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Infants of women with diabetes in pregnancy are at increased risk of hypoglycaemia, admission to a neonatal intensive care unit (NICU), and not being exclusively breastfed. Many clinicians encourage women with diabetes in pregnancy to express and store breastmilk in late pregnancy, yet no evidence exists for this practice. We aimed to determine the safety and efficacy of antenatal expressing in women with diabetes in pregnancy. We did a multicentre, two-group, unblinded, randomised controlled trial in six hospitals in Victoria, Australia. We recruited women with pre-existing or gestational diabetes in a singleton pregnancy from 34 to 37 weeks' gestation and randomly assigned them (1:1) to either expressing breastmilk twice per day from 36 weeks' gestation (antenatal expressing) or standard care (usual midwifery and obstetric care, supplemented by support from a diabetes educator). Randomisation was done with a computerised random number generator in blocks of size two and four, and was stratified by site, parity, and diabetes type. Investigators were masked to block size but masking of caregivers was not possible. The primary outcome was the proportion of infants admitted to the NICU. We did the analyses by intention to treat; the data were obtained and analysed masked to group allocation. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000217909. Between June 6, 2011, and Oct 29, 2015, we recruited and randomly assigned 635 women: 319 to antenatal expressing and 316 to standard care. Three were not included in the primary analysis (one withdrawal from the standard care group, and one post-randomisation exclusion and one withdrawal from the antenatal expressing group). The proportion of infants admitted to the NICU did not differ between groups (46 [15%] of 317 assigned to antenatal expressing vs 44 [14%] of 315 assigned to standard care; adjusted relative risk 1·06, 95% CI 0·66 to 1·46). In the antenatal expressing group, the most common serious adverse event for infants was admission to the NICU for respiratory support (for three [<1%] of 317. In the standard care group, the most common serious adverse event for infants was moderate to severe encephalopathy with or without seizures (for three [<1%] of 315). There is no harm in advising women with diabetes in pregnancy at low risk of complications to express breastmilk from 36 weeks' gestation. Australian National Health and Medical Research Council.

Australia has maintained low rates of SARS-COV-2 (COVID-19) infection, due to geographic location and strict public health restrictions. However, the financial and social impacts of these restrictions can negatively affect parents' and children's mental health. In an existing cohort of mothers recruited for their experience of adversity, this study examined: 1) families' experiences of the COVID-19 pandemic and public health restrictions in terms of clinical exposure, financial hardship family stress, and family resilience (termed 'COVID-19 impacts'); and 2) associations between COVID-19 impacts and maternal and child mental health. Participants were mothers recruited during pregnancy (2013-14) across two Australian states (Victoria and Tasmania) for the 'right@home' trial. A COVID-19 survey was conducted from May-December 2020, when children were 5.9-7.2 years old. Mothers reported COVID-19 impacts, their own mental health (Depression, Anxiety, Stress Scales short-form) and their child's mental health (CoRonavIruS Health and Impact Survey subscale). Associations between COVID-19 impacts and mental health were examined using regression models controlling for pre-COVID-19 characteristics. 319/406 (79%) mothers completed the COVID-19 survey. Only one reported having had COVID-19. Rates of self-quarantine (20%), job or income loss (27%) and family stress (e.g., difficulty managing children's at-home learning (40%)) were high. Many mothers also reported family resilience (e.g., family found good ways of coping (49%)). COVID-19 impacts associated with poorer mental health (standardised coefficients) included self-quarantine (mother: β = 0.46, child: β = 0.46), financial hardship (mother: β = 0.27, child: β = 0.37) and family stress (mother: β = 0.49, child: β = 0.74). Family resilience was associated with better mental health (mother: β = -0.40, child: β = -0.46). The financial and social impacts of Australia's public health restrictions have substantially affected families experiencing adversity, and their mental health. These impacts are likely to exacerbate inequities arising from adversity. To recover from COVID-19, policy investment should include income support and universal access to family health services.

