Objectives: In Latin America, up-to-date information to monitor UNAIDS 95-95-95 HIV targets in key populations, such as men who have sex with men, is limited. Elsewhere, structural homophobia restricts access to ART. Conceptual frameworks suggest that intersecting forms of violence and discrimination may negatively influence HIV care outcomes through psychosocial and structural pathways, although empirical evidence remains limited. The study aimed to assess whether sexual orientation outness and recent homophobic violence are associated with not being on ART among Latin American MSM living with HIV. Methods: This cross-sectional study is a secondary analysis of data from LAMIS-2018, including 7,609 MSM aged 18+ with an HIV diagnosis ≥1 year prior from 18 Latin American countries. Participants self-reported ART status, sociodemographic characteristics, homophobic violence, and sexual orientation outness. Bivariate and multivariate logistic regressions identified those factors associated with not being on ART. Results: Nine percent of MSM with HIV were not on ART, 18% reported low sexual orientation outness, and 27% experienced homophobic violence, especially in Andean and Central American countries. Not being on ART was associated with recent homophobic violence (aPR=1.25), low outness (aPR=1.22), unemployment (aPR=1.27), and residence in the Andean subregion (aPR=1.87), Mexico (aPR=1.28), or the Southern Cone (aPR=1.45) versus Brazil. Protective factors included being older (25–39: aPR=0.72; >39: aPR=0.49), living in large cities (aPR=0.72), having a stable partner (aPR=0.78), and university education (aPR=0.74). Conclusions: Recent homophobic violence and low sexual orientation outness were associated with not being on ART among MSM in Latin America. While access varies across countries, structural factors such as stigma and violence may limit engagement in care. Addressing these barriers alongside strengthening health systems may be key to improving ART uptake and advancing progress toward the 95–95–95 targets. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The author(s) received no specific funding for this work. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Institutional Ethics Committee of Universidad Peruana Cayetano Heredia (code: CIEI-196-20-24). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes This study did not generate primary data. Secondary data from the LAMIS-2018 database were used, which can be requested from the study coordinators (lamis{at}coalitionplus.org ) through the following form: https://docs.google.com/document/d/1gHoX\_E90jyrMTokzSJWT6OfZs3\_0icB_/edit.”

AIMS:Iron levels imbalances are linked to cardiovascular outcomes. We aimed to assess the association between genetically predicted lifelong higher iron levels and cardiovascular outcomes, employing a two-sample Mendelian randomization (MR) approach to account for confounding biases. METHODS AND RESULTS:We used a study involving 257 953 subjects across six cohort studies that identified genetic variants consistently associated with iron biomarkers, including ferritin, serum iron, total iron binding capacity (TIBC), and transferrin saturation (TSAT). The UK Biobank study was used to investigate the association between the same genetic variants and left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), left ventricular mass (LVM), and left ventricular mass-to-end-diastolic volume ratio (LVMVR). Two-sample MR approach was used in our main analysis. Heterogeneity, pleiotropy, bidirectional MR, MR-Egger, weighted median, and weighted mode were explored in the sensitivity analysis. One standard deviation (SD) increase in genetically predicted serum iron levels was associated with lower LVEDV (beta (95%CI): -0.11, (-0.19, -0.03), P-value = 0.006) and lower LVESV (-0.11 (-0.19, -0.03), P-value = 0.007). Moreover, one SD increase in genetically predicted TSAT was associated with higher LVMVR (0.09, (0.03, 0.15), P-value = 0.005). Heterogeneity, pleiotropy, and bidirectional effects were not observed. The identified associations were explained by HFE, TMPRSS6, TF, and TFR2 genes. No other associations were identified between iron biomarkers and cardiovascular outcomes. CONCLUSION:Our study provides MR evidence that iron status may alter cardiovascular function and structure. HFE, TMPRSS6, TF and TFR2 genes play a crucial role in the identified associations.

