Quality of care during childbirth at public health facilities in Bangladesh: a cross-sectional study using WHO/UNICEF 'Every Mother Every Newborn (EMEN)' standards

Background

This manuscript presents findings from a baseline assessment of health facilities in Bangladesh prior to the implementation of the ‘Every Mother Every Newborn Quality Improvement’ initiative.

Methodology

A cross-sectional survey was conducted between June and August 2016 in 15 government health facilities. Structural readiness was assessed by observing the physical environment, the availability of essential drugs and equipment, and the functionality of the referral system. Structured interviews were conducted with care providers and facility managers on human resource availability and training in the maternal and newborn care. Observation of births, reviews of patient records and exit interviews with women who were discharged from the selected health facilities were used to assess the provision and experience of care.

Results

Only six (40%) facilities assessed had designated maternity wards and 11 had newborn care corners. There were stock-outs of emergency drugs including magnesium sulfate and oxytocin in nearly all facilities. Two-thirds of the positions for medical officers was vacant in district hospitals and half of the positions for nurses was vacant in subdistrict facilities. Only 60 (45%) healthcare providers interviewed received training on newborn complication management. No health facility used partograph for labour monitoring. Blood pressure was not measured in half (48%) and urine protein in 99% of pregnant women. Only 27% of babies were placed skin to skin with their mothers. Most mothers (97%) said that they were satisfied with the care received, however, only 46% intended on returning to the same facility for future deliveries.

Conclusions

Systematic implementation of quality standards to mitigate these gaps in service readiness, provision and experience of care is the next step to accelerate the country’s progress in reducing the maternal and neonatal deaths.

Competence of healthcare professionals in diagnosing and managing obstetric complications and conducting neonatal care: a clinical vignette-based assessment in district and subdistrict hospitals in northern Bangladesh

BACKGROUND

This study assesses the competency of maternal and neonatal health (MNH) professionals at district-level and subdistrict-level health facilities in northern Bangladesh in managing maternal and newborn complications using clinical vignettes. The study also examines whether the professional's characteristics and provision of MNH services in health facilities influence their competencies.

METHODS

134 MNH professionals in 15 government hospitals were interviewed during August and September 2016 using structured questionnaire with clinical vignettes on obstetric complications (antepartum haemorrhage and pre-eclampsia) and neonatal care (low birthweight and immediate newborn care). Summative scores were calculated for each vignette and median scores were compared across different individual-level and health facility-level attributes to examine their association with competency score. Kruskal-Wallis test was performed to identify the significance of association considering a p value<0.05 as statistically significant.

RESULTS

The competency of MNH professionals was low. About 10% and 24% of the health professionals received 'high' scores (>75% of total) in maternal and neonatal vignettes, respectively. Medical doctors had higher competency than nurses and midwives (score=11 vs 8 out of 19, respectively; p=0.0002) for maternal vignettes, but similar competency for neonatal vignettes (score=30.3 vs 30.9 out of 50, respectively). Professionals working in health facilities with higher use of normal deliveries had better competency than their counterparts. Professionals had higher competency in newborn vignettes (significant) and maternal vignettes (statistically not significant) if they worked in health facilities that provided more specialised newborn care services and emergency obstetric care, respectively, in the last 6 months.

CONCLUSIONS

Despite the overall low competency of MNH professionals, exposure to a higher number of obstetric cases at the workplace was associated with their competency. Arrangement of periodic skill-based and drill-based in-service training for MNH professionals in high-use neighbouring health facilities could be a feasible intervention to improve their knowledge and skill in obstetric and neonatal care.

Time trends and sociodemographic determinants of preterm births in pregnancy cohorts in Matlab, Bangladesh, 1990-2014

Introduction

Preterm birth is the major cause of under-five mortality. Population-based data on determinants and proportions of children born preterm are limited, especially from low-income countries. This study aimed at assessing time trends and social, reproductive and environmental determinants of preterm births based on a population-based pregnancy cohort over 25 years in rural Bangladesh.

Methods

In this cohort study in Matlab, a rural area in Bangladesh, we used data from the Health and Demographic Surveillance System from 1990 to 2014. Gestational age at birth was based on the reported last menstrual period and verified by ultrasound assessments. Preterm birth proportions were assessed within strata of social and reproductive characteristics, and time series analysis was performed with decomposition for trend and seasonality. We also determined the prevented fractions of preterm birth reduction associated with social and demographic changes during the follow-up period.

Results

Analyses were based on 63 063 live births. Preterm birth decreased from 29% (95% CI 28.6 to 30.1) in 1990-1994 to 11% (95% CI 10.5 to 11.6) in 2010-2014. Low education, older age and multi-parity were associated with higher proportions of preterm births across the study period. Preterm births had a marked seasonal variation. A rapid increase in women's educational level and decrease in parity were associated with the decline in preterm births, and 27% of the reduction observed from 1990 to 2014 could be attributed to these educational and reproductive changes.

Conclusion

The reduction in preterm birth was to a large extent associated with the sociodemographic transition, especially changes in maternal education and parity. The persistent seasonal variation in the proportion of preterm birth may reflect the environmental stressors for pregnant women across the study period. Continued investments in girls' education and family planning programmes may contribute to further reduction of preterm births in Bangladesh.

