among the remote and poor marginalized populations of Zambia is much lower than the national averages. Finding that women that receive ANC once from a skilled attendant among the remote and poorest populations are more likely to have a SBA and PNC, suggests the importance of contact with a skilled health worker even if it is just once, in influencing use of services. Therefore, it appears that in order for women in these marginalized communities to benefit from SBA and PNC, it is important for them to have at least one ANC provided by a skilled personnel, rather than non-skilled health-care providers.

Vaccination is critical to minimize serious illness and death from COVID-19. Yet uptake of COVID-19 vaccines remains highly variable, particularly among marginalized communities. This article shares lessons learned from four UNICEF interventions that supported Governments to generate acceptance and demand for COVID-19 vaccines in Zambia, Iraq, Ghana, and India. In Zambia, community rapid assessment provided invaluable real-time insights around COVID-19 vaccination and allowed the identification of population segments that share beliefs and motivations regarding COVID-19 vaccination. Findings were subsequently used to develop recommendations tailored to the different personas. In Iraq, a new outreach approach (3iS: Intensification of Integrated Immunization) utilized direct community engagement to deliver health messages and encourage service uptake, resulting in over 4.4 million doses of COVID-19 and routine immunization vaccines delivered in just 8 months. In Ghana, a human-centered design initiative was applied to co-develop community-informed strategies to improve COVID-19 vaccination rates. In India, a risk communication and community engagement initiative reached half a million people over six months, translating into a 25% increase in vaccination rates. These shared approaches can be leveraged to improve COVID-19 vaccination coverage and close gaps in routine immunization across diverse and marginalized communities.

INTRODUCTION: Effective community health management information systems (C-HMIS) are important in low-resource countries that rely heavily on community-based health care providers. Zambia currently lacks a functioning C-HMIS to provide real-time, community-based health information from community health workers (CHWs) to health center staff and higher levels of the health system. PROGRAM DESCRIPTION: We developed a C-HMIS mobile platform for use by CHWs providing integrated community case management (iCCM) services and their supervisors to address challenges of frequent stock-outs and inadequate supportive supervision of iCCM-trained CHWs. The platform used simple feature mobile phones on which were loaded the District Health Information System version 2 (DHIS2) software and Java 2 platform micro edition (J2ME) aggregation and tracker applications. This project was implemented in Chipata and Chadiza districts, which supported previous mHealth programs and had cellular coverage from all 3 major network carriers in Zambia. A total of 40 CHWs and 20 CHW supervisors received mobile phones with data bundles and training in the mobile application, after which they implemented the program over a period of 5.5 months, from February to mid-July 2016. CHWs used the mobile phones to submit data on iCCM cases seen, managed, and referred, as well as iCCM medical and diagnostic supplies received and dispensed. Using their mobile phones, the supervisors tracked CHWs' reported cases with medicine consumption, sent CHWs feedback on their referrals, and received SMS reminders to set up mentorship sessions. OBSERVATIONS: CHWs were able to use the mobile application to send weekly reports to health center supervisors on disease caseloads and medical commodities consumed, to make drug and supply requisitions, and to send pre-referral notices to health centers. Health center staff used the mobile system to provide feedback to CHWs on the case outcomes of referred patients and to receive automated monthly SMS reminders to invite CHWs to the facility for mentorship. District- and central-level staff were able to access community-level health data in real time using passwords. LESSONS LEARNED: C-HMIS, using simple feature phones, was feasible and viable for the provision of real-time community-based health information to all levels of the health care system in Zambia, but smartphones, laptops, or desktop computers are needed to perform data analysis and visualization. Ongoing technical support is needed to address the hardware and software challenges CHWs face in their day-to-day interaction with the application on their mobile phones.

