A novel approach to frontline health worker support: a case study in increasing social power among private, fee-for-service birthing attendants in rural Bangladesh.

BACKGROUND: Expanding the health workforce to increase the availability of skilled birth attendants (SBAs) presents an opportunity to expand the power and well-being of frontline health workers. The role of the SBA holds enormous potential to transform the relationship between women, birthing caregivers, and the broader health care delivery system. This paper will present a novel approach to the community-based skilled birth attendant (SBA) role, the Skilled Health Entrepreneur (SHE) program implemented in rural Sylhet District, Bangladesh. CASE PRESENTATION: The SHE model developed a public-private approach to developing and supporting a cadre of SBAs. The program focused on economic empowerment, skills building, and formal linkage to the health system for self-employed SBAs among women residents. The SHEs comprise a cadre of frontline health workers in remote, underserved areas with a stable strategy to earn adequate income and are likely to remain in practice in the area. The program design included capacity-building for the SHEs covering traditional techno-managerial training and supervision in programmatic skills and for developing their entrepreneurial skills, professional confidence, and individual decision-making. The program supported women from the community who were social peers of their clients and long-term residents of the community in becoming recognized, respected health workers linked to the public system and securing their livelihood while improving quality and access to maternal health services. This paper will describe the SHE program's design elements to enhance SHE empowerment in the context of discourse on social power and FLHWs. CONCLUSION: The SHE model successfully established a private SBA cadre that improved birth outcomes and enhanced their social power and technical skills in challenging settings through the mainstream health system. Strengthening the agency, voice, and well-being of the SHEs has transformative potential. Designing SBA interventions that increase their power in their social context could expand their economic independence and reinforce positive gender and power norms in the community, addressing long-standing issues of poor remuneration, overburdened workloads, and poor retention. Witnessing the introduction of peer or near-peer women with well-respected, well-compensated roles among their neighbors can significantly expand the effectiveness of frontline health workers and offer a model for other women in their own lives.

Mental healthcare-seeking behavior during the perinatal period among women in rural Bangladesh.

INTRODUCTION: Mental health conditions are of rising concern due to their increased contribution to the global burden of disease. Mental health issues are inextricably linked with other socio-cultural and health dimensions, especially in the rural areas in developing countries. The complex relationship between mental health issues and socio-cultural settings may largely toll upon healthcare-seeking behavior. So, it urges to document the current status of mental healthcare-seeking behavior during the perinatal period among rural women in Bangladesh to develop a context-specific intervention in the future. METHODS: This study was carried out in one sub-district in Bangladesh from April 2017 to June 2018. We conducted 21 In-depth Interviews (IDIs) and seven Focus Group Discussions (FGDs) with different groups of purposively selected participants. After collecting the recorded interview and making the verbatim transcription, the data were coded through Atlasti 5.7.a. Data were analyzed thematically to interpret the findings. RESULTS: Two-thirds of the total respondents did not seek mental healthcare during the perinatal period at the community level. They also did not know about the mental health service provider or the facility to get set these services. Only one respondent out of twenty-one sought maternal mental healthcare from a gynecologist from a private hospital. Socio-cultural factors such as social stigma, traditional beliefs and practices, social and religious taboos, and social capital negatively influence healthcare-seeking behaviors. Besides, the community-level service providers were not found to be adequately trained and did not have proper guidelines regarding its management. CONCLUSION: The findings provide evidence that there is an urgent need to increase the awareness for service users and formulate a guideline for the community-level service provider to manage maternal mental problems during the perinatal period of women in rural Bangladesh.

Developing targeted client communication messages to pregnant women in Bangladesh: a qualitative study.

