Intermittent Needs for Family Planning among Women with an Internal Migrant Husband in Bangladesh: A Qualitative Study.

Bangladesh is one of the major labour-exporting countries in the world, with large-scale labour migration flows occurring both internationally and domestically. Spousal separation due to migration has the potential to disrupt women's ability to use contraception in line with their reproductive goals. This qualitative study complements the 2014 Bangladesh Demographic and Health Survey (BDHS) data; we conducted in-depth interviews with a sub-sample of 23 BDHS respondents whose husbands stayed elsewhere but returned at least once a year to Barisal Division, Bangladesh. The study explores how husbands' migration patterns influence couples' fertility intentions, contraceptive decision-making and behaviour, and unintended pregnancies. Results showed that contraceptive use was high among the study participants, with nearly all couples using some method to avoid pregnancy - usually pills and condoms. However, the use was episodic and inconsistent, reducing effectiveness. Experiences of side effects were commonplace, which contributed to this pattern of inconsistent use: women used pills only during the duration of their husband's visits. Half of the informants experienced unintended pregnancies either due to the inconsistent use of pills or other method failures. The study findings indicate that women with migrant husbands need family planning education related to their particular circumstances and access to a wider range of family planning choices. Quality counselling should respect women's experiences with side effects and include thorough discussion of viable alternatives.

Male involvement interventions and improved couples' emotional relationships in Tanzania and Zimbabwe: 'When we are walking together, I feel happy'.

Male involvement in maternal and child health is recognised as a valuable strategy to improve care-seeking and uptake of optimal home care practices for women and children in low- and middle-income settings. However, the specific mechanisms by which involving men can lead to observed behaviour change are not well substantiated. A qualitative study conducted to explore men's and women's experiences of male involvement interventions in Tanzania and Zimbabwe found that, for some women and men, the interventions had fostered more loving partner relationships. Both male and female participants identified these changes as profoundly meaningful and highly valued. Our findings illustrate key pathways by which male involvement interventions were able to improve couples' emotional relationships. Findings also indicate that these positive impacts on couple relationships can motivate and support men's behaviour change, to improve care-seeking and home care practices. Men's and women's subjective experiences of partner relationships following male involvement interventions have not been well documented to date. Findings highlight the importance of increased love, happiness and emotional intimacy in couple relationships - both as a wellbeing outcome valued by men and women, and as a contributor to the effectiveness of male involvement interventions.

Using a gender lens to understand eating behaviours of adolescent females living in low-income households in Bangladesh.

Adolescence is a critical period characterized by rapid physical, psychological, and social development and growth. In Bangladesh, high rates of undernutrition persist among adolescent females living in low-income households. Prevalence of adolescent marriage and pregnancy is extremely high, with almost half of Bangladeshi women giving birth by 18 years of age. Qualitative research was carried out from April to June 2017 to examine individual, social, and environmental factors influencing eating behaviours of female adolescents between 15 and 19 years of age living in low-income families in urban and rural settings in Bangladesh. Methods included freelisting exercises (33), key informant interviews (11), in-depth interviews (24), direct observations (16), and focus group discussions (12). Findings show that household food insecurity necessitates adjustments in meal food quality and frequency. Gender norms prescribe that females receive small meal portions and make sacrifices in food consumption so that male family members can eat more. Work and school schedules cause long breaks between meal consumption, restricting food intake of adolescent females for extended periods. Gender discrimination and its manifestations likely amplify susceptibility to psychological stresses in adolescent females. An inferior social position makes adolescent females living in food insecure households vulnerable to undernutrition, with factors affecting food deprivation increasing as they approach childbearing. Policies to increase age of marriage and reduce adolescent pregnancy must continue. Programmes must ensure that school-going adolescents eat adequately during the school day. Prolonging school education and strengthening the economic viability of women should alter cultural expectations regarding marriage age and normative female roles.

Feasibility of engaging "Village Doctors" in the Community-based Integrated Management of Childhood Illness (C-IMCI): experience from rural Bangladesh.