OBJECTIVE: To investigate trends in child malnutrition in six countries in southern Africa, in relation to the HIV epidemic and drought in crop years 2001/2 and 2002/3. DESIGN: Epidemiological analysis of sub-national and national surveys with related data. SETTING: Data from Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe, compiled and analysed under UNICEF auspices. SUBJECTS: Secondary data: children 0-5 years for weight-for-age; HIV prevalence data from various sources especially antenatal clinic surveillance. RESULTS: Child nutritional status as measured by prevalence of underweight deteriorated from 2001 onwards in all countries except Lesotho, with very substantial increases in some provinces/districts (e.g. from 5 to 20% in Maputo (Mozambique, 1997-2002), 17 to 32% in Copperbelt (Zambia, 1999-2001/2) and 11 to 26% in Midlands province (Zimbabwe, 1999-2002)). Greater deterioration in underweight occurred in better-off areas. Areas with higher HIV/AIDS prevalences had (so far) lower malnutrition rates (and infant mortality rates), presumably because more modern areas--with greater reliance on trade and wage employment--have more HIV/AIDS. Areas with higher HIV/AIDS showed more deterioration in child nutrition. A significant area-level interaction was found of HIV/AIDS with the drought period, associated with particularly rapid deterioration in nutritional status. CONCLUSIONS: First, the most vulnerable may be households in more modern areas, nearer towns, to whom resources need to be directed. Second, the causes of this vulnerability need to be investigated. Third, HIV/AIDS amplifies the effect of drought on nutrition, so rapid and effective response will be crucial if drought strikes again. Fourth, expanded nutritional surveillance is now needed to monitor and respond to deteriorating trends. Finally, with or without drought, new means are needed of bringing help, comfort and assistance to the child population.

BACKGROUND: A community-based intervention comprising both men and women, known as Safe Motherhood Action Groups (SMAGs), was implemented in four of Zambia's poorest and most remote districts to improve coverage of selected maternal and neonatal health interventions. This paper reports on outcomes in the coverage of maternal and neonatal care interventions, including antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) in the study areas. METHODOLOGY: Three serial cross-sectional surveys were conducted between 2012 and 2015 among 1,652 mothers of children 0-5 months of age using a 'before-and-after' evaluation design with multi-stage sampling, combining probability proportional to size and simple random sampling. Logistic regression and chi-square test for trend were used to assess effect size and changes in measures of coverage for ANC, SBA and PNC during the intervention. RESULTS: Mothers' mean age and educational status were non-differentially comparable at all the three-time points. The odds of attending ANC at least four times (aOR 1.63; 95% CI 1.38-1.99) and SBA (aOR 1.72; 95% CI 1.38-1.99) were at least 60% higher at endline than baseline surveillance. A two-fold and four-fold increase in the odds of mothers receiving PNC from an appropriate skilled provider (aOR 2.13; 95% CI 1.62-2.79) and a SMAG (aOR 4.87; 95% CI 3.14-7.54), respectively, were observed at endline. Receiving birth preparedness messages from a SMAG during pregnancy (aOR 1.76; 95% CI, 1.20-2.19) and receiving ANC from a skilled provider (aOR 4.01; 95% CI, 2.88-5.75) were significant predictors for SBA at delivery and PNC. CONCLUSIONS: Strengthening community-based action groups in poor and remote districts through the support of mothers by SMAGs was associated with increased coverage of maternal and newborn health interventions, measured through ANC, SBA and PNC. In remote and marginalised settings, where the need is greatest, context-specific and innovative task-sharing strategies using community health volunteers can be effective in improving coverage of maternal and neonatal services and hold promise for better maternal and child survival in poorly-resourced parts of sub-Saharan Africa.