In Sub-Saharan Africa (SSA), the burden of low birthweight (LBW) remains high, leading to considerable short- and long-term consequences for both newborns and mothers. However, limited evidence exists on the disparities and geographical distribution of LBW among adolescent (15–19 years) and non-adolescent women (20–49 years). This study aimed to assess the age-related disparity, geospatial distribution and determinants of LBW in SSA. The study used Demographic and Health Survey (DHS) data from 33 SSA countries released between 2010 and 2023. Concentration curves and indices, absolute and relative difference measures, spatial autocorrelation and hotspot analysis, and multilevel modelling were employed to explore differences in LBW by maternal age group. A total of 27,889 (15.5%) of adolescent women and 152,521 (84.5%) non-adolescent women were included in the analysis. LBW was significantly concentrated among adolescents (CI = − 0.096, p  < 0.001), with a 13.2% prevalence compared to 8.3% in non-adolescents, highlighting a 4.9% absolute difference (relative difference = 1.60, p  < 0.001). Lower educational level, unemployment, fewer number of antenatal care (ANC) visits, lacking permission to get medical care and being single marital status were the common variables significantly associated with LBW in both adolescent and non-adolescent women. However, unintended pregnancy and early sexual initiation were significantly associated with LBW in only adolescent women while distance to healthcare facilities and lower parity were found to be significantly associated with LBW only in non-adolescent women. At community level, region was a significant factor for LBW in both groups. Spatial autocorrelation and hotspot analysis showed that LBW was randomly distributed among adolescents (Moran’s test of − 0.0106 and  p value = 0.904) but clustered in Mauritania, Mali, Niger, and Chad for non-adolescent women. This study found significant age-related disparities in LBW across SSA, with adolescent mothers facing a disproportionate burden. This underscores the need to focus on preventing adolescent pregnancy and providing support for pregnant adolescents by improving access to ANC, education, and economic empowerment to prevent adverse birth outcomes. Random distribution of LBW in adolescent women indicates the need for adolescent-specific regional interventions across SSA countries.

Background Globally, approximately 15% to 20% of newborns are born with low birth weight (LBW), with over 90% of these cases occurring in low- and middle-income countries (LMICs). Although previous research on LBW has largely focused on clinical and nutritional factors, economic barriers associated with LBW remain under-researched. This study aimed to assess the association between out-of-pocket (OOP) payment for antenatal care and LBW in Eastern Ethiopia. Methods A prospective cohort study followed pregnant women for ten months to examine the incidence of LBW. The cost of ANC and other follow up variables were collected during pregnancy. Direct medical and non-medical costs were summed to calculate total OOP expenditures. Face to face interviews were used to collect baseline and follow-up data. Poisson regression with robust variance was used to assess the independent predictors of LBW. Adjusted risk ratios (aRR) with 95% confidence intervals (CI) were computed. The direct and indirect association between OOP and LBW were estimated using Generalized Structural Equation Modeling (GSEM). Results A total of 385 women was followed for 10 months. The study found that 10.9% of women gave birth to LBW neonates. After controlling for confounding factors, OOP expenditure (aRR = 3.21, 95% CI: 1.19, 8.64), prenatal depression (aRR = 2.91, 95% CI: 1.65, 5.13), and lack of birth preparedness and complication readiness (BPCR) (aRR = 4.12, 95% CI: 1.52, 11.20), poor wealth status (aRR = 3.30, 95% CI: 1.16, 9.38), incomplete ANC visits (aRR = 2.37, 95% CI: 1.01, 5.53), unplanned pregnancy (aRR = 1.92, 95% CI: 1.14, 3.22) and long travelling time (1.99, 95% CI: 1.15, 3.44) were significantly associated with LBW. In GSEM, prenatal depression (β = 1.30 (95% CI: 0.21, 2.80) and lack of preparation for birth (β = 1.55 (95% CI: 0.29, 2.80) mediated the association between LBW and OOP expenditures, while ANC visits mediated the association between long travelling time and LBW (β = 1.04, 95% CI: 0.04, 1.05). Conclusion There was a significant positive association between OOP payment and LBW which was partly mediated by prenatal depression and lack of BPCR. To reduce the incidence of LBW, an integrated approach should be adopted that combines financial risk protection, psychosocial support and geographical accessibility of services.

