Prevention of Low Birthweight Infants Among Pregnant Women in Rural Bangladesh: A Cluster Randomized Controlled Trial

The low birthweight (LBW) prevalence in Bangladesh varies between 22-50%, which positioned Bangladesh 4th globally among the countries having highest burden of LBW. LBW imposes greater risk of mortality and morbidities among children under five and creates a long-term negative impact on development and wellbeing in adolescence and adulthood. Therefore, the objective of the research was to investigate the effects of ‘balanced plate nutrition education’ (nutrition education on balanced diet with practical demonstration of balanced plate) in combination with engagement of family decision makers, to reduce incidences of LBW infants among pregnant women by increasing birthweight. The specific objectives included developing the ‘balanced plate nutrition education’ intervention for rural pregnant women and measuring the effect of the intervention on birthweight of infants and incidences of LBW, and exploring the barriers of and household coping strategies related to compliance. It also examined the association of household food insecurity and size of infants at birth. Both quantitative and qualitative methods were applied for this research. For the quantitative analysis, primary data were derived from a randomized controlled trial conducted in rural Bangladesh (Chapter 4) and secondary data from Bangladesh Demographic and Health Survey 2011 (Chapter 6). Statistical analyses were performed using multivariable linear and binomial regression with log link function. We adjusted for the clustered randomisation using generalised estimating equations (GEE). We constructed survey-weighted logistic regression models for BDHS data to account for different sampling probabilities and different response rate. A qualitative study was conducted in the trial area among the balanced plate nutrition education intervention recipients. We conducted in-depth interviews (n=10) with mothers of infants (0-6 months), focus group discussions (n=2) with their husbands and older women in the family and key informant interviews (n=4) with Shasthya Kormi (community health workers) of BRAC (an NGO in Bangladesh, formerly known as Bangladesh Rural Advancement Committee). Interviews were audio-recorded during collection, later transcribed in Bangla, and translated into English. The transcripts were manually coded and analysed using the thematic approach. Chapter 4 demonstrated that pregnant women who received balanced plate nutrition education had heavier infants compared to those received standard nutrition education. The incidence of low birthweight (LBW) was also lower among women in the balanced plate group compared to the latter. The mean birthweight increased by 125.3 g (95% confidence interval (CI) 5·7, 244·9; p=0·04) and the risk of LBW was reduced by 54% (relative risk (RR) 0·46; 95% CI 0·28, 0·78; p=0·004) in the intervention compared to the comparison group. The effect of intervention was greater among adolescent mothers in terms of birthweight and incidence of LBW than the non-adolescent mothers mean difference 297·3 g; 95% CI 85·0, 509·6; p=0·006 and RR 0·31; 95% CI 0·12, 0·77; p=0·01). Chapter 5 exhibited that accessing animal source food was the greatest barrier in practicing balanced diet. Perceived gap in understanding appropriate portion size and importance of diversified food for a pregnant woman were the other reported barriers. Mothers-in-law’s authority and control over pregnant women’s diet led to intrahousehold food mal-distribution with less nutritious food share for them. Active engagement of the family decision makers (husbands and elderly women in the family) in the nutrition counseling and demonstration session created an agreement on balanced diet for pregnant women. Husbands were inclined to finance more for purchasing nutritious foods such as cheap fishes, milk and fruits. Women were selfmotivated to increase consumption of vegetables and animal source foods with right proportion of rice. Mothers-in-law’s approval and husbands’ voluntary contribution enabled women to practice the balanced diet. Chapter 6 showed an inverse association between household food insecurity and perceived birth size of infants in Bangladesh. Infants from food insecure household were 36% more at risk of being small at birth compared to infants born in food secure households, which was aggravated by less utilization of antenatal care and first birth. There was an obvious regional variation of prevalence of smaller infants in geographically hard to reach areas; women in Sylhet and Chittagong districts were more vulnerable to give birth to smaller infants than mothers living in Barisal. In conclusion, balanced plate nutrition education in pregnancy impacted on the birthweight of infants and incidence of LBW in rural Bangladesh. Practical demonstration of making balanced plate in combination with family engagement can create an enabling environment for pregnant women to adopt a balanced diet with self-motivation. Household food insecurity is major driver in determining fetal growth and subsequent size of infants at birth. The insights from this research will help to design nutrition behaviour change communications for pregnant women and target household with greatest need to improve perinatal nutrition for better child survival, growth, development and productivity in Bangladesh and other LMICs

Can community level interventions have an impact on equity and utlization of maternal health care : Evidence from rural Bangladesh