BACKGROUND: There is considerable evidence that health systems, in so far as they ensure access to healthcare, promote population health even independent of other determinants. Access to child health services remains integral to improving child health outcomes. Cognisant that improvements in child health have been unevenly distributed, it is imperative that health services and research focus on the disadvantaged groups. Children residing in urban slums are known to face a health disadvantage that is masked by the common view of an urban health advantage. Granted increasing urbanisation rates and proliferation of urban slums resulting from urban poverty, the health of under-five children in slums remains a public health imperative in Malawi. We explored determinants of healthcare-seeking from a biomedical health provider for childhood symptoms of fever, cough with fast breathing and diarrhoea in three urban slums of Lilongwe, Malawi. METHODS: This was a population-based cross-sectional study involving 543 caregivers of under-five children. Data on childhood morbidity and healthcare seeking in three months period were collected using face-to-face interviews guided by a validated questionnaire. Data were entered in CS-Pro 5.0 and analysed in SPSS version 20 using descriptive statistics and logistic regression analyses. RESULTS: 61% of caregivers sought healthcare albeit 53% of them sought healthcare late. Public health facilities constituted the most frequently used health providers. Healthcare was more likely to be sought: for younger than older under-five children (AOR = 0.54; 95% CI: 0.30-0.99); when illness was perceived to be severe (AOR = 2.40; 95% CI: 1.34-4.30); when the presenting symptom was fever (AOR = 1.77; 95% CI: 1.10-2.86). Home management of childhood illness was negatively associated with care-seeking (AOR = 0.54; 95% CI: 0.36-0.81) and timely care-seeking (AOR = 0.44; 95% CI: 0.2-0.74). Caregivers with good knowledge of child danger signs were less likely to seek care timely (AOR = 0.57; 95% CI: 0.33-0.99). CONCLUSIONS: Even in the context of geographical proximity to healthcare services, caregivers in urban slums may not seek healthcare or when they do so the majority may not undertake timely healthcare care seeking. Factors related to the child, the type of illness, and the caregiver are central to the healthcare decision making dynamics. Improving access to under-five child health services therefore requires considering multiple factors.

As part of a larger study of adolescent sexual and reproductive health in urban Zambia, the issue of unwanted pregnancy and abortion was considered through the examination of the perceptions of both adolescents and adults. Young people rank sexual health as their primary health issue, and sexual behaviour is integrally linked into other aspects of their lives. Pregnancies were deemed to be a common occurrence amongst the adolescents, with an estimated two-thirds of unwanted pregnancies ending in unsafe abortion. The decision to abort is primarily determined by the reaction of the boyfriend and his willingness to accept paternity and the associated financial implications. Other crucial influences are the desire to stay in school and the stigma attached to unwanted pregnancy. The decision-making process regarding the abortion itself is related to the perceived advantages and disadvantages of various service providers. Around 40% of the respondents stated that in the event of an abortion being carried out, it would be performed either by the girl herself or with the assistance of other non-medical personnel. Less popular but still significant are traditional healers and private doctors. Formal health services tend to be rejected due to their poor perception by young people, centred on the lack of privacy and confidentiality, and the de facto illegal nature of abortion itself. The services of nurses are sought, but outside of the clinic setting. The most popular method of self-induced abortion is overdosing on chloroquine. Other methods involve the use of traditional medicines such as various types of roots, as well as more modern methods such as ingesting washing powder. Recommendations for policy-makers concentrate on the improvement of formal, 'youth friendly' health services and the development of appropriate outreach education methods which address specific concerns widely held by young people.

BACKGROUND: Rwanda's National PMTCT program aims to achieve elimination of new HIV infections in children by 2015. In November 2010, Rwanda adopted the WHO 2010 ARV guidelines for PMTCT recommending Option B (HAART) for all HIV-positive pregnant women extended throughout breastfeeding and discontinued (short course-HAART) only for those not eligible for life treatment. The current study aims to assess the cost-effectiveness of this policy choice. METHODS: Based on a cohort of HIV-infected pregnant women in Rwanda, we modelled the cost-effectiveness of six regimens: dual ARV prophylaxis with either 12 months breastfeeding or replacement feeding; short course HAART (Sc-HAART) prophylaxis with either 6 months breastfeeding, 12 months breastfeeding, or 18 months breastfeeding; and Sc-HAART prophylaxis with replacement feeding. Direct costs were modelled based on all inputs in each scenario and related unit costs. Effectiveness was evaluated by measuring HIV-free survival at 18 months. Savings correspond to the lifetime costs of HIV treatment and care avoided as a result of all vertical HIV infections averted. RESULTS: All PMTCT scenarios considered are cost saving compared to "no intervention." Sc-HAART with 12 months breastfeeding or 6 months breastfeeding dominate all other scenarios. Sc-HAART with 12 months breastfeeding allows for more children to be alive and HIV-uninfected by 18 months than Sc-HAART with 6 months breastfeeding for an incremental cost per child alive and uninfected of 11,882 USD. This conclusion is sensitive to changes in the relative risk of mortality by 18 months for exposed HIV-uninfected children on replacement feeding from birth and those who were breastfed for only 6 months compared to those breastfeeding for 12 months or more. CONCLUSION: Our findings support the earlier decision by Rwanda to adopt WHO Option B and could inform alternatives for breastfeeding duration. Local contexts and existing care delivery models should be part of national policy decisions.