Evidence for a benefit of interventions to help women who screen positive for intimate partner violence (IPV) in health-care settings is limited. We assessed whether brief counselling from family doctors trained to respond to women identified through IPV screening would increase women's quality of life, safety planning and behaviour, and mental health. In this cluster randomised controlled trial, we enrolled family doctors from clinics in Victoria, Australia, and their female patients (aged 16–50 years) who screened positive for fear of a partner in past 12 months in a health and lifestyle survey. The study intervention consisted of the following: training of doctors, notification to doctors of women screening positive for fear of a partner, and invitation to women for one-to-six sessions of counselling for relationship and emotional issues. We used a computer-generated randomisation sequence to allocate doctors to control (standard care) or intervention, stratified by location of each doctor's practice (urban vs rural), with random permuted block sizes of two and four within each stratum. Data were collected by postal survey at baseline and at 6 months and 12 months post-invitation (2008–11). Researchers were masked to treatment allocation, but women and doctors enrolled into the trial were not. Primary outcomes were quality of life (WHO Quality of Life-BREF), safety planning and behaviour, mental health (SF-12) at 12 months. Secondary outcomes included depression and anxiety (Hospital Anxiety and Depression Scale; cut-off ≥8); women's report of an inquiry from their doctor about the safety of them and their children; and comfort to discuss fear with their doctor (five-point Likert scale). Analyses were by intention to treat, accounting for missing data, and estimates reported were adjusted for doctor location and outcome scores at baseline. This trial is registered with the Australian New Zealand Clinical Trial Registry, number ACTRN12608000032358. We randomly allocated 52 doctors (and 272 women who were eligible for inclusion and returned their baseline survey) to either intervention (25 doctors, 137 women) or control (27 doctors, 135 women). 96 (70%) of 137 women in the intervention group (seeing 23 doctors) and 100 (74%) of 135 women in the control group (seeing 26 doctors) completed 12 month follow-up. We detected no difference in quality of life, safety planning and behaviour, or mental health SF-12 at 12 months. For secondary outcomes, we detected no between-group difference in anxiety at 12 months or comfort to discuss fear at 6 months, but depressiveness caseness at 12 months was improved in the intervention group compared with the control group (odds ratio 0·3, 0·1–0·7; p=0·005), as was doctor enquiry at 6 months about women's safety (5·1, 1·9–14·0; p=0·002) and children's safety (5·5, 1·6–19·0; p=0·008). We recorded no adverse events. Our findings can inform further research on brief counselling for women disclosing intimate partner violence in primary care settings, but do not lend support to the use of postal screening in the identification of those patients. However, we suggest that family doctors should be trained to ask about the safety of women and children, and to provide supportive counselling for women experiencing abuse, because our findings suggest that, although we detected no improvement in quality of life, counselling can reduce depressive symptoms. Australian National Health and Medical Research Council.

This study investigated variations in healthcare expenditure for colorectal cancer (CRC) patients in South Australia by socioeconomic position (SEP) and remoteness area. Benefits incidence analysis (BIA) was used to examine healthcare expenditure and utilisation in relation to CRC patients by SEP and remoteness areas. Utilisation data was obtained for patients diagnosed with CRC in 2003–2013 from a dataset linked to a population‐based cancer registry, Medicare Benefits Scheme (MBS), Pharmaceutical Benefits Scheme (PBS), hospital and death data. Concentration indices estimated the distribution of health expenditure on MBS, MBS palliative care, PBS and general practitioners. Costs of claims data and length of stay in hospital were used as indicators of healthcare utilisation. The results indicated that MBS palliative healthcare services utilisation favoured the more advantaged groups for both SEP and remoteness area (Concentration index (CI)= 0.1681, t‐value=54.42 (SEP) and CI=0.1546, t‐value=41.64). MBS expenditure was also favourable to the more advantaged groups (CI: 0.0785 and 0.0493).PBS and MBS general practitioner expenditure were equal (−0.0093 to 0.0250). Overall MBS and PBS healthcare expenditure for CRC patients was close to equality, however utilisation of MBS‐funded palliative healthcare services was less concentrated in low SEP and more remote areas. Whether the differences in palliative healthcare utilisation supplied by private providers are offset by other services requires investigation to determine if there is a need for initiatives to improve equality and give greater support to those who choose to die at home.

