A non-inferiority analysis of hemoglobin levels in postpartum IUD users in Bangladesh.

OBJECTIVE: The objective of this study was to compare postpartum hemoglobin (Hb) between postpartum intrauterine device (PPIUD) and non-PPIUD users. METHODS: A sample of 3697 postpartum women (475 PPIUD users, 3222 non-PPIUD users) from 5 tertiary referral hospitals in Bangladesh were assessed at multiple time points between 6 weeks and 12 months postpartum. Non-inferiority linear regression analysis compared changes in Hb levels at 29-52 weeks postpartum between the two groups. Non-inferiority was declared if the lower 95% confidence interval of the estimated difference in Hb change since delivery between PPIUD and non-PPIUD users was greater than -0.05 g/dl. RESULTS: At approximately 9 months postpartum, 276 women in the PPIUD group (58.1%) and 1086 women in the comparison group (33.7%) attended follow-up. In total, 57.9% of PPIUD users and 61.0% of non-PPIUD users had taken iron supplementation. Change in Hb was 0.02 g/dl (95% CI: -0.16, 0.19) higher in the PPIUD users than the comparison group. The lower limit of the 95% CI was greater than -0.05 g/dl, providing good evidence that PPIUD users were non-inferior to the comparison group in their Hb levels. CONCLUSION: In the presence of offering iron supplementation, and an uptake of just over 60%, no difference in anemia was observed between the PPIUD and control group.

Economic Evaluation of Provision of Postpartum Intrauterine Device Services in Bangladesh and Tanzania.

INTRODUCTION: Postpartum family planning is an effective means of achieving improved health outcomes for women and children, especially in low- and middle-income settings. We assessed the cost-effectiveness of an immediate postpartum intrauterine device (PPIUD) initiative compared with standard practice in Bangladesh and Tanzania (which is no immediate postpartum family planning counseling or service provision) to inform resource allocation decisions for governments and donors. METHODS: A decision analysis was constructed to compare the PPIUD program with standard practice. The analysis was based on the number of PPIUD insertions, which were then modeled using the Impact 2 tool to produce estimates of cost per couple-years of protection (CYP) and cost per disability-adjusted life years (DALYs) averted. A micro-costing approach was used to estimate the costs of conducting the program, and downstream cost savings were generated by the Impact 2 tool. Results are presented first for the program as evaluated, and second, based on a hypothetical national scale-up scenario. One-way sensitivity analyses were conducted. RESULTS: Compared to standard practice, the PPIUD program resulted in an incremental cost-effectiveness ratio (ICER) of US$14.60 per CYP and US$91.13 per DALY averted in Bangladesh, and US$54.57 per CYP and US$67.67 per DALY averted in Tanzania. When incorporating estimated direct health care costs saved, the results for Bangladesh were dominant (PPIUD is cheaper and more effective versus standard practice). For Tanzania, the PPIUD initiative was highly cost-effective, with the ICER (incorporating direct health care costs saved) estimated at US$15.20 per CYP and US$18.90 per DALY averted compared to standard practice. For the national scale-up model, the results were dominant in both countries.Conclusions/implications: The PPIUD initiative was highly cost-effective in Bangladesh and Tanzania, and national scale-up of PPIUD could produce long-term savings in direct health care costs in both countries. These analyses provide a compelling case for national governments and international donors to invest in PPIUD as part of their family planning strategies.

Feasibility and effectiveness of electronic vs. paper partograph on improving birth outcomes: A prospective crossover study design.

