Comparing modelled predictions of neonatal mortality impacts using LiST with observed results of community-based intervention trials in South Asia

Background There is an increasing body of evidence from trials suggesting that major reductions in neonatal mortality are possible through community-based interventions. Since these trials involve packages of varying content, determining how much of the observed mortality reduction is due to specific interventions is problematic. The Lives Saved Tool (LiST) is designed to facilitate programmatic prioritization by modelling mortality reductions related to increasing coverage of specific interventions which may be combined into packages

The effect of intrapartum antibiotics on early-onset neonatal sepsis in Dhaka, Bangladesh: a propensity score matched analysis

Background: We estimate the effect of antibiotics given in the intrapartum period on early-onset neonatal sepsis in Dhaka, Bangladesh using propensity score techniques. Methods: We followed 600 mother-newborn pairs as part of a cohort study at a maternity center in Dhaka. Some pregnant women received one dose of intravenous antibiotics during labor based on clinician discretion. Newborns were followed over the first seven days of life for early-onset neonatal sepsis defined by a modified version of the World Health Organization Young Infants Integrated Management of Childhood Illnesses criteria. Using propensity scores we matched women who received antibiotics with similar women who did not. A final logistic regression model predicting sepsis was run in the matched sample controlling for additional potential confounders. Results: Of the 600 mother-newborn pairs, 48 mothers (8.0%) received antibiotics during the intrapartum period. Seventy-seven newborns (12.8%) were classified with early-onset neonatal sepsis. Antibiotics appeared to be protective (odds ratio 0.381, 95% confidence interval 0.115–1.258), however this was not statistically significant. The results were similar after adjusting for prematurity, wealth status, and maternal colonization status (odds ratio 0.361, 95% confidence interval 0.106–1.225). Conclusions: Antibiotics administered during the intrapartum period may reduce the risk of early-onset neonatal sepsis in high neonatal mortality settings like Dhaka

"You should go so that others can come"; The Role of Facilities in Determining an Early Departure after Childbirth in Morogoro Region, Tanzania.

Tanzania is among ten countries that account for a majority of the world's newborn deaths. However, data on time-to-discharge after facility delivery, receipt of postpartum messaging by time to discharge and women's experiences in the time preceding discharge from a facility after childbirth are limited. Household survey of 1267 women who delivered in the preceding 2-14 months; in-depth interviews with 24 women, 12 husbands, and 5 community elders. Two-thirds of women with vaginal, uncomplicated births departed within 12 h; 90 % within 24 h, and 95 % within 48 h. Median departure times varied significantly across facilities (hospital: 23 h, health center: 10 h, dispensary: 7 h, p < 0.001). Quantitative and qualitative data highlight the importance of type of facility and facility amenities in determining time-to-discharge. In multiple logistic regression, level of facility (hospital, health center, dispensary) was the only significant predictor of early discharge (p = 0.001). However across all types of facilities a majority of women depart before 24 h ranging from hospitals (54 %) to health centers (64 %) to dispensaries (74 %). Most women who experienced a delivery complication (56 %), gave birth by caesarean section (90 %), or gave birth to a pre-term baby (70 %) stayed longer than 24 h. Reasons for early discharge include: facility practices including discharge routines and working hours and facility-based discomforts for women and those who accompany them to facilities. Provision of postpartum counseling was inadequate regardless of time to discharge and regardless of type of facility where delivery occurred. Our quantitative and qualitative findings indicate that the level of facility care and comforts existing or lacking in a facility have the greatest effect on time to discharge. This suggests that individual or interpersonal characteristics play a limited role in deciding whether a woman would stay for shorter or longer periods. Implementation of a policy of longer stay must incorporate enhanced postpartum counseling and should be sensitive to women's perceptions that it is safe and beneficial to leave hospitals soon after birth

How well does LiST capture mortality by wealth quintile? A comparison of measured versus modelled mortality rates among children under-five in Bangladesh

Background In the absence of planned efforts to target the poor, child survival programs often favour the rich. Further evidence is needed urgently about which interventions and programme approaches are most effective in addressing inequities. The Lives Saved Tool (LiST) is available and can be used to model mortality levels across economic groups based on coverage levels for child survival interventions