Nurse home visiting (NHV) is widely implemented to address inequities in child and maternal health. However, few studies have examined longer-term effectiveness or delivery within universal healthcare systems. We evaluated the benefits of an Australian NHV program (\"right@home\") in promoting children's language and learning, general and mental health, maternal mental health and wellbeing, parenting and family relationships, at child ages 4 and 5 years. Randomised controlled trial of NHV delivered via universal, child and family health services (the comparator). Pregnant women experiencing adversity (≥2 of 10 risk factors) were recruited from 10 antenatal clinics across 2 states (Victoria, Tasmania) in Australia. Mothers in the intervention arm were offered 25 nurse home visits (mean 23·2 home visits [SD 7·4, range 1-43] received) of 60-90 minutes, commencing antenatally and continuing until children's second birthdays. At 4 and 5 years, outcomes were assessed via parent interview and direct assessment of children's language and learning (receptive and expressive language, phonological awareness, attention, and executive function). Outcomes were compared between intervention and usual care arms (intention to treat) using adjusted regression with robust estimation to account for nurse/site. Missing data were addressed using multiple imputation and inverse probability weighting. Of 722 women enrolled in the trial, 225 of 363 (62%) intervention and 201 of 359 (56%) usual care women provided data at 5 years. Estimated group differences showed an overall pattern favouring the intervention. Statistical evidence of benefits was found across child and maternal mental health and wellbeing, parenting and family relationships with effect sizes ranging 0·01-0·27. An Australian NHV program promoted longer-term family functioning and wellbeing for women experiencing adversity. NHV can offer an important component of a proportionate universal system that delivers support and intervention relative to need. 2013-2016, registration ISRCTN89962120.

Community-acquired pneumonia (CAP) is a major cause of mortality and morbidity worldwide. Efficient use of resources is fundamental for best use of money among the available and novel treatment options for the management of pneumonia. The objective of this study was to systematically review the economic analysis of management strategies of pneumonia. A systematic search was performed using Academic Search Complete, MEDLINE, EconLit, Global health, MEDLINE complete and Embase databases using specific subject headings or key words in May 2018 without restricting publication year. All search results were recorded and any type of economic evaluation for management of CAP was included for detailed review. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used for quality appraisal. Nineteen studies met the inclusion criteria; ten studies were trial based, five conducted analysis using model based techniques and the rest of the studies were either based on observational, record review or pre-post intervention studies. Most of the studies conducted cost-effectiveness analysis (n = 15) and compared different combinations of antimicrobials. Most were based on developed countries (n = 17), considered adult age groups (n = 16) and used a provider perspective (n = 14). Nine studies reported dominant alternatives (lower cost with higher benefit). Sensitivity analysis was performed by the majority of studies (n = 15). Fourteen studies were assessed as either being excellent, very good or good quality, with no relationship found between publication year and study quality. Methodological variation, type of microbial used, perspective, costs and outcome measures limit the compatibility among the results of the included studies. Economic evaluation of interventions for management of CAP to date supports cost-effectiveness of studied interventions. However, evidence relates largely to antimicrobials choice in older populations in developed countries. Parallel economic evaluation of different management strategies of CAP is recommended for both developed and developing countries to support rigorous and robust comparative economic analysis within health care systems. PROSPERO registration no: CRD42018097174.