BACKGROUND: The partograph has been endorsed by World Health Organization (WHO) since 1994 which presents an algorithm for assessing maternal and foetal conditions and labor progression. Monitoring labour with a partograph can reduce adverse pregnancy outcomes such as prolonged labor, emergency C-sections, birth asphyxia and stillbirths. However, partograph use is still very low, particularly in low and middle income countries (LMICs). In Bangladesh the reported partograph user rate varies from 1.4% to 33.0%. Recently, an electronic version of the partograph, with the provision of online data entry and user aid for emergency clinical support, has been tested successfully in different settings. With this proven evidence, we conducted and operations research to test the feasibility and effectiveness of implementing an e-partograph, for the first time, in 2 public hospitals in Bangladesh. METHODS: We followed a prospective crossover design. Two secondary level referral hospitals, Jessore and Kushtia District Hospital (DH) were the study sites. All pregnant women who delivered in the study hospitals were the study participants. All nurse-midwives working in the labor ward of study hospitals were trained on appropriate use of both types of partograph along with standard labour management guidelines. Collected quantitative data was analyzed using SPSS 23 statistical software. Discrete variables were expressed as percentages and presented as frequency distribution and cross tabulations. Chi square tests were employed to test the association between exposure and outcome variables. Potential confounding factors were adjusted using multivariate binary logistic regression methods. Ethical approval was obtained from the institutional review board of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b). FINDINGS: In total 2918 deliveries were conducted at Jessore DH and 2312 at Kushtia DH during one-year study period. Of them, 1012 (506 in each facility) deliveries were monitored using partograph (paper or electronic). The trends of facility based C-section rates was downwards in both the hospitals; 43% to 37% in Jessore and from 36% to 25% in Kushtia Hospital. There was a significant reduction of prolonged labour with e-partograph use. In Kushtia DH, the prolonged labour rate was 42% during phase 1 with the paper version which came down to 29% during phase-2 with the e-partograph use. The similar result was observed in Jessore DH where the prolonged labour rate reduced to 7% with paper partograph from the reported 30% prolonged labour with e-partograph. The e-partograph user rate was higher than the paper partograph during both phases (phase 1: 3.31, CI: 2.04-5.38, p < .001 and in phase 2: 15.20 CI: 6.36-36.33, p < .001) after adjusting for maternal age, parity, gestational age, religion, mother's education, husband's education, and fetal sex. CONCLUSION: The partograph user rate has significantly improved with the e- partograph and was associated with an overall reduction in cesarean births. Use of the e-partograph was also associated with reduced rates of prolonged labour. This study has added to the growing body of evidence on the positive impact of e-partograph use. We recommend implementing e-partograph intervention at scale in both public and private hospitals in Bangladesh. TRIAL REGISTRATION: ClinicalTrials.gov NCT03509103.

Genetic diversity and population structure analysis of Asian and African aromatic rice (Oryza sativa L.) genotypes.

Rice germplasms collected from different regions could be used as valuable resources for the future breeding programme. For the utilization of such collections, knowledge about the level and distribution of genetic diversity among these collections will facilitate the breeder. In this study, we report the phenotypic correlation, biochemical quality parameters and population genetic analysis of 35 rice accessions including 34 aromatic rice from different countries and a nonaromatic, Nagina 22, a well-known drought resistance variety. Further biochemical quality analysis, gel consistency test, molecular diversity analysis with 55 simple sequence repeat markers, population structure analysis and pair wise FST analysis were also conducted to assess the genetic diversity. The collected rice genotypes showed significant variability in different agronomic traits, i.e. spikelet per panicle, branches per panicle etc. Results obtained from the above tests demonstrated the importance of regional genetic studies for understanding the diversification of aromatic rice in Asian and African rice.

Impact of contraceptive counselling training among counsellors participating in the FIGO postpartum intrauterine device initiative in Bangladesh.

OBJECTIVE: To evaluate the impact of structured training given to dedicated family planning counsellors on postpartum intrauterine device (PPIUD) services across six tertiary hospitals in Bangladesh. METHODS: Family planning counsellors underwent structured training on postpartum family planning, PPIUD in particular, over a four-day period. Impact of training was evaluated by comparing PPIUD counselling rates, consent rates, insertion rates, and removal rates five months before and five months after the training, using data from women delivering in the participating facilities. RESULTS: A total of 27 622 women were included in this analysis: 11 263 (40.8%) before the training intervention and 16 359 (59.2%) after it. There was an increase in the proportion of women who were counselled (from 75.3% to 83.8%, P<0.001), and a small decrease in the proportion of women agreeing to have a PPIUD inserted following counselling (13.7% vs 12.9%, P=0.03). Overall insertion rate was similar before and after training (9.5% vs 9.8%, P=0.42), while removal rate reduced from 2.8% to 1.8% (P=0.41). CONCLUSION: Structured training had no impact on overall PPIUD insertion rate. However, it did impact numbers of women receiving counselling, perceived quality of the counselling received, and overall removal rates.

