Childcare burdens limit productivity among women in the informal sector, but we know little about the optimal design of childcare support. We randomize 883 women market vendors in Kampala, Uganda to receive free workplace- or community-based childcare. Free childcare redistributes caregiving away from household members, raises women’s hourly earnings, and improves child development and women’s well-being. Community centers achieve higher utilization and larger gains in development and well-being, while workplace centers generate larger economic impacts. Both models have a high marginal value of public funds. Community centers currently dominate, but workplace-based centers could prove superior if operated at scale.
Jacklyn Makaaru Arinaitwe, George Bogere, Anna Fiore et al.
Preterm birth remains a leading contributor to neonatal mortality and long-term morbidity worldwide, with Sub-Saharan Africa bearing a disproportionate share of the burden. Structural inequities, limited maternal healthcare access, and socioeconomic vulnerabilities are associated with higher model-predicted probability of preterm birth. Despite its significance, large-scale predictive modeling of preterm birth in this region remains limited. This study aimed to develop robust machine-learning–based prediction models and identify key factors associated with preterm birth using recent multi-country Demographic and Health Survey (DHS) data from (2019–2024). A pooled cross-sectional analysis was conducted using nationally representative DHS data from eleven Sub-Saharan African countries, including 411,863 women aged 15–49 years. Four supervised machine learning algorithms were trained and tested using an 80/20 train–test split. Model performance was evaluated using accuracy, precision, recall, F1-score, and ROC-AUC. Model interpretability was assessed using SHapley Additive exPlanations (SHAP). The Random Forest model demonstrated the highest predictive performance for preterm birth, achieving an accuracy of 90.20% and ROC-AUC of 96.92%, outperforming the Decision Tree (accuracy of 89.2% and ROC-AUC of 92.19%), and other classifiers. The use of SMOTE for class imbalance handling and evaluation with precision–recall metrics improved model robustness in identifying minority class outcomes. SHAP-based feature importance analysis identified key predictors of the outcome,including low maternal educational attainment,unmarried marital status, lack of media exposure, lower household wealth index, and advanced maternal age (≥ 35 years). Additional important predictors were substance use,rural residence,employed women,anemia, abnormal maternal body mass index, insufficient antenatal care attendance (< 4 visits), and short birth interval. Overall, all these factors were associated with an increased predicted probability of preterm birth. Machine learning models, particularly ensemble methods, demonstrated strong predictive performance for preterm birth in Sub-Saharan Africa. Random Forest performed best, highlighting the effectiveness of ensemble learning in handling complex and imbalanced datasets. Key socio-demographic and maternal health factors were consistently associated with preterm birth in a predictive (non-causal) framework. The integration of explainable artificial intelligence enhances model transparency and supports interpretation of predictive patterns in maternal health data. Findings should be interpreted as predictive associations rather than causal relationships, and caution is required when generalizing across heterogeneous country contexts.