Factors affecting early identification of pregnant women by community health workers in Morogoro, Tanzania

Background: It is recommended that Antenatal Care (ANC) be initiated within the first trimester of pregnancy for essential interventions, such folic acid supplementation, to be effective. In Tanzania, only 24% of mothers attend their first ANC appointment during their first trimester. Studies have shown that women who have had contact with a health worker are more likely to attend their first antenatal care appointment earlier in pregnancy. Community health workers (CHWs) are in an opportune position to be this contact. This study explored CHW experiences with identifying women early in gestation to refer them to facility-based antenatal care services in Morogoro, Tanzania. Methods: This qualitative study employed 10 semi-structured focus group discussions, 5 with 34 CHWs and 5 with 34 recently delivered women in three districts in Morogoro, Tanzania. A thematic analytical approach was used to identify emerging themes among the CHW and RDW responses.ResultsStudy findings show CHWs play a major role in identifying pregnant women in their communities and linking them with health facilities. Lack of trust and other factors, however, affect early pregnancy identification by the CHWs. They utilize several methods to identify pregnant women, including: asking direct questions to households when collecting information on the national census, conducting frequent household visits and getting information about pregnant women from health facilities. Conclusions: We present a framework for the interaction of factors that affect CHWs' ability to identify pregnant women early in gestation. Further studies need to be conducted investigating optimal workload for CHWs, as well as reasons pregnant women might conceal their pregnancies.USAID through the Health Research Challenge for Impact (HRC) [GHS-A-00-09-00004-00]Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

The case for launch of an international DNA-based birth cohort study

The global health agenda beyond 2015 will inevitably need to broaden its focus from mortality reduction to the social determinants of deaths, growing inequities among children and mothers, and ensuring the sustainability of the progress made against the infectious diseases. New research tools, including technologies that enable high-throughput genetic and ‘-omics’ research, could be deployed for better understanding of the aetiology of maternal and child health problems. The research needed to address those challenges will require conceptually different studies than those used in the past. It should be guided by stringent ethical frameworks related to the emerging collections of biological specimens and other health related information. We will aim to establish an international birth cohort which should assist low- and middle-income countries to use emerging genomic research technologies to address the main problems in maternal and child health, which are still major contributors to the burden of disease globally

Child supervision practices for drowning prevention in rural Bangladesh: a pilot study of supervision tools