Early initiation of breastfeeding and severe illness in the early newborn period: An observational study in rural Bangladesh

BACKGROUND

In Bangladesh, neonatal sepsis is the cause of 24% of neonatal deaths, over 65% of which occur in the early-newborn stage (0-6 days). Only 50% of newborns in Bangladesh initiated breastfeeding within 1 hour of birth. The mechanism by which early initiation of breastfeeding reduces neonatal deaths is unclear, although the most likely pathway is by decreasing severe illnesses leading to sepsis. This study explores the effect of breastfeeding initiation time on early newborn danger signs and severe illness.

METHODS AND FINDINGS

We used data from a community-based trial in Bangladesh in which we enrolled pregnant women from 2013 through 2015 covering 30,646 newborns. Severe illness was defined using newborn danger signs reported by The Young Infants Clinical Science Study Group. We categorized the timing of initiation as within 1 hour, 1 to 24 hours, 24 to 48 hours, ≥48 hours of birth, and never breastfed. The analysis includes descriptive statistics, risk attribution, and multivariable mixed-effects logistic regression while adjusting for the clustering effects of the trial design, and maternal/infant characteristics. In total, 29,873 live births had information on breastfeeding among whom 19,914 (66.7%) initiated within 1 hour of birth, and 4,437 (14.8%) neonates had a severe illness by the seventh day after birth. The mean time to initiation was 3.8 hours (SD 16.6 hours). The proportion of children with severe illness increased as the delay in initiation increased from 1 hour (12.0%), 24 hours (15.7%), 48 hours (27.7%), and more than 48 hours (36.7%) after birth. These observations would correspond to a possible reduction by 15.9% (95% CI 13.2-25.9, p < 0.001) of severe illness in a real world population in which all newborns had breastfeeding initiated within 1 hour of birth. Children who initiated after 48 hours (odds ratio [OR] 4.13, 95% CI 3.48-4.89, p < 0.001) and children who never initiated (OR 4.77, 95% CI 3.52-6.47, p < 0.001) had the highest odds of having severe illness. The main limitation of this study is the potential for misclassification because of using mothers' report of newborn danger signs. There could be a potential for recall bias for mothers of newborns who died after being born alive.

CONCLUSIONS

Breastfeeding initiation within the first hour of birth is significantly associated with severe illness in the early newborn period. Interventions to promote early breastfeeding initiation should be tailored for populations in which newborns are delivered at home by unskilled attendants, the rate of low birth weight (LBW) is high, and postnatal care is limited.

TRIAL REGISTRATION

Trial Registration number: anzctr.org.au ID ACTRN12612000588897.

Relative contributions of the correlates of stunting in explaining the mean length-for-age z-score difference between 24-month-old stunted and non-stunted children living in a slum of Dhaka, Bangladesh: results from a decomposition analysis

OBJECTIVE

Using MAL-ED (Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health) Bangladesh birth cohort data, we sought to measure the relative contributions of the most predictive correlates of stunting to mean length-for-age z (LAZ) score difference between stunted and non-stunted children at 24 months of age.

SETTING

Dhaka, Bangladesh PARTICIPANTS: 211 slum-dwelling children enrolled within 17 days of their birth.

VARIABLES AND METHOD

The explanatory variables were identified from the following groups: maternal characteristics, birth characteristics, macronutrient intake, socioeconomic status, morbidity and serum micronutrient level. At step 1, predictive correlates of stunting were identified longitudinally (from 9 to 24 months of age) using generalized estimating equations (GEE) model. Then, the relative contributions of the most predictive correlates of stunting to mean LAZ score difference between stunted and non-stunted children at 24 months of age was measured using Blinder-Oaxaca decomposition analysis RESULTS: The GEE multivariable model identified maternal height, birth weight, people per room, gender, having separate room for kitchen and energy intake as the most predictive correlates of stunting. At 24 months, mean LAZ score difference between stunted and non-stunted children was 1.48. The variable by variable decomposition of the LAZ gap identified maternal height (coefficient: -3.04; 95% CI: 0.35 to -6.44), birth weight (coefficient: -0.21; 95% CI: 0.88 to -1.30), people per room (coefficient: 0.31; 95% CI: 0.92 to -0.30) and energy intake (coefficient: -0.12; 95% CI: 0.22 to -0.46) as the top most factors responsible for the mean LAZ score difference between stunted and non-stunted children at 24 months of age.

CONCLUSIONS

The relative contributions of maternal height and birth weight to LAZ gap signifies that improvement in nutritional status of a women during her adolescence and pregnancy would have an impact on birth weight of her offspring, and ultimately, on linear growth of the child.

Prevalence and determinants of initiation of breastfeeding within one hour of birth: An analysis of the Bangladesh Demographic and Health Survey, 2014

Background

Breastfeeding within one hour of birth is a critical component of newborn care and is estimated to avert 22% of neonatal mortality globally. Understanding the determinants of early initiation of breastfeeding (EIBF) is essential for designing targeted and effective breastfeeding promotion programmes. The aim of this study was to determine the prevalence and determinants of early initiation of breastfeeding among Bangladeshi women.

