INTRODUCTION:Large-for-gestational-age (LGA) and macrosomic births pose significant maternal and neonatal health risks, particularly in low- and middle-income countries (LMICs), where access to care are often limited. Despite well-established associations between LGA, macrosomia, and various risk factors, the relative contributions of these factors remain underexplored in LMICs. This study aims to identify risks factors for LGA and macrosomia in LMICs, with an emphasis on modifiable ones, and quantify their population attributable fractions (PAFs). METHODS AND ANALYSIS:A systematic review will be conducted across the following databases: MEDLINE, Scopus and ProQuest Central and regional databases (Africa Index Medicus, Index Medicus for South Asia and Latin America and Caribbean literature of health sciences). Eligible studies will include observational studies, reviews and interventional research conducted between 2000 and 2025 that report on prevalence or association of risk factors for large-for-gestational-age (LGA) and/or macrosomia births in low- and middle-income countries (LMICs). Data extraction will encompass study characteristics, prevalence/incidence estimates, risk factor distributions and measures of association. Quality assessment will be performed by two independent reviewers using the Newcastle-Ottawa Scale for observational cohort, case-control and cross-sectional studies. While Cochrane Risk of Bias Tool will be used for randomised controlled trials and a Measurement Tool to Assess Quality of Systematic Reviews 2 (AMSTAR-2) for systematic reviews and meta-analyses. Meta-analyses using a random-effects model, which accounts for population heterogeneity, will synthesise risk estimates for factors examined in three or more studies from LMICs, up-to-date meta-analysis including all relevant studies identified through our search. Population attributable fractions for individual and combined risk factors will be calculated. ETHICS AND DISSEMINATION:This systematic review will use only previously published information. Ethical approval is therefore not required. The results will be submitted for publication in a peer-reviewed journal and the findings will be presented at international conferences to engage relevant stakeholders including policymakers and public health organisations in LMICs with the aim of informing the development of targeted interventions to reduce the burden of LGA and macrosomia births in the region.

Introduction: Reliable age- and cause-specific mortality estimates for children and adolescents depend on the availability and comparability of empirical cause-of-death (COD) data. In many high-mortality settings, incomplete civil registration and fragmented surveillance systems limit such data. This review aims to identify and consolidate COD evidence for individuals aged 0–19 years. Methods: We conducted a systematic review of empirical COD studies for 0–19-year age groups in high-mortality settings with incomplete or no vital registration (VR) systems. Bibliographic database research was completed in February 2023 and supplemented by investigator-led identification. Eligible studies reported surveillance data from 1980 onwards, applied standardized COD ascertainment and met predefined criteria for population coverage, and data quality. Screening and data extraction were performed independently by two reviewers using machine-learning–assisted workflows and COD were harmonized to ensure comparability across studies. Results: We identified 77 eligible studies contributing 368 data points across age groups. Data availability was greatest for 1–59 months and sparse for older children and adolescents. Most evidence originated from South Asia and Eastern and Southern Africa. Leading causes varied by age group, with infectious causes predominating in under-5 and injuries more prominent at older ages. Verbal autopsy (VA) was the predominant method of COD ascertainment, accounting for 89% of data points. Conclusions: This review consolidates empirical COD data for 0-19 years in high mortality settings, supporting more accurate and reproducible mortality estimation where VR is limited, while highlighting persistent data gaps and the need for expanded population based, nationally representative mortality surveillance.

