Iron and Folic Acid Supplementation in Pregnancy: Findings from the Baseline Assessment of a Maternal Nutrition Service Programme in Bangladesh.

Effective coverage of antenatal iron and folic acid (IFA) supplementation is important to prevent adverse maternal and newborn health outcomes. We interviewed 2572 women from two rural districts in Bangladesh who had a live birth in the preceding six months. We analysed the number of IFA tablets received and consumed during pregnancy and examined the factors influencing IFA consumption by multiple linear regression and user adherence-adjusted effective coverage of IFA (consuming ≥180 IFA tablets) by Poisson regression. Overall, about 80% of women consumed IFA supplements in any quantity. About 76% of women received antenatal care at least once, only 8% received ≥180 IFA tablets, and 6% had user adherence-adjusted coverage of antenatal IFA supplementation. Multivariable analysis showed a linear relationship between the number of antenatal care (ANC) visits and the number of IFA supplements consumed, which was modified by the timing of the first ANC visit. Women's education, free IFA, and advice on IFA were also associated with higher IFA consumption. Interventions targeting at least eight ANC contacts, starting early in pregnancy, providing advice on the importance of IFA, and providing IFA supplements in higher quantity at ANC contacts are likely to increase effective coverage of antenatal IFA supplementation.

Bottleneck analysis of maternal and newborn health services in hard-to-reach areas of Bangladesh using 'TANAHASHI' framework': An explanatory mixed-method study.

Maternal and Newborn Health (MNH) is of paramount importance in the realm of attaining sustainable development goals that also focuses on universal health coverage (UHC). The study aimed at identifying and exploring the bottlenecks in MNH services in Hard-to-reach (HtR) areas of Bangladesh using the Tanahashi framework exploring the possible remedial approaches. The study was conducted in four different types of HtR areas (hilly, coastal, lowlands, and river islands) by utilizing a sequential explanatory mixed-method design. Overall, we collected information from 20 health facilities and 2,989 households by interviewing 2,768 recently delivered women (RDW) with a structured questionnaire and qualitative interviews (n = 55) of facility managers, local stakeholders, RDWs, and health care providers (HCP). The quantitative data were analyzed principally for descriptive statistics and the qualitative data was analyzed by utilizing the thematic approach. Antenatal care, under-5 care, and family planning services were available in almost all the facilities. However, Normal vaginal deliveries were performed in 55.6% of the union-level facilities. Only 40% of sub-district level facilities had provision for C-sections. Blood transfusion services were available in only 20.1% of facilities, whereas laboratory services were obtainable in 51.7% of facilities. Overall, the bottlenecks were identified in cases of availability of drugs, human resources, transportation, lack of knowledge regarding different essential services and health components, out of pocket expenditure etc. There have been several remedial approaches suggested from both the demand and supply side that included incentives for care providers for staying in these areas, a coordinated transport/referral system, and health education campaigns. More research works are warranted in HtR areas, especially to test the proposed interventions. Meanwhile, the government should take the necessary steps to overcome the bottlenecks identified.

Assessing the impact of a combined nutrition counselling and cash transfer intervention on women's empowerment in rural Bangladesh: a randomised control trial protocol.

INTRODUCTION: There is growing interest in assessing the impact of health interventions, particularly when women are the focus of the intervention, on women's empowerment. Globally, research has shown that interventions targeting nutrition, health and economic development can affect women's empowerment. Evidence suggests that women's empowerment is also an underlying determinant of nutrition outcomes. Depending on the focus of the intervention, different domains of women's empowerment will be influenced, for example, an increase in nutritional knowledge, or greater control over income and access to resources. OBJECTIVE: This study evaluates the impact of the Shonjibon Cash and Counselling (SCC) Trial that combines nutrition counselling and an unconditional cash transfer, delivered on a mobile platform, on women's empowerment in rural Bangladesh. METHODS AND ANALYSIS: We will use a mixed-methods approach, combining statistical analysis of quantitative data from 2840 women in a cluster randomised controlled trial examining the impact of nutrition behaviour change communications (BCCs) and cash transfers on child undernutrition. Pregnant participants will be given a smartphone with a customised app, delivering nutrition BCC messages, and will receive nutrition counselling via a call centre and an unconditional cash transfer. This study is a component of the SCC Trial and will measure women's empowerment using a composite indicator based on the Project-Level Women's Empowerment in Agriculture Index, with quantitative data collection at baseline and endline. Thematic analysis of qualitative data, collected through longitudinal interviews with women, husbands and mothers-in-law, will elicit a local understanding of women's empowerment and the linkages between the intervention and women's empowerment outcomes. This paper describes the study protocol to evaluate women's empowerment in a nutrition-specific and sensitive intervention using internationally validated, innovative tools and will help fill the evidence gap on pathways of impact, highlighting areas to target for future programming. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the International Centre for Diarrhoeal Disease Research (Ref. PR 17106) and The University of Sydney (Ref: 2019/840). Findings from this study will be shared in Bangladesh with dissemination sessions in-country and internationally at conferences, and will be published in peer-reviewed journals.

