Antimicrobial activity of leaf extract of Basilicum polystachyon (L) Moench.

Phenolic extract of leaves of Basilicum polystachyon (L) Moench was tested for in vitro antimicrobial activity against five bacteria (Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, Bacillus subtilis, Micrococcus leuteus) and three fungi (Fusarium oxysporum, Aspergillus niger, Helminthosporium oryzae). Efficacy of organic solvents, methanol and ethanol, as agents for extraction was compared with acidic water (2M; HCl). High-pressure liquid chromatographic (HPLC) data showed that acidic extraction (2M; HCl) resulted in higher yield of caffeic acid (0.437 mg g(-1)) and rosmarinic acid (0.919 mg g(-1)). Acidic extract showed high activity against Gram (+) ve bacteria, but was less active against Gram (-) ve bacteria. Amongst the tested fungi, maximum activity was exhibited against Aspergillus niger. This is the first report on the phenolic constituents and bioactivity of B. polystachyon.

Low nutrient intakes among infants in rural Bangladesh are attributable to low intake and micronutrient density of complementary foods.

We assessed the adequacy of nutrient intakes of 135 rural Bangladeshi breast-fed infants 6-12 mo of age and examined nutritional trade-offs due to possible displacement of breast milk by complementary foods. Observers completed 12-h daytime measurements of breast milk and complementary food intakes; data for the previous 12 h were obtained from maternal recall, yielding estimates of total 24-h intakes. On average, infants were mildly wasted (mean +/- SD weight-for-length Z-score = -0.92 +/- 0.88) and moderately stunted (length-for-age Z-score = -1.49 +/- 0.96). Total energy intakes at 6-8 and 9-12 mo were 88 and 86% of absolute energy requirements (kJ/d), 106 and 105% of requirements per kg body weight, and 97 and 94% of requirements per kg median weight-for-length, respectively. Breast milk contributed 78% of energy intake at 6-8 mo and 75% at 9-12 mo. Mean meal frequency and energy density of complementary foods were generally consistent with recommendations, but only small amounts of food were offered. Nevertheless, only 72% of the food energy offered was consumed. Total energy intake was positively correlated with meal frequency, quantity consumed per meal, and energy intake from breast milk, but not with energy density of complementary foods. Energy intake from complementary foods was inversely related to energy intake from breast milk. The diets fell short of recommended intakes for numerous vitamins and minerals. We conclude that although greater intakes of complementary foods were associated with higher total energy intake, micronutrient intake remained low due to the low micronutrient density of the complementary foods consumed and the partial displacement of breast milk.

Behavior-change trials to assess the feasibility of improving complementary feeding practices and micronutrient intake of infants in rural Bangladesh.

This study used simple rapid-assessment techniques to test the feasibility of increasing the consumption of complementary foods by infants by asking mothers to increase meal quantity or frequency or by altering the viscosity/energy density of the food. The feasibility of using micronutrient supplements either added directly to food or administered as liquid drops was also examined. The study was conducted in rural Bangladesh and involved four separate short-term behavioral change trials. Depending on the trial, fieldworkers recruited 30 to 45 infants 6 to 12 months of age. Following recommendations to increase the amount of food provided to infants, the mean intakes from single meals increased from 40 +/- 23 g on day 1 to 64 +/- 30 g on day 7 (p < 0.05). In a second trial, the mean meal frequency increased from 2.2 +/- 1.3 on day 1 to 4.1 +/- 1.3 on day 7 (p < 0.05). Provision of high-energy-density diets, prepared by decreasing viscosity with alpha-amylase or by hand-mashing rice and dhal into a paste before feeding, increased single-meal energy consumption from 54 +/- 35 kcal to 79 +/- 52 kcal or 75 +/- 37 kcal (p < 0.05), respectively. Both types of micronutrient supplements were well accepted and used according to recommendations. In conclusion, it was possible to change short-term child-feeding behaviors to promote increased food intake, mealfrequency, energy density, and micronutrient consumption. Because each of these interventions lasted for only about 1 week, however, the long-term sustainability of these changes is not known. Moreover, the effect of increased feeding of complementary foods on intakes of breastmilk and total daily consumption of energy and nutrients requires further study.