Objective To estimate cause specific mortality among neonates and children under 5 for 195 countries from 2000 to 2024. Design Secondary data analysis using a Bayesian multinomial logistic regression model to estimate cause specific mortality fractions. Data sources PubMed, Embase, Web of Science, SCOPUS, Cochrane, Global Health Index Medicus, PAHO, Global Health OVID, Africa-Wide Information, IndMed, WHO Mortality Database, Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), and Health and Demographic and Surveillance Systems (HDSS). Inclusion criteria Studies in the general population reporting empirical cause specific mortality for at least two causes in the age groups of interest, with a specified method for cause ascertainment. For studies identifying causes of mortality with verbal autopsy, ≥25 deaths reported with ≤25% of these deaths with unknown cause. For vital registration, ≥80% population completeness and ≤10% deaths assigned to ill defined causes determined by the international classification of diseases, 10th revision. Results Cause specific mortality for countries with adequate quality vital registration was estimated with their own data with minor adjustments. For countries with low mortality without adequate quality vital registration, cause specific mortality was modeled by age group and based on vital registration. For high mortality areas, cause specific mortality was modeled primarily on the basis of verbal autopsy data identified in a systematic review. Estimated cause distributions were applied to all cause mortality rates and death counts estimated by the United Nations Inter-agency Group for Child Mortality Estimation. Among 4.9 million estimated global deaths in under 5s in 2024, the most important cause of death was preterm birth complications, with 0.82 (90% uncertainty interval 0.76 to 0.88) million deaths and 6.17 (5.93 to 6.42) deaths for every 1000 live births. This was followed closely by lower respiratory infections at 0.66 (0.60 to 0.71) million deaths, intrapartum related events (0.48 (0.43 to 0.52) million), and malaria (0.45 (0.39 to 0.51) million). Analysis for trends over time showed that the decline in most causes has slowed since 2016. Conclusion With the recent slowed pace of decline in under 5 mortality for most primary causes of death, many high mortality countries are at risk of missing the sustainable development goal targets of ≤12 neonatal deaths and ≤25 under 5 deaths per 1000 live births without acceleration. Estimates presented here can help countries to determine the most appropriate course of action to reduce under 5 mortality and achieve these targets.

[This corrects the article DOI: 10.1371/journal.pgph.0006455.].

Introduction Communicable disease control in Afghanistan has deteriorated amid growing fragility, health system disruption and declining international aid since the 2021 regime change. Outbreaks of measles, pertussis, pneumonia, cholera, malaria, dengue, Crimean-Congo haemorrhagic fever, tuberculosis and polio continue to plague the population in Afghanistan. This study addresses a critical evidence gap by systematically ranking research priorities for communicable diseases in Afghanistan. Methods This study applied the Child Health and Nutrition Research Initiative (CHNRI) methodology, which is a widely used approach for systematic, transparent and collaborative research priority setting. It leverages expert consultation to generate, score and rank research questions. This study identified and invited 303 Afghanistan-health researchers, based globally, to complete the survey which consisted of 33 research questions related to communicable diseases that were submitted by 15 researchers. Results This CHNRI exercise included 44 respondents, 63.6% of whom were of Afghan origin. The top 10 highest-ranked questions focused on identifying barriers to low measles and polio vaccination coverage, assessing disease burden by region and strategies to reduce the incidence of tuberculosis. Respondents of Afghan origin ranked antibiotic resistance and gender-related disparities in tuberculosis as the highest-priority questions. The majority of priority questions were description questions. Conclusions Researchers, governments, donors, policy makers and programme implementers can use these findings as a starting point to strategically align research agendas, guide resource allocation, and prioritise evidence-based interventions for life-saving communicable disease prevention and control in Afghanistan.