Shonjibon cash and counselling: a community-based cluster randomised controlled trial to measure the effectiveness of unconditional cash transfers and mobile behaviour change communications to reduce child undernutrition in rural Bangladesh.

BACKGROUND: Undernutrition is strongly associated with poverty - levels of undernutrition are higher in poor countries than in better-off countries. Social protection especially cash transfer is increasingly recognized as an important strategy to accelerate progress in improving maternal and child nutrition. A critical method to improve nutrition knowledge and influence feeding practices is through behaviour change communication intervention. The Shonjibon Cash and Counselling study aims to assess the effectiveness of unconditional cash transfers combined with a mobile application on nutrition counselling and direct counselling through mobile phone in reducing the prevalence of stunting in children at 18 months. METHOD: The study is a longitudinal cluster randomised controlled trial, with two parallel groups, and cluster assignment by groups of villages. The cohort of mother-child dyads will be followed-up over the intervention period of approximately 24 months, starting from recruitment to 18 months of the child's age. The study will take place in north-central Bangladesh. The primary trial outcome will be the percentage of stunted children at 18 m as measured in follow up assessments starting from birth. The secondary trial outcomes will include differences between treatment arms in (1) Mean birthweight, percentage with low birthweight and small for gestational age (2) Mean child length-for age, weight for age and weight-for-length Z scores (3) Prevalence of child wasting (4) Percentage of women exclusively breastfeeding and mean duration of exclusive breastfeeding (5) Percentage of children consuming > 4 food groups (6) Mean child intake of energy, protein, carbohydrate, fat and micronutrients (7) Percentage of women at risk of inadequate nutrient intakes in all three trimesters (8) Maternal weight gain (9) Household food security (10) Number of events for child suffering from diarrhoea, acute respiratory illness and fever (11) Average costs of mobile phone BCC and cash transfer, and benefit-cost ratio for primary and secondary outcomes. DISCUSSION: The proposed trial will provide high-level evidence of the efficacy and cost-effectiveness of mobile phone nutrition behavior change communication, combined with unconditional cash transfers in reducing child undernutrition in rural Bangladesh. TRIAL REGISTRATION: The study has been registered in the Australian New Zealand Clinical Trials Registry ( ACTRN12618001975280 ).

Prevalence and factors associated with caesarean section in four Hard-to-Reach areas of Bangladesh: Findings from a cross-sectional survey.

BACKGROUND: Caesarean section (C-section) is a major obstetric life-saving intervention for the prevention of pregnancy and childbirth related complications. Globally C-section is increasing, as well as in Bangladesh. This study identifies the prevalence of C-section and socio-economic and health care seeking related determinants of C-section among women living in hard-to-reach (HtR) areas in Bangladesh. METHODS: A cross-sectional survey was conducted using a structured questionnaire between August and December 2017 at four distinct types of HtR areas of Bangladesh, namely coastal, hilly, haor (wetland), and char areas (shallow land-mass rising out of a river). Total 2,768 women of 15-49 years of age and who had delivery within one year prior to data collection were interviewed. For the analysis of determinants of C- section, the explanatory variables were maternal age, educational status of women and their husbands, women's religion, employment status and access to mobile phone, wealth index of the household, distance to the nearest health facility from the household, the number of ANC visits and presence of complications during pregnancy and the last childbirth. Logistic regression model was run among 850 women, who had facility delivery. Variables found significantly associated with the outcome (C-section) in bivariate analysis were included in the multivariable logistic model. A p-value <0.05 was considered as statistically significant in the analyses. RESULTS: Of the 2,768 women included in the study, 13% had C-sections. The mean (±SD) age of respondents was 25.4 (± 0.1) years. The adjusted prevalence of C-section was 13.1 times higher among women who had their delivery in private facilities than women who delivered in public facilities (Adjusted Odds Ratio, AOR: 13.1; 95% CI 8.6-19.9; p-value: <0.001). Women from haor area and coastal area had 4.7 times (AOR: 4.7; 95% CI 2.4-9.4; p value: <0.001) and 6.8 times (AOR: 6.8; 95% CI 3.6-12.8; p value: <0.001) more chance of having C-section, respectively, than women living in char area. Among women who reported complications during the last childbirth, the AOR of C-section was 3.6 times higher than those who did not report any complication (AOR: 3.6; 95% CI 2.4-5.4; p value: <0.001). CONCLUSIONS: The study identifies that the prevalence of C-sections in four HtR areas of Bangladesh in substantially below the national average, although, the prevalence was higher in coastal areas than three other HtR regions. Both public and private health services for C-section should be made available and accessible in remote HtR areas for women with pregnancy complications. Establishment of an accreditation system for regulating private hospitals are needed to ensure rational use of the procedure.