Improved indicators of infant mortality for integrated primary healthcare programmes.

Mortality and fertility rates are decreasing rapidly in many developing countries. It is argued that the indices commonly used as measures of these changes, i.e. infant mortality rate and fertility rate, ignore the interaction between mortality and fertility, and do not reflect their combined impact in lowering overall infant mortality. The paper proposes new indicators of infant mortality, termed fertility-adjusted infant mortality ratio (FIMR), age-specific, fertility-adjusted IMR (AFIMR), and total infant mortality ratio (TIMR) that are more sensitive to rapid demographic changes. These indicators include the combined effects of changes in both fertility and infant mortality rates on overall infant mortality in a region and appear to measure the effects of integrated health programmes better. Further, these conceptualize the mother-infant pair as an appropriate unit with which to monitor mortality, and may be used for guiding allocation of resources intended to lower infant mortality. The application and usefulness of these indicators have been illustrated, using one hypothetical example and empirical data from the maternal-child health and family-planning programme in Matlab, Bangladesh, as well as data from white and black population groups in the U.S.A. The results of these examples demonstrate that the new indicators are more sensitive than traditional measures when describing infant mortality, and may better reflect the perception in infant mortality status in the community.

Chemopreventive activity of quercetin during carcinogenesis in cervix uteri in mice.

The chemopreventive action of quercetin was examined during 20-methyl cholanthrene induced cervical neoplasia in virgin Swiss albino mice. The effects were evaluated on the basis of histopathological observation of the cervical epithelium, micronucleus frequency in vaginal exfoliated cells and some biochemical parameters in the host liver. Quercetin was found to arrest or reverse the progression of cervical neoplasia. The micronucleus frequency was reduced following its administration. The potential anti-carcinogenic effect of quercetin noted in this study is attributed to its antioxidant property which was reflected in the lipid peroxides and their role in the host detoxification system, as expressed in liver glutathione level, glutathione-S-transferase, glutathione peroxidase, catalase and superoxide dismutase activity. As an integral part of the diet quercetin may offer protection to the epithelium from the damaging effects of carcinogenic chemicals.

Prenatal screening in rural Bangladesh: from prediction to care.

The role of antenatal care is being increasingly questioned, particularly in resource poor environments. The low predictability of antenatal markers for adverse maternal outcomes has led some to reject antenatal care as an efficient strategy in the fight against maternal and perinatal mortality. Few studies, however, have assessed the predictability of adverse outcomes other than dystocia or perinatal death, and most studies have been hospital based. This population-based cohort study was undertaken to assess whether prenatal screening can identify women at risk of severe labour or delivery complications in a rural area in Bangladesh. Antenatal risk markers, signs and symptoms were assessed for their association with severe maternal complications including dystocia, malpresentation, haemorrhage, hypertensive diseases, twin delivery and death. The results of the study suggest that antenatal screening by trained midwives fails to adequately distinguish women who will need special care during labour and delivery from those who will not need such care. The large majority of the women with dystocia or haemorrhage had no warning signs during pregnancy. A single blood pressure measurement and the assessment of fundal height, on the other hand, may detect a substantial number of women with hypertensive diseases and twin pregnancies. In addition, women who had an antenatal visit were four times more likely to deliver with a midwife than women who had no antenatal visit. Antenatal care may not be an efficient strategy to identify those most in need for obstetric service delivery, but if promoted in concurrence with effective emergency obstetric care, and delivered in skilled hands, it may become an effective instrument to facilitate better use of emergency obstetric care services.

Breast milk immune factors in Bangladeshi women supplemented postpartum with retinol or beta-carotene.