In rural Indigenous communities in the Peruvian Amazon, access to quality care is difficult, home births are frequent, and neonatal mortality remains high. Peru has a large cadre of Community health workers (CHW), yet their potential is not harnessed. A recent outcome evaluation of a community-based intervention showed improvements in essential newborn care (ENC) for home births and small increases in facility births. To explain these findings, elucidate the pathways of change, and derive policy recommendations, we conducted a mixed-methods process evaluation. Implementation strength, mechanisms of change, and influence of contextual factors were assessed using data collected from women, CHW, traditional birth attendants (TBA), supervisors, and community members. We calculated programme coverage and intervention exposure and explored experiences, perceptions, and birth stories through interviews, focus group discussions, and participant observation using content analysis. Triangulated findings were narratively synthesized and contrasted to hypothesized intervention mechanisms. The programme achieved high coverage of well-trained CHW and TBA supported by intensive supervision. Multiple pathways of change were identified: Trained TBA as main providers of home-based birth care implementing ENC; CHW home visits sensitizing women through educational videos and provision of delivery kits, albeit with less reach and counselling than expected; and supervisor-led, women-only educational meetings. Some CHW proactively facilitated access to facility care, while promotion alone to increase demand appeared insufficient. Pathways of change identified support a causal link between the intervention and observed behaviour changes in the outcome evaluation. Our findings demonstrate the potential of community-based approaches involving CHW and TBA which should be given greater importance in national health policy. To improve impact and sustainability of the Peruvian CHW programme, we provide several context-specific recommendations.

BACKGROUND:Peru faces a double burden of malnutrition, characterised by the co-existence of overnutrition and undernutrition. Although several fiscal policies have been implemented to address nutrition challenges, these have been designed and implemented separately, limiting their potential for synergistic impact. This paper investigates the potential impact of retrofitting unhealthy food and beverage taxation for 'double-duty' action by allocating revenues towards welfare transfers and fruit and vegetable subsidies on overweight and stunting in Peru. METHODS AND FINDINGS:We developed a system dynamics model to simulate overweight and stunting in children and adults of reproductive age, using secondary data sources and published effect estimates. We modelled several fiscal policy scenarios, informed by WHO recommendations and Peru's policy landscape. We performed several tests to build confidence in the model. Fiscal policy scenarios can have beneficial effects on overweight compared to business-as-usual, mainly through the impact of additional unhealthy food and beverage taxes, which would reduce cumulative person-years lived with adult overweight between 2024 and 2040 by -58.6 (95% Uncertainty Interval [UI] [-77.7, -37.9]) million, mainly among the richest. Reinvesting tax revenue to increase the amount of cash offered through Peru's existing conditional cash transfer could reduce cumulative person-years lived with child stunting by up to 876 thousand (95% UI [-1,139, -567]) by 2040, with 82% of these being among the poorest. This study relies on several assumptions regarding policy impacts and responses and does not incorporate cost-effectiveness analysis due to its exclusion of older age groups. CONCLUSIONS:Retrofitting unhealthy food and beverage taxation to reallocate revenue towards targeted welfare programmes, such as cash transfers, has substantial potential for 'double-duty' impacts on overnutrition and undernutrition in Peru.

Acute appendicitis may be uncomplicated or may present with life threatening complications. Since the outbreak of the COVID-19 pandemic, there has been an increase in the number of cases of complicated appendicitis, suggesting a possible association between them. Therefore, we aimed to determine the association between SARS-CoV-2 infection and complicated appendicitis in surgical patients in Lima, Peru, from March 2020 to December 2021. A matched case-control study was conducted. Clinical records of patients ≥ 18 years old who underwent surgery for appendicitis and had at least one positive SARS-CoV-2 diagnostic test were selected. Patients undergoing surgery for complicated appendicitis were considered cases, and patients undergoing surgery for uncomplicated appendicitis were controls. A 1:1 matching by sex, age, and month of surgery was performed. Conditional logistic regression modeling was performed to calculate crude and adjusted conditional odds ratios (cOR). The positivity rate for COVID-19 tests was 73.6

INTRODUCTION:The diagnosis and treatment of gastric cancer may have been affected during the COVID-19 pandemic, ultimately influencing mortality from this disease. OBJECTIVE:To evaluate changes in gastric cancer mortality during the COVID-19 pandemic years. MATERIALS AND METHODS:An interrupted time series analysis was conducted to assess changes in gastric cancer mortality. Data were obtained from the National Death Information System. Three periods were compared: pre-pandemic (2017-2019), pandemic (2020-2021), and post-pandemic (2022-2023). Segmented regression models were used. RESULTS:Before the pandemic, an average of 2,107 deaths per year was recorded. During 2020 and 2021, mortality increased by 39% and 118%, respectively. The highest peaks occurred between April and July 2020. An additional rise was observed during the early months of 2021. Although mortality progressively declined in 2023, pre-pandemic levels were not restored. The analysis showed that observed deaths consistently exceeded expected projections through late 2022. CONCLUSIONS:The COVID-19 pandemic generated a temporary but significant increase in gastric cancer-related mortality in Peru.

