Neonatal deaths in a rural area of Bangladesh: an assessment of causes, predictors and health care seeking using verbal autopsy

Poor neonatal health is a major contributor to mortality in under-five children in developing countries, accounting for more than two thirds of all deaths in the first year of life, and for about half of all deaths in children under-five. A major constraint to effective neonatal survival programmes in developing countries, such as Bangladesh, has been the lack of accurate epidemiological data on neonatal deaths. The current study aimed to (1) describe the causes of neonatal death in a rural subdistrict of Bangladesh; (2) describe associated birth and obstetric characteristics of neonatal deaths; (3) describe the patterns of care-seeking practices during the fatal neonatal illness episode; (4) compare deaths and care-seeking patterns between the Maternal and Child Health and Family Planning (MCH-FP) service area of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and the adjoining government service area; (5) identify the predictors of neonatal deaths; and (6) assess the accuracy in assigning causes of death from verbal autopsy data by comparing physician review with medical assistant review and computer-based algorithm.This study was carried out during 2003 and 2004 in a demographic surveillance area in the Matlab rural sub-district of eastern Bangladesh. The surveillance system covers a population of ~220,000 and is maintained by ICDDR,B. Community health workers (CHRW) visit each household monthly to record vital demographic, morbidity and health care seeking data. Half of the surveillance population receives MCH-FP services from ICDRR,B (ICDDR,B service area) and the remaining half receives standard government services (government service area).Verbal autopsies, consisting of retrospective interviews with caregivers of recently deceased neonates about the circumstances leading to their death, were carried out by the staff trained in verbal autopsy. The interviews were held with the mothers of all deceased neonates (n=365) who had died during 2003 and 2004. The verbal autopsy data were then independently reviewed by three physicians and a medical assistant to assign a direct cause of death and an originating cause of death. A computer algorithm using evidence-based clinical signs and/or symptoms was also used for assigning cause of death. Agreement of at least two of the three physicians was used to determine direct causes of death. Diagnostic accuracy and reliability of medical assistant and algorithm in assigning direct cause of death were evaluated by comparing with the diagnoses provided by the physicians. Linked epidemiological data on all live births in the Matlab area during 2003 and 2004 were also analysed.There were 365 deaths among the 11,291 live births recorded during 2003 and 2004, yielding a neonatal mortality rate (NMR) of 32.3 per 1000 live births. The NMR was lower in the ICDDR,B area compared to the government area. Of all neonatal deaths, 37% occurred within 24 hours, 76% within three days, 84% within seven days, and the remaining 16% between eight and 28 days of birth.Five causes accounted for 85% of the deaths: birth asphyxia (45%), prematurity/low birth weight (LBW) (15%), sepsis/meningitis (12%), respiratory distress syndrome (7%), and pneumonia (6%). The majority of neonatal death cases were low birth weight (56%) and singleton births (82%). There were some differences in the distribution of causes of death between the ICDDR,B and government areas, the most notable being prematurity/LBW which was twice as common in the ICDDR,B area than in government area.Strikingly, more than a third (37%) of the deceased neonates had not been taken to any source of health care for the fatal illness episode, and another quarter (25%) sought care from traditional healers or from unqualified practitioners. Only 37% sought modern biomedical care from a doctor or paramedic.Among the 365 neonatal deaths, a much higher proportion (48.5%) of the deliveries occurred at a health facility in the ICDDR,B area, compared to 15.3% in the government area. Vaginal delivery was the commonest mode of delivery in both areas, with a higher proportion of caesarean sections in the ICDDR,B area (9.3%) compared with the comparison government area (1.6%).The verbal autopsy method appears to be highly effective in that agreement on a direct cause of death was reached by at least two physicians in 339 (93%) cases. Using the physician review as the gold standard, the medical assistant review of causes of death demonstrated a sensitivity ranging from 47.7% to 83.5% depending on the cause of death, a specificity ranging from 93.0% to 97.5%, and kappa values ranging from 0.51 to 0.77. Similarly, depending on the cause of death, algorithm demonstrated a sensitivity ranging from 35.6% to 77.4%, specificity ranging from 86.8% to 95.9%, and kappa values ranging from 0.24 to 0.69.Independent predictors of neonatal mortality included lack of maternal education, single parity, and lack of antenatal care (ANC) during the last trimester. Male sex of the neonate, multiple births, and facility-based delivery were also significantly associated with excess neonatal mortality.In conclusion, the study highlighted the central role of birth asphyxia, prematurity/LBW, and sepsis/meningitis in neonatal deaths, indicating that the core of interventional packages to prevent neonatal deaths in rural Bangladesh should incorporate these causes. Community awareness about early care seeking, skilled attendance at delivery, and training and integration into mainstream services of traditional/unqualified care practitioners are some of the approaches needed to reduce neonatal mortality further. Improving access to female education and antenatal care would also have beneficial effects on neonatal survival.This study revealed the value of both review by medical assistant and computerbasedalgorithm to reliably assign major causes of neonatal deaths from verbalautopsy data. Further research could be undertaken to develop optimal combinationsof the medical assistant and hierarchical algorithm for assigning major causes ofdeath in low-resource settings such as Matlab