BACKGROUND: Vitamin A supplementation of mothers postpartum may improve infant health, not only by increasing vitamin A delivery to the infant through breast milk but also by increasing delivery of milk immune factors. Our hypothesis was that postpartum supplementation with vitamin A increases milk concentrations of certain soluble immune factors. DESIGN: In a double-blind trial conducted in Matlab, Bangladesh, women at 1-3 wk postpartum were randomly assigned to receive until 9 mo postpartum 1) a single dose of 60 mg retinol as retinyl palmitate followed by daily placebos (n = 69), 2) daily doses of 7.6 mg beta-carotene (n = 72), or 3) daily placebos (n = 71). Milk samples collected at baseline and 3 mo postpartum were analyzed by enzyme-linked immunosorbent assay for secretory immunoglobulin A, lactoferrin, lysozyme, and interleukin 8; by HPLC for total retinol; and by atomic absorption spectroscopy for sodium and potassium. RESULTS: After mammary epithelial permeability (defined as an elevated Na:K) and baseline immune factor concentrations were controlled for, there were no significant treatment effects on immune factors at 3 mo. Increased mammary permeability was common (25% of women at baseline and 12% at 3 mo) and was associated with higher concentrations of milk immune factors. Low body vitamin A stores at baseline, as assessed by the modified-relative-dose-response test, were associated with a higher Na:K, but neither retinol nor beta-carotene supplementation affected the prevalence of increased mammary permeability. CONCLUSIONS: Postpartum vitamin A supplementation does not increase milk concentrations of immune factors. The causes of increased mammary epithelial permeability in this population require further study.

Maternal vitamin A or beta-carotene supplementation in lactating bangladeshi women benefits mothers and infants but does not prevent subclinical deficiency.

The effects of maternal postpartum vitamin A or beta-carotene supplementation on maternal and infant serum retinol concentrations, modified relative dose-response (MRDR) ratios and breast milk vitamin A concentrations were assessed during a community-based trial in Matlab, Bangladesh. At 1-3 wk postpartum, women were randomly assigned to receive either (1) a single dose of 200,000 international units [60,000 retinol equivalents (RE)] vitamin A followed by daily placebos (n = 74), (2) daily doses of beta-carotene [7.8 mg (1300 RE)] (n = 73) or (3) daily placebos (n = 73) until 9 mo postpartum. Compared to placebos, vitamin A supplementation resulted in lower maternal MRDR ratios (i.e., increased liver stores) and higher milk vitamin A concentrations at 3 mo, but these improvements were not sustained. The beta-carotene supplementation acted more slowly, resulting in milk vitamin A concentrations higher than the placebo group only at 9 mo. Irrespective of treatment group, over 50% of women produced milk with low vitamin A concentrations (/=0. 06. We conclude that while both interventions were beneficial, neither was sufficient to correct the underlying subclinical vitamin A deficiency in these women nor to bring their infants into adequate vitamin A status.

Adherence to cotrimoxazole treatment for acute lower respiratory tract infections in rural Bangladeshi children.

This study evaluates compliance with taking oral cotrimoxazole in an ALRI control programme in rural Bangladesh. Health workers administered the first dose to children with moderate disease and entrusted relatives to give the remaining doses. A team of medical assistants visited the families of cases 3 to 5 days after initiating treatment and counted the remaining tablets. Medical assistants undertook 367 visits to families of children under treatment at a mean (SD) of 4.4 (0.99) days after treatment began. All children appeared to have been given the antibiotic, but one-quarter were being under-dosed on the day of the visit. Under-dosing did not correlate with any of the socio-demographic variables studied, and seemed to be homogeneously distributed in the community. Under-dosed children did not seem to have a higher risk of subsequent ALRI episodes during the study period. There was no indication of progression to severe disease or death in home-managed cases of moderate pneumonia in this study. These findings raise a question about the need for 5 days of oral antibiotic in the management of moderate pneumonia. Careful studies of the effect on subsequent morbidity, mortality and antibiotic resistance of providing briefer treatment for moderate episodes of ALRI are required. If a briefer course proves effective, this would have important implications for funding programmes of control of ALRI in the community.