BackgroundWe examined the impact of COVID-19 on childhood immunization coverage and inequalities in Peru, focusing on pentavalent, rotavirus, and pneumococcal (PCV) vaccines. Since the 1990s, Peru has worked to improve childhood vaccine coverage, but the COVID-19 pandemic posed significant challenges to the health system.MethodsWe analysed data from nationally representative health surveys conducted annually between 2015 and 2023. The surveys measured vaccine coverage among children aged 18-29 months, namely three doses for pentavalent and PCV and two doses for the rotavirus vaccine, based on data from home-based records. We studied inequalities at the individual child level using the slope index of inequality (SII) based on household wealth quintiles.ResultsIn 2019, the home-based record coverage levels for pentavalent, PCV and rotavirus vaccines were 78.0%, 74.5%, and 75.9%, respectively. In 2020, these rates dropped significantly due to pandemic disruptions: PCV and pentavalent coverage fell by 14% points, and rotavirus by 12 points. By 2021, coverage levels improved, returning to pre-pandemic rates by 2022 and 2023. Individual-level analyses showed that pro-rich inequalities were present during the full study period, but these increased sharply during the pandemic in 2020, with poorer children experiencing more significant drops in coverage than wealthier children. This trend reversed by 2021 and 2022 when inequality measures returned to pre-pandemic levels. Due to reasons that are still unclear, inequality increased again in 2023. Nevertheless, the confidence intervals for the summary inequality measures are wide and must be interpreted cautiously.ConclusionsThe COVID-19 pandemic temporarily disrupted Peru's childhood immunization efforts, particularly affecting poorer populations, but coverage rebounded to pre-pandemic levels by 2022. These findings contribute to the scant literature on the pandemic's impact on vaccine equity.

Introducción: El diagnóstico y tratamiento del cáncer gástrico pudo verse afectado durante la pandemia COVID-19, influyendo finalmente en la mortalidad por esta enfermedad. Objetivo: Evaluar el cambio de la mortalidad por cáncer gástrico durante los años de la pandemia COVID-19. Materiales y métodos: Se realizó un análisis de series de tiempo interrumpidas para evaluar los cambios en la mortalidad por cáncer gástrico. Los datos se obtuvieron del Sistema Informático Nacional de Defunciones. Se compararon tres periodos: prepandemia (2017–2019), pandemia (2020–2021) y post-pandemia (2022–2023). Se utilizaron modelos de regresión segmentada. Resultados: Antes de la pandemia se registraron 2,107 muertes al año. Durante los años 2020 y 2021 se observó un incremento del 39% y 118%, respectivamente. Los mayores picos ocurrieron entre abril y julio del 2020. Además, se observó un incremento durante los primeros meses del 2021. Aunque en el 2023 las defunciones disminuyeron progresivamente, no se logró alcanzar los niveles pre-pandémicos. Mediante el análisis realizado se evidenció que las muertes observadas superaron consistentemente las proyecciones esperadas hasta fines del 2022. Conclusiones: La pandemia COVID-19 generó un incremento temporal pero significativo de la mortalidad asociada a cáncer gástrico en Perú.

Objective:To evaluate the outcome of Peru's strategy to introduce new vaccines in the poorest regions with high child mortality rates. Methods:We analysed data from nationally representative annual health surveys conducted between 2004 and 2022. We examined associations between vaccine coverage and poverty (proportion of households in the poorest 40% of the national wealth index) at the ecological level using the country's 25 regions and at the individual child level using household wealth quintiles. We obtained vaccination data from home-based records. Findings:The surveys included 49 023 children aged 18-29 months. In the ecological analyses, coverage for Haemophilus influenzae type b, pneumococcal conjugate and rotavirus vaccines was positively associated with poverty prevalence in the initial post-introduction period, but these associations disappeared over time. In contrast, the individual-level analyses indicated that children from wealthier families were consistently more likely to be vaccinated than children from poorer families. In the most recent period (2018-2022), vaccination coverage in the wealthiest quintile was about 10 percentage points higher than in the poorest quintile. Coverage levels for boys and girls were similar. Children whose low-income families were enrolled in the Juntos cash transfer programme had higher coverage than the rest of the population. Conclusion:The strategy increased coverage in the poorest districts initially and, as national coverage grew, regional disparities were eliminated. However, socioeconomic differences persisted, with wealthier children maintaining higher vaccination rates throughout the study. To eliminate these disparities, geographic targeting should be complemented with household-level targeting.

