Feasibility of introducing pulse oximetry for identifying hypoxaemia among children with pneumonia in paediatric outpatient settings in Bangladesh: Generating evidence and synthesising knowledge for influencing policy, programme planning and practice

BACKGROUND: Pneumonia is the leading cause of childhood mortality, accounting for 16% of all under-5 deaths globally. Hypoxaemia is common among children with pneumonia and one of the strongest predictors of mortality. Since 2014, the World Health Organization has recommended introducing pulse oximetry for hypoxaemia identification and pneumonia classification in the Integrated Management of Childhood Illness (IMCI) services, which is a global strategy developed explicitly for outpatient management of common childhood illnesses, including pneumonia, in low-resource and high-burden settings by minimally trained health care providers. Unfortunately, there are few experiences of introducing pulse oximetry in paediatric outpatient settings and integrating it with IMCI services by adopting a health system strengthening approach. Bangladesh is one of the South Asian countries with high burdens of childhood pneumonia and hypoxaemia. Although Bangladesh has adopted the IMCI strategy and scaled up it nationally, pulse oximetry is neither recommended nor routinely used in IMCI services in Bangladesh. Successful introduction of a generic recommendation, technology, or device, like pulse oximetry, in routine services, demands an in-depth understanding of the problem and the context, followed by context-specific adaptations, demonstrations, and feasibility assessments. Also, it requires strategic and extensive engagement with policymakers and stakeholders to promote country ownership and government leadership, which are prerequisites for scalability and sustainability. OBJECTIVES AND METHOD: The overall goal of my PhD is to improve the management of childhood pneumonia by introducing and integrating pulse oximetry in routine IMCI services in Bangladesh. Furthermore, the aim is to support the Government of Bangladesh in taking an evidence-based decision in this regard. Hence, I was engaged in a series of discussions with the policymakers of the Ministry of Health and Family Welfare of the Government of Bangladesh to understand their perspectives on the existing evidence gaps and research priorities for making informed decisions regarding pulse oximetry integration. Based on these consultations, I identified my PhD objectives. RESULTS: A. Estimating the burden of hypoxaemia among children with pneumonia: I conducted a systematic review and meta-analysis by searching 11 bibliographic databases and citation indices. I reported pooled prevalence of hypoxaemia (SpO2<90%) by classification of clinical severity and by clinical settings by using the random-effects meta-analysis models. I identified 2,825 unique records from the databases, of which 57 studies met the eligibility criteria: 26 from Africa, 23 from Asia, four from South America, and four from multiple continents. The prevalence of hypoxaemia was 31% (95% CI, 26 to 36; 101,775 children) among all children with WHO-defined pneumonia, 41% (95% CI, 33 to 49; 30,483 children) among those with very severe or severe pneumonia, and 8% (95% CI, 3 to 16; 2,395 children) among those with non-severe pneumonia. The prevalence was much higher in studies conducted in emergency and inpatient settings than those conducted in outpatient settings. In 2019, we estimated that over 7 million children (95% UR, 5 to 8 million) were admitted to the hospital with hypoxaemic pneumonia. I also conducted a secondary analysis of data obtained from icddr,b-Dhaka Hospital, a secondary level referral hospital located in Dhaka, Bangladesh. I included 2,646 children aged 2-59 months admitted with WHO-defined severe pneumonia during 2014-17. On admission, the prevalence of hypoxaemia among children hospitalised with pneumonia was approximately 40% (95% CI, 38 to 42). Hypoxaemia was the strongest predictor of mortality (AOR = 11.1; 95% CI, 7.3 to 16.9) and referral (AOR = 5.9; 95% CI, 4.3 to 17.0) among other factors such as age, sex, history of fever and cough or difficulty in breathing, and severe acute malnutrition. Among those who survived, the median duration of hospital stay was 7 days (IQR, 4 to 11) in the hypoxaemic group and 6 days (IQR, 4 to 9) in the non-hypoxaemic group, and the difference was significant at p<0.001. B. Understanding the context of managing children with pneumonia, including hypoxaemia in Bangladesh: I conducted a secondary analysis using data from the 2017-18 round of the Bangladesh Demographic and Health Survey (BDHS), which adopts a nationally representative sample of households. I included 456 deaths among children under 5 years of age in our analysis. Descriptive statistics were used to present the causes, timing, and places of death with uncertainty ranges (UR). Pneumonia is the major killer (19%, 95% CI, 15.3 to 22.7), accounting for approximately 24,268 (UR, 21,626 to 26,695) under-5 deaths per year. Among children aged 1-11 months, pneumonia accounts for approximately 43% of deaths. I further conducted a secondary analysis of the Bangladesh Health Facility Survey 2017, which was conducted with a nationally representative sample including all administrative divisions and types of health facilities. More than 90% of the district hospital and sub-district hospitals and three-fourths of primary level health centres provide IMCI-based pneumonia management services. Pulse oximetry was available in 27% of the district hospitals, 18% of the sub-district level hospitals and none of the primary level health centres. Around 72% of the sub-district hospitals