Peer reviewedPublisher PD

Effectiveness of health voucher scheme and micro-health insurance scheme to support the poor and extreme poor in selected urban areas of Bangladesh: An assessment using a mixed-method approach

Background National healthcare financing strategy recommends tax-based equity funds and insurance schemes for the poor and extreme poor living in urban slums and pavements as the majority of these population utilise informal providers resulting in adverse health effects and financial hardship. We assessed the effect of a health voucher scheme (HVS) and micro-health insurance (MHI) scheme on healthcare utilisation and out-of-pocket (OOP) payments and the cost of implementing such schemes. Methods HVS and MHI schemes were implemented by Concern Worldwide through selected NGO health centres, referral hospitals, and private healthcare facilities in three City Corporations of Bangladesh from December 2016 to March 2020. A household survey with 1,294 enrolees, key-informant interviews, focus group discussions, consultative meetings, and document reviews were conducted for extracting data on healthcare utilisation, OOP payments, views of enrolees, and suggestions of implementers, and costs of services at the point of care. Results Healthcare utilisation including maternal, neonatal and child health (MNCH) services, particularly from medically trained providers, was higher and OOP payments were lower among the scheme enrolees compared to corresponding population groups in general. The beneficiaries were happy with their access to healthcare, especially for MNCH services, and their perceived quality of care was fair enough. They, however, suggested expanding the benefits package, supported by an additional workforce. The cost per beneficiary household for providing services per year was €32 in HVS and €15 in MHI scheme. Conclusion HVS and MHI schemes enabled higher healthcare utilisation at lower OOP payments among the enrolees, who were happy with their access to healthcare, particularly for MNCH services. However, they suggested a larger benefits package in future. The provider’s costs of the schemes were reasonable; however, there are potentials of cost containment by purchasing the health services for their beneficiaries in a competitive basis from the market. Scaling up such schemes addressing the drawback would contribute to achieving universal health coverage

A community-based cluster randomised controlled trial in rural Bangladesh to evaluate the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality: The Shonjibon trial

Abstract Background Iron-deficiency is the most common nutritional deficiency globally. Due to the high iron requirements for pregnancy, it is highly prevalent and severe in pregnant women. There is strong evidence that maternal iron deficiency anaemia increases the risk of adverse perinatal outcomes. However, most of the evidence is from observational epidemiological studies except for a very few randomised controlled trials. IFA supplements have also been found to reduce the preterm delivery rate and neonatal mortality attributable to prematurity and birth asphyxia. These results combined indicate that IFA supplements in populations of iron-deficient pregnant women could lead to a decrease in the number of neonatal deaths mediated by reduced rates of preterm delivery. In this paper, we describe the protocol of a community-based cluster randomised controlled trial that aims to evaluate the impact of maternal antenatal IFA supplements on perinatal outcomes. Methods/design The effect of the early use of iron-folic acid supplements on neonatal mortality will be examined using a community based, cluster randomised controlled trial in five districts with 30,000 live births. In intervention clusters trained BRAC village volunteers will identify pregnant women & provide iron-folic acid supplements. Groundwater iron levels will be measured in all study households using a validated test kit. The analysis will follow the intention to treat principle. We will compare neonatal mortality rates & their 95% confidence intervals adjusted for clustering between treatment groups in each groundwater iron-level group. Cox proportional hazards mixed models will be used for mortality outcomes & will include groundwater iron level as an interaction term in the mortality model. Discussion This paper aims to describe the study protocol of a community based randomised controlled trial evaluating the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality. This study is critical because it will determine if antenatal IFA supplements commenced in the first trimester of pregnancy, rather than later, will significantly reduce neonatal deaths in the first month of life, and if this approach is cost-effective. Trial registration This trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on 31 May 2012. The registration ID is ACTRN12612000588897

Individual and community level factors associated with health facility delivery: A cross sectional multilevel analysis in Bangladesh.