Acute lower respiratory infections in rural Bangladeshi children: patterns of treatment and identification of barriers.

A study conducted in rural Bangladesh examined the patterns of health seeking behavior, mothers' recognition of symptoms, the perceived causes and barriers to timely treatment of acute lower respiratory infections (ALRI). A total of 194 children under 5 years of age suffering from ALRI in an intensive maternal child health and family planning area was prospectively followed. About 62% of the mothers sought allopathic treatment for their children within 24 hours of case detection. No treatment of any kind was sought in 45 (23.2%) cases. Most of the mothers could recognize the different symptoms of ALRI. Cold was reported as the most common cause of ALRI. No significant difference was observed in the reported symptoms or perceived cause of the disease between those who sought no treatment and those who sought allopathic, homeopathic, spiritual or combined treatments. Failure to recognize severity followed by work loss were the most common reasons identified for not seeking any medical care. Whether or not a mother sought allopathic treatment was not associated with the child's age, sex, mother's age, mother's education, duration of illness, birth order, housing type or distance from the health center. The study indicates the potential value of giving parents clear guidelines on recognition of severity of symptoms of ALRI and motivating them to seek treatment quickly when these symptoms present. Health service providers should be aware of the heavy work loads which rural women have and the severe time constraints which deter them from seeking timely treatment from the appropriate sources.

Decline in maternal mortality in Matlab, Bangladesh: a cautionary tale.

BACKGROUND: A study in Matlab, Bangladesh, has provided evidence favouring a community-based maternity-care delivery system. 3 years of this programme coincided with a significant reduction in direct obstetric mortality compared with the 3 years before the programme. We have examined whether the effects of the programme are sustained over time. METHODS: Using data from the continuing demographic survelliance system and from special investigations into the rates and causes of maternal mortality during 1976-93, we compared the trends in direct obstetric maternal mortality ratios in the Maternal and Child Health and Family Planning (MCH-FP) area (which has received extensive services in health and family planning since 1977) with those in the comparison area (with no such intensive health inputs). We divided the areas and time periods into discrete groups that best represented the effects of the introduction of the maternity-care programme. FINDINGS: Direct obstetric mortality declined by 3% per year (rate ratio 0.97 per year [95% CI 0.95-0.99]); there was no difference between the MCH-FP and comparison areas (1.00 [0.96-1.05]). Direct obstetric mortality halved between 1976-86 and 1987-89 in the northern MCH-FP area, where the maternity-care programme was initiated in 1987 (0.50 [0.22-0.99]), but showed no change in the southern MCH-FP area, which had no such intervention at that time (1.07 [0.64-1.72]). After 1990, when the programme was expanded throughout the MCH-FP area, the southern part showed a downward (non-significant) trend in direct obstetric mortality (0.68 [0.35-1.32]). However, direct obstetric mortality also declined between 1987 and 1989 in the southern comparison area (0.48 [0.26-0.83]) in the absence of an intense maternity-care programme, and remained stable thereafter. In the northern comparison area, there was no such decline in direct obstetric mortality (0.78 [0.40-1.40]). INTERPRETATION: Although the introduction of the maternity-care programme coincided with declining trends in direct obstetric mortality in the areas covered by the programme, a decline also occurred in one of the areas not receiving any such interventions. Caution is required in the interpretation of short-term trends in one indicator in studies designed without random allocation of interventions into treatment and control groups.

