Reducing Maternal Mortality and Improving Maternal Health: Bangladesh and MDG 5

Bangladesh is on its way to achieving the MDG 5 target of reducing the maternal mortality ratio by three-quarters between 1990 and 2015, but the annual rate of decline needs to triple. Although the use of skilled birth attendants has improved over the past 15 years, it remains less than 20% as of 2007 and is especially low among poor, uneducated rural women. Increasing the numbers of skilled birth attendants, deploying them in teams in facilities, and improving access to them through messages on antenatal care to women, have the potential to increase such use. The use of caesarean sections is increasing although not among poor, uneducated rural women. Strengthening appropriate quality emergency obstetric care in rural areas remains the major challenge. Strengthening other supportive services, including family planning and delayed first birth, menstrual regulation, and education of women, are also important for achieving MDG 5

Postpartum Haemorrhage and Eclampsia: Differences in Knowledge and Care-seeking Behaviour in Two Districts of Bangladesh

In high- and low-performing districts of Bangladesh, the study explored the demand-side of maternal healthcare by looking at differences in perceived knowledge and care-seeking behaviours of women in relation to postpartum haemorrhage or eclampsia. Haemorrhage and eclampsia are two major causes of maternal mortality in Bangladesh. The study was conducted during July 2006–December 2007. Both postpartum bleeding and eclampsia were recognized by women of different age-groups as severe and life-threatening obstetric complications. However, a gap existed between perception and actual care-seeking behaviours which could contribute to the high rate of maternal deaths associated with these conditions. There were differences in care-seeking practices among women in the two different areas of Bangladesh, which may reflect sociocultural differences, disparities in economic and educational opportunities, and a discrimination in the availability of care

Factors influencing place of delivery : evidence from three south-Asian countries

Background High maternal mortality is still a significant public health challenge in many countries of the South-Asian region. The majority of maternal deaths occur due to pregnancy and deliveryrelated complications, which can mostly be prevented by safe facility delivery. Due to the paucity of existing evidence, our study aimed to examine the factors associated with place of delivery, including women's preferences for such in three selected South-Asian countries. Methods We extracted data from the most recent demographic and health surveys (DHS) conducted in Bangladesh (2014), Nepal (2016), and Pakistan (2017-18) and analyzed to identify the association between the outcome variable and socio-demographic characteristics. A total of 16,429 women from Bangladesh (4278; mean age 24.57 years), Nepal (3962; mean age 26.35 years), and Pakistan (8189; mean age 29.57 years) were included in this study. Following descriptive analyses, bivariate and multivariate logistic regressions were conducted. Results Overall, the prevalence of facility-based delivery was 40%, 62%, and 69% in Bangladesh, Nepal, and Pakistan, respectively. Inequity in utilizing facility-based delivery was observed for women in the highest wealth quintile. Participants from Urban areas, educated, middle and upper household economic status, and with high antenatal care (ANC) visits were significantly associated with facility-based delivery in all three countries. Interestingly, watching TV was also found as a strong determinant for facility-based delivery in Bangladesh (aOR = 1.31, 95% CI:1.09-1.56, P = 0.003), Nepal (aOR = 1.42, 95% CI:1.20-1.67, P<0.001) and Pakistan (aOR = 1.17, 95% CI: 1.03-1.32, P = 0.013). Higher education of husband was a significant predictor for facility delivery in Bangladesh (aOR = 1.73, 95% CI:1.27-2.35, P = 0.001) and Pakistan (aOR = 1.19, 95% CI: 0.99-1.43, P = 0.065); husband's occupation was also a significant factor in Bangladesh (aOR = 1.30, 95% CI:1.04-1.61, P = 0.020) and Nepal (aOR = 1.26, 95% CI:1.01-1.58, P = 0.041). Conclusion Our findings suggest that the educational status of both women and their husbands, household economic situation, and the number of ANC visits influenced the place of delivery. There is an urgent need to promote facility delivery by building more birthing facilities, training and deployment of skilled birth attendants in rural and hard-to-reach areas, ensuring compulsory female education for all women, encouraging more ANC visits, and providing financial incentives for facility deliveries. There is a need to promote facility delivery by encouraging health facility visits through utilizing social networks and continuing mass media campaigns. Ensuring adequate Government funding for free maternal and newborn health care and local community involvement is crucial for reducing maternal and neonatal mortality and achieving sustainable development goals in this region

