Evaluation of a Cluster-Randomized Controlled Trial of a Package of Community-Based Maternal and Newborn Interventions in Mirzapur, Bangladesh

To evaluate a delivery strategy for newborn interventions in rural Bangladesh.A cluster-randomized controlled trial was conducted in Mirzapur, Bangladesh. Twelve unions were randomized to intervention or comparison arm. All women of reproductive age were eligible to participate. In the intervention arm, community health workers identified pregnant women; made two antenatal home visits to promote birth and newborn care preparedness; made four postnatal home visits to negotiate preventive care practices and to assess newborns for illness; and referred sick neonates to a hospital and facilitated compliance. Primary outcome measures were antenatal and immediate newborn care behaviours, knowledge of danger signs, care seeking for neonatal complications, and neonatal mortality.A total of 4616 and 5241 live births were recorded from 9987 and 11153 participants in the intervention and comparison arm, respectively. High coverage of antenatal (91% visited twice) and postnatal (69% visited on days 0 or 1) home visitations was achieved. Indicators of care practices and knowledge of maternal and neonatal danger signs improved. Adjusted mortality hazard ratio in the intervention arm, compared to the comparison arm, was 1.02 (95% CI: 0.80-1.30) at baseline and 0.87 (95% CI: 0.68-1.12) at endline. Primary causes of death were birth asphyxia (49%) and prematurity (26%). No adverse events associated with interventions were reported.Lack of evidence for mortality impact despite high program coverage and quality assurance of implementation, and improvements in targeted newborn care practices suggests the intervention did not adequately address risk factors for mortality. The level and cause-structure of neonatal mortality in the local population must be considered in developing interventions. Programs must ensure skilled care during childbirth, including management of birth asphyxia and prematurity, and curative postnatal care during the first two days of life, in addition to essential newborn care and infection prevention and management.Clinicaltrials.gov NCT00198627

Measuring Coverage in MNCH:A Prospective Validation Study in Pakistan and Bangladesh on Measuring Correct Treatment of Childhood Pneumonia

Antibiotic treatment for pneumonia as measured by Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) is a key indicator for tracking progress in achieving Millennium Development Goal 4. Concerns about the validity of this indicator led us to perform an evaluation in urban and rural settings in Pakistan and Bangladesh.Caregivers of 950 children under 5 y with pneumonia and 980 with "no pneumonia" were identified in urban and rural settings and allocated for DHS/MICS questions 2 or 4 wk later. Study physicians assigned a diagnosis of pneumonia as reference standard; the predictive ability of DHS/MICS questions and additional measurement tools to identify pneumonia versus non-pneumonia cases was evaluated. Results at both sites showed suboptimal discriminative power, with no difference between 2- or 4-wk recall. Individual patterns of sensitivity and specificity varied substantially across study sites (sensitivity 66.9% and 45.5%, and specificity 68.8% and 69.5%, for DHS in Pakistan and Bangladesh, respectively). Prescribed antibiotics for pneumonia were correctly recalled by about two-thirds of caregivers using DHS questions, increasing to 72% and 82% in Pakistan and Bangladesh, respectively, using a drug chart and detailed enquiry.Monitoring antibiotic treatment of pneumonia is essential for national and global programs. Current (DHS/MICS questions) and proposed new (video and pneumonia score) methods of identifying pneumonia based on maternal recall discriminate poorly between pneumonia and children with cough. Furthermore, these methods have a low yield to identify children who have true pneumonia. Reported antibiotic treatment rates among these children are therefore not a valid proxy indicator of pneumonia treatment rates. These results have important implications for program monitoring and suggest that data in its current format from DHS/MICS surveys should not be used for the purpose of monitoring antibiotic treatment rates in children with pneumonia at the present time

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

Vulnerability of Newborns to Environmental Factors: Findings from Community Based Surveillance Data in Bangladesh