FIGO postpartum intrauterine device initiative: Complication rates across six countries.

OBJECTIVE: To record and analyze complication rates following postpartum intrauterine device (PPIUD) insertion in 48 hospitals in six countries: Sri Lanka, India, Nepal, Bangladesh, Tanzania, and Kenya. METHODS: Healthcare providers were trained in counselling and insertion of PPIUD via a training-the-trainer model. Data were collected on methodology, timing, cadre of staff providing care, and number of insertions. Data on complications were collected at 6-week follow-up. Statistical analysis was performed to elucidate factors associated with increased expulsion and absence of threads. RESULTS: From May 2014 to September 2017, 36 766 PPIUDs were inserted: 53% vaginal and 47% at cesarean delivery; 74% were inserted by doctors. Follow-up was attended by 52%. Expulsion and removal rates were 2.5% and 3.6%, respectively. Threads were not visible in 29%. Expulsion was less likely after cesarean insertion (aOR 0.33; 95% CI, 0.26-0.41), following vaginal insertion at between 10 minutes and 48 hours (aOR 0.59; 95% CI, 0.42-0.83), and when insertion was performed by a nurse (aOR 0.33; 95% CI, 0.22-0.50). CONCLUSION: PPIUD has low complication rates and can be safely inserted by a variety of trained health staff. Given the immediate benefit of the one-stop approach, governments should urgently consider adopting this model.

Vitamin A deficiency and determinants of vitamin A status in Bangladeshi children and women: findings of a national survey.

OBJECTIVE: Using data from the national micronutrients survey 2011-2012, the present study explored the status of subclinical vitamin A nutrition and the underlying determinants in the Bangladeshi population. DESIGN: A nationwide cross-sectional study. Settings The survey covered 150 clusters; fifty in each of rural, urban and slum strata. SUBJECTS: Three population groups: (i) pre-school age children (6-59 months; PSAC); (ii) school age children (6-14 years; SAC); and (iii) non-pregnant non-lactating women (15-49 years; NPNLW). RESULTS: National prevalence of subclinical vitamin A deficiency was 20·5, 20·8 and 5·3 % in PSAC, SAC and NPNLW, respectively. Slum populations had higher prevalence compared with urban (PSAC: 38·1 v. 21·2 %, P0·05 for differences in ß between <3 months v. 3-6 months, 6-9 months and 9-12 months). CONCLUSIONS: Prevalence of subclinical vitamin A deficiency was high in children in Bangladesh. Intakes of animal-source foods and leafy vegetables were associated with higher and lower retinol status, respectively. Increased food diversity through animal-source foods is required.

Status of zinc nutrition in Bangladesh: the underlying associations.

Bangladesh is a country with a high burden of micronutrient malnutrition. Stunting affects 41 % of children aged under 5 years. Zn is one of the key micronutrients that is associated with stunting. The present study, as part of the national micronutrient survey 2011-2012, revealed for the first time the nationally representative prevalence of Zn deficiency and determined the associations of the condition. A cross-sectional 'nationwide' survey was conducted in pre-school-age children (6-59 months; PSAC) and non-pregnant non-lactating women (15-49 years; NPNLW). Multistage random sampling was done in 150 clusters; fifty in each of the rural, urban and slum strata. Data were analysed on 662 PSAC and 1073 NPNLW. Serum Zn was assayed by atomic absorption spectrophotometry. Zn deficiency was defined as serum Zn of <9·9 and <10·1 µmol/l in PSAC and NPNLW, respectively. The national prevalence of Zn deficiency was 44·6 and 57·3 % in PSAC and NPNLW, respectively. In PSAC, it was 29·5, 48·6 and 51·7 %, respectively, in urban, rural and slum strata. Household expenses (ß = 0·13; P = 0·007), Hb (ß = 0·10; P = 0·005), intake of animal-source Zn (ß = 0·096; P = 0·02) and asset score (ß = 0·11; P = 0·03) were positively associated with serum Zn in NPNLW. Residence in an urban area (ß = 0·33; P = 0·03) and intake of plant-origin Zn (ß = -0·13; P = 0·038) determined higher and lower status of Zn in PSAC, respectively. Zn deficiency was highly prevalent in Bangladesh, and it was principally related to inadequate quality of diet. To improve Zn nutrition, Bangladesh needs to strengthen research and programmes related to Zn biofortification, fortification and phytate-reducing technologies in the food system in the short and medium term. In addition, promotion of animal-source Zn for all is important in the long run.