OBJECTIVE: To assess how quality and availability of reproductive, maternal, neonatal (RMNH) services vary by district wealth and urban/rural status in Zambia. METHODS: We conducted a retrospective analysis of data from the Millennium Development Goal Acceleration Initiative baseline assessment of 117 health facilities in 9 districts. Quality was assessed through a composite score of 23 individual RMNH indicators, ranging from 0 to 1. Availability was evaluated by density of providers and facilities. Districts were divided into wealth groups based on the multidimensional poverty index (MPI). Relative inequity was calculated using the concentration index for quality indicators (positive favours rich, negative favours poor). Multivariable linear regression was performed for the dependent variable composite quality indicator using MPI, urban/rural, and facility level of care as independent variables. RESULTS: 13 hospitals, 85 health centres and 19 health posts were included. The RMNH composite quality indicator was 0.64. Availability of facilities and providers was universally low. The concentration index for the composite quality indicator was -0.015 [-0.043, 0.013], suggesting no clustering to favour either rich or poor districts. Rich districts had the highest absolute numbers of health facilities and providers, but lowest numbers per facility per 1 000 000 population. Urban districts had slightly better service quality, but not availability. Using regression analysis, only facility level of care was significantly associated with quality outcome. CONCLUSIONS: Composite quality of RMNH services did not vary by district wealth, but was slightly higher in urban districts. The availability data suggest that the higher population in richer districts outpaces health infrastructure.

Community-Led Total Sanitation (CLTS) and Household-Led Water Supply (HLWS) are zero subsidy approaches to water and sanitation service provision that have been recently piloted in Zambia. The increases in access to sanitation and toilet usage levels achieved in one year under CLTS were far greater than any achieved in subsidised programmes of the past. Similarly, HLWS has shown that rural households are willing to invest in their own infrastructure and that they can increase coverage of safe water without external hardware subsidy. The promotion of self-sufficiency rather than dependency is a key component of both approaches, as is the focus on the development of sustainable services rather than the external provision of infrastructure. Zero subsidy strategies have the potential to deliver far more rapid increases in service coverage and higher levels of sustainability than the conventional subsidised approaches that predominate in low-income countries.

OBJECTIVES: In Zambia, only 56% of rural women deliver in a health facility, and improving facility delivery rates is a priority of the Zambian government. 'Mama kit' incentives - small packages of childcare items provided to mothers conditional on delivering their baby in a facility - may encourage facility delivery. This study measured the impact and cost-effectiveness of a US$4 mama kit on rural facility delivery rates in Zambia. METHODS: A clustered randomised controlled trial was used to measure the impact of mama kits on facility delivery rates in thirty rural health facilities in Serenje and Chadiza districts. Facility-level antenatal care and delivery registers were used to measure the percentage of women attending antenatal care who delivered at a study facility during the intervention period. Results from the trial were then used to model the cost-effectiveness of mama kits at-scale in terms of cost per death averted. RESULTS: The mama kits intervention resulted in a statistically significant increase in facility delivery rates. The multivariate logistic regression found that the mama kits intervention increased the odds of delivering at a facility by 63% (P-value < 0.01, 95% CI: 29%, 106%), or an increase of 9.9 percentage points, yielding a cost-effectiveness of US$5183 per death averted. CONCLUSIONS: This evaluation confirms that low-cost mama kits can be a cost-effective intervention to increase facility delivery rates in rural Zambia. Mama kits alone are unlikely to completely solve safe delivery challenges but should be embedded in larger maternal and child health programmes.