Objective To estimate cause specific mortality among children and adolescents aged 5-19 years for 195 countries from 2000 to 2024. Design Secondary data analysis using a bayesian multinomial logistic regression model to estimate cause specific mortality fractions. Data sources PubMed, Embase, Web of Science, Scopus, Cochrane Library, Global Index Medicus, Pan American Health Organization, Global Health Ovid, Africa-Wide Information, IndMed, WHO Mortality Database, Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and Health and Demographic and Surveillance Systems. Inclusion criteria Studies of the general population reporting cause specific mortality based on primary data for at least two causes in the age groups of interest, with a specified method for determining cause. For studies identifying causes of mortality with verbal autopsy, eligibility required between 15 and 5000 total deaths, with 25% or fewer of these deaths with unknown cause. For vital registration, country data points were limited to those with at least five years of data from 2010 or later with a minimum of 80% of total deaths assigned to a meaningful cause of death determined by international classification of diseases, ninth or 10th revision. Results Cause specific mortality fractions were calculated from vital registration data for 64 countries, disease surveillance points data for China, and modelled for the remainder. Of the 1.4 million global deaths among children and adolescents aged 5-19 years in 2024, the leading cause of death was road traffic injuries with 113 138 deaths (90% uncertainty interval 106 901 to 119 375), followed by malaria (99 219, 85 840 to 112 597) and neoplasms (87 827, 81 143 to 94 511). Deaths attributed to communicable, maternal, perinatal, and nutritional conditions comprised close to 50% of global deaths in 5-14 year olds, but less than 23% among those aged 15-19 years. In 15-19 year olds, self-harm was most prevalent in female adolescents (27 239 deaths, 24 537 to 29 941), while road traffic injuries caused the largest number of deaths in male adolescents (48 211, 44 607 to 51 816). Age and cause specific patterns varied considerably by region. In high mortality settings, the decline in most communicable, maternal, perinatal, and nutritional conditions has slowed since 2015 compared with the previous 15 years. Conclusion The estimates presented here can help countries determine the most appropriate course of action to reduce child and adolescent mortality. As mortality rates from leading causes have declined over the years, maintaining the same pace of reduction becomes more challenging, making it necessary to focus on causes that have not previously been prioritised for children and adolescents, such as child cancer and other non-communicable diseases. Maternal mortality is another area of concern where progress has stalled since 2015 and more than 80% of countries risk missing the sustainable development goal target of less than 70 deaths per 100 000 live births by 2030.

Climate change is a substantial global health threat in the 21st century, disproportionately affecting low-income and middle-income countries (LMICs), which face significant climate risks, pre-existing vulnerabilities, and have relatively few interventions in place. With a scarcity of research in LMICs, and diminishing development assistance, setting priorities to address climate change-related health impacts on women and children is both urgent and prudent. We consulted 88 climate and health researchers between 2022 and 2024 to generate relevant questions regarding climate change impacts on women and children's health and potential solutions. A diverse group of 52 experts prioritised a shortlist of 70 questions using the Child Health and Nutrition Research Initiative method. The top three priorities included vulnerability mapping, integrating climate metrics into surveillance, and long-term heat exposure effects. This Health Policy underscores key knowledge gaps in climate-related health outcomes affecting women and children in LMICs, and suggests a focused research agenda for guiding global investments in resilience and adaptation.

Early careseeking for sick children can make the difference between life and death. Verbal autopsy (VA) studies of the cause of death typically ask about severe symptoms such as seizures and possibly mild or moderate symptoms such as rash, but without examining the relationship between caregivers' perception of illness severity and appropriate careseeking. Verbal and social autopsy (VASA) is a newer method that builds on VA by also examining social factors related to death. From seven VASA studies conducted in Africa and Asia we developed a 2-sign method based on activity level and feeding behavior and a multiple sign method of identifying mild, moderate and severe illness of neonates and 1-11-month-olds. We then examined the relationship of caregivers' perception of their child's condition at illness onset and several covariates to seeking formal health care during the fatal illness. The 2-sign and multiple sign methods effectively distinguished mild, moderate, and severe illnesses, respectively, of neonates and 1-11-month-olds. Careseeking was almost uniformly decreased for severely ill neonates (8.4%-41.8% vs mild: 15.0%-66.7% and moderate: 30.5%-68.5%, p = 0.12- < 0.001), but multivariate analysis revealed that older age in all six African countries (AOR 1.11 [95% CI 1.02, 1.21], p = 0.02 to 1.10 [1.04, 1.16], p < 0.001) and moderate illness in three (4.83 [1.06, 21.96], p = 0.04 to 4.35 [1.59, 11.93], p = 0.005) were associated with careseeking, while severe illness was no longer significant. Similar to neonates, older age in three of five countries (1.26 [1.01, 1.58], p = 0.046 to 1.10 [1.03, 1.16], p = 0.003) and moderate illness in one (2.24 [1.17, 4.30], p = 0.016) were drivers of careseeking for 1-11-month-olds. Careseeking was increased in some countries for infectious illnesses but not for intrapartum- or prematurity-related conditions. Child mortality studies should assess severity level and caregivers' response at various illness stages. Because older infants have more specific illness signs, the 2-sign method should be used only for neonates. Behavior change messages encouraging careseeking for moderate illness signs should be developed. The 2-sign method can serve as a practical tool for this purpose for illnesses of neonates. Effective interventions may require overcoming local barriers to careseeking and bringing delivery and newborn care closer to communities to prevent and treat early onset neonatal illnesses.