BACKGROUND: Timely and appropriate evidence-based practices during antenatal care improve maternal and neonatal health. There is a lack of information on how pregnant women and families perceive antenatal care in Bangladesh. The aim of our study was to develop targeted client communication via text messages for increasing antenatal care utilization, as part of an implementation of an electronic registry for maternal and child health. METHODS: Using a phenomenological approach, we conducted this qualitative study from May to June 2017 in two sub-districts of Chandpur district, Bangladesh. We selected study participants by purposive sampling. A total of 24 in-depth interviews were conducted with pregnant women (n = 10), lactating women (n = 5), husbands (n = 5), and mothers-in-law (n = 4). The Health Belief Model (HBM) was used to guide the data collection. Thematic analysis was carried out manually according to the HBM constructs. We used behavior change techniques to inform the development of targeted client communication based on the thematic results. RESULTS: Almost no respondents mentioned antenatal care as a preventive form of care, and only perceived it as necessary if any complications developed during pregnancy. Knowledge of the content of antenatal care (ANC) and pregnancy complications was low. Women reported a variety of reasons for not attending ANC, including the lack of information on the timing of ANC; lack of decision-making power; long-distance to access care; being busy with household chores, and not being satisfied with the treatment by health care providers. Study participants recommended phone calls as their preferred communication strategy when asked to choose between the phone call and text message, but saw text messages as a feasible option. Based on the findings, we developed a library of 43 automatically customizable text messages to increase ANC utilization. CONCLUSIONS: Pregnant women and family members had limited knowledge about antenatal care and pregnancy complications. Effective health information through text messages could increase awareness of antenatal care among the pregnant women in Bangladesh. This study presents an example of designing targeted client communication to increase antenatal care utilization within formal scientific frameworks, including a taxonomy of behavior change techniques. TRIAL REGISTRATION: ISRCTN69491836 . Registered on December 06, 2018. Retrospectively registered.

Understanding individual, family and community perspectives on delaying early birth among adolescent girls: findings from a formative evaluation in rural Bangladesh.

BACKGROUND: Pregnancy among adolescent girls in Bangladesh is high, with 66% of women under the age of 18 reporting a first birth; this issue is particularly acute in the northern region of Bangladesh, an area that is especially impoverished and where girls are at heightened risk. Using formative research, CARE USA examined the underlying social, individual and structural factors influencing married girls' early first birth and participation in alternative opportunities (such as education or economic pursuits) in Bangladesh. METHODS: In July of 2017, researchers conducted in-depth interviews of community members in two sub-districts of northern Bangladesh (Kurigram Sadar and Rajarhat). Participants (n = 127) included adolescent girls (both married and unmarredi), husbands of adolescent girls, influential adults in the girls' lives, community leaders, and health providers. All interviews were transcribed, coded and organized using Dedoose software. RESULTS: Participants recognize the health benefits of delaying first birth, but stigma around infertility and contraceptive use, pressure from mothers-in-law and health provider bias interfere with a girl's ability to delay childbearing. Girls' social isolation, lack of mobility or autonomy, and inability to envision alternatives to early motherhood compound the issue; provider bias may also prevent access to methods. While participants agree that pursuit of education and economic opportunities are important, better futures for girls do not necessarily supersede their marital obligations of childrearing and domestic chores. CONCLUSIONS: Findings indicate the need for a multi-level approach to delaying early birth and stimulating girls' participation in economic and educational pursuits. Interventions must mitigate barriers to reproductive health care; train adolescent girls on viable economic activities; and provide educational opportunities for girls. Effective programs should also address contextual issues by including immediate members of the girls' families, particularly the husband and mother-in-law.

Contraceptive practices among married women of reproductive age in Bangladesh: a review of the evidence.

BACKGROUND: Bangladesh has experienced a sevenfold increase in its contraceptive prevalence rate (CPR) in less than forty years from 8% in 1975 to 62% in 2014. However, despite this progress, almost one-third of pregnancies are still unintended which may be attributed to unmet need for family planning and discontinuation and switching of methods after initiation of their use. METHODS: We conducted an extensive literature review on contraceptive use among married women of reproductive age (MWRA) in Bangladesh. A total of 263 articles were identified through database search and after final screening ten articles were included in this synthesis. RESULTS: Findings showed that method discontinuation and switching, method failure, and method mix may offset achievements in the CPR. Most of the women know of at least one contraceptive method. Oral pill is the most widely used (27%) method, followed by injectables (12.4%), condoms (6.4%), female sterilization (4.6%), male sterilization (1.2%), implants (1.7%), and IUDs (0.6%). There has been a decline in the use of long acting and permanent methods over the last two decades. Within 12 months of initiation, the rate of method discontinuation particularly the short-acting methods remain high at 36%. It is important to recognize the trends as married Bangladeshi women, on average, wanted 1.6 children, but the rate of actual children was 2.3. CONCLUSIONS: A renewed commitment from government bodies and independent organizations is needed to implement and monitor family planning strategies in order to ensure the adherence to and provision of the most appropriate contraceptive method for couples.