Abstract Background Though many studies have discussed the impact of health insurance on access to medical services, few have considered Western Africa. Despite decades of targeted efforts, West Africa has the most elevated maternal mortality rates (MMR) and under-five mortality rates in the world. The solution to this issue is widely believed to be the implementation of universal health coverage (UHC) as most causes of death could be effectively dealt with through primary health care providers. It is possible that UHC without additional efforts to tackle important determinants of health such as education and poverty is insufficient. The objective of this study is to examine the link between being covered by health insurance and access to health services for mothers and children in West Africa. Methods A systematic literature review will be conducted. We will search the online databases MEDLINE complete, Embase, CINAHL complete, and Global Health from inception onwards. The focus will be on primary research studies and grey literature that examined health insurance in relation to access to maternal and child health services. Two reviewers will independently screen all citations, full-text articles, and abstract data. The primary outcome will be maternal and child access to health insurance and access to primary and secondary services such as attending the minimum number of prenatal visits and accessing services in emergency circumstances where catastrophic expenditures may have been an obstacle. A standardized data extraction form by the Cochrane library will be used. A narrative synthesis will be conducted with a summary of findings tables to be produced. Discussion The systematic review will present findings on the impact of access to health insurance on access to maternal and child health care. The findings will inform discussion around the pursuit of UHC as a key health systems policy. The final manuscript will be disseminated through peer-reviewed journal and scientific conferences. Systematic review registration PROSPERO CRD42020203859
Nigeria’s agricultural sector is central to food security, employment generation, economic diversification, and rural development, yet its transformative potential remains constrained by persistent structural, environmental, institutional, and socioeconomic challenges. This narrative review critically examines contemporary issues affecting Nigerian agriculture between 2020 and 2025, evaluates strategies for sectoral revitalisation, and draws lessons from relevant international experiences. Secondary data were obtained from peer-reviewed literature, policy documents, and national and international databases, including Scopus, Web of Science, Google Scholar, African Journals Online, and the Central Bank of Nigeria, the National Bureau of Statistics, FAOSTAT, the World Bank, and FEWS NET. Evidence was synthesised thematically around key agricultural problems, transformation models, international experiences, and policy recommendations. The review identifies declining land and labour productivity, weak input and extension systems, inadequate irrigation, poor rural infrastructure, high post-harvest losses, limited agro-processing capacity, climate variability, environmental degradation, insecurity, policy inconsistency, underinvestment, land constraints, and unequal access to digital technologies and agricultural finance as major barriers to agricultural transformation. Although initiatives such as the Anchor Borrowers’ Programme, NIRSAL, digital agriculture, climate-smart practices, and value-chain development have generated important opportunities, their impacts have been limited by weak implementation, institutional fragmentation, inadequate funding, and exclusion of smallholders, women, and youth. International experiences from Asia, Latin America, India, and the Sahel demonstrate the importance of sustained public investment, effective farmer organisations, community-led adaptation, integrated value-chain development, and stable policy institutions.
Abstract The place of residence is a major determinant of RMNCH outcomes, with rural areas often lagging in sub-Saharan Africa. This long-held pattern may be changing given differential progress across areas and increasing urbanization. We assessed inequalities in child mortality and RMNCH coverage across capital cities, other urban and rural areas. We analyzed mortality data from 162 DHS and MICS in 39 countries with the most recent survey conducted between 1990 and 2020, and RMNCH coverage data from 39 countries. We assessed inequality trends in neonatal and under-five mortality and in RMNCH coverage using multilevel linear regression models. Under-five mortality and RMNCH service coverage inequalities by place of residence have reduced substantially in sub-Saharan Africa, with rural areas experiencing faster progress than other areas. The absolute gap in child mortality between rural areas and capital cities, and that between rural and other urban areas reduced respectively from 41 and 26 deaths per 1000 live births in 2000 to 23 and 15 by 2015. Capital cities are losing their primacy in child survival and RMNCH coverage over other urban areas and rural areas, especially in Eastern Africa where under-five mortality gap between capital cities and rural areas closed almost completely by 2015. While child mortality and RMNCH coverage inequalities are closing rapidly by place of residence; slow trends in capital cities and urban areas suggest gradual erosion of capital city and urban health advantage. Monitoring child mortality and RMNCH coverage trends in urban areas, especially among the urban poor, and addressing factors of within urban inequalities are urgently needed.
Agbessi Amouzou, Dessalegn Y. Melesse, Fernando C. Wehrmeister et al.