Background:We examined COVID-19's impact on the number of small vulnerable newborns (SVN) at national and regional levels in Peru and Brazil. Methods:Using national birth registries, we examined monthly numbers of preterm (PT), low birthweight (LBW), and small for gestational age (SGA) newborns. We analysed COVID-19's impact on SVN using two interrupted time series models. We estimated SVN's expected numbers in the absence of the pandemic using mixed-effects regressions and calculated percent changes by comparing these estimates to observed during the pandemic. Incidence rate ratios (IRR) were estimated using Poisson regression. Results:In Peru, the average percent changes in PT, LBW, and SGA births were -17%, -11%, and -3% in 2020, and -10%, -4%, and +2% in 2021, respectively. The IRR of PT and LBW declined throughout the pandemic, while SGA IRR increased in August 2020-November 2020 and May 2021-December 2021. The Coast region experienced the greatest drop in PT, LBW, and SGA IRR in 2020, followed by a slight increase in 2021, whereas the Highlands and Amazon regions had increased LBW and SGA IRR. In Brazil, the percent changes in PT, LBW, and SGA births were +1%, -3%, and -8% in 2020, and +1%, 0%, and -1% in 2021, respectively. Most PT, LBW, and SGA IRRs decreased during the pandemic, except in the Northeast and Southeast regions, where PT increased in 2020. All regions experienced declines in LBW and SGA in 2020, with the Central-West and South regions showing the greatest LBW declines and Central-West region the highest SGA decrease. Conclusions:No significant worsening of neonatal outcomes were observed during the COVID-19 pandemic. In Peru, PT and LBW births declined, while SGA increased from August 2020. In Brazil, PT births slightly increased, while LBW and SGA births declined in 2020, remaining stable in 2021.

OBJECTIVE:To assess the effects of a neonatal resuscitation training program using traditional training and partial distance learning. METHOD:Through an open cluster-randomized trial, the authors compared a traditional approach involving face-to-face theory and practice sessions using information and communication technology to offer theory and distance examination, followed by face-to-face practice. Twelve health facilities were allocated by blocked randomization. Comparisons were made adjusting for clustering in qualitative and quantitative data. The primary outcome was the percentage of infants with heart rates ≥100 per minute at the second minute after birth. The authors performed a cluster-level analysis for cluster randomized trials, simplifying the adjustment for individual- and cluster-level covariates. RESULTS:The authors trained 403 health professionals in two arms in twelve facilities. After six months, the authors assessed 2180 birth deliveries, 966 newborns in the traditional training group (TT), and 1214 in the partial distance learning training group (pDL). The authors found no statistical evidence favoring any of the two trial arms (RR = 0.9859, CI 95 % = 0.9446; 1.0292, p = 0.4819). CONCLUSIONS:The authors found no statistical evidence favoring traditional or distance learning methods for neonatal resuscitation training. Further research could assess improved online platforms to enable sustainable virtual reality instructor/provider interaction for theory, practice and testing, addressed to health cadres of rural and remote areas.

Background:Peru's progress in reducing stunting has stagnated since 2018, while the country is facing increasing levels of overnutrition, leading to a double burden of malnutrition. However, this shift in nutrition burden is not reflected in Peru's nutrition policy agenda. This study aims to identify leverage points for actions against population-level double burden of malnutrition in Peru. Methods:We developed a system dynamics model that simulates changes in overweight and stunting over time in Peru through changes in food system drivers. The model was conceptually informed by policymakers, practitioners and community members in Peru and used quantitative and qualitative data from secondary sources and published literature. Findings:The model indicated that several overnutrition policies, including policies targeting food availability and affordability, may decelerate but not halt the increase of overweight in the country, mainly due to industry resistance. However, in the long term, the reallocation of resources towards overnutrition policies may inadvertently hinder progress towards stunting targets. Transforming nutrition policy governance, from siloed overnutrition and undernutrition policies towards a common policy framework against the double burden of malnutrition was the only modelled scenario that halted the rise in overnutrition, while keeping Peru on course to reach its stunting goals. Interpretation:Transition away from policy landscapes that focus on single nutrition outcomes towards synergistic actions that target malnutrition in all forms is a long-term solution towards achieving global nutrition goals. Such policy transitions are especially important in low and middle-income countries like Peru, which are affected by the double burden of malnutrition. Funding:This study was supported by a research grant from the Biotechnology and Biological Sciences Research Council (BBSRC) (grant reference: BB/T009004/1).

