BACKGROUND: Despite improvement, maternal mortality in Haiti remains high at 359/100,000 live births. Improving access to high quality antenatal and postnatal care has been shown to reduce maternal mortality and improve newborn outcomes. Little is known regarding the quality and uptake of antenatal and postnatal care among Haitian women. METHODS: Exit interviews were conducted with all pregnant and postpartum women seeking care from large health facilities (n = 10) in the Nord and Nord-Est department and communes of St. Marc, Verrettes, and Petite Riviere in Haiti over the study period (March-April 2015; 3-4 days/facility). Standard questions related to demographics, previous pregnancies, current pregnancy, and services/satisfaction during the visit were asked. Total number of antenatal visits were abstracted from charts of recently delivered women (n = 1141). Provider knowledge assessments were completed by antenatal and postnatal care providers (n = 39). Frequencies were calculated for descriptive variables and multivariable logistic regression was used to explore predictors of receiving 5 out of 10 counseling messages among pregnant women. RESULTS: Among 894 pregnant women seeking antenatal care, most reported receiving standard clinical service components during their visit (97% were weighed, 80% had fetal heart tones checked), however fewer reported receiving recommended counseling messages (44% counselled on danger signs, 33% on postpartum family planning). Far fewer women were seeking postnatal care (n = 63) and similar service patterns were reported. Forty-three percent of pregnant women report receiving at least 5 out of 10 counseling messages. Pregnant women on a repeat visit and women with greater educational attainment had greater odds of reporting having received 5 out of 10 counseling messages (2nd visit: adjusted odds ratio [aOR] =1.70, 95% confidence interval [CI]: 1.09-2.66; 5+ visit: aOR = 5.44, 95% CI: 2.91-10.16; elementary school certificate: aOR = 2.06, 95% CI: 1.17-3.63; finished secondary school or more aOR = 1.97, 95% CI = 1.05-3.02). Chart reviews indicate 27% of women completed a single antenatal visit and 36% completed the recommended 4 visits. CONCLUSIONS: Antenatal and postnatal care uptake in Haiti is sub-optimal. Despite frequent reports of provision of standard service components, counseling messages are low. Consistent provision of standardized counseling messages with regular provider trainings is recommended to improve quality and uptake of care in Haiti.

The global commitment to reach the United Nations 90-90-90 targets will require a tremendous effort to almost double the number of HIV-infected individuals receiving antiretroviral treatment (ART), from 15.8 to 29.9 million, in the next 4 years [1]. In sub-Saharan Africa alone, ART initiation for an additional 6.2 million persons will be needed to reach this target. Given the infrastructure constraints and healthcare worker shortages in many resource-limited settings, there is increasing recognition that traditional facility-based models of clinician-led HIV service delivery will not be feasible with the increase in patient volume. In response, multiple proposed alternative service delivery models have been developed that center on transitioning at least some aspects of care out of health facilities into the community to decongest clinics and maximize the use of limited healthcare worker resources [2]. | Several commonly employed service delivery modifications have documented success in improving patient outcomes. One of the most common focuses on multimonth prescribing in which pharmacies dispense more than a month's supply of ART, requiring fewer patient visits to collect medications [2]. Another employs alternative ART delivery points; for example, HIV-infected patients can collect their ART at a community pharmacy/drug delivery site or have ART delivered to their homes by a cadre of lay workers [3]. A third model reduces the number of required follow-up visits for certain patients, most often those considered ‘stable’ by criteria such as time on ART and/or viral load suppression. These patients are seen at the facility by medical staff only once or twice per year [4]. Other models employ community adherence clubs, where groups of HIV-infected individuals receive all of their medication and care in the community on a particular day [5]. Finally, community ART groups rely on the member of the group to collect monthly antiretrovirals (ARVs) for all members while visiting the health facility for their yearly/biyearly visit [6]. This list is not exhaustive, and new strategies ideally suited for specific populations are continuing to be implemented. However, one commonality among most alternative models of ART service delivery is that children have almost uniformly been excluded.