Methods

This paper analyses the data from the Bangladesh Demographic and Health Survey, 2014. Analysis was based on responses of women who had at least one live birth in the two years preceding the survey (n = 3,162) collected using a structured questionnaire. The primary outcome was breastfeeding initiation within one hour of birth ascertained by women’s self-report. Explanatory variables included woman’s age, education, religion, household wealth, place of residence and place of delivery, birth order, child’s size, antenatal care (ANC), postnatal care (PNC) and skin-to-skin contact. Associations between variables were assessed by simple and multivariable logistic regressions.

Results

Of the 3,162 recently delivered mothers, 51% initiated breastfeeding within one hour of delivery. Prevalence of EIBF varied significantly between different types of mode of delivery, among different geographical regions and among women who had PNC with their newborn. Women who had caesarean section (C-section) were less likely to initiate breastfeeding early after birth than women who had normal vaginal delivery (NVD) (AOR: 0.32, 95% CI 0.23 0.43; p value < 0.001). Women who had received PNC with their newborns within one hour of delivery were more likely to breastfeed their babies within one hour of birth compared to those who did not (AOR: 1.61, 95% CI 1.26 2.07; p value < 0.001). Mother’s age, education, religion, household wealth index, place of residence and place of delivery, birth order, number of antenatal visits, child’s size and skin-to-skin contact were not significantly associated with EIBF.

Conclusions

Findings from this study suggest that investing more effort in ensuring immediate PNC of mother-newborn pair can increase EIBF. Solutions should be explored to increase EIBF among mothers who undergo C-section as C-section is rising rapidly in Bangladesh. Further research is needed to explore the regional differences in the country, including specific cultural practices that influence EIBF.

Analyzing spatial and space-time clustering of facility-based deliveries in Bangladesh

Background

A spatial and temporal study of the distribution of facility-based deliveries can identify areas of low and high facility usage and help devise more targeted interventions to improve delivery outcomes. Developing countries like Bangladesh face considerable challenges in reducing the maternal mortality ratio to the targets set by the Sustainable Development Goals. Recent studies have already identified that the progress of reducing maternal mortality has stalled. Giving birth in a health facility is one way to reduce maternal mortality.

Methods

Facility delivery data from a demographic surveillance site was analyzed at both village and Bari (comprising several households with same paternal origins) level to understand spatial and temporal heterogeneity. Global spatial autocorrelation was detected using Moran’s I index while local spatial clusters were detected using the local Getis G_i* statistics. In addition, space-time scanning using a discrete Poisson approach facilitated the identification of space-time clusters. The likelihood of delivering at a facility when located inside a cluster was calculated using log-likelihood ratios.

Results

The three cluster detection approaches detected significant spatial and temporal heterogeneity in the distribution of facility deliveries in the study area. The hot and cold spots indicated contiguous and relocation type diffusion and increased in number over the years. Space-time scanning revealed that when a parturient woman is located in a Bari inside the cluster, the likelihood of delivering at a health facility increases by twenty-seven times.

Conclusions

Spatiotemporal studies to understand delivery patterns are quite rare. However, in resource constraint countries like Bangladesh, detecting hot and cold spot areas can aid in the detection of diffusion centers, which can be targeted to expand regions with high facility deliveries. Places and periods with reduced health facility usages can be identified using various cluster detection techniques, to assess the barriers and facilitators in promoting health facility deliveries.

Electronic supplementary material

The online version of this article (10.1186/s41182-019-0170-9) contains supplementary material, which is available to authorized users.

Awareness and perceptions of women regarding human rights related to maternal health in rural Bangladesh

Background

The global development community has increasingly come to frame preventable maternal mortality and morbidity principally as a violation of women’s basic human rights, necessitating a human rights-based approach to be appropriately addressed. In this article, we explore how human rights are understood and perceived in relation to maternal health at the local level in rural Bangladesh. This is essential given the momentum at the global level to promote rights and apply rights-based approaches to maternal health.

Methods

A community-based, cross-sectional household survey was conducted in three upazilas (sub-districts) of Brahmanbaria district, Bangladesh in 2018. A total of 1367 women with a birth outcome in the past 12 months were interviewed. Descriptive statistics were used to report the awareness and perceptions of human rights related to maternal health. Multiple logistic regression was used to identify the associations between awareness and perceptions of human rights and background characteristics and, finally, with the use of skilled maternal health services.

Results

Over two-thirds of women reported that they were aware that women have human rights related to maternal health. However, less than 10% were able to mention at least three specific human rights related to maternal health. Half of the women mentioned husbands as duty-bearers, while only 20% mentioned the government as a duty-bearer. One-third of women reported that they are able to realize their rights related to maternal health satisfactorily. Awareness and perceptions of human rights related to maternal health were significantly associated with higher educational attainment and wealth status. They were also associated with increased use of antenatal care.

Conclusions

These findings suggest that interventions promoting the awareness of human rights related to maternal health would be appropriate within the communities of rural Bangladesh as part of a broader human rights-based approach to improving maternal health.

The Prevalence and Risk Factors of Overweight and Obesity Among Women of Reproductive Age with Iron Deficiency Anaemia in Urban Bangladesh (P10-064-19)

Objectives

This study aims to identify the prevalence and risk factors of overweight and obesity among women of reproductive age (15–49 years) with iron deficiency anaemia in urban Bangladesh.

