Objective: This study identified the prevalence of miscarriages and perinatal deaths from a community perspective. Design: A population-based, cross-sectional household study. Setting: Sierra Leone (West-Africa) from 2019-2020 Population: Women of reproductive age Methods: Seventy-five randomized clusters were selected, 25 households in each cluster and two random participants from each household. Female participants between 12 and 50 years of age were interviewed about family planning methods and obstetrical history. Main outcome measures: miscarriage and perinatal death Results: A total of 914 women of reproductive age were included. Family planning methods were used by 29% of the women. In total, 2,160 life-time pregnancies were recalled of which 104 (5%, 95% CI 4-6%) resulted in an early pregnancy loss. Eighty-three (80%) were reported as spontaneous abortion, 17% (18) were intentional abortions, of which 9 were induced with medication outside the hospital. The stillbirth rate was 18.5 (95% CI 9-31) per 1000 births and the perinatal mortality rate was 38,4 (95% CI 24-54) per 1000 births calculated over a 5-year period. Conclusion: This study confirms that the perinatal death rate in Sierra Leone exceeds the global average. The miscarriages both spontaneous and intentional, are likely to be underreported. Medical attention should be placed to treat and investigate the causes of miscarriages and perinatal deaths. Improving the use of family planning is needed to decrease the hidden burden of intentional abortions. Funding: Norwegian University of Science and Technology (NTNU) and University of Amsterdam’s Center of Tropical Medicine and Travel Medicine.

Introduction This study investigates drivers of childhood pulmonary tuberculosis (PTB) using a childhood ecosystem approach in South Africa. An ecosystem approach towards identifying risk factors for PTB may identify new directions for intervention. Methods Data were collected as part of a prospective cohort study of children presenting at a primary care facility or tertiary hospital with suspected TB. Characterization of the childhood ecosystem included proximal, medial and distal determinants. Proximal determinants included child characteristics that could impact PTB outcomes. Medial determinants included relational factors such as caregiver health that might impact interactions with the child. Distal determinants included macro-level determinants of disease such as socioeconomic status and food insecurity. Children started on TB treatment were followed for up to 6 months. Multivariate regression models tested independent associations between factors associated with PTB in children. Results Of 1,738 children enrolled in the study, 242 (20%) of children had confirmed PTB, 756 (63%) were started on TB treatment, and 444 (37%) had respiratory conditions other than TB. In univariate analyses, childhood malnutrition and caregiver smoking were associated with treated or confirmed PTB. In multivariate analyses, proximal factors such as male gender and hospitalization and low socio-economic status as a distal factor were associated with PTB. Conclusions Interventions may need to target subgroups of children and families at elevated risk for PTB. Screening for risk factors such caregiver health may guide targeting, and provision of social protection programs to bolster economic security may be important interventions for attenuating childhood exposure to risk factors.