BACKGROUND: Informal health care providers particularly "village doctors" are the first point of care for under-five childhood illnesses in rural Bangladesh. We engaged village doctors as part of the Multi-Country Evaluation (MCE) of Integrated Management of Childhood Illness (IMCI) and assessed their management of sick under-five children before and after a modified IMCI training, supplemented with ongoing monitoring and supportive supervision. METHODS: In 2003-2004, 144 village doctors across 131 IMCI intervention villages in Matlab Bangladesh participated in a two-day IMCI training; 135 of which completed pre- and post-training evaluation tests. In 2007, 38 IMCI-trained village doctors completed an end-of-project knowledge retention test. Village doctor prescription practices for sick under-five children were examined through household surveys, and routine monitoring visits. In-depth interviews were done with mothers seeking care from village doctors. RESULTS: Village doctors' knowledge on the assessment and management of childhood illnesses improved significantly after training; knowledge of danger signs of pneumonia and severe pneumonia increased from 39% to 78% (P < 0.0001) and from 17% to 47% (P < 0.0001) respectively. Knowledge on the correct management of severe pneumonia increased from 62% to 84% (P < 0.0001), and diarrhoea management improved from 65% to 82% (P = 0.0005). Village doctors retained this knowledge over three years except for home management of pneumonia. No significant differences were observed in prescribing practices for diarrhoea and pneumonia management between trained and untrained village doctors. Village doctors were accessible to communities; 76% had cell phones; almost all attended home calls, and did not charge consultation fees. Nearly all (91%) received incentives from pharmaceutical representatives. CONCLUSIONS: Village doctors have the capacity to learn and retain knowledge on the appropriate management of under-five illnesses. Training alone did not improve inappropriate antibiotic prescription practices. Intensive monitoring and efforts to target key actors including pharmaceutical companies, which influence village doctors dispensing practices, and implementation of mechanisms to track and regulate these providers are necessary for future engagement in management of under-five childhood illnesses.

An examination of women experiencing obstetric complications requiring emergency care: perceptions and sociocultural consequences of caesarean sections in Bangladesh.

Little is known about the physical and socioeconomic postpartum consequences of women who experience obstetric complications and require emergency obstetric care (EmOC), particularly in resource-poor countries such as Bangladesh where historically there has been a strong cultural preference for births at home. Recent increases in the use of skilled birth attendants show socioeconomic disparities in access to emergency obstetric services, highlighting the need to examine birthing preparation and perceptions of EmOC, including caesarean sections. Twenty women who delivered at a hospital and were identified by physicians as having severe obstetric complications during delivery or immediately thereafter were selected to participate in this qualitative study. Purposive sampling was used for selecting the women. The study was carried out in Matlab, Bangladesh, during March 2008-August 2009. Data-collection methods included in-depth interviews with women and, whenever possible, their family members. The results showed that the women were poorly informed before delivery about pregnancy-related complications and medical indications for emergency care. Barriers to care-seeking at emergency obstetric facilities and acceptance of lifesaving care were related to apprehensions about the physical consequences and social stigma, resulting from hospital procedures and financial concerns. The respondents held many misconceptions about caesarean sections and distrust regarding the reason for recommending the procedure by the healthcare providers. Women who had caesarean sections incurred high costs that led to economic burdens on family members, and the blame was attributed to the woman. The postpartum health consequences reported by the women were generally left untreated. The data underscore the importance of educating women and their families about pregnancy-related complications and preparing families for the possibility of caesarean section. At the same time, the health systems need to be strengthened to ensure that all women in clinical need of lifesaving obstetric surgery access quality EmOC services rapidly and, once in a facility, can obtain a caesarean section promptly, if needed. While greater access to surgical interventions may be lifesaving, policy-makers need to institute mechanisms to discourage the over-medicalization of childbirth in a context where the use of caesarean section is rapidly rising.

Violence against women with chronic maternal disabilities in rural Bangladesh.

This study explored violence against women with chronic maternal disabilities in rural Bangladesh. During November 2006-July 2008, in-depth interviews were conducted with 17 rural Bangladeshi women suffering from uterine prolapse, stress incontinence, or fistula. Results of interviews showed that exposure to emotional abuse was almost universal, and most women were sexually abused. The common triggers for violence were the inability of the woman to perform household chores and to satisfy her husband's sexual demands. Misconceptions relating to the causes of these disabilities and the inability of the affected women to fulfill gender role expectations fostered stigma. Emotional and sexual violence increased their vulnerability, highlighting the lack of life options outside marriage and silencing most of them into accepting the violence. Initiatives need to be developed to address misperceptions regarding the causes of such disabilities and, in the long-term, create economic opportunities for reducing the dependence of women on marriage and men and transform the society to overcome rigid gender norms.

Cluster of Nipah virus infection, Kushtia District, Bangladesh, 2007.