PIP: This study examines the impact of the Maternal-Child Health and Family Planning (MCH-FP) program in the Matlab, Bangladesh. Data were obtained from the Matlab surveillance system for treatment and comparison areas. This study reports the trends in maternal mortality since 1976. The MCH-FP area received extensive services in health and family planning since 1977. Services included trained traditional birth attendants and essential obstetric care from government district hospitals and a large number of private clinics. Geographic ease of access to essential obstetric care varied across the study area. Access was most difficult in the northern sector of the MCH-FP area. Contraception was made available through family welfare centers. Tetanus immunization was introduced in 1979. Door-to-door contraceptive services were provided by 80 female community health workers on a twice-monthly basis. In 1987, a community-based maternity care program was added to existing MCH-FP services in the northern treatment area. The demographic surveillance system began collecting data in 1966. During 1976-93 there were 624 maternal deaths among women aged 15-44 years in Matlab (510/100,000 live births). 72.8% of deaths were due to direct obstetric causes: postpartum hemorrhage, induced abortion, eclampsia, dystocia, and postpartum sepsis. Maternal mortality declined in a fluctuating fashion in both treatment and comparison areas. Direct obstetric mortality declined at about 3% per year. After 1987, direct obstetric mortality declined in the north by almost 50%. After the 1990 program expansion in the south, maternal mortality declined, though not significantly, in the south. Maternal mortality declined in the south comparison area during 1987-89 and stabilized. The comparison area of the north showed no decline.

Why did maternal mortality decline in Matlab?

In 1991, an article on the Maternity Care Program in Matlab, Bangladesh, reported a substantial decline in direct obstetric deaths in the intervention area, but not in the control area. The decline was attributed primarily to the posting of midwives at the village level. In this article, data are presented from the same period and area on a variety of intermediate events. They indicate that the decline in deaths was probably due to the combined efforts of community midwives and the physicians at the Matlab maternity clinic. Their ability to refer patients to higher levels of care was important. The data further indicate that the decline in deaths depended upon the functioning of the government hospital in Chandpur, where cesarean sections and blood transfusions were available. Midwives might also have made a special contribution by providing early termination of pregnancy, which is legal in Bangladesh.

PIP: Data were collected during 1993 from the Matlab Demographic Surveillance System, midwives' cards, the Matlab maternity clinic record book, and records at the government's district hospital. This study analyzed these data in order to determine why maternal mortality declined in the intervention area. Direct obstetric deaths declined from 20 deaths during the 3 years before the Maternity Care Program was implemented to 6 deaths during the 3 years after program implementation. In the control area, mortality remained stable at 20 deaths during the same time period. The declines were apparent among diagnoses for induced abortion, eclampsia and pre-eclampsia, and prolonged obstructed labor. There were few changes in causes of death in the control area. During the intervention period, midwives in villages administered services to 49 women with preeclampsia, of whom 6 later developed eclampsia. There were 20 referrals to the maternity clinic for a variety of complications including eclampsia. The Matlab clinic received 54 patients during the intervention period with a primary diagnosis of pre-eclampsia or eclampsia. Midwives provided care for 77 women with prolonged labor. Matlab clinic received 116 patients due to prolonged labor. 4% of the 2364 midwives' cards indicated referral. 83% of referrals were to the Matlab clinic. The Matlab maternity clinic had 300 admissions during the study period, of which 65% (194 women) were from the intervention area. Women from the intervention area were 2.3 times more likely to be treated at the Matlab clinic than women from the control area. 69% of admissions at Chandpur District Hospital were from the Matlab intervention area. Case fatality rates in the hospital did not differ among intervention and control populations. The authors conclude that greater use of midwives, referrals and proper transport, and better service conditions significantly contributed to maternal mortality decline.

Acute respiratory infections (ARI) in rural Bangladesh: perceptions and practices.

Acute Respiratory Infections (ARI) are a major cause of death in children under five in rural Bangladesh. A popular strategy for lowering ARI mortality in such settings includes detecting and managing pneumonia in children at the community level. The success of programs using this approach requires a well-trained community-based cadre of health workers and the appropriate utilization of services provided. Determinants of health care seeking behavior are clearly of interest in this regard. A qualitative study was conducted in Matlab, Bangladesh to describe community perceptions of signs and symptoms of ARI, case management behavior, and constraints to service utilization. Mothers recognized pneumonia and thought it to be caused by "exposure to cold." They were able to identify labored breathing, chest retractions, lethargy, and inability to feed as signs of severe disease needing treatment outside the home. Nevertheless, similar illnesses were sometimes believed to be due to attack by evil influences. In these cases, spiritual healers were sought and allopathic treatment was avoided or delayed. The mothers' observance of purdah and "proper" behavior were reported to play a role in prevention of child death from disease. Implications of this belief and its impact on service utilization are discussed. Suggestions for program managers are made in addition to recommendations for further research.