Normal reference values of strength in pelvic floor muscle of women: a descriptive and inferential study

Background: To describe the clinical, functional and quality of life characteristics in women with Stress Urinary Incontinence (SUI). In addition, to analyse the relationship between the variables reported by the patients and those informed by the clinicians, and the relationship between instrumented variables and the manual pelvic floor strength assessment.Methods: Two hundred and eighteen women participated in this observational, analytical study. An interview about Urinary Incontinence and the quality of life questionnaires (EuroQoL-5D and SF-12) were developed as outcomes reported by the patients. Manual muscle testing and perineometry as outcomes informed by the clinician were assessed. Descriptive and correlation analysis were carried out.Results: The average age of the subjects was (39.93 ± 12.27 years), (24.49 ± 3.54 BMI). The strength evaluated by manual testing of the right levator ani muscles was 7.79 ± 2.88, the strength of left levator ani muscles was 7.51 ± 2.91 and the strength assessed with the perineometer was 7.64 ± 2.55. A positive correlation was found between manual muscle testing and perineometry of the pelvic floor muscles (p < .001). No correlation was found between outcomes of quality of life reported by the patients and outcomes of functional capacity informed by the physiotherapist.Conclusion: A stratification of the strength of pelvic floor muscles in a normal distribution of a large sample of women with SUI was done, which provided the clinic with a baseline. There is a relationship between the strength of the pelvic muscles assessed manually and that obtained by a perineometer in women with SUI. There was no relationship between these values of strength and quality of life perceived

A longitudinal study of urinary incontinence in community-based women: prevalence, incidence, resolution, and associated factors, and impact on well-being and quality of life