Background The coronavirus disease 2019 (COVID-19) pandemic disrupted essential health care services worldwide, including those related to immunisation. National data from Bangladesh shows that child immunisation may have been adversely affected by the pandemic but regional evidence is limited. We therefore aimed to explore the regional differences in the indirect effects of COVID-19 on child immunisation in Bangladesh. Methods We extracted data from the District Health Information Software (DHIS2) spanning the period from January 2017 to December 2021. We examined three essential immunisation indicators: Bacille Calmette-Guerin (BCG), pentavalent third dose, and measles vaccinations. We examined both the yearly and monthly trends to explore fluctuations in the number of immunisations to pinpoint specific periods of service utilisation regression. Segmented regression with Poisson distribution was implemented given the count-based outcome. We reported incidence rate ratios (IRRs) with 95% confidence intervals (CIs) in different regions in 2020 and 2021 compared to the reference period (2017-19). Results We initially observed a notable decline in vaccine administration in April 2020 compared to the pre-pandemic period of 2017-19 with a drop of approximately 53% for BCG vaccines, 55% for pentavalent third doses, and 51% for measles vaccines followed by May 2020. The second half of 2020 saw an increase in vaccination numbers. There were noticeable regional disparities, with Sylhet (IRR = 0.75; 95% CI = 0.67-0.84 for pentavalent administration, IRR= 0.79; 95% CI= 0.71- 0.88 for measles administration) and Chattogram (IRR = 0.77; 95% CI = 0.72-0.83 for BCG administration) experiencing the most significant reductions in 2020. In April 2020, Dhaka also experienced the largest decline of 67% in measles vaccination. In 2021, most divisions experienced a rebound in BCG and pentavalent administration, exceeding 2019 levels, except for Chittagong, where numbers continued to decline, falling below the 2019 figure. Conclusions Our findings highlight the impact of the COVID-19 pandemic on childhood immunisation across regions in Bangladesh. Sylhet, Chattogram, and Dhaka divisions experienced the most significant reductions in immunisation services during 2020. This underscores the importance of targeted interventions and regional strategies to mitigate the indirect effects of future challenges on essential health care services, particularly childhood immunisation, in Bangladesh.