Methods

We obtained data for this study from the baseline assessment of a randomized control trial conducted among women of reproductive age with iron deficiency anemia (Hb <12 g/dl & serum ferritin <30 μg/L). The trial was carried out in Mirpur, Dhaka, Bangladesh between December 2017 and January 2019. As part of the baseline assessment, we collected data on women's sociodemographic characteristics and reproductive history from 525 participants. We also measured the height, weight, and MUAC at the baseline. We estimated BMI using formula; weight in kilograms divided by the square of height in meters. As per the WHO classification, we considered women with BMI ≥25 kg/m2 to be overweight and ≥30 kg/m2 to be obese. A multivariable logistic regression model was used to ascertain the risk factors of overweight and obesity.

Results

Of the 525 study participants, 157 (30%; 95% CI 26.0 - 34.0) were overweight and 69 (13%; 95% CI 10.3 - 16.3) were obese. Bivariate analysis indicated that the age of women, parity, women's education, women's employment, marital status, husband's education and household wealth were associated with overweight and obesity. The multivariable analysis showed married women (OR 2.9; CI 1.0–8.3), women aged 40 to 49 years (OR 7.4; CI 2.4–22.9) and women from the higher social economic household (OR 5.8; CI 2.7‐12.4) has the highest risk of overweight and obesity. Both age and household socioeconomic status showed dose response relationship.

Conclusions

The prevalence of overweight and obesity among women of reproductive age with iron deficiency anemia in urban Bangladesh is three times higher than the WHO critical threshold of 15%. This highlights that Bangladesh is undergoing an epidemiologic transition characterized by the double burden of malnutrition. It is crucial that the policy makers understand what new interventions and policy initiatives are needed to address the double burden of malnutrition in the country.

Funding Sources

Saving Lives at Birth and Medical Research Council, UK.

Supporting Tables, Images and/or Graphs

Assessing the Efficacy of Bovine Lactoferrin to Correct Iron Deficiency Anemia in Non-pregnant Non-lactating Women: A Randomized Controlled Trial (FS08-02-19)

Objectives

1. To determine if bovine lactoferrin (bLf) is at least as effective as oral ferrous sulfate in iron deficiency anemia in non-pregnant women of reproductive age (WRA)

2. To determine the optimal dose of oral bLf

3. To compare the side-effects of the treatments

Methods

Design: Non-inferiority, double-blind, individually RCT in non-pregnant WRA with iron deficiency anemia (Hb <12 g/dl & serum ferritin <30 μg/L)

Setting: Mirpur, Dhaka, Bangladesh

Participants: 555 non-pregnant, non-lactating women of 15–49 years.

Interventions: Women were allocated individually (1:1:1) in three arms. Arm A, B and C received daily oral 200 mg bLf, 400 mg bLf and 60 mg ferrous sulfate. All received 400 μg of folic acid daily. Treatment was for 12 weeks.

Outcomes: Serum Hb and serum ferritin at baseline and every 30 days for 3 months. Inflammatory markers: C-reactive protein (CRP); alpha(1)-Acid glycoprotein (AGP); hepcidin, at baseline and end line. Possible adverse effects were assessed.

Results

Women on 200 mg bLf had a decrease in Hb of 0.3 g/dl (95% CI, −0.60 to 0.00 g/dl, P = 0.05), women on 400 mg bLf arm had no change in Hb: 0.0 g/dl (95% CI, −0.32 to 0.32 g/dl, P = 1.00), and women on ferrous sulfate arm had an increase in Hb: 1.1 g/dl (95% CI, 0.83 to 1.37 g/dl, P < 0.0001).

Women on 200 mg bLf had an increase in ferritin: 2.8 μg/l (95% CI, 0.38 to 5.22 μg/l, P = 0.02), women on 400 mg bLf had an increase in ferritin: 3.5 μg/l (95% CI, 0.64 to 6.36 μg/l, P = 0.02) and women on ferrous sulfate arm had an increase in ferritin: 41.1 μg/l (95% CI, 35.74 to 46.47 μg/l, P < 0.0001).

There were no significant differences in AGP and CRP between arms at the base line (P = 0.38 and 0.95) and end line (P = 0.87 and 0.14). Those on ferrous sulfate had a significant increase in hepcidin concentration after 90 days (P = .000).

Abdominal pain, indigestion, diarrhea and black stool were significantly higher on ferrous sulfate group. There were no differences for other side-effects across treatment arms

Conclusions

Ferrous sulfate has better efficacy than bLf for iron deficiency anemia in non-pregnant non-lactating women of reproductive age in urban Bangladesh. This lactoferrin product may be inactive, or there may have been inadequate dietary iron for bLF to promote its absorption.

Funding Sources

Saving Lives at Birth and Medical Research Council, UK.

Opting for home birth in rural Bangladesh: An assessment of the current status and reasons

BACKGROUND

In Bangladesh, over half of women give birth at home, generally without the support of a skilled birth attendant. In this article, we examined the decision-making around birthplace and explored the reported reasons of preferring home birth over facility birth in a rural district of Bangladesh.

METHODS

A cross-sectional household survey with 1367 women was conducted in Brahmanbaria district. Choice of birthplace and actual place of birth were the main outcomes of interest. Associations between the outcomes of interest and background characteristics were analyzed through binary logistic regression. Effects of the covariates and confounders were adjusted through multiple logistic regression.