A neuroimaging study in childhood autism

Background: Childhood autism is now widely viewed as being of developmental neurological origin. Abnormality in neuroimaging is reported in autism.Objectives: To delineate the proportion of structural magnetic resonance imaging (MRI) and electro encephalography (EEG) abnormality among the children with Autism and to assess any association of MRI and EEG changes with co morbid mental illness.Methods: It was a cross sectional descriptive study done at a child and adolescent consultation centre, Dhaka. The study was Carried out from January 2009 to December 2009. Both boys and girls were included in the study. A total of 42 children with childhood autism aged between two and 12 years partici­pated in this study. Diagnosis of autism was based on ICD-10(DCR) criteria. Results: Abnormalities were found to be 35.7% in MRI and 42.9% in EEG. EEG abnormalities were found in the form of defuse slow waves activities, generalized faster activities, epileptogenic discharge and mixed discharge. The abnormalities in MRI was found in the form of diffuse cortical atrophic changes, focal cortical atrophy in frontal and temporal cortex with widening of major sulci, prominent ventricles, periventricular degeneration and abnormal basal ganglia. EEG changes were significantly associated with increased number of co-morbid illness (mental retardation, epilepsy and others). Conclusion: A number of abnom1alities that observed in the present study indicative of relations between structural and physiological dysfunctions and childhood autism. Further exploratory and in-depth researches are certainly required in this field. Intervention of autism needs to address co morbidities for better outcome

Causes of Neonatal Deaths in a Rural Subdistrict of Bangladesh: Implications for Intervention

The study assessed the timing and causes of neonatal deaths in a rural area of Bangladesh. A population-based demographic surveillance system, run by the International Centre for Diarrhoeal Disease Research, Bangladesh, recorded livebirths and neonatal deaths during 2003-2004 among a population of 224,000 living in Matlab, a rural subdistrict of eastern Bangladesh. Deaths were investigated using the INDEPTH/World Health Organization verbal autopsy. Three physicians independently reviewed data from verbal autopsy interview to assign the cause of death. There were 11,291 livebirths and 365 neonatal deaths during the two-year period. The neonatal mortality rate was 32.3 per 1,000 livebirths. Thirty-seven percent of the neonatal deaths occurred within 24 hours, 76% within 0-3 days, 84% within 0-7 days, and the remaining 16% within 8-28 days. Birth asphyxia (45%), prematurity/low birthweight (15%), sepsis/meningitis (12%), respiratory distress syndrome (7%), and pneumonia (6%) were the major direct causes of death. Birth asphyxia (52.8%) was the single largest category of cause of death in the early neonatal period while meningitis/sepsis (48.3%) was the single largest category in the late neonatal period. The high proportion of deaths during the early neonatal period and the far-higher proportion of neonatal deaths caused by birth asphyxia compared to the global average (45% vs 23-29%) indicate the lack of skilled birth attendance and newborn care for the large majority of births that occur in the home in rural Bangladesh. Resuscitation of newborns and management of low-birthweight/premature babies need to be at the core of neonatal interventional packages in rural Bangladesh

Psychiatric morbidity among rural and slum female population: A comparative study