Each year, approximately 35 million babies—more than 25% of all newborns worldwide–are born too soon (before 37 completed gestation weeks) or too small (birth weight <2500 g or smaller than expected for gestational age and sex). These small vulnerable newborns (SVN) experienced adverse exposures during their intrauterine period, leading to fetal growth restriction, preterm birth, or both. After birth, they will have a markedly increased risk of neonatal death and later childhood mortality. Being born too soon or too small is also associated with stillbirth and multiple morbidities with short-term and long-term adverse consequences, for newborns and their families. For society, there is a major loss of human and economic capital. Therefore, prevention of SVN births is critical both for global child health and for societal development. We can and should devote our best efforts to prevent the birth of SVN, by preventing fetal growth restriction and preterm birth. There are effective and simple interventions that should be widely implemented, but progress is too slow all over the world. A recently published Lancet Series on Small Vulnerable Newborns provides supporting evidence to tackle the problem1Ashorn P. Ashorn U. Muthiani Y. et al.UNICEF–WHO Low Birthweight Estimates Group. Small vulnerable newborns-big potential for impact.Lancet. 2023; 401: 1692-1706https://doi.org/10.1016/S0140-6736(23)00354-9Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 2Lawn J.E. Ohuma E.O. Bradley E. et al.Small babies, big risks: global estimates of prevalence and mortality for vulnerable newborns to accelerate change and improve counting.Lancet. 2023; 401: 1707-1719https://doi.org/10.1016/S0140-6736(23)00522-6Summary Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 3Hunter P.J. Awoyemi T. Ayede A.I. et al.Biological and pathological mechanisms leading to the birth of a small vulnerable newborn.Lancet. 2023; 401: 1720-1732https://doi.org/10.1016/S0140-6736(23)00573-1Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 4Hofmeyr G.J. Black R.E. Rogozińska E. et al.Evidence-based antenatal interventions to reduce the incidence of small vulnerable newborns and their associated poor outcomes.Lancet. 2023; 401: 1733-1744https://doi.org/10.1016/S0140-6736(23)00355-0Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar and contains a call for action with recommended international and national interventions.5Mohiddin A. Semrau K.E.A. Simon J. et al.The ethical, economic, and developmental imperative to prevent small vulnerable newborns and stillbirths: essential actions to improve the country and global response.Lancet. 2023; (published online May 8)https://doi.org/10.1016/S0140-6736(23)00721-3Summary Full Text Full Text PDF Scopus (3) Google Scholar Concrete actions at regional and national levels should follow. We need to speak loud and clear, so the SVN are included as a top priority in the global and national agendas. The 2023 Lancet Series on SVN was presented and discussed in Lima, Peru, on 30 November 2023, as part of a series of regional launches, with the participation of co-authors, members of the academia, other stakeholders of public and private sectors, and the civil society. There was a lively discussion about the current situation in the world, in Latin America and in Peru, and several valuable ideas were provided by the participants on the way forward. In Latin America and the Caribbean (LAC; represented in this reference by Argentina (2017–2018), Brazil (2010–2021), Chile (2000–2021), Mexico (2000–2021), Peru (2010–2021) and Uruguay (2010–2021)), of all reported live births between 2000 and 2021, 12.6% were SVN, representing over 6.7 million newborns, with Peru being on the top-three rank for all four types of SVN. At country level, from 2010 to 2021, over 11% of all Peruvian newborns were SVN, amounting to over 330,000 newborns, mostly due to preterm newborns adequate for gestational age (5.2%) and full-term babies small for gestational age (4.6%).6Suárez-Idueta L. Yargawa J. Blencowe H. et al.Vulnerable newborn types: analysis of population-based registries for 165 million births in 23 countries, 2000-2021.BJOG. 2023; ([published online ahead of print, 2023 May 8])https://doi.org/10.1111/1471-0528.17505Crossref Scopus (9) Google Scholar The SVN problem is surely concentrated among the poorest, in the most remote areas and indigenous communities, which will ultimately influence the response strategies, likely requiring a territorial approach. However, all segments of the population are affected, as the continued high caesarean section rates show in Peru and the whole region.7Quezada-Pinedo H.G. Cajachagua-Torres K.N. Guzman-Vilca W.C. Tarazona-Meza C. Carrillo-Larco R.M. Huicho L. Flat trend of high caesarean section rates in Peru: a pooled analysis of 3,376,062 births from the national birth registry, 2012 to 2020.Lancet Reg Health Am. 2022; 12: Nonehttps://doi.org/10.1016/j.lana.2022.100293Summary Full Text Full Text PDF Scopus (3) Google Scholar,8Betran A.P. Ye J. Moller A.B. Souza J.P. Zhang J. Trends and projections of caesarean section rates: global and regional estimates.BMJ Glob Health. 2021; 6e005671https://doi.org/10.1136/bmjgh-2021-005671Crossref PubMed Scopus (379) Google Scholar During the launch event in Lima, key recommendations for action proposed in the Lancet series were explored, further discussed, and consolidated in a proposed high-level National SVN Roadmap that takes into account the particular context of Peru (Table 1), whose salient aspects include the importance of: 1) integrating systems and ensuring data quality, 2) generating data and disseminating findings by the academia, 3) making the SVN part of the public agenda with close participation of the civil society to help ground the issue and help prioritize it, and 4) designing an "SVN Peru Plan" and promote for it to be included in the national plans along with the necessary investment.Table 1Proposed high-level, short- and medium-term SVN roadmap.aDiscussed and agreed on during the Lima meeting, in November 2023.PillarsNational actionWhat (the problem)HowWho1. Problem recognition: make SVN prevention a health priority1.1. Develop or integrate within other national plans•SVN not on the national agenda•Weak communication and leadership, political instability•Low budget execution, fiscal policy not aligned to health policy•Introduce SVN in the national agenda•Resume successful national experiences (e.g., childhood stunting)•Include SVN in country budget allocation•Multiple actors, regional and local2. Intervention implementation: scale-up quality care for women, particularly during pregnancy and at birth2.1. Ensure early start of high-quality antenatal and childbirth care for all pregnant women•Interventions focused on treatment•Community health agents not formally recognized.•Decentralization: a pending agenda•Reverse the curative approach strengthening the primary level•Work with other programs/sectors to face challenges, create synergies and amplify impact•Multiple actors•Incorporate community health agents•Work with the academia2.2. Scale up interventions; include them as part of Universal Health Coverage•Antenatal care not focused on quality•Ministry of Health's approach not linked with the community•Focus on quality antenatal care•Work with communities, supported by community health agents•Multiple actors; include community health agents3. Increased accountability: improved measurement and monitoring3.1. Date all pregnancies, weigh all newborns and stillbirths and collate data on preterm and SGA newborns•Low coverage of antenatal ultrasound•Registry of stillbirths insufficient•Deficient information systems, without budget allocation•Expand coverage of antenatal ultrasounds•Strengthen the vital events registration system•Integrate systems and ensure data quality•Healthcare professionals•Information systems staff3.2. Promote societal level action with a multi-sectoral approach•Lack of an equitable multisectoral approach•Weak governance and accountability•Lack of regional and local evidence•Strengthen equitable multi-sectoral actions and accountability mechanisms, building on previous experiences•Generation and dissemination of data by academia•All sectorsa Discussed and agreed on during the Lima meeting, in November 2023. Open table in a new tab Peru has a long tradition of successful efforts in the process of achieving substantial progress in reproductive, maternal and child health. It was able to reduce dramatically in the last two decades the under-five mortality rate, the under-five stunting prevalence and the neonatal mortality rate, although huge gaps remain, particularly between the rural and urban areas and between the richest and the poorest segments of the population.9Huicho L. Segura E.R. Huayanay-Espinoza C.A. et al.Child health and nutrition in Peru within an antipoverty political agenda: a Countdown to 2015 country case study.Lancet Glob Health. 2016; 4: e414-e426https://doi.org/10.1016/S2214-109X(16)00085-1Summary Full Text Full Text PDF PubMed Scopus (87) Google Scholar,10Huicho L. Vidal-Cárdenas E. Akseer N. et al.Drivers of stunting reduction in Peru: a country case study.Am J Clin Nutr. 2020; 112: 816S-829Shttps://doi.org/10.1093/ajcn/nqaa164Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar Key drivers of progress included strong civil society advocacy and the equitable implementation of multisectoral interventions, within the context of sustained economic growth.9Huicho L. Segura E.R. Huayanay-Espinoza C.A. et al.Child health and nutrition in Peru within an antipoverty political agenda: a Countdown to 2015 country case study.Lancet Glob Health. 2016; 4: e414-e426https://doi.org/10.1016/S2214-109X(16)00085-1Summary Full Text Full Text PDF PubMed Scopus (87) Google Scholar Building on this rich experience, Peru is in a unique position to tackle successfully the challenge posed by the SVN. But it needs to recognize the problem and define it clearly, to appropriately reorientate the strong advocacy role of the stakeholders earlier involved so effectively in the advancement of the Reproductive, Maternal, Newborn and Child Health (RMNCH) agenda, engage them in the SVN particular challenges, and to persuade technocrats to invest in the design and implementation of existing interventions for SVN. We acknowledge that while this proposed action plan is only a first step in the complex process to effectively tackle the problem, it is a necessary one. We are confident to boost with this appeal further discussion on the SVN in Peru and the entire LAC region. All authors conceived the paper. LH and EVC prepared the first draft of the manuscript. All authors provided critical scientific and editorial input to improve the manuscript. All authors approved the submitted version. None to declare. Download .xlsx (.02 MB) Help with xlsx files Supplementary File