Since 2014, the Wasting and Stunting Technical Interest Group and others have amassed a body of evidence on the relationship between child wasting and stunting. The resulting research papers and reports have enhanced our understanding of undernutrition, particularly how children become wasted and/or stunted and how they experience these conditions and their consequences. Evidence highlights the common determinants and interconnected physiological processes leading to a child becoming wasted and/or stunted and we have built a greater understanding of how wasting treatment, or its lack, impacts children's linear growth. We also know more about the mortality-risk consequences for a child being concurrently wasted and stunted, how commonly this occurs, which children are particularly at risk and how to best identify and potentially support them. Based on this evidence, some shifts to policy and programme approaches, and to how research is conducted, are indicated in order to more effectively address both forms of undernutrition. These include conducting common contextual causal analysis, developing common prevention strategies that target overlapping drivers including in utero, considering wasting as part of the pathway to stunting, and vice versa when designing prevention strategies and including children at greatest mortality risk owing to multiple deficits in treatment targeting. This article is part of the theme issue 'Biological, biomedical and environmental drivers of stunting'.

Bangladesh continues to experience high levels of child undernutrition, with stunting affecting approximately 24% of children under 5 years of age. Environmental enteric dysfunction (EED), a subclinical intestinal disorder characterized by chronic inflammation, immune activation, and nutrient malabsorption, may reduce the effectiveness of nutritional interventions. Identifying factors that may enhance resilience to EED could guide intervention design. This study measured two biomarkers of EED, fecal calprotectin (CAL) and myeloperoxidase (MPO), among 160 Bangladeshi children 9-11 months of age and assessed associations between these biomarkers and indicators of child growth, micronutrient status, and inflammation using multivariate logistic regression. Outcomes were defined as CAL, MPO, or both biomarkers below the 25th percentile. CAL (> 160 µg/g) and MPO (> 2000 ng/mL) were elevated in over 90% and 70% of children, respectively, indicating widespread intestinal inflammation. In multivariable models, higher mid-upper arm circumference-for-age Z-scores (MUAC-Z) were associated with lower CAL (OR 1.51, 95% CI 1.04-2.18) and combined low CAL and MPO values (OR 1.72, 95% CI 1.06-2.81). Higher retinol-binding protein (RBP) was strongly associated with lower MPO (OR 4.91, 95% CI 1.28-18.83), while lower α-1-acid glycoprotein (AGP) levels were associated with lower MPO values (OR 0.53, 95% CI 0.27-1.04). Better ponderal growth, adequate vitamin A status, and lower systemic inflammation characterized children with lower concentrations of EED biomarkers. Reducing the burden of EED may help to enhance the effectiveness of nutrition interventions.

Introduction Micronutrient deficiencies during pregnancy have serious consequences for both mother and child; thus the longstanding standard of care in low- and low-middle income countries (LMICs) has been daily prenatal iron–folic acid (IFA) supplementation. While prenatal multiple micronutrient supplements (MMSs) provide additional significant benefits in comparison to IFA supplements, the view that MMS is too expensive has hindered national MMS adoption. However, increased competition, volume procurement and the use of advanced purchase commitments have significantly reduced the cost of MMS.Methods Using new cost data, we estimate the benefits of replacing IFA with MMS in both health (averted low birth weights (LBWs), stillbirths and female neonatal mortality) and monetary (costs of averted LBW and death; total economic value; benefit–cost ratios) terms in 25 LMICs with the greatest burden of LBW. A number of scenarios describing different coverage and procurement cost scenarios are explored.Results Replacing preventive antenatal IFA with MMS would avert 3 514 594 LBW births, 186 369 stillbirths and 218 914 female neonatal deaths over 5 years in these countries. Providing MMS to all pregnant women receiving at least one antenatal care visit averts 7 272 320 LBW, 473 471 stillbirths and 541 591 female neonatal deaths. The total cost of replacing IFA with MMS ranges from US$201.8 million to US$1.326 billion, equivalent to between 0.5% and 3.0% of current spending on efforts to reduce undernutrition. Using the most conservative estimate, this would generate US$7.19 billion in economic returns and a benefit–cost ratio greater than 10. The cost of averting a stillbirth or neonatal death ranges from US$497 to US$1306.Conclusion Replacing prenatal IFA with MMS cost-effectively generates large health benefits.