Integrated infant and young child feeding (IYCF)/micronutrient powder (MNP) programs are increasingly used to address poor IYCF practices and micronutrient deficiencies in low-income settings; however, little is known about how MNP use may affect IYCF practices. We describe how MNP use was associated with IYCF practices in a pilot program in select districts of Nepal where free MNP for children 6-23 months were added to an existing IYCF platform. Representative cross-sectional surveys were conducted in pilot districts with mothers of eligible children at 3 months (plains ecozone, n=1054) or 15 months (hill ecozone, rural only, n=654) after implementation of an integrated MNP/IYCF program. We used logistic regression to assess how IYCF practices varied by MNP use (none, 1-30, 30-60 sachets). At both time points, consuming 30-60 MNP sachets vs. none was associated with achieving minimum dietary diversity and minimum acceptable diet. In the 3 month survey consuming 30- 60 MNP sachets vs none was also associated with achieving minimum meal frequency and continued breastfeeding at 2 years. In this setting, addition of MNP to an existing platform of IYCF messaging did not appear detrimental to IYCF practices.; Publisher: Abstract available from the publisher.; chi

BACKGROUND: Despite the benefits of breastfeeding, rates in the United States are low. Shorter maternity leave is associated with lower initiation and shorter durations of breastfeeding; however, little is known about how paid maternity leave may influence breastfeeding rates. METHODS: We used data from the 2006-2010 U.S. National Survey of Family Growth on the most recent birth to employed women who delivered a child within the previous 5 years. Separate multivariable logistic regression models were used to describe the associations between paid leave duration (0, 1-5, 6-11, ≥ 12 weeks, maternity leave not taken) and three outcomes: 1) breastfeeding initiation, 2) 6-month duration, and 3) 6-month duration among initiators. RESULTS: Twenty-eight percent of prenatally employed women received no paid leave. Women who received 12 or more weeks of paid leave were more likely to initiate breastfeeding compared to women with no paid leave (87.3% vs 66.7%, adjusted odds ratio [aOR] 2.83 [95% confidence interval {CI} 1.23-6.48]). Similarly, women with 12 or more weeks of paid leave were more likely to breastfeed at 6 months, compared to women with no paid leave (24.9% vs 50.1%, aOR 2.26 [95% CI 1.20-4.26]). Among women who initiated breastfeeding, having received 12 or more weeks' paid leave increased the odds of breastfeeding for 6 or more months; however, the association was not statistically significant in the adjusted model (aOR 1.81 [95% CI 0.93-3.52]). CONCLUSIONS: Employed women who received 12 or more weeks of paid maternity leave were more likely to initiate breastfeeding and be breastfeeding their child at 6 months than those without paid leave.

OBJECTIVE: Poor adherence to recommended intake protocols is common and a top challenge for micronutrient powder (MNP) programmes globally. Identifying modifiable predictors of intake adherence could inform the design and implementation of MNP projects. DESIGN: We assessed high MNP intake adherence among children who had received MNP ≥2 months ago and consumed ≥1 sachet (n 771). High MNP intake adherence was defined as maternal report of child intake ≥45 sachets. We used logistic regression to assess demographic, intervention components and perception-of-use factors associated with high MNP intake. SETTING: Four districts of Nepal piloting an integrated infant and young child feeding and MNP project. SUBJECTS: Children aged 6-23 months were eligible to receive sixty MNP sachets every 6 months with suggested intake of one sachet daily for 60 d. Cross-sectional surveys representative of children aged 6-23 months were conducted. RESULTS: Receiving a reminder card was associated with increased odds for high intake (OR=2.18, 95 % CI 1.14, 4.18); exposure to other programme components was not associated with high intake. Mothers perceiving ≥1 positive effects in their child after MNP use was also associated with high intake (OR=6.55, 95 % CI 4.29, 10.01). Perceiving negative affects was not associated; however, the child not liking the food with MNP was associated with lower odds of high intake (OR=0.12, 95 % CI 0.08, 0.20). CONCLUSIONS: Behaviour change intervention strategies tailored to address these modifiable predictors could potentially increase MNP intake adherence.