had the availability of one of any of the four oxygen sources (oxygen concentrators, filled oxygen cylinder with flowmeter, filled oxygen cylinder without flowmeter, and oxygen distribution system), followed by district hospitals (66%). Almost none of the primary level health centres had oxygen sources available on the day of the visit. C. Assessing the feasibility of introducing pulse oximetry in routine IMCI services: Based on literature review and expert consultations, I developed a conceptual framework, which guided the planning and implementation of a 4-step stakeholder engagement process for introducing pulse oximetry in routine IMCI services in Bangladesh. In the first step, a comprehensive desk review and key informant interviews were conducted to identify stakeholder organisations and score them based on their power and interest levels regarding IMCI implementation in Bangladesh. In the second step, two national level, two district level and five sub- district level sensitisation workshops were organised to orient all stakeholder organisations having high power or high interest regarding the importance of using pulse oximetry for pneumonia assessment and classification. In the third step, national and district level high power-high interest stakeholder organisations were involved in developing a joint action plan for introducing pulse oximetry in routine IMCI services. In the fourth step, led by a formal working group under the leadership of the Ministry of Health, we updated the National IMCI Implementation Package, including all guidelines, training manuals, services registers and referral forms in English and Bangla. Our engagement process contributed to the national decision to introduce pulse oximetry in paediatric outpatient settings and update the National IMCI Implementation Package demonstrating country ownership, government leadership and multi-partner involvement, which are steppingstones towards scalability and sustainability. However, our experience clearly delineates that stakeholder engagement is a context-driven, time-consuming, resource-intensive, iterative, and mercurial process that demands meticulous planning, prioritisation, inclusiveness, and adaptability. Based on WHO’s global recommendation in 2014, the National IMCI Programme of Bangladesh decided to introduce pulse oximetry in routine IMCI services in 2019 and developed a short training package for IMCI service providers. They decided to test the package in a relatively controlled setting for finalising the content and choice of pulse oximetry device before the demonstration in routine outpatient settings and subsequent scale-up. A cross-sectional study was conducted among children admitted to a rural district hospital. We employed 11 nurses and seven paramedics as assessors who received a one-day training on pulse oximetry. Each assessor performed at least 30 pulse oximetry measurements on children with two types of handheld devices. The assessors successfully established a stable SpO2 reading in all attempts (n=1478) except one. The median time taken was 30 seconds (IQR, 22 to 42), and within 60 seconds, 92% of attempts were successful. The median time was significantly (p<0.0001) higher among assessments conducted with a Lifebox device (36 seconds, IQR, 25 to 50) than those with a Masimo device (27 seconds, IQR, 20 to 35). Similarly, assessors aged >25 years are 4.8 (95% CI, 1.2 to 18.6) times more likely to obtain a stable reading within 60 seconds. Regarding patient-related factors, the odds of obtaining a stable SpO2 reading was 2.6 (95% CI, 1.6 to 4.2) times higher among children aged 12-59 months than among children aged 2-11 months. The National IMCI Programme of Bangladesh designed and developed a district implementation model for introducing pulse oximetry in IMCI services through stakeholder engagement and demonstrated the model in the Kushtia district by adopting a health system strengthening approach. Between December 2020 and June 2021, two assessment rounds were conducted based on WHO’s implementation research framework and outcome variables in 12 facilities involving 22 IMCI service providers and 1860 children presenting with cough/difficulty in breathing in the IMCI consultation rooms. WE OBSERVED THAT IMCI SERVICE PROVIDERS PERFORMED PULSE OXIMETRY ON ALMOST ALL ELIGIBLE CHILDREN, OF WHICH 99% OF ASSESSMENTS WERE SUCCESSFUL; 85% (95% CI, 83 TO 87) IN ONE ATTEMPT AND 69% (95% CI, 67 TO 71) WITHIN ONE MINUTE. The adherence to standards of procedures related to pulse oximetry was 92% (95% CI, 91 to 93), and agreement regarding identifying hypoxaemia was 96% (95% CI, 95 to 97). The median performance time was 36 seconds (IQR, 20 to 75), which was longer among younger children (2-11 months: 44 seconds, IQR, 22 to 78; 12-59 months: 30 seconds, IQR 18 to 53, p<0.001) and among those classified as pneumonia/severe pneumonia than as no pneumonia (41 seconds, IQR, 22 to 70; 32 seconds, IQR, 20 to 62, p<0.001). We observed improvements in all indicators in the second round of assessments. Caregivers showed positive attitudes towards using this novel technology for the assessment of children. CONCLUSION: Based on context-specific experience generated through these studies, the Government of Bangladesh decided to integrate pulse oximetry into routine IMCI services throughout Bangladesh. Furthermore, the learnings synthesised through these studies can also help convince the policymakers and managers of other LMICs with similar burdens and contexts to introduce pulse oximetry in routine settings providing outpatient-based paediatric services and contribute to achieving the target of averting all preventable childhood pneumonia deaths by 2025