Association of food security and other socio-economic factors with dietary diversity and nutritional statuses of children aged 6-59 months in rural Bangladesh.

INTRODUCTION: Dietary diversity score (DDS) is a proxy indicator for measuring nutrient adequacy. In this study, we aimed to identify the nutritional statuses and current patterns of DDS among children between 6-59 months old and their associations with different individual and household level factors in rural Bangladesh. METHODS: The Nobokoli programme of World Vision Bangladesh was implemented in Mymensingh, Sherpur, Rangpur, Dinajpur, Thakurgaon, Panchagar, and Nilphamari districts of Bangladesh between 2014 and 2017. A cross-sectional community household survey was administered between July and October 2014 to collect baseline data to evaluate the Nobokoli programme. A total of 6,468 children between 6-59 months old were included in the final analysis. Anthropometric data was collected following WHO guidelines on using wooden height and digital weight scales. We collected food intake information for the past 24 hours of the survey. The WHO's child growth standard medians were used to identify the nutritional indices of stunting, wasting, and underweight. Food items consumed were categorized into nine food groups and the DDS was constructed by counting the consumption of food items across these groups during the preceding 24 hour period. The association of DDS and nutritional status (stunting, wasting and underweight) with sociodemographic factors and household food security status were examined using multivariable models; linear regression and logistics regression respectively. RESULTS: The prevalence of stunting, wasting and underweight among children aged 6-59months were 36.8%, 18.2% and 37.7% respectively. Our findings revealed that almost all children ate any form of starch followed by consumption of milk or milk products (76%) and fleshy meat /fish (61%) respectively. The mean DDS among children was 3.93(sd 1.47). Forty percent of the children obtained a DDS score less than 4. Multivariable analysis suggested that children whose mothers had higher educational attainment and are skilled workers had higher DDS (15% and 48% respectively) compared to their counterparts. The DDS showed strong positive association with household wealth status. Children from food secure households had 26% higher DDS compared to children from food insecure households. Similarly, increasing maternal education and household wealth were found to be protective against childhood stunting and undernutrition. DISCUSSION: Our findings reiterate the need for improving household socioeconomic factors and household food security status for improving dietary diversity practices and nutritional status of children. Evidence-based solutions are needed to be implemented and expanded at scale to ensure appropriate dietary practices and improve nutritional status of the children in local context.

Determinants of hardship financing in coping with out of pocket payment for care seeking of under five children in selected rural areas of Bangladesh.

BACKGROUND: Around 63% of total health care expenditure in Bangladesh is mitigated through out of pocket payment (OOP). Heavy reliance on OOP at the time of care seeking poses great threat for financial impoverishment of the households. Households employ different strategies to cope with the associated financial hardship. OBJECTIVE: The aim of this paper is to understand the determinants of hardship financing in coping with OOP adopted for health care seeking of under five childhood illnesses in rural setting of Bangladesh. METHODS: A community based cross sectional survey was conducted during August to October, 2014 in 15 low performing sub-districts of northern and north-east regions of Bangladesh. Of the 7039 mothers of under five children surveyed, 1895 children who suffered from illness and sought care for their illness episodes were reported in this study. Descriptive statistics and ordinal regression analysis were conducted. RESULTS: A total number of 7,039 under five children reported to have suffered illness by their mothers. Among these children 37% suffered from priority illness. Care was sought for 88% children suffering from illnesses. Among them 26% went to a public or private sector medically trained provider. 5% of households incurred illness cost more than 10% of the household's monthly expenditure. The need for assistance was higher among those compared to others (31% vs 13%). Different financing mechanisms adopted to meet OOP are loan with interest (6%), loan without interest (9%) and financial help from relatives (6%) Need for financial assistance varied from 19% among households in the lowest quintile to 9% in the highest wealth. Ordinal regression analysis revealed that burden of hardship financing increases by 2.17 times when care is sought from a private trained provider compared to care seeking from untrained provider (CI: 1.49, 3.17). Similarly, for families that incur a health care expenditure that is more than 10% of their total monthly expenditure (CI:1.46, 3.88), the probability of falling into more severe financial burden increases by 2.4 times. We also found severity of the hardship financing to be around half for households with monthly income of more than BDT 7500 (OR = 0.56, CI: 0.37, 0.86). The burden increased by 2.10 times for households with a deficit (CI: 1.53, 2.88) between their monthly income and expenditure. The interaction between family income and severity of illness showed to significantly affect the scale of hardship financing. Children suffering from priority illness belonging to poor households were found have two times (CI: 1.09, 3.47) higher risks of suffering from hardship financing. CONCLUSION AND POLICY IMPLICATIONS: Findings from this study will help the policy makers to identify the target groups and thereby design effective health financing programs.