PIP: 20 case history interviews with mothers of children younger than 5 and 12 focus groups with young and older mothers, mothers-in-law (grandmothers), traditional birth attendants, spiritual healers, and untrained or semitrained allopaths (village doctors) were conducted in the Matlab in Bangladesh. The qualitative research aimed to examine obstacles to service utilization and community beliefs and practices regarding acute respiratory infections (ARIs) in a rural community where an ARI control project operates. Severe signs and symptoms were more likely to upset mothers than grandmothers. Signs that mothers recognized as severe enough to seek treatment outside the home were labored breathing, chest retractions, lethargy, and inability to feed. Mothers believed that exposure to cold was responsible for pneumonia. Yet, they often thought that an attack by evil influences caused similar illnesses. They refrained from or delayed taking their children with an evil-induced illness for allopathic treatment. Instead, they would seek the services of spiritual healers. Previous experience with a successfully treated case of pneumonia (caused by exposure to cold) was the factor most strongly associated with the decision to seek allopathic treatment. The most common external constraint to bringing children to the Matlab hospital was no one at home to do household work, particularly care for other children. Internal constraints included reluctance to violate purdah and fear of traveling alone. Mothers thought that adhering to purdah kept disease attacks from their children. Mother-blaming attitudes were prevalent, which had a negative effect on mothers' ability to obtain appropriate treatment for ill children.

Acute toxicity of vitamin A given with vaccines in infancy.

A double-blind, randomised, placebo-controlled trial was conducted to evaluate the safety and toxicity of vitamin A supplementation within the Expanded Programme on Immunisation (EPI) in rural Bangladesh. 191 infants received 3 doses of either 50,000 IU of vitamin A or placebo at about 1.5, 2.5, and 3.5 months and were examined on days 1, 2, 3, and 8 after supplementation. 11 infants (11.5%) supplemented with vitamin A had episodes of bulging of the fontanelle as opposed to 1 (1%) in the placebo group. 16 of the 17 events occurred in the vitamin A supplemented group. No other side effects were noted. There was a tendency towards a cumulative effect of toxicity with increasing doses.

PIP: The International Center for Diarrhoeal Disease Research, Bangladesh, conducted a double-blind, randomized, placebo-controlled trial in the Matlab to examine the possibility of side effects in 191 infants who received 3 doses of either 50,000 IU vitamin A or a placebo at 1.5, 2.5, and 3.5 months within the Expanded Program of Immunization. Physicians examined the infants on the day of supplementation on days 1,3 and 8 after supplementation. The fontanelles bulged in 12 infants. The incidence of fontanelle bulging was more common in the vitamin A group than in the placebo group (11.5 vs. and 1%). There were 17 fontanelle bulging episodes, 16 taking place after vitamin A supplementation (5.5 vs. 0.3% after placebo supplementation). 8 (50%) of the vitamin A induced bulged fontanelle episodes occurred after the 3rd dose. 3 infants had fontanelle bulging episodes after the 2nd and 3rd doses. 2 other infants had these episodes after the 1st and 3rd doses. The bulging episodes persisted for 24-48 hours in all but 2 cases (48-72 hours) and returned to normal without treatment. No infant with a bulging fontanelle died. No other side effects occurred. The increased incidence of bulging fontanelles among infants receiving vitamin A supplementation and the fact that almost all episodes occurred after vitamin A supplementation suggested that vitamin A supplementation caused the bulging fontanelles. Increased intracranial pressure caused by vitamin A toxicity was responsible for the bulging fontanelles.

Antioxidant defenses in the bile duct-ligated rat.