OBJECTIVE: In March 2007, we investigated a cluster of Nipah encephalitis to identify risk factors for Nipah infection in Bangladesh. METHODS: We defined confirmed Nipah cases by the presence of IgM and IgG antibodies against Nipah virus in serum. Case-patients, who resided in the same village during the outbreak period but died before serum could be collected, were classified as probable cases. RESULTS: We identified three confirmed and five probable Nipah cases. There was a single index case. Five of the secondary cases came in close physical contact to the index case when she was ill. Case-patients were more likely to have physical contact with the index case (71% cases versus 0% controls, p = <0.001). The index case, on her third day of illness, and all the subsequent cases attended the same religious gathering. For three probable cases including the index case, we could not identify any known risk factors for Nipah infection such as physical contact with Nipah case-patients, consumption of raw date palm juice, or contact with sick animals or fruit bats. CONCLUSION: Though person-to-person transmission remains an important mode of transmission for Nipah infection, we could not confirm the source of infection for three of the probable Nipah case-patients. Continued surveillance and outbreak investigations will help better understand the transmission of Nipah virus and develop preventive strategies.

Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial.

BACKGROUND: WHO and UNICEF launched the Integrated Management of Childhood Illness (IMCI) strategy in the mid-1990s to reduce deaths from diarrhoea, pneumonia, malaria, measles, and malnutrition in children younger than 5 years. We assessed the effect of IMCI on health and nutrition of children younger than 5 years in Bangladesh. METHODS: In this cluster randomised trial, 20 first-level government health facilities in the Matlab subdistrict of Bangladesh and their catchment areas (total population about 350 000) were paired and randomly assigned to either IMCI (intervention; ten clusters) or usual services (comparison; ten clusters). All three components of IMCI-health-worker training, health-systems improvements, and family and community activities-were implemented beginning in February, 2002. Assessment included household and health facility surveys tracking intermediate outputs and outcomes, and nutrition and mortality changes in intervention and comparison areas. Primary endpoint was mortality in children aged between 7 days and 59 months. Analysis was by intention to treat. This study is registered, number ISRCTN52793850. FINDINGS: The yearly rate of mortality reduction in children younger than 5 years (excluding deaths in first week of life) was similar in IMCI and comparison areas (8.6%vs 7.8%). In the last 2 years of the study, the mortality rate was 13.4% lower in IMCI than in comparison areas (95% CI -14.2 to 34.3), corresponding to 4.2 fewer deaths per 1000 livebirths (95% CI -4.1 to 12.4; p=0.30). Implementation of IMCI led to improved health-worker skills, health-system support, and family and community practices, translating into increased care-seeking for illnesses. In IMCI areas, more children younger than 6 months were exclusively breastfed (76%vs 65%, difference of differences 10.1%, 95% CI 2.65-17.62), and prevalence of stunting in children aged 24-59 months decreased more rapidly (difference of differences -7.33, 95% CI -13.83 to -0.83) than in comparison areas. INTERPRETATION: IMCI was associated with positive changes in all input, output, and outcome indicators, including increased exclusive breastfeeding and decreased stunting. However, IMCI implementation had no effect on mortality within the timeframe of the assessment. FUNDING: Bill & Melinda Gates Foundation, WHO's Department of Child and Adolescent Health and Development, and US Agency for International Development.

Childhood drowning in Matlab, Bangladesh: an in-depth exploration of community perceptions and practices.

While reductions in infectious disease have resulted in impressive declines in child mortality in Bangladesh, drowning is becoming proportionately more important as a major cause of death, accounting for at least 19% of deaths of children between 1 and 4 years of age in trend analysis since 2000. Little is known about indigenous beliefs and behaviors associated with drowning, which may be critical to preventing child-related drowning deaths. Qualitative research was carried out over 13 months in Matlab, Bangladesh to describe the indigenous explanatory model of drowning and to identify behavioral factors increasing the risk for drowning deaths. Methods included cognitive mapping procedures as well as open-ended interviews with families who had lost a child or experienced a near-death due to drowning and families with at least one child under 5 years living near a body of water. Along with diarrhea, fever, and pneumonia, drowning is perceived as a leading cause of child death. Causal explanations are primarily associated with "evil spirits" believed to entice young children to water or bewitch mothers so that they forget about the child. Another primary interpretation relates to a water goddess known to prey on small children. When a young child is discovered in water, parents refrain from rescuing the child due to a belief that if a parent touches a drowning child, the child will die. After the child is removed from the water, traditional practices that have no known benefit are employed. The research identified locally constructed beliefs and practices such as refraining from touching the child that may increase the incidence of drowning deaths. Future efforts are required to address these beliefs and assess the feasibility, cultural acceptability and effectiveness of strategies designed to prevent drowning.