RESULTS

Sixty-four percent of women planned to give birth at home, and 62% gave birth at home. Planning to give birth at home was significantly associated with eventually giving birth at home (AOR [CI]: 4.93 [3.79-6.43]). Multiparous women and women from larger households were significantly more likely to give birth at home, whereas more educated and wealthier women and those attending antenatal care were significantly less likely to give birth at home. The main reported reasons for home birth were perceived lack of importance of facility birth, financial reasons, fear of cesarean section, and not being permitted by a husband of other family member to seek facility birth.

CONCLUSIONS

Home is the preferred birthplace and main actual place of birth in rural Bangladesh. The maternal health program of Bangladesh should look critically at the preferences of women and reasons for those preferences for further promotion of skilled attendance at birth in rural settings.

Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries

Inadequate micronutrient intakes are relatively common in low- and middle-income countries (LMICs), especially among pregnant women, who have increased micronutrient requirements. This can lead to an increase in adverse pregnancy and birth outcomes. This review presents the conclusions of a task force that set out to assess the prevalence of inadequate micronutrient intakes and adverse birth outcomes in LMICs; the data from trials comparing multiple micronutrient supplements (MMS) that contain iron and folic acid (IFA) with IFA supplements alone; the risks of reaching the upper intake levels with MMS; and the cost-effectiveness of MMS compared with IFA. Recent meta-analyses demonstrate that MMS can reduce the risks of preterm birth, low birth weight, and small for gestational age in comparison with IFA alone. An individual-participant data meta-analysis also revealed even greater benefits for anemic and underweight women and female infants. Importantly, there was no increased risk of harm for the pregnant women or their infants with MMS. These data suggest that countries with inadequate micronutrient intakes should consider supplementing pregnant women with MMS as a cost-effective method to reduce the risk of adverse birth outcomes.

"Every Newborn-BIRTH" protocol: observational study validating indicators for coverage and quality of maternal and newborn health care in Bangladesh, Nepal and Tanzania

Background

To achieve Sustainable Development Goals and Universal Health Coverage, programmatic data are essential. The Every Newborn Action Plan, agreed by all United Nations member states and >80 development partners, includes an ambitious Measurement Improvement Roadmap. Quality of care at birth is prioritised by both Every Newborn and Ending Preventable Maternal Mortality strategies, hence metrics need to advance from health service contact alone, to content of care. As facility births increase, monitoring using routine facility data in DHIS2 has potential, yet validation research has mainly focussed on maternal recall surveys. The Every Newborn – Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aims to validate selected newborn and maternal indicators for routine tracking of coverage and quality of facility-based care for use at district, national and global levels.

Methods

EN-BIRTH is an observational study including >20 000 facility births in three countries (Tanzania, Bangladesh and Nepal) to validate selected indicators. Direct clinical observation will be compared with facility register data and a pre-discharge maternal recall survey for indicators including: uterotonic administration, immediate newborn care, neonatal resuscitation and Kangaroo mother care. Indicators including neonatal infection management and antenatal corticosteroid administration, which cannot be easily observed, will be validated using inpatient records. Trained clinical observers in Labour/Delivery ward, Operation theatre, and Kangaroo mother care ward/areas will collect data using a tablet-based customised data capturing application. Sensitivity will be calculated for numerators of all indicators and specificity for those numerators with adequate information. Other objectives include comparison of denominator options (ie, true target population or surrogates) and quality of care analyses, especially regarding intervention timing. Barriers and enablers to routine recording and data usage will be assessed by data flow assessments, quantitative and qualitative analyses.

Conclusions

To our knowledge, this is the first large, multi-country study validating facility-based routine data compared to direct observation for maternal and newborn care, designed to provide evidence to inform selection of a core list of indicators recommended for inclusion in national DHIS2. Availability and use of such data are fundamental to drive progress towards ending the annual 5.5 million preventable stillbirths, maternal and newborn deaths.

Capacities of women and men to improve maternal and newborn health: Effect of a community-based intervention package in rural Bangladesh

Background

Despite improvement in recent decades, maternal and newborn mortality in Bangladesh remain high. A community-based intervention package was initiated in 2009 in Netrokona, a rural district in Bangladesh, to engage individuals, families and communities to improve maternal and newborn health. In this article, we present the effect of the intervention package on improvement of women’s capacities with regard to maternal and newborn health, their husbands’ capacities to effectively support them and use of skilled services during pregnancy, childbirth and after childbirth.

Methods

We adopted a quasi-experimental design to evaluate the effect of the intervention package. A cross-sectional household survey was conducted in the intervention and comparison sites at baseline in 2014 and at endline in 2016. A total of 725 women were interviewed at baseline (intervention n = 444; comparison n = 281) and 737 at end-line (intervention n = 442; comparison n = 295). A total of 317 of their husbands were interviewed at baseline (intervention n = 178; comparison n = 139) and 731 at endline (intervention n = 440; comparison n = 291). Propensity score matching (1:1) was performed and the subsequent analysis was restricted among 235 matched women at baseline and 217 matched women at endline. Descriptive analyses were performed for the covariates for matching. Bivariate analyses between baseline and endline were done for reporting women and their husbands’ knowledge regarding pregnancy and childbirth, birth preparedness and complication readiness practices and utilization of health services.