Background Available data indicate that urinary incontinence (UI) is a condition in women, which adversely impacts on quality of life and daily activities. It affects women of all ages, but is particularly common in older women. It has been associated with significant physical morbidities, lowered well-being, loss of independence as well as sexual difficulties. It also causes a considerable financial burden on both individuals and the healthcare system. A detailed understanding of UI in terms of its prevalence, incidence and risk factors in women is an essential step in reducing the impact of this condition. However, the reported prevalence of UI among women varies widely between studies, with most studies reporting a prevalence of any UI in the range of 25 to 50%. This range is a result of the different definitions used for UI, the heterogeneity of study populations and the different data collection procedures applied for this sensitive health issue. UI is commonly viewed as a permanent condition once it develops. However, few studies have examined the progression and resolution of UI in community-based women with or without treatment. To date no study of the prevalence and incidence of UI in Australian women has been undertaken using a validated instrument. Also, little is known about the natural history of UI and its association with fecal incontinence. The aetiology of UI is widely recognised to be multifactorial and various risk factors have been identified in different studies. However, the estimated magnitude of risks varies widely in these studies and there is inconsistent evidence with regard to certain factors including mode of delivery, hysterectomy and hormone therapy use. Aims The aims of this doctoral thesis are to comprehensively examine UI in community-dwelling women in Australia in terms of its age-specific prevalence, risk factors, impact on quality of life, natural history (incidence and resolution) and its relationship with fecal incontinence (FI). Methods The project involved 542 community-based women aged 24 to 80 years in 2006 who were originally recruited from a previous cross-sectional study of 1423 women who participated in the Study of Androgens in Women (SAW). The SAW women were recruited from a database established from the Victorian Electoral Roll. Of the 1423 women who participated in the SAW, 754 agreed to be re-contacted regarding further research and of those, 542 women expressed interest in participating in the study of UI. A detailed self-administered questionnaire was mailed to the participants of this research at baseline in 2006 and again at follow-up in 2008. UI was assessed using a validated questionnaire, the Questionnaire for Urinary Incontinence Diagnosis (QUID) and FI by the Pelvic Floor Distress Inventory (PFDI). The PFDI was included in the follow-up study only. Definitions of stress and urge UI that conform to the standards recommended by the International Continence Society were used. The Bristol Female Lower Urinary Tract Symptoms Questionnaire (BFLUTS) was used to assess the impact of UI on condition-specific quality of life. The impact of UI on well-being was assessed using the Psychological General Well-being Index (PGWBI). Results Five hundred and six women provided data for the baseline analysis and 442 women for the follow-up data analysis. Prevalence: The overall point prevalence of any UI was 41.7% [95% confidence interval (CI): 37.2-45.8%] at baseline and increased to 44.6% [95%CI: 40.0-49.2%] by the end of the follow-up period. Of the 210 women reporting UI at baseline, 16% [95%CI: 12.9-19.3%] reported stress UI; 7.5% [95%CI: 5.2-9.8%] reported urge UI and 18% [95%CI: 14.7-21.5%] reported a mixed pattern. Stress UI was found to be the most common type among middle-aged women (25.3% of women aged 35-44 years), while urge UI was the most common type in women over the age of 75 years (24.2%). Risk factors: In logistic regression analyses, obesity (P<0.001) and parity (P=0.019) were found to be associated significantly with stress UI. Greater age (P=0.002) was associated significantly with urge UI, and higher body mass index (BMI) (P=0.035) and hysterectomy (P=0.021) were associated significantly with mixed UI. Impact on well-being and quality of life: Incontinent women had a lower total PGWBI score (76.9 ± 16.5), indicating lower well-being than women with no UI (81.6 ± 15.3) (p=0.001). The total PGWBI mean score was significantly lower in women suffering from stress UI (77.8 ± 16.2, p=0.05) and mixed UI (74.2 ± 17.8, p<0.001) compared with women with no UI. All types of UI were associated with impaired quality of life (p<0.001) and adversely impacted on daily activities, as determined by BFLUTS. Change over time: Over the 2-year follow-up period the incidence of any UI was 17% [95%CI: 12.4-21.6%] among the unaffected women and the resolution was 16.8 % [95%CI: 11.4-22.2%] among the incontinent women including women who had no treatment for UI. There was also movement of women between diagnoses of stress UI, urge UI and mixed type during the follow-up period. Only 34 women reported specific treatment for their UI during the follow-up period, and of them, 5 experienced resolution of their condition. Relationship with FI: The overall prevalence of any FI at follow-up was 20.7% (95% CI: 16.9%–24.5%). The prevalence for loose FI was 20.7% (95% CI: 16.9%–24.5%) and well-formed FI, 4.5% (95% CI: 2.6%–6.4%). All of the women with well-formed FI also reported loose FI. About two-thirds of the women with any FI reported co-existing UI. Loose FI was associated significantly with any UI [OR, 2.8(95% CI: 1.7-4.8)] after adjusting for age and BMI (p<0.001). Conclusions Stress, urge and mixed incontinence have different age distributions and risk factors. Stress UI is the most common type in women at midlife and urge UI at older ages. UI is a dynamic clinical condition, with movement between diagnostic subtypes of stress, urge and mixed UI and periods of resolution. Having any UI negatively impacts on well-being and is significantly associated with impaired quality of life. The relatively low proportion of women who have treatment for their UI suggests there are barriers to treatment that merit further investigation. Loose FI is also a common condition, affecting one in five adult women in our study. Women with loose FI were more likely to have UI, independent of their age and BMI. It is therefore important that clinicians are aware that this is not an uncommon problem and consider the possibility of FI when assessing patients, especially women with UI

A longitudinal study of urinary incontinence in community-based women: prevalence, incidence, resolution, and associated factors, and impact on well-being and quality of life