Preterm birth and neonatal mortality in selected slums in and around Dhaka City of Bangladesh: A cohort study.

BACKGROUND: Although under-five mortality has declined appreciably in Bangladesh over the last few decades, neonatal mortality still remains high. The objective of the study is to assess the level and determinants of preterm birth and the contribution of preterm birth to neonatal mortality. METHODS: Data for this study came from selected slums in and around Dhaka city, where; since 2015, icddr,b has been maintaining the Health and Demographic Surveillance System (HDSS). The HDSS data were collected by female Field Workers by visiting each household every three months; however, during the visit, data on the Last Menstrual Period (LMP) were also collected by asking each eligible woman to ascertain the date of conception. Gestational age was estimated in complete weeks by subtracting LMP from the date of the pregnancy outcome. In this study, 6,989 livebirths were recorded by HDSS during 2016-2018, and these births were followed for neonatal survival; both bivariate and multivariate analyses were performed. RESULTS: Out of total births, 21.7% were born preterm (before 37 weeks of gestation), and sub-categories were: 2.19% for very preterm (28 to 31 weeks), 3.81% for moderate preterm (32 to 33 weeks), and 15.71% for late preterm (34 to 36 weeks). The study revealed that preterm babies contributed to 39.6% of neonatal deaths; however, the probability of death was very high on the 1st day of birth (0.124 for very preterm, 0.048 for moderate preterm, 0.024 for late preterm, and 0.013 for term birth), and continued until the 3rd day. In the regression analysis, compared to the term neonates, the odds of neonatal mortality were 8.66 (CI: 5.63, 13.32, p<0.01), 4.13 (CI: 2.69, 6.34, p<0.01) and 1.48 (CI: 1.05, 2.08, p<0.05) respectively for very, moderate, and late preterm birth categories. The population attributable fraction for neonatal mortality was 23%, and sub-categories were 14% for very preterm, 10% for moderate preterm, and 6% for late preterm. CONCLUSIONS: Although urban slums are in proximity to many health facilities, a substantial proportion of preterm births contribute to neonatal deaths. So, pregnant women should be targeted, to ensure timely care during pregnancy, delivery, and post-partum periods to improve the survival of new-borns in general and preterm birth in particular.

Caesarean delivery and neonatal mortality: evidence from selected slums in and around Dhaka city, Bangladesh- A prospective cohort study.

BACKGROUND: This study examined the neonatal mortality for newborn of women who delivered by caesarean section or vaginally using a prospective cohort. METHODS: A total of 6,989 live births registered from 2016 to 2018, were followed for neonatal survival from the selected slums of Dhaka (North and South) and Gazipur city corporations, where icddr,b maintained the Health and Demographic Surveillance System (HDSS). Neonatal mortality was compared by maternal and newborn characteristics and mode of delivery using z-test. Logistic regression model performed for neonatal mortality by mode of delivery controlling selected covariates and reported adjusted odd ratios (aOR) with 95% confidence interval (CI). RESULTS: Out of 6,989 live births registered, 27.7% were caesarean and the rest were vaginal delivery; of these births, 265 neonatal deaths occurred during the follow-up. The neonatal mortality rate was 2.7 times higher (46 vs. 17 per 1,000 births) for vaginal than caesarean delivered. Until 3rd day of life, the mortality rate was very high for both vaginal and caesarean delivered newborn; however, the rate was 24.8 for vaginal and 6.3 per 1,000 live births for caesarean delivered on the 1st day of life. After adjusting the covariates, the odds of neonatal mortality were higher for vaginal than caesarean delivered (aOR: 2.63; 95% CI: 1.82, 3.85). Additionally, the odds were higher for adolescent than elderly adult mother (aOR: 1.60; 95% CI: 1.03, 2.48), for multiple than singleton birth (aOR: 5.40; 95% CI: 2.82, 10.33), for very/moderate (aOR: 5.13; 95% CI: 3.68, 7.15), and late preterm birth (aOR: 1.48; 95% CI: 1.05, 2.08) than term birth; while the odds were lower for girl than boy (aOR: 0.74; 95% CI: 0.58, 0.96), and for 5th wealth quintile than 1st quintile (aOR: 0.59, 95% CI: 0.38, 0.91). CONCLUSION: Our study found that caesarean delivered babies had significantly lower neonatal mortality than vaginal delivered. Therefore, a comprehensive delivery and postnatal care for vaginal births needed a special attention for the slum mothers to ensure the reduction of neonatal mortality.