Background The resilience of Perus health system was weakened by a political crisis that started in 2016 and was further challenged by the coronavirus 2019 (COVID-19) pandemic. We assessed the indirect impact of the pandemic on the utilisation of essential maternal and child health (MCH) services in Peru at national and subnational levels. Methods We assessed the trends in MCH services utilisation and the percentage change from 2018 to 2021, using routine health facility data. We used an interrupted time series analysis to quantify the impact of COVID-19 on the utilisation of health services. Results The utilisation of most maternal and child health services dropped dramatically in 2020 after the outbreak. However, we observed quick recovery in 2021, with service utilisation fairly similar or higher to the pre-pandemic period (2018-2019). The decrease was higher in the utilisation of antenatal care visit one or more (incidence rate ratio (IRR) = 0.79; 95% CI = 0.74-0.83) and antenatal care visits four or more (IRR= 0.76; 95% = 0.74-0.79) in 2020. The IRR showed a drop of 5, 6, 9, and 13% in the utilisation of skilled birth attendances, institutional deliveries, caesarean sections and postnatal care visits within two days of childbirth, respectively in 2020 in comparison to pre-pandemic service utilisation. In 2020 the utilisation decreased in all three natural regions, with the Rainforest being the most affected. In 2021 there was a recovery in all natural regions. Conclusions The pandemic decreased the utilisation of essential maternal and child health services in Peru. This highlights the need to preserve the resilience of a health system both at central and local levels, to face more successfully future pandemics.