BACKGROUND: Despite progress made over the past twenty years, child mortality remains high, with 5.3 million children under five years having died in 2018 globally. Pneumonia, diarrhoea, and malaria remain among the commonest causes of under-five mortality; contributing 15%, 8%, and 5% of global mortality respectively. Recent evidence shows that integrated community case management (iCCM) of pneumonia, diarrhoea, and malaria can reduce under-five mortality. However, despite growing evidence of the effectiveness of iCCM, there are implementation challenges, especially stock out of iCCM commodities and inadequate supportive supervision of community health workers (CHWs). This study aimed to address these two key challenges to successful iCCM implementation by using mobile health (mHealth) technology. METHODS: This cluster randomised controlled trial compared health centre catchment areas (clusters) where CHWs and their supervisors implemented mHealth-enhanced iCCM supportive supervision and supply chain management vs clusters implementing iCCM as per current Zambian guidelines. CHWs in intervention clusters used community DHIS2 platform on mobile phones to report on a weekly basis children with iCCM conditions and make requisitions for iCCM commodities. Their supervisors received electronic reports on disease caseloads and monthly automated supervision reminders. The supervisors on receipt of requisitions, organized the medical supplies and notified CHWs for collection. Intention-to-treat analysis on the primary outcome, the percentage of children aged 2-59 months receiving appropriate treatment for malaria, pneumonia, or diarrhoea from an iCCM trained CHW, was performed using a generalized linear model. Prevalence ratios and 95% confidence intervals comparing the prevalence of appropriate treatment in the intervention and control groups were calculated using log binomial regression with an exchangeable correlation matrix, adjusted for clustering by health facility. RESULTS: In the intervention clusters, 61.3% (98/160) of expected monthly supervision visits took place vs 52.0% (78/150) in the controls. A total of 3690 children 2-59 months old presented with malaria, diarrhoea, or pneumonia. In the intervention group, 65.9% (1,252/1,899) of children received appropriate care for iCCM conditions, compared to 63.3% (1,134/1,791) in the control group. The mHealth intervention was associated with 18.0% improvement in supportive supervision and 21.0% increase in appropriate treatment for pneumonia; these changes were not statistically significant. There was a 2-3-fold increase in the proportion of CHWs receiving supplies ordered: prevalence ratios ranged from 2.82 (confidence interval (CI) = 1.50, 5.30) to 3.01 (95% CI = 1.29, 7.00) depending on the particular commodity. CONCLUSION: This study was unable to determine whether using mHealth technology would strengthen supervision and supply chain management of iCCM commodities for community-level workers. There was no statistically significant effect of mHealth enhanced iCCM on appropriate diagnosis and treatment for children with malaria, pneumonia, and diarrhoea in rural Zambia. Longer term longitudinal studies are required to determine the impact of mHealth enhanced iCCM on health outputs and outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02866097.

ABSTRACTDespite evidence for the substantial benefits of school readiness among children in low- and middle-income countries (LMICs), most lack access to any pre-primary education at all, let alone...

OBJECTIVE: To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021. DESIGN: Descriptive multi-country secondary data analysis. SETTING: Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021. POPULATION: Liveborn infants. METHODS: Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study. RESULTS: Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%). CONCLUSIONS: Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