Cost of behavior change communication channels of Manoshi -a maternal, neonatal and child health (MNCH) program in urban slums of Dhaka, Bangladesh.

BACKGROUND: The cost of behavior change communication (BCC) interventions has not been rigorously studied in Bangladesh. This study was conducted to assess the implementation costs of a BCC intervention in a maternal, neonatal and child health program (Manoshi) run by BRAC, which has been operating in the urban slums of Dhaka since 2007. The study estimates the costs of BCC tools per exposure among the different types of BCC channels: face-to-face, group counseling, and mass media. METHODS: The study was conducted from November 2010 to April 2011 in the Dhaka urban slum area. A micro-costing approach was applied using primary and secondary data sources to estimate the cost of BCC tools. Primary data were collected through interviews with service-providers and managers from the Manoshi program, observations of group counseling, and mass media events. RESULTS: Per exposure, the cost of face-to-face counseling was found to be 3.08 BDT during pregnancy detection, 3.11 BDT during pregnancy confirmation, 12.42 BDT during antenatal care, 18.96 BDT during delivery care and 22.65 BDT during post-natal care. The cost per exposure of group counseling was 22.71 BDT (95% CI 21.30-24.87) for Expected Date of Delivery (EDD) meetings, 14.25 BDT (95% CI 12.37-16.12) for Women Support Group meetings, 17.83 BDT (95% CI 14.90-20.77) for MNCH committee meetings and 6.62 BDT (95% CI 5.99-7.26) for spouse forum meetings. We found the cost per exposure for mass media interventions was 9.54 BDT (95% CI 7.30-12.53) for folk songs, 26.39 BDT (95% CI 23.26-32.56) for street dramas, 0.39 BDT for TV-broadcasting and 7.87 BDT for billboards. Considering all components reaching the target audience under each broader type of channel, the total cost per exposure was found to be 60.22 BDT (0.82 USD) for face-to-face counseling, 61.40 BDT (0.82 USD) for group counseling and 44.19 BDT (0.61 USD) for mass media. CONCLUSIONS: The total cost for group counseling was the highest per exposure, followed by face-to-face counseling and mass media. The cost per exposure varied substantially across BCC channels due to differences in cost drivers such as personnel, materials and refreshments. The cost per exposure can be valuable for planning and resource allocation related to the implementation of BCC interventions in low resource settings.

Factors associated with the timely initiation of antenatal care: findings from a cross-sectional study in Northern Bangladesh.