Changes in pro-oxidant and antioxidant balance in the serum and liver were studied in an experimental model of obstructive jaundice in the rat. The results showed a decrease in plasma vitamin E concentration (P < 0.01) and a threefold reduction in liver vitamin E concentration (P < 0.001). There was also a threefold reduction in levels of the liver enzymes glutathione peroxidase (P < 0.01) and glutathione transferase (P < 0.001), together with a six-fold reduction in catalase activity (P < 0.001). The serum selenium level decreased by 35% in the jaundiced rats (P < 0.05). The total liver glutathione level decreased to half the control value (P < 0.01). The malonyldialdehyde level, the measure of lipid peroxidation used in this study, doubled (P < 0.01). The results suggest a shift in the pro-oxidant/antioxidant balance in favor of lipid peroxidation. The possible etiology of this change and its relationship to human cholestasis are discussed.

Utilization of medically-trained birth attendants in rural Bangladesh.

Using case-control methodology, this study compared the characteristics of women who requested medically-trained birth attendants at home with those who did not, in order to identify constraints to service delivery and suggest program changes to increase service utilization in a rural area of Bangladesh. By several different measures, prior contact with medical professionals were much more common among cases than controls, with the greatest differences observed in the frequency of antenatal visits. At least one antenatal visit was the strongest predictor that a woman would call a medically-trained birth attendant, though primiparity, proximity to the provider, previous contact with the clinic, and education (both of the mother and her spouse) were also predictive. Recommendations include increasing contact through antenatal visits, and extending midwife coverage through training and supervision of traditional birth attendants. This study demonstrates the usefulness of case-control methodology in evaluating health care utilization.

Effect on mortality of community-based maternity-care programme in rural Bangladesh.

Various community-based interventions have been proposed to improve maternity care, but hardly any studies have reported the effect of these measures on maternal mortality. In this study, the efficacy of a maternity-care programme to reduce maternal mortality has been evaluated in the context of a primary health-care project in rural Bangladesh. Trained midwives were posted in villages, and asked to attend as many home-deliveries as possible, detect and manage obstetric complications at onset, and accompany patients requiring referral for higher-level care to the project central maternity clinic. The effect of the programme was evaluated by comparison of direct obstetric maternal mortality ratios between the programme area and a neighbouring control area without midwives. Random assignment of the intervention was not possible but potentially confounding characteristics, including coverage and use of other health and family planning services, were similar in both areas. Maternal mortality ratios due to obstetric complications were similar in both areas during the 3 years preceding the start of the programme. By contrast, during the following 3 years, the ratio was significantly lower in the programme than in the control area (1.4 vs 3.8 per 1000 live births, p = 0.02). The findings suggest that maternal survival can be improved by the posting of midwives at village level, if they are given proper training, means, supervision, and back-up. The inputs for such a programme to succeed and the constraints of its replication on a large scale should not be underestimated.

PIP: This study considers the effects of a maternity care program within a community based maternal and child health and family planning program (MCH--FP) in rural Bangladesh (Matlab subdistrict). The area is rural and poor, with literacy rates of 30% for men and 17% for women; total fertility rates range from 5.5 to 4.3/woman and infant mortality from 110/1000 live births to 75/1000 in 1989. A demographic surveillance system was begun in 1966, and in 1977, MCH-FP was set up as a special treatment area separate from a comparable area with only Government health services. There are 80 community health workers (CHWs) who visit and collect data on each household of every village every 2 weeks. Maternal mortality is established by protocol. Maternal mortality in this study is defined as deaths occurring during pregnancy, delivery, or 6 weeks postpartum and attributable to obstetric complications but not conditions aggravated by the pregnancy or postpartum status (diarrhea, hepatitis, respiratory tract infections). Maternity care and referral is provided by the CHWs. Up to 1986, contraceptive use prevalence rates increased but maternal mortality remained at 5.5/1000 live births. Interventions based on a retrospective study of causes and conditions of maternal mortality were instituted in 1987. These consisted of posting professional midwives equipped to treat immediately obstetric complications in villages and a backup referral system. The intervention program was set up in 50% of the MCH--FP area and consisted of 48,000 people living in 39 villages. There were 1600 pregnancies a year in the program area, or an average of 33 a month/midwife (4 midwives in 2 outposts). Backup included a new maternity clinic without surgical, radiological or modern laboratory facilities, but staff available to stabilize patients for transfer to a regional hospital. Data was collected by the midwives, including the ratio of deaths/1000 live births as the best measure of the risk of dying during pregnancy. The results of the comparison between the intervention area, which also had a higher infant and adult female mortality rate, and the control area for 1987-89 showed that the odds ratio of obstetric death in the pre and post period was .31 (95% CI .11-.81, p=.007); there was no significant change in the control area. The principal causes of death reduced by the program and ranked in decreasing order were abortion complications, postpartum hemorrhage, postpartum sepsis, obstructed labor and eclampsia. It is likely that the intervention was the significant factor in the mortality reduction since the areas were similar sociodemographically. Another method for reducing maternal mortality has been implemented and being evaluated: the use of female paramedical field workers to detect high risk pregnancies.

