Unintended Consequences of mHealth Interactive Voice Messages Promoting Contraceptive Use After Menstrual Regulation in Bangladesh: Intimate Partner Violence Results From a Randomized Controlled Trial.

BACKGROUND: Mobile phones for health (mHealth) hold promise for delivering behavioral interventions. We evaluated the effect of automated interactive voice messages promoting contraceptive use with a focus on long-acting reversible contraceptives (LARCs) among women in Bangladesh who had undergone menstrual regulation (MR), a procedure to "regulate the menstrual cycle when menstruation is absent for a short duration." METHODS: We recruited MR clients from 41 public- and private-sector clinics immediately after MR. Eligibility criteria included having a personal mobile phone and consenting to receive messages about family planning by phone. We randomized participants remotely to an intervention group that received at least 11 voice messages about contraception over 4 months or to a control group (no messages). The primary outcome was LARC use at 4 months. Adverse events measured included experience of intimate partner violence (IPV). Researchers recruiting participants and 1 analyst were blinded to allocation groups. All analyses were intention to treat. The trial is registered with ClinicalTrials.gov (NCT02579785). RESULTS: Between December 2015 and March 2016, 485 women were allocated to the intervention group and 484 to the control group. We completed follow-up on 389 intervention and 383 control participants. Forty-eight (12%) participants in the intervention group and 59 (15%) in the control group reported using a LARC method at 4 months (adjusted odds ratio [aOR] using multiple imputation=0.95; 95% confidence interval [CI]=0.49 to 1.83; P=.22). Reported physical IPV was higher in the intervention group: 42 (11%) intervention versus 25 (7%) control (aOR=1.97; 95% CI=1.12 to 3.46; P=.03) when measured using a closed question naming acts of violence. No violence was reported in response to an open question about effects of being in the study. CONCLUSIONS: The intervention did not increase LARC use but had an unintended consequence of increasing self-reported IPV. Researchers and health program designers should consider possible negative impacts when designing and evaluating mHealth and other reproductive health interventions. IPV must be measured using closed questions naming acts of violence.

Feasibility of assessing the safety and effectiveness of menstrual regulation medications purchased from pharmacies in Bangladesh: a prospective cohort study.

OBJECTIVE: To assess the feasibility of following up women who purchase mifepristone+misoprostol or misoprostol-only from pharmacies in order to measure the safety and effectiveness of self-administration of menstrual regulation. STUDY DESIGN: A prospective cohort study followed women purchasing mifepristone+misoprostol or misoprostol-only from pharmacies in Bangladesh. Participants were recruited by pharmacy workers either in person or indirectly via the purchaser of the drugs. End users were contacted by phone 2 weeks after recruitment, screened and interviewed. RESULTS: Study recruitment rates by pharmacy workers were low (30%, 109 of 642 women informed about the study), but 2-week follow-up rates were high (87%). Of the 109 end users interviewed, 87 purchased mifepristone+misoprostol and 20 misoprostol-only, while 2 women did not know what drugs they had purchased. Mean self-reported number of weeks of pregnancy was 5.7 weeks. Information provision by pharmacy workers was inadequate (40.4% received none, 8.7% received written information or pictures). A total of 80.5% of mifepristone+misoprostol users were sold the correct regimen versus 9 out of 20 misoprostol-only users. A total of 68.8% did not report experiencing any complications (70.0% misoprostol-only; 69.0% mifepristone+misoprostol users, p=1.0). A total of 94.3% of mifepristone+misoprostol users and 75% of misoprostol-only users reported that they were not pregnant at day 15 (p=.020). However, 7.3% of all users sought additional treatment. CONCLUSIONS: Challenges in assessing outcomes of self-managed menstrual regulation medications purchased from pharmacies must be overcome through further development of this methodology. Interventions are urgently needed to ensure that women have access to correct dosages, accurate information and necessary referrals. IMPLICATIONS: This paper assesses the outcomes of women who self-manage menstrual regulation medications purchased from pharmacies. The methodology requires further development, but our study provides preliminary positive evidence on the safety and effectiveness of self-management despite low information provision from pharmacy workers.

Interrupting pathways to sepsis: Effectiveness of an intervention to reduce delays in timely care for sick children in rural Bangladesh.

RATIONALE: The time it takes for a child with suspected sepsis to receive care is critical. OBJECTIVE: We evaluated care-seeking practices for sick children under 5 years in rural Bangladesh, following interpersonal communication to inform households of newly introduced supports for quality care. Based on the Delays Framework, we assessed length and source of care-seeking delays, use of formal providers, and autonomous decision-making among mothers. METHOD: Using two cross-sectional rounds before and after the 3-year intervention (August 2012 and August 2015), we surveyed 400 mothers of recently sick children in 26 randomly sampled villages from 2 intervention and 2 control subdistricts, using structured questions about delays. Six to ten times during the 18-month intervention period, local workers communicated four key messages to most intervention households in 292 villages: serious symptoms of suspected sepsis in children, a call-in center number for referral advice, a reliable transport hub, and upgrades to the local hospital. RESULTS: Compared to baseline, endline results demonstrated a significant difference in the total delay between the onset of child's illness and seeking external care, with intervention families having shorter delays. Over 90% of mothers informed someone in the family, mainly the husband, about the sick child before acting to seek care. Delays due to transportation and receiving provider care were short and not different. Using a benchmark of seeking external care within 24 h of onset, only 14.14% of intervention households and 13.40% of control households were "timely" in seeking care. Approximately 78% of parents, similar for the two groups, sought care from a non-formal practitioner (the village doctor). CONCLUSION: The results demonstrate that the delay in deciding to seek external care is most serious, and that communication strategies at the community level are necessary to increase the uptake of improved health services.