Minimally invasive tissue sampling (MITS) has been used as an alternative to complete autopsy to track causes of death (CoDs) in South Asia and sub-Saharan Africa as part of the Child Health and Mortality Prevention Surveillance program. However, community acceptance, rapid identification of deaths, and adequate functional laboratory infrastructures (e.g., pathology, conventional microbiology, and molecular microbiology) are critical for successful implementation. We describe the experience of implementing MITS in an urban district with socioeconomic and cultural diversity in Zambézia Province, central Mozambique. For successful implementation of mortality surveillance using MITS, high-level advocacy involving the Provincial Government and all stakeholders as well as engagement and sensitization of all segments of the communities, including traditional healers, community leaders, and mass media, were critical for the acceptability of the procedure. Additionally, social and behavior studies were conducted to assess perceptions, sociocultural factors, acceptability, and feasibility of the MITS procedure. These studies helped adapt the MITS protocol to the local context to minimize the risk of misunderstanding the mortality surveillance using MITS procedures. There was significant investment in capacity building, including financial support for laboratory equipment acquisition and maintenance, reagents, and consumables required for microbiological screening protocols of MITS and to support the needs for diagnostics of patients with severe disease seeking care. Experiences from Quelimane and other sites and data generated in the Countrywide Mortality Surveillance for Action to support evidence-based decision-making processes on health policy were critical for the community to understand the benefit of determining young children CoD to guide future interventions.

Children who receive therapeutic feeding for wasting treatment but do not reach the anthropometric definitions of recovery (usually within 12-16 weeks) are categorised as 'non-responders' and considered as treatment failures. We conducted a pooled analysis to explore the growth trajectories of non-responders and the appropriateness of the definition of 'non-response'. We pooled 14 studies of children aged 6-59 months receiving treatment for wasting. We included children classified by their studies as recovered or as non-responders. Observing the pooled data of non-responders' mid-upper arm circumference (MUAC), weight, weight-for-age z-score, weight-for-height z-score and daily weight gain rate, we found that the first quartile differentiated those who did not grow at all versus those that demonstrated some growth. We therefore defined 'low growth non-responders' as < 25th percentile anthropometric gain between admission and exit using the non-responders' pooled study data, and 'high growth non-responders' as ≥ 25th percentile gain. We plotted the growth trajectories of MUAC-, weight- and height-related indices of the recovered, high growth and low growth non-responder groups over time using mixed effects generalised additive models. We compared age, sex and anthropometric characteristics of the three groups and explored predictors of non-response category using a multivariate multinomial logistic regression model. For all outcomes, the high growth non-responders started with a worse anthropometric status compared to those who recovered, but then tracked along a near-parallel growth trajectory. The low growth non-responders showed limited growth throughout treatment. High growth non-responders are better viewed as 'delayed responders' and may need to be kept longer under treatment to recover and reduce the risks from early discharge. Low growth non-responders are the true treatment failures and should be referred for further investigations as quickly as possible. In conclusion, non-responders are not a homogenous group; ~75% of them respond well to treatment and ~25% are treatment failures.