The global community has called for the elimination of new HIV infections among children by 2015 and keeping their mothers alive [1]. Though viewed by some as overly optimistic and aspirational, this call to action has generated unprecedented momentum and transformed the global dialogue around prevention of mother-to-child HIV transmission (PMTCT) to emphasize efficiency, effectiveness and measurable impact of efforts to prevent new pediatric HIV infections. The 2013 WHO guidelines for the use of antiretroviral drugs in pregnant and breastfeeding women also represent a major paradigm shift from previous recommendations for PMTCT in low and middle-income settings (Table 1) [2].Table 1: Summary of recommendations for use of antiretroviral drugs for pregnant and breastfeeding women and HIV-exposed infants in the 2013 WHO guidelines [2].For the first time, the ART strategy for pregnant women is fully harmonized with the recommended first-line regimen for nonpregnant adults (once-daily tenofovir + lamivudine/efavirenz + emtracitabine). And, perhaps, more dramatically, the PMTCT regimen will no longer be determined by the woman's health status. Rather, all women, irrespective of CD4+ T-cell count or clinical stage, will initiate standard first-line ART to reduce the risk of HIV transmission to the child and to her uninfected partners. For programmatic and operational reasons, particularly in generalized HIV epidemics, all pregnant and breastfeeding women with HIV should initiate ART as lifelong treatment (the 'option B+' approach), whereas in some countries, for women not eligible for ART for their own health, consideration can be given to stopping the antiretroviral drug regimen after the period of MTCT risk has ceased ('option B') [2]. Using pregnancy status as the sole criterion to initiate ART represents a substantial change from previous PMTCT guidance, which traditionally recommended different antiretroviral regimens (prophylaxis vs. treatment) on the basis of maternal health status and vertical transmission risk. This simplified approach – initiation of the tenofovir + lamivudine/efavirenz + emtracitabine for all pregnant and breastfeeding women and, for most, continuation as lifelong treatment – furthers the notion of treatment as prevention, which has been the basic tenet of PMTCT, and should dramatically expand access to ART among pregnant and breastfeeding women. Over the past decade, there has been a progressive increase in antiretroviral drug use for PMTCT, from single-dose nevirapine, to short-course prophylaxis, to, in 2010 [3], a stratified approach with lifelong ART for eligible pregnant women and, for healthier women, a prophylaxis regimen of either twice-daily zidovudine during pregnancy and daily nevirapine to their infants during breastfeeding (option A), or maternal triple antiretroviral drug through breastfeeding (option B). And although thought to be highly and equally efficacious regimens for preventing transmission, implementation in the field has been fraught with complexity. Few low and middle-income countries have been successful in efforts to scale up these antiretroviral regimens [4], particularly to identify and treat ART-eligible women who are at highest risk for both HIV disease progression and MTCT during pregnancy and breastfeeding [5]. In 2012, among pregnant women who needed ART for their own health, less than 50% received it in 10 priority countries for the elimination of mother-to-child transmission Global Plan [4]. By eliminating the need for CD4+ T-cell count determination to identify treatment eligibility, and with the use of the same once-daily regimen for all pregnant women as in nonpregnant adults, option B+ simplifies program implementation, and as demonstrated in Malawi [6], where the approach was innovated, should substantially improve ART uptake among pregnant and breastfeeding women [7]. Historically, the PMTCT community has been moderately conservative in recommended approaches and regimens, balancing risk of transmission, maternal health concerns, and safety of drugs for mother and fetus. There has been particular reluctance to use emtracitabine during pregnancy, given teratogenic effects observed in primates exposed in utero to emtracitabine, several reports of neural tube and other central nervous system defects in children with first trimester exposure [8], and an US Food and Drug Administration (FDA) pregnancy category D classification [9]. Given other drug options, emtracitabine was generally avoided for pregnant women and women considering pregnancy. However, emtracitabine use has increased