Determinants of iron status and Hb in the Bangladesh population: the role of groundwater iron.

OBJECTIVE: Using data from the national micronutrients survey 2011-2012, the present study explored the determinants of Fe status and Hb levels in Bangladesh with a particular focus on groundwater Fe. DESIGN: Cross-sectional study conducted at the nationwide scale. Settings The survey was conducted in 150 clusters, fifty in each of the three strata of rural, urban and slum. SUBJECTS: Three population groups: pre-school age children (6-59 months; PSAC), school age children (6-14 years; SAC) and non-pregnant non-lactating women (15-49 years; NPNLW). RESULTS: National prevalence of Fe deficiency was 10·7 %, 7·1 % and 3·9-9·5 % in PSAC, NPNLW and SAC, respectively. Prevalence of anaemia was 33·1 % (PSAC), 26·0 % (NPNLW) and 17·1-19·1 % (SAC). Multivariate regression analyses showed that the area with 'predominantly high groundwater Fe' was a determinant of higher serum ferritin levels in NPNLW (standardized ß=0·19; P=0·03), SAC (standardized ß=0·22; P=0·01) and PSAC (standardized ß=0·20; P=0·03). This area also determined higher levels of Hb in PSAC (standardized ß=0·14; P=0·01). CONCLUSIONS: National prevalence of Fe deficiency in Bangladesh is low, contrary to the widely held assumption. High Fe level in groundwater is associated with higher Fe status (all populations) and higher Hb level (PSAC).

Improving manual vacuum aspiration service delivery, introducing misoprostol for cases of incomplete abortion, and strengthening postabortion contraception in Bangladesh.

The Obstetrical and Gynaecological Society of Bangladesh was an important advocate in mobilizing government authorities to adopt new techniques for postabortion care and provide long-acting contraceptives post abortion. With the support of the International Federation of Gynecology and Obstetrics (FIGO), the Society provided commodities and training to increase the use of these techniques in 7 private and public hospitals and clinics. Data from two of these institutes for the January 2012 to June 2013 period showed a rapid decrease in the use of dilation and curettage, an increase in the use of manual vacuum aspiration (MVA) and misoprostol, and the progressive adoption of long-acting reversible contraceptives, permanent contraception, and injectable contraceptives in one of these two hospitals. The Directorates General of Health and Family Planning incorporated training in the use of MVA and misoprostol in their national operation plans. The success in these hospitals shows that the proposed changes have been well accepted by providers and clients.

Iodine deficiency disorders in Bangladesh, 2004-05: ten years of iodized salt intervention brings remarkable achievement in lowering goitre and iodine deficiency among children and women.

A survey was conducted to monitor the current status of iodine deficiency disorders in children aged 6-12 years and women aged 15-44 years in Bangladesh as measured by goitre prevalence and urinary iodine excretion. Conducted between September 2004 and March 2005, the survey followed a stratified multistage cluster sampling design to provide nationally representative data, with self-weighted rural-urban disaggregation. A total of 7233 children and 6408 women were examined for goitre and 4848 urine samples (2447 from children and 2401 from women) were analyzed for iodine. In addition, 5321 household salt samples were analyzed for iodine. In children, the total goitre rate (TGR) was 6.2%, compared to 49.9% in 1993 and the TGR among women was 11.7%, while in 1993 it was 55.6%. Prevalence of iodine deficiency (Urinary Iodine Excretion <100 microg/L) was 33.8% in children and 38.6% in women (compared to 71.0% and 70.2%, respectively in 1993). Iodine nutrition status in urban areas was considerably better than in rural areas. There was a clear inverse relationship between iodine deficiency and the coverage of households using adequately iodized salt (> or =15 ppm). The findings of the survey revealed that Bangladesh has achieved a commendable progress in reducing goitre rates and iodine deficiency among children and women ever since the universal salt iodization programme was instituted 10 years ago. However, physiological iodine deficiency still persists among more than one-third of children and women, which points to the need for all stakeholders to redouble their efforts in achieving universal salt iodization.