INTRODUCTION:Afghanistan's health system has faced considerable challenges since the Taliban takeover in 2021, leaving the population vulnerable to an increased risk of morbidity and mortality. Research to illuminate the current functioning of the health system and approaches for strengthening its key components is critically needed to address imminent and evolving health needs of the Afghan people. METHODS:A health systems' research agenda for Afghanistan that uses a systematic and evidence-based wisdom of the crowds' approach has yet to be developed. Using the Child Health and Nutrition Research Initiative methodology, this study identifies the top 20 health systems' research priorities among experienced Afghanistan health researchers. Priorities were also considered when disaggregating data by subgroups, such as Afghan versus non-Afghan respondents and those from low- and middle-income versus high-income settings. RESULTS:A total of 303 researchers were invited to score the research questions; 86 responded to the scoring survey and 55 completed it (60% were of Afghan origin). The highest priority questions were relatively diverse in terms of topic area, with questions spanning system-level factors, healthcare quality, community-based healthcare, improvements in the pharmaceutical sector, epidemiological trends, health management information systems and surveillance, access to care and approaches to improving service delivery in Afghanistan, among many others. 'Delivery'-focused and 'development'-focused questions were prioritised, demonstrating that participants assigned greater importance to more practical research questions that would explore features of and approaches to improving existing health system structures within the current Afghan context. Results were consistent across subgroups. CONCLUSION:This research prioritisation exercise fills a gap by generating consensus and establishing a research agenda for strengthening Afghanistan's health system.

ABSTRACT In Bangladesh, anaemia is estimated to affect 52% of children 6–59 months, with the youngest children (6–23 months) experiencing the highest levels of anaemia (71%). Micronutrient powders (MNPs) are designed to increase micronutrient intake in young children; however, in some settings, the prevalence of anaemia may remain elevated despite the high coverage of MNPs. In a secondary analysis of the Zinc in Powders trial (ZiPT), we identified risk factors that were associated with anaemia among Bangladeshi children 9–11 months of age who received standard 15‐component MNPs, including 10 mg of iron, daily for 24 weeks. At enrolment, socio‐demographic characteristics were collected. Morbidity symptoms were assessed on a semi‐weekly basis. Haemoglobin (measured via single‐drop capillary blood using Hemocue 301+) and child anthropometry were assessed at enrolment and endline (24 weeks). Risk factors for anaemia at endline (24 weeks) were identified using minimally adjusted (age and sex) logistic regression models. Multivariate models were subsequently constructed, controlling for age, sex and significant risk factors. Of the 481 children randomized to the MNP arm, 442 completed the trial and had haemoglobin data available at endline. Anaemia (haemoglobin < 10.5 g/dL) prevalence declined from 54.1% at baseline to 32.6% at endline. In minimally adjusted models, season of enrolment, underweight at enrolment, asset score, hygiene score and frequent morbidity symptoms were associated with the odds of anaemia at endline. However, some factors lost statistical significance in multivariate models. MNPs are an important tool for anaemia prevention; however, they should be part of an integrated approach for anaemia control.

Background Prenatal multiple micronutrient supplementation (MMS), in comparison to iron and folic acid supplementation (IFA), improves pregnancy outcomes, but less is known about their effect on infant growth. Objectives We conducted a systematic review of trials comparing maternal MMS to IFA and assessed the effect on infants’ anthropometric outcomes at birth, 3, 6, 12, 18, and 24 mo of age. Methods We included trials from a Cochrane review and new studies identified through systematic literature searches in 3 databases. We calculated the pooled effect estimates with 95% confidence intervals (CIs) using a generic inverse variance method, with fixed (primary analysis) and random-effects, and assessed subgroup differences. Results The 19 included trials showed that MMS, compared to IFA, led to significantly greater length and weight from birth to 6 mo, head circumference (HC) from birth to 12 mo, and mid-upper arm circumference (MUAC) through 3 mo. Infants born to pregnant women consuming MMS were longer at birth (mean difference: 0.05 cm; 95% CI: 0.02, 0.08 cm) and had higher length-for-age z-score at birth (0.09; 95% CI: 0.06, 0.12), 3 mo (0.09; 95% CI: 0.06, 0.12), and 6 mo (0.04; 95% CI: 0.01, 0.07) of age but not thereafter. MMS resulted in significantly higher weight-for-age z-score and HC-for-age z-score until 6 mo and higher weight-for-length z-score and MUAC-for-age z-score until 3 mo. MMS reduced risk of stunting (risk ratio [RR]: 0.86; 95% CI: 0.82, 0.91), underweight (RR: 0.86; 95% CI: 0.81, 0.90), small HC (RR: 0.84; 95% CI: 0.79, 0.90), and low MUAC (RR: 0.90; 95% CI: 0.82, 0.99) at 3 mo and wasting (RR: 0.90; 95% CI: 0.85, 0.96) at birth. For some outcomes, effects were greater when MMS was continued postpartum and in settings with higher prevalence of low birthweight. Conclusions Prenatal MMS improves size at birth and subsequent infant growth through 6 mo of age but not thereafter. These results strengthen the evidence on MMS benefits beyond birth outcomes.This study was registered in PROSPERO as CRD42024551864.