Background Malnutrition among children under five remains a major public health challenge in sub-Saharan Africa, with those born to young mothers being particularly vulnerable. Evidence on the role of water, sanitation, and hygiene (WASH) in this subgroup is limited in Ghana. We estimated the association between WASH and childhood malnutrition, and characterized its spatial and socioeconomic distribution, in young mother–child pairs in Ghana. Methods We analyzed 620 child–mother pairs (mothers aged 15–24 years) from the 2022 Ghana Demographic and Health Survey. Outcomes were stunting, wasting, and underweight, defined using WHO growth standards (< −2 SD). Survey-weighted multilevel logistic regression examined WASH–nutrition associations. Spatial patterns were assessed using Global Moran’s I, and LISA and Getis-Ord G*. Socioeconomic inequality was measured via concentration indices, the Theil T index, Lorenz curves, and difference/relative indices. Population attributable fractions (PAF) and risks (PAR) were estimated for binary WASH exposures. Results Stunting prevalence was 18.8% (95% CI 15.5–22.6), wasting 8.7% (6.2–11.9), and underweight 15.6% (12.4–19.4). Volta Region recorded the highest observed weighted prevalence for all three outcomes (stunting 32.0%, wasting 16.8%, underweight 39.4%), but these estimates were based on a small subsample (unweighted n = 20). Global spatial autocorrelation was not statistically significant for any outcome (all p ≥ 0.296). LISA identified Oti as a possible hotspot for underweight ( p = 0.039), and Central and Bono as cold spots for stunting ( p = 0.047) and wasting ( p = 0.018). Improved water access showed the largest protective population-level association (PAF: stunting −36 to −41%; underweight −37%), interpreted as a population-level attributable-burden estimate under a cross-sectional design. Concentration indices were negative for all outcomes, indicating disproportionate burden among poorer and less-educated households, reaching statistical significance for underweight. WASH covariates were not significantly associated with any outcome in fully adjusted models. Multilevel models showed high apparent discrimination (AUC 0.859–0.868). Conclusion Malnutrition among children of young mothers in Ghana is unevenly distributed and concentrated among socioeconomically disadvantaged populations. Equitable WASH services, alongside targeted nutrition programming, may help reduce nutritional inequalities in support of SDG 2 and SDG 6.
Deda Ogum, Yula Salifu, Abdul Razak Abubakari et al.
Background. Even though immunisation coverage is tracked through the district health system in South Africa (SA), limited information is available regarding interventions linked to the Expanded Programme on Immunisation (EPI) and the impact on the nutritional status of children <5 years of age. Objectives. To describe coverage of immunisations, vitamin A supplementation and deworming among children <5 years old in an urban area of Nelson Mandela Bay, Eastern Cape Province, SA. A secondary objective was to investigate whether a history of missed immunisations, vitamin A supplementation or deworming was associated with wasting or stunting in children. Methods. A descriptive study was conducted between September 2015 and February 2016, where cross-sectional anthropometrical data were collected from 1 513 children in 32 pre-schools, together with a retrospective analysis of the participants’ Road-to-Health/clinic cards to collect data on immunisation, vitamin A and deworming. Participants were categorised into 3-month age intervals to facilitate data analysis. Ethical approval was obtained from the Nelson Mandela University Research Ethics Committee (Human). Results. Data of 1 496 children were included in the analysis. The prevalence of underweight was 2.5% (n=37), while 11.2% (n=167) were stunted and 1.1% (n=16) were wasted. There were associations between age category and delayed vitamin A supplementation (χ2=32.105; df=19; n=836; p=0.03) and deworming (χ2= 45.257; df=17; n=558; p<0.001), but there was no association between delayed vaccinations and age category. There were no significant differences in anthropometrical indicators for children with delayed vitamin A supplementation, deworming and vaccinations compared with children in this sample who were up to date regarding the relevant indicators. However, weight-for-age, height-for-age and weight-for-height z-scores and stunting risk were associated with low birthweight (LBW) (odds ratio (OR) 4.658; p<0.001). Conclusion. Coverage of vitamin A supplementation and deworming but not immunisations was poorer among children in older age categories. A history of delayed vitamin A, deworming and vaccinations was not associated with the anthropometrical status of children. Children with LBW should be considered for more rigorous follow-up, as they are at higher risk of stunting.