ABSTRACT Background Injuries are an increasing child health concern and have become a leading cause of child mortality in the 1e4 years age group in many developing countries, including Bangladesh. Methods Household observations during 9 months of a community-based pilot of two supervision toolsda door barrier and a playpenddesigned to assess their community acceptability in rural Bangladesh are reported in this article. Results Statistical analysis of 2694 observations revealed that children were directly supervised or protected by a preventive tool in 96% of visits. Households with a supervision tool had a significantly lower proportion of observations with the child unsupervised and unprotected than households without a tool. Families that received a playpen had 6.89 times the odds of using it at the time of the visit than families that received a door barrier. Conclusions Interventions such as the playpen, when introduced to households through community-based programs, are accepted by parents. Field trials are urgently needed to establish the effectiveness of barrierbased interventions at reducing under-five drowning mortality rates in low-income countries like Bangladesh. Drowning is the second leading cause of injuryrelated mortality among children worldwide, 1 with 90% of child drowning deaths occurring in low-and middle-income countries. 2 Despite the high rates of drowning, limited research has been conducted on causes and prevention strategies specific to the unique hazards in low-and middle-income countries. 2e6 There is a clear need for research that identifies risk factors for drowning in low-and middle-income countries and helps lead to effective interventions. This article discusses findings from household observations made during a community-based pilot exploring potential interventions to prevent drowning in children under age 5 years in rural Bangladesh. The incidence rate of drowning for children under 5 years in Bangladesh is estimated at 156 deaths per 100 000 child-years, and up to 43% of deaths among 1-to 4-year-olds are due to drowning. 5 7 8 Recent work demonstrates that the vast majority of childhood drowning deaths in Bangladesh occur when at least one parent is at home and engaged in household chores. 9 These findings are consistent with other research demonstrating that parental supervision practices are correlated with injury rates. The goal of this article is to contribute to the body of knowledge on childhood drowning in low-and middle-income countries. The specific objectives of this study in Bangladesh were (1) to assess utilisation and preferences for supervision tools and factors associated with their use, and (2) to assess the effect of supervision tools on childhood supervision practices. 14 Six villages were purposively selected to participate in the pilot study, with two villages randomly assigned to each of three intervention packages: (1) educational drowning prevention messages, (2) educational messages and door barrier, and (3) educational messages and playpen. A convenience sample of households from the villages with children aged 6e54 months was recruited to participate through community meetings conducted by community health workers. Participating households received an initial enrolment visit from the community health worker during which the intervention was delivered. Afterwards, community health workers made up to 11 unannounced follow-up observations at each enrolled household to record supervision practices and tool use on a standardised observation form. Observations occurred at staggered times, and intervention use was defined as the child being in the home and behind the door barrier or the child being inside the playpen, both at the time of the observation. METHODS Observation forms were collected by community health worker supervisors, and responses were entered into a Microsoft Access database and converted to STATA v. 8.0 for statistical analysis. 15 Descriptive statistics of the observation data were compiled for each study arm, and the differences between continuous means and binomial proportions were tested using the KruskalleWallis and the Wilcoxon rank-sum non-parametric tests to account for the non-normal distribution of the data. 16 A logistic regression model was used to evaluate factors that predict the use of the intervention in the playpen and door barrier arms. RESULTS A total of 2694 household observations were conducted over a 9-month period with a median of 3 observations (IQR 2 to 5) per household. The Short report average age of children included in the study at the first observation was 27.27 months (CI 26.08 to 28.47), with the educationonly arm having a higher average age by approximately 4 months (p&lt;0.05). Community health workers observed the child being directly supervised by an adult at the time of the observation or protected by an intervention tool in 96.8% of household observations Community health workers observed intervention tool use during 56.6% of observations in the playpen arm and only 18.7% of observations in the door barrier arm (p&lt;0.01). Direct adult supervision was the most often observed protection in use in the door barrier arm (78.6%), while the playpen was most frequent in the playpen arm (56.6%). The door barrier group accounted for 49% of negative intervention comments and 86% of mechanical problems reported. Simple and multiple logistic regression analyses demonstrate that intervention type, child age and observation number have a significant impact on intervention tool use. Households given the playpen had a 6.89 times greater odds (CI 5.43 to 8.75) of using the tool than households that received a door barrier, when controlling for child age (months), observation number and time of day. Increasing child age and observation number decreased the odds of using the intervention tool; an increase in age of 6 months results in 0.83 times lesser odds of using the intervention tool while each progressive observation causes 0.89 lesser odds of using the intervention tool. The time of day of the observation did not have a significant effect on use. DISCUSSION This pilot study revealed that when households in Bangladesh are provided with supervision tools, they use them; moreover, having a supervision tool is associated with a significantly lower proportion of observations where children are unprotected (through either supervision or proper use of the tool). Moreover, households seemed to prefer the playpen over the door barrier and were seven times more likely to use the playpen than the door barrier at the time of an observation. This study was not an effectiveness trial and did not include a control group; the households enrolled in the study were a convenience sample. However, the study indicates that the playpen, when introduced to households in Bangladesh through community-based interventions, has good uptake and the possibility of improving parental supervision practices. Effectiveness trials are needed to establish the impact of these tools on under-five drowningspecific mortality rates

Sex and Socioeconomic Differentials in Child Health in Rural Bangladesh: Findings from a Baseline Survey for Evaluating Integrated Management of Childhood Illness