Validating the measurement of social capital in Bangladesh: a cognitive approach.

Despite the growing evidence linking social capital to improvements in health and health behaviors, reliable measures of social capital are lacking in low-income countries. To accurately measure social capital in new contexts, there is a need to validate social capital survey questions in each new cultural setting. In this article, we examine the content validity of the measurement of social capital in Bangladesh using qualitative methods. In December 2012, we conducted four focus group discussions and 32 cognitive interviews in one rural subdistrict (Durgapur) and one urban slum (Mirpur). We used the findings from the focus groups and cognitive interviews to create a new social capital survey instrument that can be used by health and development organizations in Bangladesh. Furthermore, in this article, we provide insight into social capital survey research in general, including suggestions for the measurement of group membership, social support, collective action, and social trust.

Transforming maternal and newborn health social norms and practices to increase utilization of health services in rural Bangladesh: a qualitative review.

BACKGROUND: Since 2008, Participatory Action for Rural Development Innovation (PARI) Development Trust, with the support of Enfants du Monde, has been implementing a maternal and newborn health (MNH) program based on the World Health Organization's (WHO) framework for Working with Individuals, Families and Communities (IFC) to improve MNH in Netrokona district, Bangladesh. This program aims to empower women and families and increase utilization of quality health services, thereby helping women realize their rights related to maternal health. Birth preparedness and complication readiness and working with traditional birth attendants (TBAs) to exercise a new role in MNH and have formed key interventions of this program. The purpose of this study was to explore how the program has contributed to changing social norms and practices surrounding MNH at midpoint. METHODS: This study relied primarily on qualitative data collection. Two focus group discussions (FGDs) were conducted with women who were pregnant or had recently given birth and one FGD with each of the following groups: husbands, family members, TBAs, and health workers. In-depth interviews were conducted with women who were pregnant or had recently given birth, family members of these women, health care providers, TBAs and community health workers in selected intervention areas. RESULTS: Since implementation of interventions informants report an increase in planning for birth and complications and a shift in preference toward skilled care at birth. However, women still prefer to receive services at home. TBAs report encouraging women to access skilled care for both routine and emergency services. While community members' understanding of rights related to maternal health remains limited, they report increased women's participation in household decision- making processes, an important indicator of the realization of rights. CONCLUSION: Results suggest that community-level interventions aiming to affect change in social norms and practices surrounding MNH can influence knowledge and practices even after a short period of time. Further evaluations will be required to quantify the degree to which these changes are having an impact on health services utilization.

Husbands' involvement in delivery care utilization in rural Bangladesh: A qualitative study.

BACKGROUND: A primary cause of high maternal mortality in Bangladesh is lack of access to professional delivery care. Examining the role of the family, particularly the husband, during pregnancy and childbirth is important to understanding women's access to and utilization of professional maternal health services that can prevent maternal mortality. This qualitative study examines husbands' involvement during childbirth and professional delivery care utilization in a rural sub-district of Netrokona district, Bangladesh. METHODS: Using purposive sampling, ten households utilizing a skilled attendant during the birth of the youngest child were selected and matched with ten households utilizing an untrained traditional birth attendant, or dhatri. Households were selected based on a set of inclusion criteria, such as approximate household income, ethnicity, and distance to the nearest hospital. Twenty semi-structured interviews were conducted in Bangla with husbands in these households in June 2010. Interviews were transcribed, translated into English, and analyzed using NVivo 9.0. RESULTS: By purposefully selecting households that differed on the type of provider utilized during delivery, common themes--high costs, poor transportation, and long distances to health facilities--were eliminated as sufficient barriers to the utilization of professional delivery care. Divergent themes, namely husbands' social support and perceived social norms, were identified as underlying factors associated with delivery care utilization. We found that husbands whose wives utilized professional delivery care provided emotional, instrumental and informational support to their wives during delivery and believed that medical intervention was necessary. By contrast, husbands whose wives utilized an untrained dhatri at home were uninvolved during delivery and believed childbirth should take place at home according to local traditions. CONCLUSIONS: This study provides novel evidence about male involvement during childbirth in rural Bangladesh. These findings have important implications for program planners, who should pursue culturally sensitive ways to involve husbands in maternal health interventions and assess the effectiveness of education strategies targeted at husbands.