over the past years in nonpregnant adult populations in low and middle-income settings and in 2010 WHO-recommended tenofovir + lamivudine/efavirenz + emtracitabine as first-line ART regimen for adults [3]. Given high rates of unintended pregnancy and late entry into antenatal care in many countries, this recommendation paved the way for increased emtracitabine use during pregnancy. Although data on both emtracitabine and tenofovir use in pregnant women remain limited, more data have become available since 2010 and provide increased reassurance around safety of the recommended regimen for use during pregnancy and breastfeeding [10–12]. In June 2012, WHO issued a technical update on emtracitabine use during pregnancy delineating the clinical and programmatic risks and benefits and concluding that the balance favored inclusion of emtracitabine as part of the preferred first-line ART regimen for pregnant women [13]. Harmonizing the available fixed dose combination tenofovir + lamivudine/efavirenz + emtracitabine as first-line treatment for adults and all pregnant women including those with higher CD4+ T-cell counts was a logical next step. Emtracitabine was further preferred over nevirapine given concerns about the increased risk of maternal hepatotoxicity of nevirapine in this group [14,15]. The following article by Ford et al. provides additional evidence of the safety of emtracitabine in pregnancy for women with HIV [16]. This is the third updated systematic review and meta-analysis, including data from the Antiretroviral Pregnancy Registry. Overall, there were 44 congenital anomalies reported among 1995 live births to women receiving emtracitabine in the first trimester. The authors found no increase in overall birth defects and no elevated signal for emtracitabine compared with other antiretroviral drug exposures in pregnancy [relative risk 0.78; 95% confidence interval (CI) 0.56–1.09]. With one identified neural tube defect, the estimated prevalence from the systematic review continues to be approximately 7 per 10 000 population (0.07%), which is comparable to the estimates of 0.1% in the general population. Although a much larger sample size is needed to definitively rule out a two-fold increase in low-incidence birth defects, these findings are reassuring. Similarly, concerns linger around tenofovir use during pregnancy. In adult and pediatric populations, tenofovir has been associated with renal dysfunction and bone density loss. Findings from several studies of infants with in-utero tenofovir exposure suggest no increase in poor pregnancy outcomes or congenital defects [12,17,18]. Studies are currently underway to formally evaluate tenofovir exposure on a variety of infant outcomes including growth and bone mineral content. Any antiretroviral drug use during pregnancy is not without risk to the fetus, but when balanced against the benefits of preventing infant infection and treating maternal HIV disease, ART use appears to be highly favorable. Operational and programmatic imperatives further support the choice of once-daily tenofovir + lamivudine/efavirenz + emtracitabine as the first-line regimen for pregnant and breastfeeding women. It will be, however, critical to continue to monitor outcomes and confirm the findings of Ford et al., as these drugs are more widely used in pregnant and breastfeeding populations. Over the past decade, the ART scale-up in low and middle-income countries has met with unprecedented success. More than 9.7 million people have initiated ART and an estimated 5.5 million AIDS-related deaths have been averted in low and middle-income countries [4]. Unfortunately, pregnant women have been somewhat marginalized and under-represented among those on ART [19]. Option B/B+ offers a unique opportunity to achieve equity for this population, but it will require thoughtful investment – investments in the health systems in which women and children receive PMTCT and other health services, as well as investments to transform PMTCT services into ART programs prepared to engage in lifetime ART care for this population [20]. The WHO 2013 guidelines for the use of antiretroviral drugs for treating and preventing HIV infection provides a platform and a catalyst to effectively prevent new pediatric HIV infections and keep mothers alive, but it remains up to the global community to ensure that these aspirations are realized. Acknowledgements Conflicts of interest Dr. Abrams was the co-chair of the maternal-child group for the WHO 2013 guidelines. Dr. Tsague was a member of the maternal-child group for the WHO 2013 guidelines.