Out-of-pocket expenditure for seeking health care for sick children younger than 5 years of age in Bangladesh: findings from cross-sectional surveys, 2009 and 2012.

BACKGROUND: Bangladesh has committed to universal health coverage, and options to decrease household out-of-pocket expenditure (OPE) are being explored. Understanding the determinants of OPE is an essential step. This study aimed to estimate and identify determinants of OPE in seeking health care for sick under-five children. METHODS: Cross-sectional data was collected by structured questionnaire in 2009 (n = 7362) and 2012 (n = 6896) from mothers of the under-five children. OPE included consultation fees and costs of medicine, diagnostic tests, hospital admission, transport, accommodation, and food. Expenditure is expressed in US dollars and adjusted for inflation. Linear regression was used for ascertaining the determinants of OPE. RESULTS: Between 2009 and 2012, the median OPE for seeking care for a sick under-five child increased by ~ 50%, from USD 0.82 (interquartile range 0.39-1.49) to USD 1.22 (0.63-2.36) per child/visit. Increases were observed in every component OPE measured, except for consultation fees which decreased by 12%. Medicine contributed the major portion of overall OPE. Higher overall OPE for care seeking was associated with a priority illness (20% increase), care from trained providers (90% public/~ 2-fold private), residing in hilly/wet lands areas (20%), and for mothers with a secondary education (19%). CONCLUSION: OPE is a major barrier to quality health care services and access to appropriate medicine is increasing in rural Bangladesh. To support the goal of universal health care coverage, geographic imbalances as well as expanded health financing options need to be explored.

Production and use of estimates for monitoring progress in the health sector: the case of Bangladesh.

BACKGROUND:  In order to support the progress towards the post-2015 development agenda for the health sector, the importance of high-quality and timely estimates has become evident both globally and at the country level. OBJECTIVE AND METHODS: Based on desk review, key informant interviews and expert panel discussions, the paper critically reviews health estimates from both the local (i.e. nationally generated information by the government and other agencies) and the global sources (which are mostly modeled or interpolated estimates developed by international organizations based on different sources of information), and assesses the country capacity and monitoring strategies to meet the increasing data demand in the coming years. Primarily, this paper provides a situation analysis of Bangladesh in terms of production and use of health estimates for monitoring progress towards the post-2015 development goals for the health sector. RESULTS: The analysis reveals that Bangladesh is data rich, particularly from household surveys and health facility assessments. Practices of data utilization also exist, with wide acceptability of survey results for informing policy, programme review and course corrections. Despite high data availability from multiple sources, the country capacity for providing regular updates of major global health estimates/indicators remains low. Major challenges also include limited human resources, capacity to generate quality data and multiplicity of data sources, where discrepancy and lack of linkages among different data sources (local sources and between local and global estimates) present emerging challenges for interpretation of the resulting estimates. CONCLUSION: To fulfill the increased data requirement for the post-2015 era, Bangladesh needs to invest more in electronic data capture and routine health information systems. Streamlining of data sources, integration of parallel information systems into a common platform, and capacity building for data generation and analysis are recommended as priority actions for Bangladesh in the coming years. In addition to automation of routine health information systems, establishing an Indicator Reference Group for Bangladesh to analyze data; building country capacity in data quality assessment and triangulation; and feeding into global, inter-agency estimates for better reporting would address a number of mentioned challenges in the short- and long-run.