OBJECTIVE: This paper explored the factors that influence the timely initiation of antenatal care (ANC) in Bangladesh. DESIGN: This was a cross-sectional survey. SETTING: This study conducted in two rural subdistricts and one urban area from three Northern districts of Bangladesh from August to November 2016. PARTICIPANTS: Women who had a live birth in the last 1 year prior to data collection were enrolled for this study. In each study area, around 900 women were interviewed, and finally, we completed 2731 interviews. PRIMARY OUTCOME MEASURES: The primary outcome was timely first ANC from a Medically Trained Provider (MTP). RESULTS: About 43% of pregnancies were detected at their earliest time. The majority of participants (82%) received at least one ANC from an MTP. Only 11% received timely first ANC from an MTP as per the WHO FANC model. The women who detected pregnancy earlier were more likely (adj.OR 1.99, 95% CI 1.31 to 3.01) to receive the timely first ANC. The urban women were more likely (adj.OR 1.78, 95% CI 1.13 to 2.80) to receive the timely first ANC from an MTP than those of the rural women. Besides, their husbands' educational status (adj.OR 1.61, 95% CI 1.0 to 2.60) was significantly associated with the timely first ANC. CONCLUSION: Apart from sociodemographic factors, early pregnancy detection was strongly associated with the timely first ANC visit. Timely initiation of ANC is an opportunity to adhere to all the WHO recommended timely ANC visits for a pregnant woman. The findings suggest maternal, neonatal, and child health programmes to focus on the early detection of pregnancy to ensure universal ANC coverage and its timeliness.

An Electronic Registry for Improving the Quality of Antenatal Care in Rural Bangladesh (eRegMat): Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: Digital health interventions (DHIs) can alleviate several barriers to achieving better maternal and child health. The World Health Organization's guideline recommendations for DHIs emphasize the need to integrate multiple DHIs for maximizing impact. The complex health system of Bangladesh provides a unique setting for evaluating and understanding the role of an electronic registry (eRegistry) for antenatal care, with multiple integrated DHIs for strengthening the health system as well as improving the quality and utilization of the public health care system. OBJECTIVE: The aim of this study is to assess the effect of an eRegistry with DHIs compared with a simple digital data entry tool without DHIs in the community and frontline health facilities. METHODS: The eRegMat is a cluster-randomized controlled trial conducted in the Matlab North and Matlab South subdistricts in the Chandpur district, Bangladesh, where health facilities are currently using the eRegistry for digital tracking of the health status of pregnant women longitudinally. The intervention arm received 3 superimposed data-driven DHIs: health worker clinical decision support, health worker feedback dashboards with action items, and targeted client communication to pregnant women. The primary outcomes are appropriate screening as well as management of hypertension during pregnancy and timely antenatal care attendance. The secondary outcomes include morbidity and mortality in the perinatal period as well as timely first antenatal care visit; successful referrals for anemia, diabetes, or hypertension during pregnancy; and facility delivery. RESULTS: The eRegistry and DHIs were co-designed with end users between 2016 and 2018. The eRegistry was implemented in the study area in July 2018. Recruitment for the trial started in October 2018 and ended in June 2020, followed by an 8-month follow-up period to capture outcome data until February 2021. Trial results will be available for publication in June 2021. CONCLUSIONS: This trial allows the simultaneous assessment of multiple integrated DHIs for strengthening the health system and aims to provide evidence for its implementation. The study design and outcomes are geared toward informing the living review process of the guidelines for implementing DHIs. TRIAL REGISTRATION: ISRCTN Registry ISRCTN69491836; https://www.isrctn.com/ISRCTN69491836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26918.

Filling the human resource gap through public-private partnership: Can private, community-based skilled birth attendants improve maternal health service utilization and health outcomes in a remote region of Bangladesh?

BACKGROUND: In Sunamganj there are fewer than four skilled providers per 10,000 population and just 27% of births are assisted by a skilled attendant. We evaluate a private community skilled birth attendant (P-CSBA) model, developed through the GSK-CARE Frontline Health Worker Programme, designed to address this gap and report on changes in service utilization and health outcomes from baseline to three years post-baseline. METHODS: This analysis presents the results of a pre-post cross sectional design. A baseline survey (n = 1800) was conducted using a multistage cluster sampling approach. Three years post-baseline a second cross-sectional survey (n = 1755) was conducted across the same project area. To describe demographic characteristics of the study participants descriptive statistical techniques were used as appropriate. Logistic and multiple logistic regression, controlling for a comprehensive set of covariates, were used to assess odds ratios for key maternal health behaviors and outcomes. RESULTS: Birth planning and the use of key maternal health services improved from baseline to follow-up. There was a dramatic increase in the proportion of respondents reporting skilled attendance at birth (aOR: 2.18, p = .001). Women also reported significantly fewer complications during the prenatal (aOR: .30, p<.001), labor and delivery (aOR: 0.41, p<.0001) and postnatal periods (aOR: 0.32, p<.0001). CONCLUSION: Private-sector approaches, when coupled with robust efforts to strengthen and collaborate with the public sector, can work successfully to deliver services in underserved communities. The success of this model lends credence to the growing appreciation that reaching our development targets will require governments to work in partnership with private sector actors and highlights the potential of private-public partnerships as we drive towards universal health coverage.

