Vayu bubble continuous positive airway pressure is a promising solution with favorable treatment outcomes for respiratory distress syndrome in newborns: a qualitative study in Bangladesh.

Background: According to Bangladesh Demographic and Health Survey (2022), neonatal mortality, comprising 67% of under-5 deaths in Bangladesh, is significantly attributed to prematurity and low birth weight (LBW), accounting for 32% of neonatal deaths. Respiratory distress syndrome (RDS) is a prevalent concern among preterm and LBW infants, leading to substantial mortality. The World Health Organization (WHO) recommends bubble continuous positive airway pressure (bCPAP) therapy, but the affordability and accessibility of conventional bCPAP devices for a large number of patients become major hurdles in Bangladesh due to high costs and resource intensiveness. The Vayu bCPAP, a simple and portable alternative, offers a constant flow of oxygen-enriched, filtered, humidified, and pressurized air. Our study, conducted in five health facilities, explores the useability, acceptability, and perceived treatment outcome of Vayu bCPAP in the local context of Bangladesh. Methods: A qualitative approach was employed in special care newborn units (SCANUs) of selected facilities from January to March 2023. Purposive sampling identified nine key informants, 40 in-depth interviews with service providers, and 10 focus group discussions. Data collection and analysis utilized a thematic framework approach led by trained anthropologists and medical officers. Results: Service providers acknowledged Vayu bCPAP as a lightweight, easily movable, and cost-effective device requiring minimal training. Despite challenges such as consumable shortages and maintenance issues, providers perceived the device as user-friendly, operable with oxygen cylinders, and beneficial during referral transportation. Treatment outcomes indicated effective RDS management, reduced hospital stays, and decreased referrals. Though challenges existed, healthcare providers and facility managers expressed enthusiasm for Vayu bCPAP due to its potential to simplify advanced neonatal care delivery. Conclusions: The Vayu bCPAP device demonstrated useability, acceptability, and favorable treatment outcomes in the care of neonates with RDS. However, sustained quality service necessitates continuous monitoring, mentoring and retention of knowledge and skills. Despite challenges, the enthusiasm among healthcare providers underscores the potential of Vayu bCPAP to save lives and simplify neonatal care delivery. Development of Standard Operating procedure on Vayu bCPAP is required for systematic implementation. Further research is needed to determine how the utilization of Vayu bCPAP devices enhances accessibility to efficient bCPAP therapy for neonates experiencing RDS.

Midwife-led birthing centres in Bangladesh, Pakistan and Uganda: an economic evaluation of case study sites.

INTRODUCTION: Achieving the Sustainable Development Goals to reduce maternal and neonatal mortality rates will require the expansion and strengthening of quality maternal health services. Midwife-led birth centres (MLBCs) are an alternative to hospital-based care for low-risk pregnancies where the lead professional at the time of birth is a trained midwife. These have been used in many countries to improve birth outcomes. METHODS: The cost analysis used primary data collection from four MLBCs in Bangladesh, Pakistan and Uganda (n=12 MLBC sites). Modelled cost-effectiveness analysis was conducted to compare the incremental cost-effectiveness ratio (ICER), measured as incremental cost per disability-adjusted life-year (DALY) averted, of MLBCs to standard care in each country. Results were presented in 2022 US dollars. RESULTS: Cost per birth in MLBCs varied greatly within and between countries, from US$21 per birth at site 3, Bangladesh to US$2374 at site 2, Uganda. Midwife salary and facility operation costs were the primary drivers of costs in most MLBCs. Six of the 12 MLBCs produced better health outcomes at a lower cost (dominated) compared with standard care; and three produced better health outcomes at a higher cost compared with standard care, with ICERs ranging from US$571/DALY averted to US$55 942/DALY averted. CONCLUSION: MLBCs appear to be able to produce better health outcomes at lower cost or be highly cost-effective compared with standard care. Costs do vary across sites and settings, and so further exploration of costs and cost-effectiveness as a part of implementation and establishment activities should be a priority.

Midwife-led birthing centres in four countries: a case study.