Results

There was significant increase in awareness of danger signs during pregnancy, childbirth and following childbirth among women and their husbands, as well as increase in awareness of rights related to maternal and newborn health. There was also significant increase in birth preparedness and complication readiness practice among pregnant women and their husbands in the intervention site. Regarding use of skilled health services, there was significant increase in early initiation of antenatal care, attending at least one antenatal care contact and attending at least four antenatal care contacts. No notable improvement was observed in giving birth in the presence of skilled attendant or use of postnatal care.

Conclusions

We conclude that the intervention package was effective in building the capacities of women and in engaging their husbands positively in maternal and newborn health. This may have translated into increased use of skilled care during pregnancy.

Study protocol of a 4- parallel arm, superiority, community based cluster randomized controlled trial comparing paper and e-platform based interventions to improve accuracy of recall of last menstrual period (LMP) dates in rural Bangladesh

BACKGROUND

Gestational age (GA) is a key determinant of newborn survival and long-term impairment. Accurate estimation of GA facilitates timely provision of essential interventions to improve maternal and newborn outcomes. Menstrual based dating, ultrasound based dating, and neonatal estimates are the primarily used methods for assessing GA; all of which have some strength and weaknesses that require critical consideration. Last menstrual period (LMP) is simple, low-cost self-reported information, recommended by the World Health Organization for estimating GA but has issues of recall mainly among poorer, less educated women and women with irregular menstruation, undiagnosed abortion, and spotting during early pregnancy. Several studies have noted that about 20-50% of women cannot accurately recall the date of LMP. The goal of this study is therefore to improve recall and reporting of LMP and by doing so increase the accuracy of LMP based GA assessment in a rural population of Bangladesh where antenatal care-seeking, availability and utilization of USG is low.

METHOD

We propose to conduct a 4- parallel arm, superiority, community based cluster randomized controlled trial comparing three interventions to improve recall of GA with a no intervention arm. The interventions include (i) counselling and a paper based calendar (ii) counselling and a cell phone based SMS alert system (iii) counselling and smart-phone application. The trial is being conducted among 3360 adolescent girls and recently married women in Mirzapur sub-district of Bangladesh.

DISCUSSION

Enrolment of study participants continued from January 24, 2017 to March 29, 2017. Data collection and intervention implementation is ongoing and will end by February, 2019. Data analysis will measure efficacy of interventions in improving the recall of LMP date among enrolled participants. Results will be reported following CONSORT guideline. The innovative conventional & e-platform based interventions, if successful, can provide substantial evidence to scale-up in a low resource setting where m-Health initiatives are proliferating with active support from all sectors in policy and implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02944747 . The trial has been registered before starting enrolment on 24 October 2016.

Antenatal care in rural Bangladesh: Gaps in adequate coverage and content

INTRODUCTION

Antenatal care (ANC) has long been considered a critical component of the continuum of care during pregnancy, with the potential to contribute to the survival and thriving of women and newborns. Although ANC utilization has increased in over the past decades, adequate coverage and content of ANC contacts have fallen under increased scrutiny. The objectives of this article are to describe the coverage and content of ANC contacts in the context of rural Bangladesh.

METHODS

A community-based, cross-sectional household survey was conducted in two sub-districts of Netrokona district, Bangladesh in 2016. A total of 737 women with a recent birth outcome were interviewed. Respondents reported on the ANC contacts and the content of these contacts. Descriptive statistics were used to report coverage and content of ANC contacts stratified by covariates. Chi-square tests were performed to explore whether the estimates are different among different categories and significant differences were reported at p<0.05.

RESULTS

Around 25% of women attended at least four ANC contacts, with only 11% initiating ANC in the first trimester of pregnancy. Blood pressure was measured in almost all of the ANC contacts (92%), and abdominal examination performed in 80% and weight measured in 85% of ANC contacts. Urine tests were conducted in less than half of the ANC contacts, whereas blood screening tests and ultrasound were conducted in 45% contacts. Health care providers counselled women on danger signs in only 66% of the ANC contacts. Overall, the content of facility-based ANC contacts were better than home-based ANC contacts across all components.

CONCLUSIONS

Adequate coverage of ANC remains poor in Netrokona, Bangladesh and important gaps remain in the content of ANC contacts when women attend these services.

Measures matter: A scoping review of maternal and newborn indicators

BACKGROUND

A variety of global-level monitoring initiatives have recommended indicators for tracking progress in maternal and newborn health. As a first step supporting the work of WHO's Mother and Newborn Information for Tracking Outcomes and Results (MoNITOR) Technical Advisory Group, we aimed to compile and synthesize recommended indicators in order to document the landscape of maternal and newborn measurement and monitoring.

METHODS

We conducted a scoping review of indicators proposed by global multi-stakeholder groups to suggest next steps to further support maternal and newborn measurement and monitoring. Indicators pertaining to pregnancy, childbirth, and postpartum/postnatal and newborn care were extracted and included in the indicator compilation, together with key indicator metadata. We examined patterns and relationships across the compiled indicators.

RESULTS

We identified 140 indicators linked to maternal and newborn health topics across the continuum of service provision. Fifty-five indicators relate to inputs and processes, 30 indicators relate to outputs, outcomes comprise 37 indicators in the database, and 18 impact indicators. A quarter of indicators proposed by global groups is either under development/discussion or is considered "aspirational", highlighting the currently evolving monitoring landscape. Although considerable efforts have been made to harmonize indicator recommendations, there are still relatively few indicators shared across key monitoring initiatives and some of those that are shared may have definitional variation.

