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 utilization of maternal health care” – Evidence from rural Bangladesh

Peer reviewe

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

Comparing apples with apples: A proposed taxonomy for “Community Health Workers” and other front-line health workers for international comparisons

This paper proposes a taxonomy for Community Health Workers (CHWs) and others engaged in front-line community health activities, encompassing formally-employed workers extending government primary health care (PHC) service delivery as well as a range of other actors with roles at the nexus of government PHC and communities. The taxonomy is grounded in current definitions from the World Health Organization and the International Labor Organization, and proposes some refinements for future iterations of guidance from these agencies. The designation, “Community Health Worker” is currently used to cover a broad range of roles. Furthermore, there are programs engaging workers or community members in roles closely adjacent to those generally recognized as CHWs that use other designations, not commonly included under the rubric of “CHW”. This potentially confusing range of roles and nomenclature leads at times to over-generalizations, applying insights and principles relevant for one type of worker or community member that are not necessarily relevant for another. It also leads to a failure to consider occupational groups not commonly thought of as CHWs—but engaged in PHC service delivery at the most peripheral level—in community-based-PHC planning and management arrangements. Building on ILO and WHO classifications and standards, a further clarification of terms and a taxonomy is proposed, with the intention of contributing to clearer communication and shared understanding and, ultimately, sounder community health policy, program planning, and implementation; and more substantial progress towards Universal Health Coverage

How Can We Improve the Consumption of a Nutritionally Balanced Maternal Diet in Rural Bangladesh? The Key Elements of the “Balanced Plate” Intervention

Social, cultural, environmental and economic factors closely regulate the selection, allocation and consumption of maternal diets. We developed a nutrition behaviour change intervention to promote a balanced diet in pregnancy through practical demonstration in rural Bangladesh and tested the impact with a cluster randomised controlled trial. This paper presents the findings of the process evaluation and describes the strategies that worked for intervention compliance. We conducted in-depth interviews with pregnant women, women who birthed recently, and their husbands; focus groups with mothers and mothers-in-law; key-informant interviews with community health workers, and observations of home visits. We identified six key areas within the intervention strategy that played a crucial role in achieving the desired adherence. These included practical demonstration of portion sizes; addressing local food perceptions; demystifying animal-source foods; engaging husbands and mothers-in-law; leveraging women’s social networks; and harnessing community health workers’ social role. Practical demonstration, opportunity to participate and convenience of making of the plate with the food available in their kitchen or neighbours’ kitchen were the most commonly mentioned reasons for acceptance of the intervention by the women and their families. The balanced plate intervention helped women through practical demonstration to learn about a balanced meal by highlighting appropriate portion sizes and food diversity. The women needed active involvement of community health workers in mobilising social support to create an enabling environment essential to bring changes in dietary behaviours. Future implementation of the intervention should tailor the strategies to the local context to ensure optimal adherence to the intervention.</jats:p

Making a balanced plate for pregnant women to improve birthweight of infants: a study protocol for a cluster randomised controlled trial in rural Bangladesh

ObjectivesLow birthweight significantly contributes to neonatal mortality, morbidities and psychosocial debilities throughout the course of life. A large proportion of infants (36–55%) in Bangladesh is born with low birthweight. Nutritional status of women during pregnancy is critical for optimal growth and development of the fetus. Nutrition education has been found to improve maternal nutritional status. Our study aims to determine whether nutrition education with a practical demonstration during pregnancy is an effective intervention for improving the birthweight of infants compared with standard nutrition education only.Methods and analysisWe will conduct a community-based cluster randomised controlled trial in one rural district of Bangladesh. Treatments will be allocated evenly between the study clusters (n=36). Participants in the intervention clusters receive ‘balanced plate nutrition education’ with a practical demonstration from community health workers 4–7 times throughout their entire pregnancy, starting from the first trimester. The control clusters will receive standard nutrition education delivered by public and other healthcare providers as per ongoing antenatal care protocol. Our sample size would be 900 pregnant women to determine 100 g differences in mean birthweight, considering 5% type 1 error, 80% power and an intra-cluster correlation coefficient of 0.03. The primary outcome of the trial is birthweight of the infants and the secondary outcomes include daily caloric intake and dietary diversity score among the pregnant women. Outcomes will be measured at enrolment, third to ninth month of gestation (monthly) and at delivery. Community health workers blinded to the study hypothesis will collect all data.Ethics and disseminationThe study was approved by the James P Grant School of Public Health, BRAC University Ethical Review Committee, Dhaka, Bangladesh. We will communicate the final results to relevant research and public health groups and publish research papers in peer-reviewed journals.Trial registration numberACTRN12616000080426.</jats:sec

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