BACKGROUND: Midwives are essential providers of primary health care and can play a major role in the provision of health care that can save lives and improve sexual, reproductive, maternal, newborn and adolescent health outcomes. One way for midwives to deliver care is through midwife-led birth centres (MLBCs). Most of the evidence on MLBCs is from high-income countries but the opportunity for impact of MLBCs in low- and middle-income countries (LMICs) could be significant as this is where most maternal and newborn deaths occur. The aim of this study is to explore MLBCs in four low-to-middle income countries, specifically to understand what is needed for a successful MLBC. METHODS: A descriptive case study design was employed in 4 sites in each of four countries: Bangladesh, Pakistan, South Africa and Uganda. We used an Appreciative Inquiry approach, informed by a network of care framework. Key informant interviews were conducted with 77 MLBC clients and 33 health service leaders and senior policymakers. Fifteen focus group discussions were used to collect data from 100 midwives and other MLBC staff. RESULTS: Key enablers to a successful MLBC were: (i) having an effective financing model (ii) providing quality midwifery care that is recognised by the community (iii) having interdisciplinary and interfacility collaboration, coordination and functional referral systems, and (iv) ensuring supportive and enabling leadership and governance at all levels. CONCLUSION: The findings of this study have significant implications for improving maternal and neonatal health outcomes, strengthening healthcare systems, and promoting the role of midwives in LMICs. Understanding factors for success can contribute to inform policies and decision making as well as design tailored maternal and newborn health programmes that can more effectively support midwives and respond to population needs. At an international level, it can contribute to shape guidelines and strengthen the midwifery profession in different settings.

Perceptions and practices on newborn care and managing complications at rural communities in Bangladesh: a qualitative study.

BACKGROUND: Community misperception on newborn care and poor treatment of sick newborn attributes to neonatal death and illness severity. Misperceptions and malpractices regarding neonatal care and neonatal complications are the leading causes of neonatal deaths in Bangladesh. The study was conducted to explore neonatal care's perceptions and practices and manage complications among Bangladesh's rural communities. METHODS: A qualitative study was conducted in Netrakona district of Bangladesh from April to June 2015. Three sub-districts (Upazilas) including Purbadhala, Durgapur and Atpara of Netrakona district were selected purposively. Five focus group discussions (FGDs) and twenty in-depth interviews (IDIs) were conducted in the rural community. Themes were identified through reading and re-reading the qualitative data and thematic analysis was performed. RESULTS: Community people were far behind, regarding the knowledge of neonatal complications. Most of them felt that the complications occurred due to lack of care by the parents. Some believed that mothers did not follow the religious customs after delivery, which affected the newborns. Many of them followed the practice of bathing the newborns and cutting their hair immediately after birth. The community still preferred to receive traditional treatment from their community, usually from Kabiraj (traditional healer), village doctor, or traditional birth attendant. Families also refrained from seeking treatment from the health facilities during neonatal complications. Instead, they preferred to wait until the traditional healers or village doctors recommended transferring the newborn. CONCLUSIONS: Poor knowledge, beliefs and practices are the key barriers to ensure the quality of care for the newborns during complications. The communities still depend on traditional practices and the level of demand for facility care is low. Appropriate interventions focusing on these issues might improve the overall neonatal mortality in Bangladesh.

Exploring the perceptions, practices and challenges to maternal and newborn health care among the underprivileged teagarden community in Bangladesh: a qualitative study.

Poor health care-seeking behaviour, access to services and availability of service delivery have implications for the health of the community. This study explored the perceptions, practices and challenges related to maternal and neonatal care in the teagarden community in Bangladesh. The study also identified service gaps and problems prevalent in teagarden health facilities. A qualitative study was conducted in five teagardens in the Moulvibazar district of Bangladesh. Six focus group discussions (FGDs) were completed with individuals from the teagarden community, and twelve in-depth interviews (IDIs) were performed with health facility staff working in those teagarden facilities. Misconceptions and harmful traditional practices were found to exist among the families in the teagardens, restricting them from accessing quality health care. Pregnant women are not aware of antenatal care, and deliveries are being conducted at home by untrained birth attendants. Unhygienic and harmful postnatal practices are used. Teagarden health facilities are not well equipped or prepared to provide good care. Inequities exist within the teagarden communities, with unregistered workers having even poorer access to care. Improvement of the quality of maternal health care for this marginalised community is needed to progress maternal health.

Gestational Diabetes: Exploring the Perceptions, Practices and Barriers of the Community and Healthcare Providers in Rural Bangladesh: A Qualitative Study.

BACKGROUND AND OBJECTIVE: Gestational Diabetes Mellitus (GDM) is a prevalent and important disease during pregnancy and has detrimental effects on both the mother and the baby. The current study explored the perception and attitude of the community people about GDM and describes the challenges and gaps in knowledge, availability and accessibility of services for GDM screening and management at a rural community in Bangladesh. METHODS: We performed a qualitative study including seven Focus Group Discussions (FGDs) and eight Key Informant Interviews (KIIs) from November 2017 to January 2018 at randomly selected areas of Tangail district. A highly trained team including two anthropologists conducted the qualitative studies (FGDs and KIIs) under the guidance of experienced researchers. Thematic analysis was performed. RESULTS: GDM is not a known term for pregnant women, their husbands, mothers, and mothers-in-law. Most of the participants (78.7%) did not even hear the term. Some of them (25.5%) perceived that GDM will persist for whole life and transmit from husband to wife and mother to baby. Some people (21.3%) thought that GDM entirely depends on the wish of the God. Most of the participants (68.1%) perceived that symptoms of other types of diabetes and GDM are almost the same. Some participants (19.1%) thought that GDM patients need to intake some medicines that might affect the fetus. The majority of the respondents (83%) had no idea when a pregnant woman should test her diabetes during pregnancy. If GDM diagnosed, pregnant women decided to follow the advice of the doctors. The results from KII with health managers found that they lack in-depth knowledge of GDM. There is no structured guideline or protocol at their facilities for GDM management. CONCLUSION: The existing barriers at the communities for adequate detection and management of GDM are identified properly. The findings of this study will be helpful for the decision-makers in taking necessary actions to control the GDM.