Impact of maternal and neonatal health initiatives on inequity in maternal health care utilization in Bangladesh

BackgroundDespite remarkable progress in maternal and child health, inequity persists in maternal care utilization in Bangladesh. Government of Bangladesh (GOB) with technical assistance from United Nation Population Fund (UNFPA), United Nation Children’s Fund (UNICEF) and World Health Organization (WHO) started implementing Maternal and Neonatal Health Initiatives in selected districts of Bangladesh (MNHIB) in 2007 with an aim to reduce inequity in healthcare utilization. This study examines the effect of MNHIB on inequity in maternal care utilization.MethodTwo surveys were carried out in four districts in Bangladesh- baseline in 2008 and end-line in 2013. The baseline survey collected data from 13,206 women giving birth in the preceding year and in end-line 7,177 women were interviewed. Inequity in maternal healthcare utilization was calculated pre and post-MNHIB using rich-to-poor ratio and concentration index.ResultsMean age of respondents were 23.9 and 24.6 years in 2008 and 2013 respectively. Utilization of pregnancy-related care increased for all socioeconomic strata between these two surveys. The concentration indices (CI) for various maternal health service utilization in 2013 were found to be lower than the indices in 2008. However, in comparison to contemporary BDHS data in nearby districts, MNHIB was successful in reducing inequity in receiving ANC from a trained provider (CI: 0.337 and 0.272), institutional delivery (CI: 0.435 in 2008 to 0.362 in 2013), and delivery by skilled personnel (CI: 0.396 and 0.370).ConclusionsOverall use of maternal health care services increased in post-MNHIB year compared to pre-MNHIB year and inequity in maternal service utilization declined for three indicators out of six considered in the paper. The reductions in CI values for select maternal care indicators imply that the program has been successful not only in improving utilization of maternal health services but also in lowering inequality of service utilization across socioeconomic groups. Maternal health programs, if properly designed and implemented, can improve access, partially overcoming the negative effects of socioeconomic disparities