Infection is the major cause of neonatal deaths. Home born newborns in rural Bangladeshi communities are exposed to environmental factors increasing their vulnerability to a number of disease agents that may compromise their health. The current analysis was conducted to assess the association of very severe disease (VSD) in newborns in rural communities with temperature, rainfall, and humidity. A total of 12,836 newborns from rural Sylhet and Mirzapur communities were assessed by trained community health workers using a sign based algorithm. Records of temperature, humidity, and rainfall were collected from the nearest meteorological stations. Associations between VSD and environmental factors were estimated. Incidence of VSD was found to be associated with higher temperatures (odds ratios: 1.14, 95% CI: 1.08 to 1.21 in Sylhet and 1.06, 95% CI: 1.04 to 1.07 in Mirzapur) and heat humidity index (odds ratios: 1.06, 95% CI: 1.04 to 1.08 in Sylhet and, 1.03, 95% CI: 1.01 to 1.04 in Mirzapur). Four months (June–September) in Sylhet, and six months in Mirzapur (April–September) had higher odds ratios of incidence of VSD as compared to the remainder of the year (odds ratios: 1.72, 95% CI: 1.32 to 2.23 in Sylhet and, 1.62, 95% CI: 1.33 to 1.96 in Mirzapur). Prevention of VSD in neonates can be enhanced if these interactions are considered in health intervention strategies

Trends in Use of Referral Hospital Services for Care of Sick Newborns in a Community-based Intervention in Tangail District, Bangladesh

The Projahnmo-II Project in Mirzapur upazila (sub-district), Tangail district, Bangladesh, is promot\uading care-seeking for sick newborns through health education of families, identification and referral of sick newborns in the community by community health workers (CHWs), and strengthening of neo\uadnatal care in Kumudini Hospital, Mirzapur. Data were drawn from records maintained by the CHWs, referral hospital registers, a baseline household survey of recently-delivered women conducted from March to June 2003, and two interim household surveys in January and September 2005. Increases were observed in self-referral of sick newborns for care, compliance after referral by the CHWs, and care-seeking from qualified providers and from the Kumudini Hospital, and decreases were observed in care-seeking from unqualified providers in the intervention arm. An active surveillance for illness by the CHWs in the home, education of families by them on recognition of danger signs and counsel\uadling to seek immediate care for serious illness, and improved linkages between the community and the hospital can produce substantial increases in care-seeking for sick newborns

Self-reported diabetes or hypertension diagnoses and antenatal care among child-bearing women in rural Bangladesh: A cross-sectional study.

Health care systems in low- and middle-income countries may not meet the needs of pregnant women where the burden of diabetes and hypertension is rapidly increasing. We asked recently pregnant women about ever having been screened for or diagnosed with hypertension or diabetes and their ANC-seeking experiences in a cross-sectional survey. We used chi-squared tests and logistic regression to test the associations between self-reported coverage of hypertension and diabetes screening, diagnoses, and elements of ANC by age, wealth, educational attainment, and gravidity. Among 4,692 respondents, for hypertension, 97% reported having been screened and 10% of screened women reported a diagnosis. Women 30-39 years of age (aOR 3.02, 95% CI 2.00, 4.56) or in the top wealth quintile (aOR 1.70, 95% CI 1.18, 2.44) were more likely to be diagnosed with hypertension compared to reference groups. Any hypertension diagnosis was associated with reporting four or more antenatal care contacts (44% vs. 35%, p < 0.01), blood pressure measurements (85% vs. 79%, p < 0.01), and urine tests (71% vs. 61%, p < 0.01) conducted during ANC visits. For diabetes, 46% of respondents reported having been screened and 3% of screened women reported a diagnosis. Women 30-39 years of age were more likely to be diagnosed with diabetes (aOR 8.19, 95% CI 1.74, 38.48) compared to the reference group. Any diabetes diagnosis was associated with reporting four or more ANC contacts (48% vs. 36%, p = 0.04) and having blood testing during pregnancy (83% vs. 66%, p < 0.01). However, the frequency and quality of ANC was below the national guidelines among all groups. Focused efforts to ensure that women receive the recommended number of ANC contacts, coupled with improved compliance with ANC guidelines, would improve awareness of hypertension and diabetes among women in Bangladesh

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

BackgroundA 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.MethodsFacility 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 Gi* 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.ResultsThe 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.ConclusionsSpatiotemporal 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

Baliakandi health and demographic surveillance system data and analyses used to estimate proportion of marriage to female children and time between first marriage and pregnancy in Baliakandi, Bangladesh.

Baliakandi health and demographic surveillance system data and analyses used to estimate proportion of marriage to female children and time between first marriage and pregnancy in Baliakandi, Bangladesh.</p