In-depth assessment of an outbreak of Nipah encephalitis with person-to-person transmission in Bangladesh: implications for prevention and control strategies.

Continued Nipah encephalitis outbreaks in Bangladesh highlight the need for preventative and control measures to reduce transmission from bats to humans and human-to-human spread. Qualitative research was conducted at the end of an encephalitis outbreak in Faridpur, Bangladesh in May 2004 and continued through December 2004. Methods included in-depth interviews with caretakers of cases, case survivors, neighbors of cases, and health providers. Results show contrasts between local and biomedical views on causal explanations and appropriate care. Social norms demanded that family members maintain physical contact with sick patients, potentially increasing the risk of human-to-human transmission. Initial treatment strategies by community members involved home remedies, and public health officials encouraged patient hospitalization. Over time, communities linked the outbreak to supernatural powers and sought care with spiritual healers. Differing popular and medical views of illness caused conflict and rejection of biomedical recommendations. Future investigators should consider local perceptions of disease and treatment when developing outbreak strategies.

Childhood drowning in low- and middle-income countries: Urgent need for intervention trials.

Data available for low- and middle-income countries (LMICs) indicate that the burden of drowning in children is significant and becoming a leading public health problem. At the same time, interventions for drowning are not well documented in LMICs. The overall purpose of this paper is to make the case for research investments in conducting intervention trials to prevent child drowning in LMICs. In high-income countries (HICs), existing drowning prevention interventions include among others: pool fencing, supervision, lifeguards and water safety training at a young age. However, these measures may not be the most relevant in curtailing the number of drowning deaths in LMICs. There are differences with regard to geographical, social, cultural and behavioural factors associated with drowning between HICs and LMICs, often making it inappropriate to apply existing interventions directly in LMIC settings. This paper focuses on drowning from LMICs and reveals a dearth of data on incidence rates and risk factors; absence of public health interventions; lack of research on intervention effectiveness and cost-effectiveness; and paucity of national drowning prevention programs. Based on this evidence, this paper calls for immediate attention to drowning prevention by increasing research investments. This paper specifically discusses Bangladesh as a case study and proposes a drowning intervention study focusing on children less than 5 years in LMICs as an example of appropriate research investment.

Foodborne transmission of Nipah virus, Bangladesh.

We investigated an outbreak of encephalitis in Tangail District, Bangladesh. We defined case-patients as persons from the outbreak area in whom fever developed with new onset of seizures or altered mental status from December 15, 2004, through January 31, 2005. Twelve persons met the definition; 11 (92%) died. Serum specimens were available from 3; 2 had immunoglobulin M antibodies against Nipah virus by capture enzyme immunoassay. We enrolled 11 case-patients and 33 neighborhood controls in a case-control study. The only exposure significantly associated with illness was drinking raw date palm sap (64% among case-patients vs. 18% among controls, odds ratio [OR] 7.9, p = 0.01). Fruit bats (Pteropus giganteus) are a nuisance to date palm sap collectors because the bats drink from the clay pots used to collect the sap at night. This investigation suggests that Nipah virus was transmitted from P. giganteus to persons through drinking fresh date palm sap.

Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomised study.

BACKGROUND: We report the preliminary findings from a continuing cluster randomised evaluation of the Integrated Management of Childhood Illness (IMCI) strategy in Bangladesh. METHODS: 20 first-level outpatient facilities in the Matlab sub-district and their catchment areas were randomised to either IMCI or standard care. Surveys were done in households and in health facilities at baseline and were repeated about 2 years after implementation. Data on use of health facilities were recorded. IMCI implementation included health worker training, health systems support, and community level activities guided by formative research. FINDINGS: 94% of health workers in the intervention facilities were trained in IMCI. Health systems supports were generally available, but implementation of the community activities was slow. The mean index of correct treatment for sick children was 54 in IMCI facilities compared with 9 in comparison facilities (range 0-100). Use of the IMCI facilities increased from 0.6 visits per child per year at baseline to 1.9 visits per child per year about 21 months after IMCI introduction. 19% of sick children in the IMCI area were taken to a health worker compared with 9% in the non-IMCI area. INTERPRETATION: 2 years into the assessment, the results show improvements in the quality of care in health facilities, increases in use of facilities, and gains in the proportion of sick children taken to an appropriate health care provider. These findings are being used to strengthen child health care nationwide. They suggest that low levels of use of health facilities could be improved by investing in quality of care and health systems support.