Background: Psychiatric disorders are more prevalent among women than men worldwide. The lifetime risk of depres­sion and dysthymia are twice as common in women as men. Rural women usually undergoes more stressful situations and also scores more on stress scale than that of urban and slum population. Objectives: The research objectives of this study are: 1) To find out the prevalence of psychiatric disorders among the study population. 2) To compare the disorders among the rural and slum female population. 3) To find out the influence of existing socio-demographic factors on psychiatric disorders. Method: This is a community-based study, which is also cross sectional and descriptive in nature. The sample for the main study constituted 366 randomly selected respondents. A two-staged screening procedure was carried in the study. First, the total population was studied by screening test-Self Reporting Questionnaire (SRQ) to divide the sample into 'screen positive' and 'screen negative' subjects. In the second stage, full assessment of a mixture of all 'screen positive' and 25% 'screen negative' was carried out by structured clinical interview for diagnosis (SCID-NP). Later SCID filled by the respondents was assessed by consultant psychiatrists by using DSMIV in order to put exact clinical diagnosis. Stress was scored according to Presumptive Stressful Life Events Scale (PSLE). The total duration of the study was from July 2010 to June 2011. Results: Higher prevalence of psychiatric morbidity was found among rural sample (22.8%) than slum (10.90%) population. Regarding pattern of psychiatric disorders among rural sample (22.8%) than slum (10.9%) population.See the PDF for the rest of the abstract

Causes of death of adults and elderly and healthcare - seeking before death in rural Bangladesh

The health system of a country needs to be adjusted to patterns of morbidity and mortality to mitigate the income-erosion consequences of prolonged ill-health and premature death of adults. Population-based data on mortality by cause are a key to modifying the health system. However, these data are scarce, particularly for rural populations in developing countries. The objectives of this study were to determine the burdens of health due to major causes of death obtained from verbal autopsy of adults and the elderly and their healthcare-seeking patterns before death in a well-defined rural population. There were 2, 397 deaths- 613 were among adults aged 15- 59 years and 1, 784 among the elderly aged 60 + years-during 2003- 2004 in the health and demographic surveil-lance area in Matlab, a rural area of Bangladesh. Trained interviewers interviewed close relatives of the deceased using a structured verbal-autopsy questionnaire to record signs and symptoms of dis-eases/conditions that led to death and medical consultations before death. Two physicians indepen-dently assigned the underlying causes of deaths with disagreements resolved by a third physician. The physicians were able to assign a specific cause in 91% of the cases. Rates and proportions were used for estimating the burden of diseases by cause. Of all deaths of adults and the elderly, commu-nicable diseases accounted for 18% and non-communicable diseases for 66%, with the proportion of non-communicable diseases increasing with age. Leading non-communicable diseases were diseases of the circulatory system ( 35%), neoplasms ( 11%), diseases of the respiratory system ( 10%), diseases of the digestive system ( 6%), and endocrine and metabolic disorders ( 6%), all of which accounted for 68% of deaths. Injury and other external causes accounted for another 5% of the deaths. During terminal illness, 31% of the adults and 25% of the elderly sought treatment from medical doc-tors, and 14% of the adults and 4% of the elderly died in healthcare facilities. The findings suggest that the health managers and policy-makers of Bangladesh should recognize the importance of pre-vention and management of chronic diseases and place it on the health agenda for rural people

Insulinoma Presenting with Psychiatric Manifestations: A Case Report

Insulinomas, the most common of pancreatic endocrine tumors, usually present with neuroglycopenic and adrenergic features. Chronic or long standing recurrent hypogycaemia can produce intellectual deterioration and neuropsychiatric manifestations. Diagnosis of insulinoma relies on clinical features along with laboratory tests and imaging investigations to aid in localization. A 32-year-old male who presented with prominent neuropsychiatric manifestations and received anti-epileptics as a case of epilepsy and was ultimately diagnosed as insulinoma is reported here. The patient experienced fasting hypoglycemia with neuropsychiatric manifestations; computerized tomography (CT scan) and magnetic resonance imaging (MRI) revealed a diffusely enhanced mass in the head area of pancreas which was histopathologically found to be an insulinoma after hand assisted laparoscopic enucleation. Surgical excision is the treatment of choice and is curative in most cases. Key words: Insulinoma; Psychiatric Manifestation.DOI: 10.3329/bsmmuj.v2i1.3710 BSMMU J 2009; 2(1): 39-4

Causes of neonatal deaths in a rural Subdistrict of Bangladesh: Implications for intervention