Background Multi-level, longer-term obesity prevention interventions that focus on inequalities are scarce. Fun ‘n healthy in Moreland! aimed to improve child adiposity, school policies and environments, parent engagement, health behaviours and child wellbeing. Methods All children from primary schools in an inner urban, culturally diverse and economically disadvantaged area in Victoria, Australia were eligible for participation. The intervention, fun ‘n healthy in Moreland!, used a Health Promoting Schools Framework and provided schools with evidence, school research data and part time support from a Community Development Worker to develop health promoting strategies. Comparison schools continued as normal. Participants were not blinded to intervention status. The primary outcome was change in adiposity. Repeated cross-sectional design with nested longitudinal subsample. Results Students from twenty-four primary schools (clusters) were randomised (aged 5–12 years at baseline). 1426 students from 12 intervention schools and 1539 students from 10 comparison schools consented to follow up measurements. Despite increased prevalence of healthy weight across all schools, after 3.5 years of intervention there was no statistically significant difference between trial arms in BMI z score post-intervention (Mean (sd): Intervention 0.68(1.16); Comparison: 0.72(1.12); Adjusted mean difference (AMD): -0.05, CI: -0.19 to 0.08, p  = 0.44). Children from intervention schools consumed more daily fruit serves (AMD: 0.19, CI:0.00 to 0.37, p  = 0.10), were more likely to have water (AOR: 1.71, CI:1.05 to 2.78, p  = 0.03) and vegetables (AOR: 1.23, CI: 0.99 to 1.55, p  = 0.07), and less likely to have fruit juice/cordial (AOR: 0.58, CI:0.36 to 0.93, p  = 0.02) in school lunch compared to children in comparison schools. More intervention schools (8/11) had healthy eating and physical activity policies compared with comparison schools (2/9). Principals and schools highly valued the approach as a catalyst for broader positive school changes. The cost of the intervention per child was $65 per year. Conclusion The fun n healthy in Moreland! intervention did not result in statistically significant differences in BMI z score across trial arms but did result in greater policy implementation, increased parent engagement and resources, improved child self-rated health, increased fruit, vegetable and water consumption, and reduction in sweet drinks. A longer-term follow up evaluation may be needed to demonstrate whether these changes are sustainable and impact on childhood overweight and obesity. Clinical trial registration ACTRN12607000385448 (Date submitted 31/05/2007; Date registered 23/07/2007; Date last updated 15/12/2009).

Background To ensure that women with disabilities (WwD) have access to essential maternal health services, understanding their service utilization within the continuum of care (CoC) framework is vital. However, the influence of women’s disability status on maternal CoC has not been fully explored. Hence, this paper examines the completion level and inequality of basic maternal CoC, as well as its association with women’s disability status. Methods We conducted analyses on demographic and health survey data of nine low- and middle-income countries collected between 2016 and 2022. Disability among reproductive-age women was assessed using the Washington Group Short Set questionnaires. The maternal CoC was defined to include receiving four or more antenatal visits, skilled birth attendance and obtaining timely postnatal care. Concentration indices were used to measure wealth-related inequalities in completing CoC. Multivariable logistic regression was used to identify factors associated with inequalities in the CoC completion. Results A total of 14.0% of women had a disability of at least some difficulty in one domain of function. Among women who made their first antenatal care contact, only 35.8% completed CoC; this percentage was lower among women with disability (32.7%). The odds of completing CoC was lower among WwD (AOR = 0.89, 95% CI: 0.83–0.95). Higher maternal education (AOR = 1.63–2.27), female-headed household (AOR = 1.14, 95% CI: 1.07–1.22), currently working (AOR = 1.29, 95% CI:1.22–1.37) and wealth quintile (increasing from poor to the richest (AOR = 1.24–2.18) were positively associated with higher odds of completing the CoC. We found overall pro-rich inequality in CoC completion (CI 0.27: 95%CI: 0.26–0.29). Higher inequalities were observed in countries with lower coverage of maternal healthcare services. Conclusion Maternal CoC completion was lower among WwD, especially those with lower socioeconomic status. Effective strategies that ensure disability-friendly maternal health care services will play a pivotal role. Maternal health service programs should prioritize women’s disability status alongside other key socioeconomic factors and address health care barriers to ensure more equitable and comprehensive maternal health care.