This paper reports on a population-based sample survey of 2,289 children aged less than five years (under-five children) conducted in 2000 as a baseline for the Bangladesh component of the Multi-country Evaluation (MCE) of the Integrated Management of Childhood Illness strategy. Of interest were rates and differentials by sex and socioeconomic status for three aspects of child health in rural Bangladesh: morbidity and hospitalizations, including severity of illness; care-seeking for childhood illness; and home-care for illness. The survey was carried out among a population of about 380,000 in Matlab upazila (subdistrict). Generic MCE Household Survey tools were adapted, translated, and pretested. Trained interviewers conducted the survey in the study areas. In total, 2,289 under-five children were included in the survey. Results showed a very high prevalence of illness among Bangladeshi children, with over two-thirds reported to have had at least one illness during the two weeks preceding the survey. Most sick children in this population had multiple symptoms, suggesting that the use of the IMCI clinical guidelines will lead to improved quality of care. Contrary to expectations, there were no significant differences in the prevalence of illness either by sex or by socioeconomic status. About one-third of the children with a reported illness did not receive any care outside the home. Of those for whom outside care was sought, 42% were taken to a village doctor. Only 8% were taken to an appropriate provider, i.e. a health facility, a hospital, a doctor, a paramedic, or a community-based health worker. Poorer children than less-poor children were less likely to be taken to an appropriate healthcare provider. The findings indicated that children with severe illness in the least poor households were three times more likely to seek care from a trained provider than children in the poorest households. Any evidence of gender inequities in child healthcare, either in terms of prevalence of illness or care-seeking patterns, was not found. Care-seeking patterns were associated with the perceived severity of illness, the presence of danger signs, and the duration and number of symptoms. The results highlight the challenges that will need to be addressed as IMCI is implemented in health facilities and extended to address key family and community practices, including extremely low rates of use of the formal health sector for the management of sick children. Child health planners and researchers must find ways to address the apparent population preference for untrained and traditional providers which is determined by various factors, including the actual and perceived quality of care, and the differentials in care-seeking practices that discriminate against the poorest households

Factors affecting recruitment and retention of community health workers in a newborn care intervention in Bangladesh

<p>Abstract</p> <p>Background</p> <p>Well-trained and highly motivated community health workers (CHWs) are critical for delivery of many community-based newborn care interventions. High rates of CHW attrition undermine programme effectiveness and potential for implementation at scale. We investigated reasons for high rates of CHW attrition in Sylhet District in north-eastern Bangladesh.</p> <p>Methods</p> <p>Sixty-nine semi-structured questionnaires were administered to CHWs currently working with the project, as well as to those who had left. Process documentation was also carried out to identify project strengths and weaknesses, which included in-depth interviews, focus group discussions, review of project records (i.e. recruitment and resignation), and informal discussion with key project personnel.</p> <p>Results</p> <p>Motivation for becoming a CHW appeared to stem primarily from the desire for self-development, to improve community health, and for utilization of free time. The most common factors cited for continuing as a CHW were financial incentive, feeling needed by the community, and the value of the CHW position in securing future career advancement. Factors contributing to attrition included heavy workload, night visits, working outside of one's home area, familial opposition and dissatisfaction with pay.</p> <p>Conclusions</p> <p>The framework presented illustrates the decision making process women go through when deciding to become, or continue as, a CHW. Factors such as job satisfaction, community valuation of CHW work, and fulfilment of pre-hire expectations all need to be addressed systematically by programs to reduce rates of CHW attrition.</p

Process evaluation of a community-based intervention promoting multiple maternal and neonatal care practices in rural Nepal

<p>Abstract</p> <p>Background</p> <p>The challenge of delivering multiple, complex messages to promote maternal and newborn health in the <it>terai </it>region of Nepal was addressed through training Female Community Health Volunteers (FCHVs) to counsel pregnant women and their families using a flipchart and a pictorial booklet that was distributed to clients. The booklet consists of illustrated messages presented on postcard-sized laminated cards that are joined by a ring. Pregnant women were encouraged to discuss booklet content with their families.</p> <p>Methods</p> <p>We examined use of the booklet and factors affecting adoption of practices through semi-structured interviews with district and community-level government health personnel, staff from the Nepal Family Health Program, FCHVs, recently delivered women and their husbands and mothers-in-law.</p> <p>Results</p> <p>The booklet is shared among household members, promotes discussion, and is referred to when questions arise or during emergencies. Booklet cards on danger signs and nutritious foods are particularly well-received. Cards on family planning and certain aspects of birth preparedness generate less interest. Husbands and mothers-in-law control decision-making for maternal and newborn care-seeking and related household-level behaviors.</p> <p>Conclusions</p> <p>Interpersonal peer communication through trusted community-level volunteers is an acceptable primary strategy in Nepal for promotion of household-level behaviors. The content and number of messages should be simplified or streamlined before being scaled-up to minimize intervention complexity and redundant communication.</p