Background Adequate infant nutrition is essential for optimal growth, cognitive development, and overall health. Although breastfeeding is the recommended source of nutrition during infancy, micronutrient deficiencies, particularly iron, vitamin A, iodine deficiencies, and anaemia, remain major public health concerns in developing countries. In South Africa, especially in rural communities, limited information exists on breastfeeding practices and the micronutrient status of breastfed infants and their mothers. This study aims to assess feeding practices, growth patterns, and the prevalence of iron, vitamin A, and iodine deficiencies among breastfed infants younger than 12 months in Thulamela Municipality, Limpopo Province. Methods A quantitative cross-sectional study will be conducted among breastfeeding mothers and their infants aged less than 12 months attending selected primary healthcare facilities in Thulamela Municipality. Based on a prevalence estimate of 13.1%, a 95% confidence level, and a 5% margin of error, a minimum sample size of 175 participants was calculated. After accounting for a 10% non-response rate, 193 mother-infant pairs will be recruited using a multistage sampling procedure. Data collection will include interviewer-administered questionnaires, anthropometric measurements, and biochemical analyses. Information on sociodemographic characteristics and breastfeeding practices will be obtained through structured questionnaires. Maternal and infant anthropometric measurements will be recorded, while haemoglobin concentration will be measured using the HemoCue® Hb 201+ Analyzer. Serum biomarkers of iron, vitamin A, iodine status, and inflammation will be analysed using the Q-Plex™ Human Micronutrient Array. Data will be analysed using SPSS. Results and Conclusion : The study is expected to determine the prevalence of iron deficiency, anaemia, vitamin A deficiency, and iodine deficiency, describe breastfeeding practices and growth patterns, and explore associations between maternal and infant nutritional status. Findings will provide evidence to guide nutrition interventions, breastfeeding promotion strategies, and public health policies aimed at improving maternal and child health in rural South African communities.
Objectives Every child around the globe should get routine childhood vaccination, which is mostly affected by the country’s economic capacity besides the socioeconomic differences. However, how well countries with different economic capacities address equitable child vaccination remains unanswered. Methods Cross-sectional data from the latest Demographic and Health Survey (DHS) database of Mali, Bangladesh, and South Africa was used for this study. The dependent variable was full child vaccination, and wealth-based inequality was assessed using rate-ratio, concentration curve, and concentration index. A multilevel Poisson regression analysis was used to determine the predictors of inequalities. A risk ratio (RR) with a p-value of 0.05 was used to declare statistical significance. All analysis was weighted. Results Full child vaccination status was 30.15%, 62.18%, and 46.94% in Mali, Bangladesh, and South Africa respectively. Even if the disparity is higher in Mali, the full vaccination favors the better-off family both in Mali, and Bangladesh respectively [CInd: 0.05, 95% CI: 0.01, 0.09], [CInd: 0.02, 95% CI: 0.001, 0.03], wealth status did not have an effect in South Africa. The multilevel poison regression indicated maternal age, occupation, wealth of household, and frequency of watching television to positively affect full vaccination, whereas the number of children in the house negatively affected full vaccination. Conclusion Wealth-based inequality in child vaccination was higher in Mali followed by Bangladesh. There was no observable significant equity gap in South Africa. Wealth status, maternal occupation, maternal age, frequency of watching television, and number of children were predictors of full child vaccination.
Abstract The introduction of salt iodization is associated with improved health and socioeconomic outcomes, but is not yet universally adopted and not always sustained. Using a quasi-experimental event study with difference-in-differences over space and time, we quantify the impacts of iodine deficiency in utero and infancy on childhood mortality and later academic achievement in Ethiopia, comparing cohorts born just before and after the May 1998 border closure that interrupted access to iodized salt. Rural children with fewer months of early-life exposure to iodized salt scored lower on standardized secondary-school exams, especially in districts with low environmental iodine, with excess deaths emerging in infancy and persisting through early childhood. These findings reveal the long-term benefits of salt iodization for health and education, especially for people with low intake of iodine from environmental sources.