Factors Associated with Maternal Deaths in a Hard-To-Reach Marginalized Rural Community of Bangladesh: A Cross-Sectional Study.

Every year in Bangladesh, approximately 5200 mothers die (172 maternal deaths/100,000 live births) due to maternal complications. The death rate is much higher in hard-to-reach areas and underprivileged communities, such as Bangladesh's tea gardens. The women living in the tea garden areas are deprived of quality health care services due to inadequate knowledge, education, and access to health care services. Poverty and early marriage, followed by early pregnancy, are also triggering factors of maternal deaths in this community. This study explored the factors associated with maternal deaths in the underprivileged tea garden community in the Moulvibazar district of Bangladesh. It was a cross-sectional study conducted between January and March 2018. All maternal deaths reported by government health care providers in two sub-districts of Moulvibazar during 2017 were selected for community verbal autopsy using a structured questionnaire. Descriptive analysis was performed on quantitative data, and content analysis was performed on qualitative data. A total of 34 maternal deaths were reported in the two sub-districts in 2017, among which 15 deaths (44%) occurred in the tea garden catchment areas, where about 34% people live in the two upazilas. The majority of the mothers who died in the tea gardens delivered their babies at home (80%), many of whom also died at home (40%). Only 27% of women who died in the tea gardens received four or more antenatal care visits. Post-partum hemorrhage was found to be the leading cause of death (47%), followed by anemia (33%) and eclampsia (20%). There is a persistent high maternal mortality observed in the marginalized tea gardens, as compared to the general community of the Moulvibazar district, Bangladesh. The sustainable development goal (SDG) that has been set for maternal mortality rate (MMR) is 70/100,000 live births in Bangladesh. The findings of our study show that focused intervention is needed to reduce the burden of maternal deaths, which will improve the overall maternal health situation and also reach the SDG on time.

Effects of Climate Change and Maternal Morality: Perspective from Case Studies in the Rural Area of Bangladesh.

This study explored the community perception of maternal deaths influenced by natural disaster (flood), and the practice of maternal complications during natural disaster among the rural population in Bangladesh. It also explored the challenges faced by the community for providing healthcare and referring the pregnant women experiencing complications during flood disaster. Three focus group discussions (FGDs) and eight in-depth interviews (IDIs) were conducted in the marginalized rural communities in the flood-prone Khaliajhuri sub-district, Netrakona district, Bangladesh. Flood is one of the major risk factors for influencing maternal death. Pregnant women seriously suffer from maternal complications, lack of antenatal checkup, and lack of doctors during flooding. During the time of delivery, it is difficult to find a skilled attendant, and referring the patient with delivery complications to the healthcare facility. Boats are the only mode of transport. The majority of maternal deaths occur on the boats during transfer from the community to the hospital. Rural people feel that the maternal deaths influenced by natural disaster are natural phenomena. Pre-preparation is needed to support pregnant women during disasters. There is unawareness of maternal health, related care, and complications during disasters among local health service providers and volunteers.

Social autopsy for maternal and perinatal deaths in Bangladesh: a tool for community dialog and decision making.

Bangladesh has an established comprehensive death review system for tracking and reviewing maternal and perinatal deaths. This death review system, established in 2010, was initially known as the "Maternal and Perinatal Death Review (MPDR) System." One of the key interventions of the MPDR system, social autopsy (SA), is generally undertaken following a maternal or perinatal death notification. Social autopsy is managed at the community level by government field health workers. The main purpose of SA is to enable community discussion and create awareness of the preventable causes of maternal or neonatal deaths. Through these conversations, it is hoped to reduce future maternal and neonatal deaths. During the scaling up of the system in Bangladesh in 2016, the Ministry of Health and Family Welfare (MoH&FW) included social autopsy as a useful intervention in reviewing death at the community level and named it "Maternal and Perinatal Death Surveillance and Response" (MPDSR). The new MPDSR tool is currently being administered for the the 2017 to 2021 period under the National Health and Nutrition Population Sector Program (HPNSP). This paper seeks to review the experiences of the social autopsy tool, from the initial MPDR system to the current MPDSR system and its role in reducing maternal and neonatal deaths in Bangladesh.