CONCLUSION

Rapid, wide-ranging work by a number of multi-stakeholder groups has resulted in a substantial number of indicators, many of which partially overlap and many are not supported with adequate documentation or guidance. The volume of indicators, coupled with the number of initiatives promoting different indicator lists, highlight the need for strengthened coordination and technical leadership to harmonize recommendations for improved measurement and monitoring of data related to maternal and newborn heath.

Care-seeking practices for sick neonates: Findings from cross-sectional survey in 14 rural sub-districts of Bangladesh

Objectives

Neonatal deaths account for 45% of all under-five deaths globally and 60% in Bangladesh. This study aimed to investigate the most common symptoms and complications in neonates, care-seeking practices of the mothers for their sick neonates, and factors associated with the care-seeking practices.

Methods

This cross-sectional study analysed data from an Endline Household Survey (as part of an evaluation of a paired cluster-randomised controlled trial study in 14 rural sub-districts in Bangladesh) of 2,931 women who gave birth recently. Descriptive analysis and logistic regressions were conducted to identify the care-seeking practices of mothers of sick neonates and the factors associated with the care-seeking from trained providers.

Results

Of the 2868 neonates, 886 (30.9%) were reported ill during first 28 days after birth. For those with reported symptoms, 748 (84.4%) of their mothers sought care. Of those who sought care, 65.2% sought care from untrained providers. Multiple logistic regression analysis showed significantly higher odds of care-seeking from trained providers when neonates had 3 or more concurrent symptoms (OR: 1.82; 95% CI: 1.07–3.08); when mothers perceived their neonates’ symptoms as severe (OR: 4.08; 95% CI: 2.92–5.70); when mothers received skilled care during pregnancy (OR: 1.95; 95% CI: 1.34–2.84); and when mothers had their delivery in a facility (OR: 3.50; 95% CI: 2.18–5.62). Mothers who delivered their babies at a facility, 43.1% of them sought care for their sick neonates at the same type of public hospital and 34.9% from same type of private hospitals where their deliveries took place.

Conclusion

Skilled care for mothers during pregnancy and delivery, and mothers’ perceptions of the severity of symptoms are the key associated factors of care-seeking for sick neonates from trained providers. Interventions should be tailored to increase care from trained providers during pregnancy and delivery at facilities to improve care-seeking for neonates from trained providers and for the survival of neonates.

Production and use of estimates for monitoring progress in the health sector: the case of Bangladesh

Background: In order to support the progress towards the post-2015 development agenda for the health sector, the importance of high-quality and timely estimates has become evident both globally and at the country level.

Objective and Methods: Based on desk review, key informant interviews and expert panel discussions, the paper critically reviews health estimates from both the local (i.e. nationally generated information by the government and other agencies) and the global sources (which are mostly modeled or interpolated estimates developed by international organizations based on different sources of information), and assesses the country capacity and monitoring strategies to meet the increasing data demand in the coming years. Primarily, this paper provides a situation analysis of Bangladesh in terms of production and use of health estimates for monitoring progress towards the post-2015 development goals for the health sector.

Results: The analysis reveals that Bangladesh is data rich, particularly from household surveys and health facility assessments. Practices of data utilization also exist, with wide acceptability of survey results for informing policy, programme review and course corrections. Despite high data availability from multiple sources, the country capacity for providing regular updates of major global health estimates/indicators remains low. Major challenges also include limited human resources, capacity to generate quality data and multiplicity of data sources, where discrepancy and lack of linkages among different data sources (local sources and between local and global estimates) present emerging challenges for interpretation of the resulting estimates.

Conclusion: To fulfill the increased data requirement for the post-2015 era, Bangladesh needs to invest more in electronic data capture and routine health information systems. Streamlining of data sources, integration of parallel information systems into a common platform, and capacity building for data generation and analysis are recommended as priority actions for Bangladesh in the coming years. In addition to automation of routine health information systems, establishing an Indicator Reference Group for Bangladesh to analyze data; building country capacity in data quality assessment and triangulation; and feeding into global, inter-agency estimates for better reporting would address a number of mentioned challenges in the short- and long-run.

Feasibility of engaging "Village Doctors" in the Community-based Integrated Management of Childhood Illness (C-IMCI): experience from rural Bangladesh

Background

Informal health care providers particularly "village doctors" are the first point of care for under-five childhood illnesses in rural Bangladesh. We engaged village doctors as part of the Multi-Country Evaluation (MCE) of Integrated Management of Childhood Illness (IMCI) and assessed their management of sick under-five children before and after a modified IMCI training, supplemented with ongoing monitoring and supportive supervision.

Methods

In 2003-2004, 144 village doctors across 131 IMCI intervention villages in Matlab Bangladesh participated in a two-day IMCI training; 135 of which completed pre- and post-training evaluation tests. In 2007, 38 IMCI-trained village doctors completed an end-of-project knowledge retention test. Village doctor prescription practices for sick under-five children were examined through household surveys, and routine monitoring visits. In-depth interviews were done with mothers seeking care from village doctors.

