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An estimated 15 million babies are born preterm annually. Preterm birth complications account for more than 15% of deaths in children younger than 5 years and survivors often have long-term consequences with respect to their health, growth, and psychosocial functioning. The most beneficial interventions available are those that improve newborn outcomes when preterm birth is inevitable (tertiary interventions) and those that focus on special care for preterm newborns. Today WHO publishes new recommendations on interventions for pregnant women in whom preterm birth is imminent (including antenatal corticosteroids, tocolytics, magnesium sulfate, antibiotics, and mode of delivery) and for care of preterm neonates (including thermal care, continuous positive airway pressure [CPAP], surfactant administration, and oxygen therapy) to improve preterm birth outcomes. Although there is strong evidence of benefit from trials after administration of antenatal corticosteroids, most of these were conducted in high-income countries, in higher-level facilities where the accuracy of gestational age estimation was high, and comprehensive maternal and newborn care was likely to be available. The recent Antenatal Corticosteroids Trial has raised concerns about extending antenatal corticosteroid use to peripheral levels of the health system in lower-income countries. The WHO Guideline Development Group therefore took a cautious approach, recommending that certain preconditions are met before antenatal corticosteroid administration, on the basis of the context of the existing trials. The guidelines therefore recommend antenatal corticosteroid therapy for women at risk of preterm birth from 24 weeks to 34 weeks of po1 when the following conditions are met: (1) gestational age can be accurately assessed, (2) preterm birth is considered imminent, (3) there is no clinical evidence of maternal infection, (4) adequate childbirth care is available, and (5) the preterm neonate can receive adequate care for complications, if needed (including resuscitation, thermal care, feeding support, infection treatment, and safe oxygen use).
Jan-Walter De Neve and colleagues provide compelling evidence of a causal relation between secondary education and HIV incidence, showing that a policy change in Botswana led to 0·792 additional years of secondary schooling, with each added year reducing HIV risk by 8 percentage points. The estimated cost per HIV infection averted was US$27 753. De Neve and colleagues thus conclude that secondary schooling is similarly cost effective for HIV prevention as pre-exposure prophylaxis, but is more expensive than male circumcision. However, they also highlight that this estimate excludes other benefits of schooling. Furthermore, it is unlikely that HIV budgets would be asked to bear the full cost of increased schooling. If, instead, secondary education is regarded as an investment of value across health and other development sectors, the relevant question is what level of co-investment in education from HIV budgets could be justified, in view of the benefits against HIV? Secondary education is a sound economic investment in its own right, but remains resource-constrained in many low-income and middle-income countries. If the parties interested in HIV prevention contributed to educational funding up to the value of their next best investment (in this case, male circumcision), further schooling expansion could be achieved. With the threshold of $1096 per infection averted, we show that HIV budgets could contribute up to 4% of total costs for an additional year of secondary schooling ().
Fumiaki Imamura and colleagues assess the consumption of key dietary items internationally by comparing healthy and unhealthy dietary patterns. However, the evidence they use to inform the classification of food items is unclear and seems to lead to some arbitrary outcomes. For example, milk was classified as a healthy item, despite the fact that the health advantages associated with milk consumption remain controversial. Two large prospective studies in Sweden have shown that high milk intake is associated with reduced life expectancy. Moreover, in populations with high prevalence of adiposity, milk consumption might simply add excess energy intake and contribute to the obesity epidemic.