Exploring perceptions of common practices immediately following burn injuries in rural communities of Bangladesh.

BACKGROUND: Burns can be the most devastating injuries in the world, they constitute a global public health problem and cause widespread public health concern. Every year in Bangladesh more than 365,000 people are injured by electrical, thermal and other causes of burn injuries. Among them 27,000 need hospital admission and over 5600 people die. Immediate treatment and medication has been found to be significant in the success of recovering from a burn. However, common practices used in the treatment of burn injuries in the community is not well documented in Bangladesh. This study was designed to explore the perception of local communities in Bangladesh the common practices used and health-seeking behaviors sought immediately after a burn injury has occurred. METHODS: A qualitative study was conducted using Focus Group Discussions (FGD) as the data collection method. Six unions of three districts in rural Bangladesh were randomly selected and FGDs were conducted in these districts with six burn survivors and their relatives and neighbours. Data were analyzed manually, codes were identified and the grouped into themes. RESULTS: The participants stated that burn injuries are common during the winter in Bangladesh. Inhabitants in the rural areas said that it was common practice, and correct, to apply the following to the injured area immediately after a burn: egg albumin, salty water, toothpaste, kerosene, coconut oil, cow dung or soil. Some also believed that applying water is harmful to a burn injury. Most participants did not know about any referral system for burn patients. They expressed their dissatisfaction about the lack of available health service facilities at the recommended health care centers at both the district level and above. CONCLUSIONS: In rural Bangladesh, the current first-aid practices for burn injuries are incorrect; there is a widely held belief that using water on burns is harmful.

Timely referral saves the lives of mothers and newborns: Midwifery led continuum of care in marginalized teagarden communities - A qualitative case study in Bangladesh.

Background: Prompt and efficient identification, referral of pregnancy related complications and emergencies are key factors to the reduction of maternal and newborn morbidity and mortality. As a response to this critical need, a midwifery led continuum of reproductive health care was introduced in five teagardens in the Sylhet division, Bangladesh during 2016. Within this intervention, professional midwives provided reproductive healthcare to pregnant teagarden women in the community.  This study evaluates the effect of the referral of pregnancy related complications. Methods: A qualitative case study design by reviewing records retrospectively was used to explore the effect of deploying midwives on referrals of pregnancy related complications from the selected teagardens to the referral health facilities in Moulvibazar district of the Sylhet division during 2016.  In depth analyses was also performed on 15 randomly selected cases to understand the facts behind the referral. Results: Out of a total population of 450 pregnant women identified by the midwives, 72 complicated mothers were referred from the five teagardens to the facilities. 76.4% of mothers were referred to conduct delivery at facilities, and 31.1% of them were referred with the complication of prolonged labour. Other major complications were pre-eclampsia (17.8%), retention of the placenta with post-partum hemorrhage (11.1%) and premature rupture of the membrane (8.9%). About 60% of complicated mothers were referred to the primary health care centre, and among them 14% of mothers were delivered by caesarean section. 94% deliveries resulted in livebirths and only 6% were stillbirths. Conclusions: This study reveals that early detection of pregnancy complications by skilled professionals and timely referral to a facility is beneficial in saving the majority of baby's as well as mother's lives in resource-poor teagardens with a considerable access barrier to health facilities.

Maternal complications in a geographically challenging and hard to reach district of Bangladesh: a qualitative study.

Background: Maternal complications contribute to maternal deaths in developing countries. Bangladesh still has a high prevalence of maternal mortality, which is often preventable. There are some geographically challenging and hard to reach rural districts in Bangladesh and it is difficult to get information about maternal complications in these areas. In this study, we examined the community lay knowledge of possible pregnancy complications. We also examined the common practices associated with complications and we discuss the challenges for the community. Methods: The study was conducted in Moulvibazar of north east Bangladesh, a geographically challenged, difficult to reach district. Qualitative methods were used to collect the information. Pregnant women, mothers who had recently delivered, their guardians and traditional birth attendants participated in focus group discussions. Additionally, in-depth interviews were conducted with the family members. Thematic analyses were performed. Results: The study revealed that there is a lack of knowledge of maternal complications. In the majority of cases, the mothers did not receive proper treatment for maternal complications.   There are significant challenges that these rural societies need to address: problems of ignorance, traditional myths and family restrictions on seeking better treatment. Moreover, traditional birth attendants and village doctors also have an important role in assuring appropriate, effective and timely treatment. Conclusions:  The rural community lacks adequate knowledge on maternal complications.  Reduction of the societal barriers including barriers within the family can improve overall practices. Moreover, dissemination of adequate information to the traditional birth attendant and village doctors may improve the overall situation, which would eventually help to reduce maternal deaths.