Background Available data indicate that urinary incontinence (UI) is a condition in women, which adversely impacts on quality of life and daily activities. It affects women of all ages, but is particularly common in older women. It has been associated with significant physical morbidities, lowered well-being, loss of independence as well as sexual difficulties. It also causes a considerable financial burden on both individuals and the healthcare system. A detailed understanding of UI in terms of its prevalence, incidence and risk factors in women is an essential step in reducing the impact of this condition. However, the reported prevalence of UI among women varies widely between studies, with most studies reporting a prevalence of any UI in the range of 25 to 50%. This range is a result of the different definitions used for UI, the heterogeneity of study populations and the different data collection procedures applied for this sensitive health issue. UI is commonly viewed as a permanent condition once it develops. However, few studies have examined the progression and resolution of UI in community-based women with or without treatment. To date no study of the prevalence and incidence of UI in Australian women has been undertaken using a validated instrument. Also, little is known about the natural history of UI and its association with fecal incontinence. The aetiology of UI is widely recognised to be multifactorial and various risk factors have been identified in different studies. However, the estimated magnitude of risks varies widely in these studies and there is inconsistent evidence with regard to certain factors including mode of delivery, hysterectomy and hormone therapy use. Aims The aims of this doctoral thesis are to comprehensively examine UI in community-dwelling women in Australia in terms of its age-specific prevalence, risk factors, impact on quality of life, natural history (incidence and resolution) and its relationship with fecal incontinence (FI). Methods The project involved 542 community-based women aged 24 to 80 years in 2006 who were originally recruited from a previous cross-sectional study of 1423 women who participated in the Study of Androgens in Women (SAW). The SAW women were recruited from a database established from the Victorian Electoral Roll. Of the 1423 women who participated in the SAW, 754 agreed to be re-contacted regarding further research and of those, 542 women expressed interest in participating in the study of UI. A detailed self-administered questionnaire was mailed to the participants of this research at baseline in 2006 and again at follow-up in 2008. UI was assessed using a validated questionnaire, the Questionnaire for Urinary Incontinence Diagnosis (QUID) and FI by the Pelvic Floor Distress Inventory (PFDI). The PFDI was included in the follow-up study only. Definitions of stress and urge UI that conform to the standards recommended by the International Continence Society were used. The Bristol Female Lower Urinary Tract Symptoms Questionnaire (BFLUTS) was used to assess the impact of UI on condition-specific quality of life. The impact of UI on well-being was assessed using the Psychological General Well-being Index (PGWBI). Results Five hundred and six women provided data for the baseline analysis and 442 women for the follow-up data analysis. Prevalence: The overall point prevalence of any UI was 41.7% [95% confidence interval (CI): 37.2-45.8%] at baseline and increased to 44.6% [95%CI: 40.0-49.2%] by the end of the follow-up period. Of the 210 women reporting UI at baseline, 16% [95%CI: 12.9-19.3%] reported stress UI; 7.5% [95%CI: 5.2-9.8%] reported urge UI and 18% [95%CI: 14.7-21.5%] reported a mixed pattern. Stress UI was found to be the most common type among middle-aged women (25.3% of women aged 35-44 years), while urge UI was the most common type in women over the age of 75 years (24.2%). Risk factors: In logistic regression analyses, obesity (P<0.001) and parity (P=0.019) were found to be associated significantly with stress UI. Greater age (P=0.002) was associated significantly with urge UI, and higher body mass index (BMI) (P=0.035) and hysterectomy (P=0.021) were associated significantly with mixed UI. Impact on well-being and quality of life: Incontinent women had a lower total PGWBI score (76.9 ± 16.5), indicating lower well-being than women with no UI (81.6 ± 15.3) (p=0.001). The total PGWBI mean score was significantly lower in women suffering from stress UI (77.8 ± 16.2, p=0.05) and mixed UI (74.2 ± 17.8, p<0.001) compared with women with no UI. All types of UI were associated with impaired quality of life (p<0.001) and adversely impacted on daily activities, as determined by BFLUTS. Change over time: Over the 2-year follow-up period the incidence of any UI was 17% [95%CI: 12.4-21.6%] among the unaffected women and the resolution was 16.8 % [95%CI: 11.4-22.2%] among the incontinent women including women who had no treatment for UI. There was also movement of women between diagnoses of stress UI, urge UI and mixed type during the follow-up period. Only 34 women reported specific treatment for their UI during the follow-up period, and of them, 5 experienced resolution of their condition. Relationship with FI: The overall prevalence of any FI at follow-up was 20.7% (95% CI: 16.9%–24.5%). The prevalence for loose FI was 20.7% (95% CI: 16.9%–24.5%) and well-formed FI, 4.5% (95% CI: 2.6%–6.4%). All of the women with well-formed FI also reported loose FI. About two-thirds of the women with any FI reported co-existing UI. Loose FI was associated significantly with any UI [OR, 2.8(95% CI: 1.7-4.8)] after adjusting for age and BMI (p<0.001). Conclusions Stress, urge and mixed incontinence have different age distributions and risk factors. Stress UI is the most common type in women at midlife and urge UI at older ages. UI is a dynamic clinical condition, with movement between diagnostic subtypes of stress, urge and mixed UI and periods of resolution. Having any UI negatively impacts on well-being and is significantly associated with impaired quality of life. The relatively low proportion of women who have treatment for their UI suggests there are barriers to treatment that merit further investigation. Loose FI is also a common condition, affecting one in five adult women in our study. Women with loose FI were more likely to have UI, independent of their age and BMI. It is therefore important that clinicians are aware that this is not an uncommon problem and consider the possibility of FI when assessing patients, especially women with UI