Status of the WHO recommended timing and frequency of antenatal care visits in Northern Bangladesh.

OBJECTIVE: There is dearth of information on the timeliness of antenatal care (ANC) uptake. This study aimed to determine the timely ANC uptake by a medically trained provider (MTP) as per the World Health Organization (WHO) recommendations and the country guideline. METHODS: Cross-sectional survey was done with 2,731 women having livebirth outcome in last one year in Dinajpur, Nilphamari and Rajshahi districts, Bangladesh from August-November,2016. RESULTS: About 82%(2,232) women received at least one ANC from a MTP. Overall, 78%(2,142) women received 4 or more ANCs by any provider and 43%(1168) from a MTP. Only 14%(378) women received their first ANC at the 1st trimester by a MTP. As per 4 schedule visits by the WHO FANC model and the country guideline 8%(203) and 20%(543) women respectively received the first 2 timely ANC by a MTP; where only 1%(32) and 3%(72) received the first 3 visits timely and 0.6%(17) and 1%(29) received all the four timely visits. Factors significantly associated with the first two timely visits are: 10 or above years of schooling of women [adj. OR 2.13 (CI: 1.05, 4.30)] and their husbands [adj. OR 2.40 (CI: 1.31, 4.38)], women's employment [adj. OR 2.32 (CI: 1.43, 3.76)], urban residential status [adj. OR 3.49 (CI: 2.46, 4.95)] and exposure to mass media [adj. OR 1.58 (CI: 1.07, 2.34)] at 95% confidence interval. According to the 2016 WHO ANC model, only 1.5%(40) women could comply with the first two ANC contacts timely by a MTP and no one could comply with all the timely 8 contacts. CONCLUSION: Despite high coverage of ANC utilization, timely ANC visit is low as per both the WHO recommendations and the country guideline. For better understanding, further studies on the timeliness of ANC coverage are required to design feasible intervention for improving maternal and child health.

Factors associated with calendar literacy and last menstrual period (LMP) recall: a prospective programmatic implication to maternal health in Bangladesh.

OBJECTIVE: To explore the prevalence and determinants of calendar literacy and last menstrual period (LMP) recall among women in Bangladesh. DESIGN: Cross-sectional survey. SETTINGS: Two rural subdistricts and one urban area from three Northern districts of Bangladesh. PARTICIPANTS: We interviewed 2731 women who had a live birth in the last 1 year. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome variable was LMP recall and the secondary outcome was calendar literacy. RESULTS: The majority of participants (65%) correctly mentioned the current date according to the English calendar while 12% mentioned according to the Bengali calendar. During the interview sessions, we used three different calendars: Bengali, English and Hijri to assess calendar literacy. We asked women to mark the current date using the calendar on the day of the interview. Almost 61% women marked the English calendar, 16% marked the Bengali calendar and 4% marked the Hijri calendar correctly. Sixty-three per cent women were found as calendar literate who marked any of the calendars. Among the participants, 58% had calendars available at their home and only 10% of women used calendars to track their LMPs. Overall, 53% women were able to recall their recent LMP. Among the calendar literate, 60% could recall their LMPs. Factors found associated with recalling LMP were: completed eight or more years of schooling (adj.OR 1.39), primigravida (adj.OR 1.88), the richest wealth quintile (adj.OR 1.55) and calendar literacy (adj.OR 1.59). CONCLUSIONS: Despite having reasonable calendar literacy and availability, the use of calendars for tracking LMP found very low. Calendar literacy and sociodemographic characteristics were found as the key factors associated with LMP recall. Maternal, neonatal and child health programmes in low-resource settings can promote a simple tool like calendar and target the communities where ultrasound is not available to ensure accurate LMP recall for early pregnancy registration and timely antenatal care coverage.