Determinants of caesarean section in Bangladesh: Cross-sectional analysis of Bangladesh demographic and health survey 2014 data

BACKGROUND:Caesarean section (CS) has been on the rise worldwide and Bangladesh is no exception. In Bangladesh, the CS rate, which includes both institutional and community-based deliveries, has increased from about 3% in 2000 to about 24% in 2014. This study examines the association of reported complications around delivery and socio-demographic, healthcare and spatial characteristics of mothers with CS, using data from the latest Bangladesh Demographic and Health Survey (BDHS). METHODS:The study is based on data from the 2014 BDHS. BDHS is a nationally representative survey which is conducted periodically and 2014 is the latest of the BDHS conducted. Data collected from 4,627 mothers who gave birth in health care institutions in three years preceding the survey were used in this study. RESULTS:Average age of the mothers was 24.6 years, while their average years of schooling were 3.2. Factors like mother being older, obese, residing in urban areas, first birth, maternal perception of large newborn size, husband being a professional, had higher number of antenatal care (ANC) visits, seeking ANC from private providers, and delivering in a private facility were statistically associated with higher rates of CS. CONCLUSIONS:Bangladesh health system urgently needs policy guideline with monitoring of clinical indications of CS deliveries to avoid unnecessary CS. Strict adherence to this guideline, along with enhance knowledge on the unsafe nature of the unnecessary CS can achieve increased institutional normal delivery in future; otherwise, an emergency procedure may end up being a lucrative practice

Ever-increasing Caesarean section and its economic burden in Bangladesh

BackgroundCesarean Section (CS) delivery has been increasing rapidly worldwide and Bangladesh is no exception. In Bangladesh, the CS rate has increased from about 3% in 2000 to about 24% in 2014. This study examines trend in CS in Bangladesh over the last fifteen years and implications of this increasing CS rates on health care expenditures.MethodsBirth data from Bangladesh Demographic and Health Survey (BDHS) for the years 2000-2014 have been used for the trend analysis and 2010 Bangladesh Maternal Mortality Survey (BMMS) data were used for estimating health care expenditure associated with CS.ResultsAlthough the share of institutional deliveries increased four times over the years 2000 to 2014, the CS deliveries increased eightfold. In 2000, only 33% of institutional deliveries were conducted through CS and the rate increased to 63% in 2014. Average medical care expenditure for a CS delivery in Bangladesh was about BDT 22,085 (USD 276) in 2010 while the cost of a normal delivery was BDT 3,565 (USD 45). Health care expenditure due to CS deliveries accounted for about 66.5% of total expenditure on all deliveries in Bangladesh in 2010. About 10.3% of Total Health Expenditure (THE) in 2010 was due to delivery costs, while CS costs contribute to 6.9% of THE and rapid increase in CS deliveries will mean that delivering babies will represent even a higher proportion of THE in the future despite declining crude birth rate.ConclusionHigh CS delivery rate and the negative health outcomes associated with the procedure on mothers and child births incur huge economic burden on the families. This is creating inappropriate allocation of scarce resources in the poor economy like Bangladesh. Therefore it is important to control this unnecessary CS practices by the health providers by introducing litigation and special guidelines in the health policy

Child mortality in Bangladesh - why, when, where and how?:A national survey-based analysis