Results

Village doctors' knowledge on the assessment and management of childhood illnesses improved significantly after training; knowledge of danger signs of pneumonia and severe pneumonia increased from 39% to 78% (P < 0.0001) and from 17% to 47% (P < 0.0001) respectively. Knowledge on the correct management of severe pneumonia increased from 62% to 84% (P < 0.0001), and diarrhoea management improved from 65% to 82% (P = 0.0005). Village doctors retained this knowledge over three years except for home management of pneumonia. No significant differences were observed in prescribing practices for diarrhoea and pneumonia management between trained and untrained village doctors. Village doctors were accessible to communities; 76% had cell phones; almost all attended home calls, and did not charge consultation fees. Nearly all (91%) received incentives from pharmaceutical representatives.

Conclusions

Village doctors have the capacity to learn and retain knowledge on the appropriate management of under-five illnesses. Training alone did not improve inappropriate antibiotic prescription practices. Intensive monitoring and efforts to target key actors including pharmaceutical companies, which influence village doctors dispensing practices, and implementation of mechanisms to track and regulate these providers are necessary for future engagement in management of under-five childhood illnesses.

A cross-sectional study of partograph utilization as a decision making tool for referral of abnormal labour in primary health care facilities of Bangladesh

BACKGROUND

In Bangladesh, female paramedics known as Family Welfare Visitors (FWVs), conduct normal deliveries in first-level primary care facilities, or Union Health and Family Welfare Centres (UH&FWC). Utilization of partographs allow for early identification of abnormal labour and referral for advanced care to Emergency Obstetric Care (EmOC) facilities. A systematic assessment of the quality of partograph utilization in clinical-decision making will contribute to understanding the use of the tool by health workers.

METHODS

In 2013, the USAID supported MaMoni HSS project, led in country by Save the Children, trained FWVs on the use of partographs in five UH&FWCs in Habiganj district. As part of the follow-up after training, intrapartum case record forms, accompanying partographs, and referral registers for all obstetric cases managed in these five facilities from July 2013 to June 2014 were reviewed. Partographs were reviewed to identify abnormal labour cases based on pre-defined indications. All referred cases were ascertained from the case records in the referral registers. Five health workers were interviewed to assess their knowledge, attitude and experience in partograph use and to explore the challenges for referral decision making associated with the tool.

RESULTS

A total of 1,198 deliveries were managed at the study sites, of which 663 presented with cervical dilatation of 8 cm or less. Partographs were initiated in 98% of these cases. Indication of abnormal labour was found in 71 partographs (11%) and among them, only 1 was referred to a higher-level facility. Foetal heart rate and cervical dilatation were appropriately recorded in 61% and 70% of the partographs, respectively. Interviews with health workers revealed poor interpretation of referral indications from the partographs. Limited accessibility to the nearest EmOC facility, inadequate time for referral, and non-compliance to referral by clients were identified by the interviewed health workers as the key barriers for referral decision making.

CONCLUSIONS

Supporting the health workers at first-level primary care facilities to better interpret and act on partograph data in a timely manner, and strengthening the referral systems are needed to ensure that women in labour receive the prompt quality care they and their babies require to survive.

Initiation of breastfeeding within one hour of birth and its determinants among normal vaginal deliveries at primary and secondary health facilities in Bangladesh: A case-observation study

BACKGROUND

Initiation of breastfeeding within one hour of birth can avert 22% of newborn mortality. Several factors influence breastfeeding practice including mothers' socio-demographic and obstetric characteristics, and factors related to time around child birth. This study explores breastfeeding initiation practices and associated influencing factors for initiating breastfeeding within one hour of birth in public health facilities of Bangladesh.

METHODS

In this study, normal deliveries were observed in 15 public health facilities from 3 districts in Bangladesh. Study participants were selected by convenient sampling i.e. delivery cases attending health facilities during the study period were selected excluding caesarean section deliveries. Among 249 mothers, time of initiation of breastfeeding was observed and its association was measured with type of health facility, privacy in delivery room, presence of separate staff for newborn, spontaneous breathing, skin-to-skin contact and postnatal contact of mother or newborn with health care providers within one hour after delivery. Data was collected during August-September, 2016. Kruskal-Wallis test was used to measure equality of median duration of breastfeeding initiation time among two or more categories of independent variables. Series of simple logistic regressions were conducted followed by multiple logistic regression to identify the determinants for breastfeeding initiation within one hour.

RESULTS

Among 249 mothers observed, 67% initiated breastfeeding within one hour of birth at health facilities and median time to initiate breastfeeding was 38 minutes (Inter-quartile range: 20-56 minutes). After controlling for maternal age as potential confounder, the odds of initiating breastfeeding within one hour of birth was significantly higher if mothers gave birth in district hospitals (AOR 3.5: 95% CI 1.5, 6.4), visual privacy was well-maintained in delivery room (AOR 2.6: 95% CI 1.2, 4.8), newborns cried spontaneously (AOR 4.9: 95% CI 3.4, 17.2), were put to skin-to-skin contact with mothers (AOR 3.4: 95% CI 1.9, 10.4) or were examined by health care providers in the facilities (AOR 2.4: 95% CI 1.3, 12.9).

CONCLUSIONS

In health facilities, initiation of breastfeeding within one hour is associated with some critical practices and events around the time of birth. With the global push toward facility-based deliveries, it is very important to identify those key factors, within the landscape of maternal and newborn care, which significantly enable health care providers and parents to engage in the evidence-based newborn care activities including early initiation of breastfeeding that will, in turn, reduce global rates of newborn mortality.