Provision of menstrual regulation with medication among pharmacies in three municipal districts of Bangladesh: a situation analysis.

OBJECTIVE: The objective was to assess the provision of the combination of mifepristone-misoprostol for menstrual regulation (MR) in randomly selected urban pharmacies in Bangladesh. STUDY DESIGN: We conducted a cross-sectional survey among 553 pharmacy workers followed by 548 mystery client visits to the same pharmacies in 3 municipal districts during July 2014-December 2015. RESULTS: The survey found that 99% of pharmacy workers visited had knowledge of MR procedures but only two-thirds (67%) could state the legal time limit correctly; they mentioned misoprostol (86%) over mifepristone-misoprostol combination (78%) as a procedure of MR with medication (MRM); 36% reported knowing the recommended dosage of mifepristone-misoprostol combination; 70% reported providing information on effectiveness of the medicines; 50% reported recommending at least one follow-up visit to them; 63% reported explaining possible complications of using the medications; and 47% reported offering any post-MR contraception to their clients. In contrast, mystery client visits found that the mifepristone-misoprostol combination (69%) was suggested over misoprostol (51%) by the pharmacy workers; 54% provided the recommended dosage of mifepristone-misoprostol combination; 42% provided information on its effectiveness; 12% recommended at least one follow-up visit; 11% counseled on possible complications; and only 5% offered post-MR contraceptives to the mystery clients. CONCLUSIONS: We found knowledge gaps regarding recommended dosage for MRM and inconsistent practice in informing women on effectiveness, follow-up visits, possible complications and provision of post-MR contraceptives among the pharmacy workers, particularly during the mystery client visits. IMPLICATIONS: Pharmacy workers in Bangladesh need to be trained on legal time limits for MR services provision, on providing accurate information on disbursed medicine, and on proper referral mechanisms. A strong monitoring and regulatory system for pharmacy provision of MRM in pharmacies should be established.

Reasons for Preference of Home Delivery with Traditional Birth Attendants (TBAs) in Rural Bangladesh: A Qualitative Exploration.

BACKGROUND AND OBJECTIVES: Although Bangladesh has made significant progress in reducing maternal and child mortality in the last decade, childbirth assisted by skilled attendants has not increased as much as expected. An objective of the Bangladesh National Strategy for Maternal Health 2014-2024 is to reduce maternal mortality to 50/100,000 live births. It also aims to increase deliveries with skilled birth attendants to more than 80% which remains a great challenge, especially in rural areas. This study explores the underlying factors for the major reliance on home delivery with Traditional Birth Attendants (TBA) in rural areas of Bangladesh. METHODS: This was a qualitative cross-sectional study. Data were collected between December 2012 and February 2013 in Sunamganj district of Sylhet division and data collection methods included key informant interviews (KII) with stakeholders; formal and informal health service providers and health managers; and in-depth interviews (IDI) with community women to capture a range of information. Key questions were asked of all the study participants to explore the question of why women and their families prefer home delivery by TBA and to identify the factors associated with this practice in the local community. RESULTS: The study shows that home delivery by TBAs remain the first preference for pregnant women. Poverty is the most frequently cited reason for preferring home delivery with a TBA. Other major reasons include; traditional views, religious fallacy, poor road conditions, limited access of women to decision making in the family, lack of transportation to reach the nearest health facility. Apart from these, community people also prefer home delivery due to lack of knowledge and awareness about service delivery points, fear of increased chance of having a caesarean delivery at hospital, and lack of female doctors in the health care facilities. CONCLUSIONS: The study findings provide us a better understanding of the reasons for preference for home delivery with TBA among this population. These identified factors can inform policy makers and program implementers to adopt socially and culturally appropriate interventions that can improve deliveries with skilled attendants and thus contribute to the reduction of maternal and neonatal mortality and morbidity in rural Bangladesh.