BACKGROUND:Impaired linear growth and stunting in children under 5 y is a marker of multiple deprivations in low-income and middle-income countries. OBJECTIVES:We aimed to assess drivers and policies influencing improvements in linear growth and stunting reduction in 10 countries with annual rates of reduction in childhood stunting averaging 1.1% (range: 0.4%-1.7%) at national-level or subnational-level, and to improve a framework of action for other countries to follow. METHODS:We used mixed methods to assess trends and patterns of improvement in linear growth in children under 5 y using available household-level data and in-depth analysis of programs and their implementation. We assessed patterns of change with multivariate regression analyses of risk factors driving stunting and affecting change. We compared results from the Oaxaca-Blinder decomposition analyses using a hierarchical approach and retrospectively assessed the appropriateness of a previously proposed 10-step process for country-level planning and implementation processes. Limited data precluded robust serial assessment of dietary intake at individual level for children and mothers. RESULTS:Rapid reduction in childhood stunting is possible and findings across exemplar countries underscore the benefits of indirect and direct interventions in health and other social sectors. These include programs focusing on poverty alleviation; water, sanitation, and hygiene; promotion of girls' education and empowerment; and maternal nutrition. The potential benefits of family planning programs and factors contributing to gains in maternal nutrition were noted. In malarial endemic areas, malaria control programs were associated with improved childhood growth, and patterns of growth indicated continued benefits of childhood disease prevention and management strategies. CONCLUSIONS:A systematic, evidence-informed approach to improve maternal and child health and nutrition is feasible and, with targeting, can accelerate reduction in linear growth faltering in childhood.

OBJECTIVES:Childhood mortality is a key indicator of progress in health and development in low- and middle-income countries, traditionally measured through household surveys with face-to-face interviews. This study explored an alternative approach that used mobile phone interviews with women in Mozambique. METHODS:Using two sampling approaches, we interviewed women of reproductive age about their pregnancy history through mobile phones. The first method used an existing database of phone numbers collected from a national mortality surveillance, Countrywide Mortality Surveillance for Action (COMSA). The second employed random digit dialling (RDD) to generate phone numbers. The COMSA phone sample successfully reached 13,545 women while the RDD sample reached 10,359 women. We compared neonatal (NMR), infant (IMR) and under-five mortality rates (U5MR) to estimates from the United Nations (UN), COMSA and the 2022 Demographic and Health Survey (DHS). The mobile phone-based mortality rates were adjusted using the raking approach. RESULTS:The mobile phone interviews incorporating pregnancy history yielded recent childhood mortality rates comparable to those reported by the DHS. The 2020-2021 U5MRs were estimated at 59.3 (95% confidence interval [95% CI]: 41.9-76.7) in the COMSA phone sample and 44.9 (95% CI: 9.0-80.7) in the RDD sample, compared to 59.6 (95% CI: 53.7-65.6) in the DHS. These estimates were lower than the UN projections at 71.6 (95% CI: 65.5-87.1) and COMSA at 80.0 (95% CI: 69.0-91.0). We observed similar trends for NMR and IMR. Childhood mortality trends were comparable between the COMSA phone sample and the DHS sample. In contrast, the RDD sample appeared to consistently underestimate childhood mortality compared to the other samples. CONCLUSION:Mobile phone surveys, including standard full pregnancy history tools, produced recent childhood mortality levels and trends for national and subnational levels similar to face-to-face approaches such as the DHS.