Current practices for treatment of dysentery in rural Bangladesh.

A rural area of Bangladesh with a population of 191,000 had 643 health care providers, of whom 324 (50%) practiced allopathic (Western) medicine, 152 (24%) were spiritualists, 109 (17%) were herbalists, and 58 (9%) were homeopaths. Two hundred eight (64%) of the allopaths had no formal training, and only 18 (6%) were graduates of medical school. In a community-based study of 480 children with bloody diarrhea and 480 children with nonbloody diarrhea, allopathic treatment was the most common care provided. Furazolidone and metronidazole were the two most commonly prescribed drugs, given to 26% and 23% of children, respectively, who were seen by a practitioner. Only 25% of children had received oral rehydration therapy. We conclude that in this region of Bangladesh care of acute diarrhea is provided mostly by private medical practitioners who have little or no training; that such care currently is largely irrational; and that the provision of rational care will require the development of simple algorithms that these practitioners can implement for treatment of this disease.

Epidemiology and cause of deaths among women in rural Bangladesh.

A total of 542 women aged 15 to 44 years died during the 10-year period 1976 to 1985 in the control area of Matlab, an area with a population of 90,000, representative of many other rural areas of southern Bangladesh. The corresponding age-specific mortality rate was 290 per 100,000 women 15-44 years. These deaths have been analysed retrospectively, using information collected through the Demographic Surveillance System set up by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and verbal autopsies conducted in the homes. Of these deaths, 175 (32%) were due to infectious diseases, 163 (30%) to direct obstetric complications, 67 (12%) to injuries, and the remaining 26% to other causes. Cause-specific and proportionate mortality rates showed a positive association with age for deaths due to infectious diseases, non-infectious diseases and unspecified causes, and an inverse association with age for deaths due to injuries. These rates showed a peak in the intermediate age group 25 to 34 years for deaths due to direct obstetric causes. No consistent trends were visible when annual rates were studied over time. Prior to death, 42% of the women were attended by traditional practitioners, and 33% were not attended at all. Demographic impact is discussed, emphasizing the contribution of obstetric causes to overall mortality. Priorities for health policy implications are proposed, focusing upon a strong maternity care programme, and improved availability of female health personnel, in the context of the socio-cultural constraints imposed on women in poor rural areas.

Determinants of reproductive change in a traditional society: evidence from Matlab, Bangladesh.

A decade has elapsed since a project was launched in Matlab, Bangladesh to test the hypothesis that contraceptive services can induce and sustain fertility decline in a rural traditional population. The demographic impact of this project has been pronounced, lending support to the view that supply-side policies can succeed even where institutional supports for demand are weak. This paper reviews the relationship between the Bangladesh climate of demand and the Matlab system of supply with the aim of explaining how such effects arise. A sociologically appropriate system of supply can induce fertility change in a society where such change would not spontaneously arise. The study of programs and the "sociology of the supply side" thus deserve the same degree of rigor accorded to research on the "sociology of demand."