Scaling the sanitation ladder decreases exposure to various illnesses including diarrheal disease, soil-transmitted helminths and trachoma. In rural Zambia, community-led total sanitation (CLTS) has been deployed to help Zambians scale the sanitation ladder. Analysis of monthly routine surveillance data of village-level sanitation coverage of 13,688 villages shows that villages moved up the sanitation ladder following CLTS intervention with more than one third of villages achieving 100% coverage of adequate sanitation. Villages also moved down the sanitation ladder – approximately half of those achieving 100% coverage of adequate sanitation also dropped from that coverage at some point during monitoring. Larger villages were less likely to achieve 100% coverage, and more likely to drop if they did achieve 100% coverage. Drops were more likely to occur during the wet season. Of those villages dropping from 100% coverage, more than half rebounded to 100% coverage. The adequate latrine components most likely to drop off from 100% coverage were handwashing stations and lids to cover holes, both key components in preventing disease transmission. These results have implications for water, sanitation and hygiene (WASH) programming – sustained support may be required to ensure villages move up the sanitation ladder and stay there.

Today, diarrhea remains the world's second leading cause of death and is the leading cause of malnutrition and stunting in children under five. Many cases of diarrhea in developing countries can be prevented through access to sanitation and water. In fact, water, sanitation, and hygiene reduce diarrhea risk by an estimated 30%. When Kamal Kar published his first paper on Community-Led Total Sanitation (CLTS) in 2003, 43% of sub-Saharan Africa's rural population was practicing open defecation. Initially taking flight in Asia, the CLTS approach was a novel shift in sanitation and hygiene improvement interventions from providing individual, household latrine subsidies to propelling subsidy-free, community-driven behavior change. Kar argues that CLTS is effective due to its focus on demand creation. By illustrating the communal costs of open defecation (e.g., that one person's bad habits result in another person's bad health), the CLTS program affects a communal resolve, i.e., "demand," for change. Akros, in partnership with Zambia's Ministry of Local Government and Housing (MLGH) and UNI-CEF, layered a unique mobile-to-web application over traditional CLTS delivery methods, resulting in an innovative service delivery and monitoring system dubbed "CLTS M2W." CLTS M2W uses mobile phones, automated data feedback loops, and engagement of traditional leaders to provide communities with the ability to clearly see their progress towards sanitation goals. CLTS M2W paved the way for unprecedented CLTS uptake in Zambia, facilitating the creation of over 1,500,000 new users of sanitation in 18 months. In short, CLTS creates the demand, and CLTS M2W creates the critical transparency necessary to drive sustained behavior change.

Malawi has one of the highest HIV prevalence rates (8.9%), and data suggest 27% pain prevalence among adolescents living with HIV (ALHIV) in Malawi. Pain among ALHIV is often under-reported and pain management is suboptimal. We aimed to explore stakeholders' perspectives and experiences on pain self-management for ALHIV and chronic pain in Malawi. We conducted cross-sectional in-depth qualitative interviews with adolescents/caregiver dyads and healthcare professionals working in HIV clinics. Data were audio-recorded, transcribed verbatim and translated (where applicable) then imported into NVivo version 12 software for framework analysis. We identified three main themes: (1) Experiencing "total pain": adolescents experienced physical, psychosocial, and spiritual pain which impacted their daily life activities. (2) Current self-management approaches: participants prefer group-based self-management approaches facilitated by healthcare professionals or peers at the clinic focussing on self-management of physical, psychosocial, and spiritual pain. (3) Current pain strategies: participants used prescribed drugs, traditional medicine, and non-pharmacological interventions, such as exercises to manage pain. A person-centred care approach to self-management of chronic pain among ALHIV is needed to mitigate the impact of pain on their daily activities. There is a need to integrate self-management approaches within the existing structures such as teen clubs in primary care.

Two case studies of parenting programs for parents of children 0 to 36 months of age, developed and implemented by Save the Children/Ministry of Health/Khesar Gyalpo University in Bhutan and UNICEF Zambia, were conducted by an independent research group. The focus was on how program delivery and scale-up were revised on the basis of feedback from implementation research. Feedback on workforce delivery quality was based on observations of deliveries using a monitoring form, as well as survey and interview data collected from the workforce. In-depth interviews with the resource team during the fourth year of implementation revealed how the feedback was used to address horizontal and vertical scaling. Delivery quality was improved in some cases by revising the delivery manual, offering refresher courses, and instituting regular monitoring. Scaling challenges in Zambia included slow progress with regard to reaching families in the two districts, which they addressed by trialing group sessions, and stemming workforce attrition. The challenges in Bhutan were low attendance and reducing the workload of providers. Vertical scaling challenges for both countries concerned maintaining demand through continuous advocacy at community and government levels to sustain financing and to show effectiveness in outcomes.

In response to the growing HIV/AIDS and other health-related issues, UNICEF through their U-Report platform receives thousands of messages (SMS) every day to provide prevention strategies, health case advice, and counseling support to vulnerable population. Due to a rapid increase in U-Report usage (up to 300% in last 3 years), plus approximately 1,000 new registrations each day, the volume of messages has thus continued to increase, which made it impossible for the team at UNICEF to process them in a timely manner. In this paper, we present a platform designed to perform automatic classification of short messages (SMS) in real-time to help UNICEF categorize and prioritize health-related messages as they arrive. We employ a hybrid approach, which combines human and machine intelligence that seeks to resolve the information overload issue by introducing processing of large-scale data at high-speed while maintaining a high classification accuracy. The system has recently been tested in conjunction with UNICEF in Zambia to classify short messages received via the U-Report platform on various health related issues. The system is designed to enable UNICEF make sense of a large volume of short messages in a timely manner. In terms of evaluation, we report design choices, challenges, and performance of the system observed during the deployment to validate its effectiveness.