IntroductionImproving maternal health remains one of the targets of sustainable development goals. A maternal death can occur at any time during pregnancy, but delivery is by far the most dangerous time for both the woman and her baby. Delivery at a health facility can avoid most maternal deaths occurring from preventable obstetric complications. The influence of both individual and community factors is critical to the use of health facility delivery services. In this study, we aim to examine the role of individual and community factors associated with health facility-based delivery in Bangladesh.MethodsThis cross-sectional study used data from the Bangladesh Maternal Mortality Survey. The sample size constitutes of 28,032 women who had delivered within five years preceding the survey. We fitted logistic random effects regression models with the community as a random effect to assess the influence of individual and community level factors on use of health facility delivery services.ResultsOur study observed substantial amount of variation at the community level. About 28.6% of the total variance in health facility delivery could be attributed to the differences across the community. At community level, place of residence (AOR 1.48; 95% CI 1.35-1.64), concentration of poverty (AOR 1.15; 95% CI 1.03-1.28), concentration of use of antenatal care services (AOR 1.11, 95% CI 1.00-1.23), concentration of media exposure (AOR 1.20, 95% CI 1.07-1.34) and concentration of educated women (AOR 1.12, 95% CI 1.02-1.23) were found to be significantly associated with health facility delivery. At individual level, maternal age, educational status of the mother, religion, parity, delivery complications, individual exposure to media, individual access to antenatal care and household socioeconomic status showed strong association with health facility-based delivery.ConclusionOur results strongly suggest factors at both Individual, and community level influenced the use of health facility delivery services in Bangladesh. Thus, any future strategy to improve maternal health in Bangladesh must consider community contexts and undertake multi-sectorial approach to address barriers at different levels. At the individual level the programs should also focus on the need of the young mother, the multiparous the less educated and women in the poorest households

The Impact of Antenatal Balanced Plate Nutrition Education for Pregnant Women on Birth Weight: A Cluster Randomised Controlled Trial in Rural Bangladesh

Low birth weight (LBW) is a global public health problem with the highest prevalence in South Asia. It is strongly associated with maternal undernutrition. In South Asia, intra-household food distribution is inequitable, with lower dietary adequacy in women. Evidence that nutrition education improves diet during pregnancy and reduces LBW is weak. We assessed the impact of nutrition education for pregnant women on birth weight in rural Bangladesh. We conducted a parallel, two-arm, cluster-randomised controlled trial, with 36 clusters allocated equally to intervention (n = 445) or standard care (n = 448). From their first trimester until delivery, intervention participants received education about eating balanced meals to meet daily dietary requirements with diverse food groups. The primary outcome of mean birth weight was 127.5 g higher in the intervention compared to control women, and the intervention reduced the risk of LBW by 57%. Post hoc analyses showed a significantly higher birth weight and a greater reduction in LBW amongst adolescent mothers. The mean number of food groups consumed was significantly higher in the intervention from the third month of pregnancy than in the control. A community-based balanced plate nutrition education intervention effectively increased mean birth weight and reduced LBW, and improved dietary diversity in rural Bangladeshi women

Nutritional status and dietary diversity of pregnant and nonpregnant reproductive‐age Rohingya women

Abstract There are no data on the nutritional status and dietary diversity of the pregnant and nonpregnant reproductive‐age Rohingya women who have recently shifted to the Bhasan Char Relocation Camp located on an island in the Bay of Bengal. A cross‐sectional survey was conducted in November–December, 2021 to assess the nutritional status and evaluate the dietary diversity of two vulnerable groups of the forcibly displaced Rohingya population: nonpregnant reproductive‐age women and pregnant mothers. Multivariable logistic regression was applied to identify the factors associated with nutritional impairments. Overall, 7.6% of the nonpregnant reproductive‐age women were underweight (Body Mass Index [BMI] < 18.5 kg/m2), and nearly one‐third of them had a BMI ≥ 25 kg/m2. However, 26.7% of the pregnant mothers were undernourished (BMI < 20.0 kg/m2) and almost one‐fourth of them were either overweight or obese (BMI ≥ 25.0 kg/m2). The prevalence of thinness (Mid Upper Arm Circumference [MUAC] < 23 cm) was 34.5% among pregnant mothers, and 10.1% of them were severely thin (MUAC < 21 cm). The mean (±SD) of the Women's Dietary Diversity Score (WDDS) was 3.3 (±1.1) for nonpregnant reproductive‐age women and 3.7 (±1.3) for pregnant mothers enrolled in this study. Overall, 63.8% of the nonpregnant women of childbearing age and 46% of the pregnant mothers had a low WDDS (WDDS < 4). The WDDS was found to be protective against thinness among nonpregnant reproductive‐age women (AOR = 0.61; 95% CI = 0.37, 0.93; p‐value = .03) and low BMI in pregnant mothers (AOR = 0.71; 95% CI = 0.55, 0.91; p‐value = .01). The results of this survey will assist in early recognition of the nutritional demands, and act as a guide to planning nutrition‐based programs among Rohingya reproductive‐age women relocated to the Bhasan Char Island