Background:We aimed to examine the national and subnational prevalence of vulnerable newborn phenotypes in Peru, 2012-2021. Methods:Newborn phenotypes were defined 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], non-LBW) using the Peruvian National Birth Registry as six (by excluding birthweight) and ten newborn phenotypes (using all three outcomes). Small phenotypes (with at least one classification of PT, SGA, or LBW) were further considered. Using individual-level data, we stratified the phenotypes by maternal educational level, maternal age, healthcare insurance, altitude of residence, and geographic region (Coast, Andes, and Amazon). Findings:The prevalence of the five vulnerable newborn phenotypes for the study period was LGA+T (15.2%), AGA+PT (5.2%), SGA+T (4.6%), LGA+PT (0.8%), and SGA+PT (0.7%). The Coast had a higher prevalence of newborns with large phenotypes (19.4%) and the Highlands a higher prevalence of newborns with small phenotypes (12.5%). Mothers with poor socioeconomic status, extreme ages and living at high altitude had a higher prevalence of newborns with small phenotypes, and mothers who were wealthier, more educated, and older had a higher prevalence of infants with large phenotypes. Interpretation:Our findings cautiously suggest that socioeconomic and geographic disparities may play a crucial role in shaping vulnerable newborn phenotypes at national and subnational level in Peru. Further studies using longitudinal data are needed to corroborate our findings and to identify individual-level risk factors. Funding:Ter Meulen Grant from the KNAW Medical Sciences Fund of the Royal Netherlands Academy of Arts and Sciences (KNAWWF/1085/TMB406, KNAWWF/1327/TMB202116), Fogarty Program (D43TW011502).

Background The coronavirus disease 2019 (COVID-19) pandemic had substantially disrupted maternal health care provision and utilisation in Bangladesh. However, the extent of geographical disparities in service utilisation and how the health system withstood these challenges have not been studied. This study explores the divisional disparities in trends and disruptions in maternal health service utilisation caused by the COVID-19 pandemic. Methods Data was extracted from the District Health Information Software of Bangladesh from January 2017 to December 2021. We assessed the trend of first antenatal care visit, institutional delivery and number of caesarean sections over these years. We explored both the yearly and monthly trends to see the variations in the number of utilisations. Segmented regression with Poisson distribution was used to assess changes in service utilisation during the COVID-19 period. We reported incidence rate ratio (IRR) of service utilisation with a 95% confidence interval (CI) in different divisions during COVID-19 (2020-2021) compared to the reference period (2017-2019). Results Initially, a notable decline in maternal health care utilisation was observed in 2020 compared to the pre-pandemic period of 2017-2019. Divisional disparities were observed in this trend. Overall, compared to the pre-pandemic period, we observed around 30% decline in all three selected indicators of maternal health care. The lowest value was observed in Chattogram in 2020 (IRR = 0.66; 95% CI = 0.55-0.79) and Rajshahi in 2021 (IRR= 0.71; 95% CI = 0.60-0.82). For institutional delivery, Barishal division had the lowest IRR (0.64; 95% CI = 0.60-0.68) in 2020 and, in 2021 Rajshahi had the lowest IRR (0.71; 95% CI = 0.60-0.82). For caesarean section, the lowest value was observed in Barishal division (IRR= 0.48; 95% CI = 0.44-0.53) in 2020 and in Mymensingh (IRR = 0.37; 95% CI = 0.32-0.43) in 2021. By 2021, the three maternal health care utilisation indicators demonstrated recovery. Conclusions The effect of the pandemic, including lockdown, on the selected maternal service utilisation was observed in Bangladesh though there were substantial geographic disparities. These disruptions slightly recovered after the initial shock. These results will support the government in preparing the national and regional health systems for future epidemics in Bangladesh.