Many countries implement micronutrient powder (MNP) programmes to improve the nutritional status of young children. Little is known about the predictors of MNP coverage for different delivery models. We describe MNP coverage of an infant and young child feeding and MNP intervention for children aged 6-23 months comparing two delivery models piloted in rural Nepal: distributing MNPs either by female community health volunteers (FCHVs) or at health facilities (HFs). Cross-sectional household cluster surveys were conducted in four pilot districts among mothers of children 6-23 months after starting MNP distribution. FCHVs in each cluster were also surveyed. We used logistic regression to describe predictors of initial coverage (obtaining a batch of 60 MNP sachets) at 3 months and repeat coverage (≥2 times coverage among eligible children) at 15 months after project launch. At 15 months, initial and repeat coverage were higher in the FCHV model, although no differences were observed at 3 months. Attending an FCHV-led mothers' group meeting where MNP was discussed increased odds of any coverage in both models at 3 months and of repeat coverage in the HF model at 15 months. Perceiving ≥1 positive effects in the child increased odds of repeat coverage in both delivery models. A greater portion of FCHV volunteers from the FCHV model vs. the HF model reported increased burden at 3 and 15 months (not statistically significant). Designing MNP programmes that maximise coverage without overburdening the system can be challenging and more than one delivery model may be needed.

BACKGROUND: Breastfeeding provides numerous health benefits for infants and mothers; however, many infants are not breastfed as long as recommended or desired by mothers. Maternal employment is frequently cited as a barrier to breastfeeding. OBJECTIVE: This study aimed to assess whether maternity leave duration and return status (full-time [FT], part-time [PT]) were associated with not meeting a mother's intention to breastfeed at least 3 months. METHODS: We used data from the Infant Feeding Practices Study II, a cohort study. Analyses were limited to women employed prenatally who intended to breastfeed 3 months or longer (n = 1172). Multivariable logistic regression was used to assess the relationship between maternity leave duration and return-to-work status (< 6 weeks/FT, < 6 weeks/PT, 6 weeks-3 months/FT, 6 weeks-3 months/PT, not working by 3 months) and meeting a mother's intention to breastfeed at least 3 months. RESULTS: Overall, 28.8% of mothers did not meet their intention to breastfeed at least 3 months. Odds of not meeting intention to breastfeed at least 3 months were higher among mothers who returned to work FT before 3 months (< 6 weeks/FT: adjusted odds ratio = 2.25, 95% confidence interval, 1.23-4.12; 6 weeks-3 months/FT: adjusted odds ratio = 1.82, 95% confidence interval, 1.30-2.56), compared with mothers not working at 3 months. CONCLUSION: Returning to work full-time before 3 months may reduce a mother's ability to meet her intention to breastfeed at least 3 months. Employer support for flexible work scheduling may help more women achieve their breastfeeding goals.

BACKGROUND: The American Academy of Pediatrics recommends 6 months of exclusive breastfeeding, however, only 16% of US infants meet this recommendation. Shorter exclusive/predominant breastfeeding durations have been observed from women who return to work early and/or full-time. OBJECTIVE: We assessed the relationship between prenatal plans for maternity leave duration and return to full-time/part-time status and plans for exclusive breastfeeding. METHODS: This study included 2348 prenatally employed women from the Infant Feeding Practices Study II (2005-2007) who planned to return to work in the first year postpartum. Bivariate analysis and logistic regression were used to describe the association of maternity leave duration and return status with plans for infant feeding. RESULTS: Overall, 59.5% of mothers planned to exclusively breastfeed in the first few weeks. Mothers planning to return to work within 6 weeks had 0.60 times the odds (95% confidence interval [CI], 0.46-0.77) and mothers planning to return between 7 and 12 weeks had 0.72 times the odds (95% CI, 0.56-0.92) of planning to exclusively breastfeed compared with mothers who were planning to return after 12 weeks. Prenatal plans to return full-time (≥ 30 hours/week vs part-time) were also associated with lower odds of planning to exclusively breastfeed (adjusted odds ratio = 0.61; 95% CI, 0.51-0.77). CONCLUSION: Mothers planning to return to work before 12 weeks and/or full-time were less likely to plan to exclusively breastfeed. Longer maternity leave and/or part-time return schedules may increase the proportion of mothers who plan to exclusively breastfeed.