The study assessed the timing and causes of neonatal deaths in a rural area of Bangladesh. A population-based demographic surveillance system, run by the International Centre for Diarrhoeal Disease Research, Bangladesh, recorded livebirths and neonatal deaths during 2003-2004 among a population of 224,000 living in Matlab, a rural subdistrict of eastern Bangladesh. Deaths were investigated using the INDEPTH/ World Health Organization verbal autopsy. Three physicians independently reviewed data from verbal au-topsy interview to assign the cause of death. There were 11,291 livebirths and 365 neonatal deaths during the two-year period. The neonatal mortality rate was 32.3 per 1,000 livebirths. Thirty-seven percent of the neonatal deaths occurred within 24 hours, 76% within 0-3 days, 84% within 0-7 days, and the remaining 16% within 8-28 days. Birth asphyxia (45%), prematurity/low birthweight (15%), sepsis/meningitis (12%), respiratory distress syndrome (7%), and pneumonia (6%) were the major direct causes of death. Birth as-phyxia (52.8%) was the single largest category of cause of death in the early neonatal period while meningi-tis/sepsis (48.3%) was the single largest category in the late neonatal period. The high proportion of deaths during the early neonatal period and the far-higher proportion of neonatal deaths caused by birth asphyxia compared to the global average (45% vs 23-29%) indicate the lack of skilled birth attendance and newborn care for the large majority of births that occur in the home in rural Bangladesh. Resuscitation of newborns and management of low-birthweight/premature babies need to be at the core of neonatal interventional packages in rural Bangladesh

A Population-based Study of Hospital Admission Incidence Rate and Bacterial Aetiology of Acute Lower Respiratory Infections in Children Aged Less Than Five Years in Bangladesh

The research was carried out to study the rate of population-based hospital admissions due to acute lower respiratory infections (ALRIs) and bacterial aetiology of ALRIs in children aged less than five years in Bangladesh. A cohort of children aged less than five years in a rural surveillance population in Matlab, Bangladesh, was studied for two years. Cases were children admitted to the Matlab Hospital of ICDDR,B with a diagnosis of severe ALRIs. Bacterial aetiology was determined by blood culture. Antimicrobial resistance patterns of Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae (Spn) isolates were determined using the disc-diffusion method. In total, 18,983 children aged less than five years contributed to 24,902 child-years of observation (CYO). The incidence of ALRI-related hospital admissions was 50.2 per 1,000 CYO. The incidences of ALRI were 67% higher in males than in females and were higher in children aged less than two years than in older children. About 34% of the cases received antibiotics prior to hospitalization. Of 840 blood samples cultured, 39.4% grew a bacterial isolate; 11.3% were potential respiratory pathogens, and the rest were considered contaminants. The predominant isolates were Staphylococcus aureus (4.5%). Hib (0.4%) and Spn (0.8%) were rarely isolated; however, resistance of both these pathogens to trimethoprim-sulphamethoxazole was common. The rate of ALRI-related hospitalizations was high. The high rate of contamination, coupled with high background antibiotic use, might have contributed to an underestimation of the burden of Hib and Spn. Future studies should use more sensitive methods and more systematically look for resistance patterns of other pathogens in addition to Hib and Spn

A Population-based Study of Hospital Admission Incidence Rate and Bacterial Aetiology of Acute Lower Respiratory Infections in Children Aged Less Than Five Years in Bangladesh

The research was carried out to study the rate of population-based hospital admissions due to acute lower respiratory infections (ALRIs) and bacterial aetiology of ALRIs in children aged less than five years in Bangladesh. A cohort of children aged less than five years in a rural surveillance population in Matlab, Bangladesh, was studied for two years. Cases were children admitted to the Matlab Hospital of ICDDR,B with a diagnosis of severe ALRIs. Bacterial aetiology was determined by blood culture. Antimicrobial resistance patterns of Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae (Spn) isolates were determined using the disc-diffusion method. In total, 18,983 children aged less than five years contributed to 24,902 child-years of observation (CYO). The incidence of ALRI-related hospital admissions was 50.2 per 1,000 CYO. The incidences of ALRI were 67% higher in males than in females and were higher in children aged less than two years than in older children. About 34% of the cases received antibiotics prior to hospitalization. Of 840 blood samples cultured, 39.4% grew a bacterial isolate; 11.3% were potential respiratory pathogens, and the rest were considered contami\uadnants. The predominant isolates were Staphylococcus aureus (4.5%). Hib (0.4%) and Spn (0.8%) were rarely isolated; however, resistance of both these pathogens to trimethoprim-sulphamethoxazole was common. The rate of ALRI-related hospitalizations was high. The high rate of contamination, coupled with high background antibiotic use, might have contributed to an underestimation of the burden of Hib and Spn. Future studies should use more sensitive methods and more systematically look for resistance patterns of other pathogens in addition to Hib and Spn