BACKGROUND: Updated information on the cause of childhood mortality is essential for developing policies and designing programmes targeting the major burden of disease. There is a paucity of evidence regarding the current estimates of the cause of death in Bangladesh, which is essential for reinvigorating the current policies and reshaping existing strategies to avert preventable deaths. This paper aims to address this critical evidence gap and report the cause, timing and place of death among children under-five years of age using a nationally representative sample. METHODS: The present study was undertaken to provide updated estimates of causes of death among children under-five years of age using data from the 2017-18 round of the Bangladesh Demographic and Health Survey (BDHS). The verbal autopsy (VA) questionnaire of the 2017-18 BDHS was adapted from the standardised WHO 2016 instruments. Specially trained physicians reviewed the responses of the VA questionnaire and assigned the cause of death based on the online-2016-version of the International Classification of Diseases (ICD-10). We included 456 deaths among children under-five years of age in our analysis. Descriptive statistics were used to present the causes, timing and places of death with uncertainty ranges (UR). RESULTS: Pneumonia is the major killer (19%), accounting for approximately 24 268 (UR = 21 626-26 695) under-five deaths per-year. It is followed by birth asphyxia (16%), prematurity and low-birth-weight (11%), serious infections including sepsis (8%) causing 20 882 (UR = 18 608-22 970), 14 956 (UR = 13 327-16,452), and 10 723 (UR = 9555-11,795) deaths per-year, respectively. Drowning (8%) caused 10 441 (UR = 9304-11 485) deaths and congenital anomaly (7%) resulted in d 8748 (UR = 7795-9623) deaths per-year. Around 29% of all deaths occurred on the first day, 52% within the first week, and 66% within the first month of life. Around 70% of birth asphyxia, prematurity, and low birth weight-related deaths happen on the day of birth. Approximately 43% of pneumonia-related deaths occur in age 1-11 months, and around 51% of drowning-related deaths happen in age 12-23 months. CONCLUSIONS: Pneumonia with other serious infections, birth asphyxia, prematurity and low-birth-weight are responsible for more than half of all deaths among children under-five years of age. Strengthening the existing maternal, neonatal and child health programmes may be helpful in averting the majority of these preventable deaths. A multisectoral approach is required for the prevention of childhood deaths, especially drowning-related fatalities. Special measures need to be taken to prevent and control emerging public health challenges like birth defects and congenital anomalies

Knowledge and involvement of husbands in maternal and newborn health in rural Bangladesh

Abstract Background Access to skilled health services during pregnancy, childbirth and postnatal period for obstetric care is one of the strongest determinants of maternal and newborn health (MNH) outcomes. In many countries, husbands are key decision-makers in households, effectively determining women’s access to health services. We examined husbands’ knowledge and involvement regarding MNH issues in rural Bangladesh, and how their involvement is related to women receiving MNH services from trained providers. Methods We conducted a cross-sectional survey in two rural sub-districts of Bangladesh in 2014 adopting a stratified cluster sampling technique. Women with a recent birth history and their husbands were interviewed separately with a structured questionnaire. A total of 317 wife-husband dyads were interviewed. The associations between husbands accompanying their wives as explanatory variables and utilization of skilled services as outcome variables were assessed using multiple logistic regression analyses. Results In terms of MNH knowledge, two-thirds of husbands were aware that women have special rights related to pregnancy and childbirth and one-quarter could mention three or more pregnancy-, birth- and postpartum-related danger signs. With regard to MNH practice, approximately three-quarters of husbands discussed birth preparedness and complication readiness with their wives. Only 12% and 21% were involved in identifying a potential blood donor and arranging transportation, respectively. Among women who attended antenatal care (ANC), 47% were accompanied by their husbands. Around half of the husbands were present at the birthplace during birth. Of the 22% women who received postpartum care (PNC), 67% were accompanied by their husbands. Husbands accompanying their wives was positively associated with women receiving ANC from a medically trained provider (AOR 4.5, p < .01), birth at a health facility (AOR 1.5, p < .05), receiving PNC from a medically trained provider (AOR 48.8, p < .01) and seeking care from medically trained providers for obstetric complications (AOR 3.0, p < 0.5). Conclusion Husbands accompanying women when receiving health services is positively correlated with women’s use of skilled MNH services. Special initiatives should be taken for encouraging husbands to accompany their wives while availing MNH services. These initiatives should aim to increase men’s awareness regarding MNH issues, but should not be limited to this