Dietary vitamin A intake and its major food sources among rural pregnant women of South-West Bangladesh.

The study aimed to estimate the dietary intake of vitamin A and its major food sources among rural pregnant women from the southwest region of Bangladesh. A multi-stage random cluster sampling method was used to select the respondents (N = 1012). A semi-structured questionnaire was used to collect the data, and statistical analysis was conducted using IBM SPSS 20.0. The mean age of the respondents was 23.27 ± 5.23 years, and the majority were in their second (48%) and third trimester (49%). The mean dietary intake of vitamin A was 392 ± 566 µg Retinol Activity Equivalent (RAE)/day (51% of Recommended Dietary Allowance). The contribution of ß-carotene (plant source) and retinol (animal source) in vitamin A intake was about 60% and 40%, respectively. The major ß-carotene contributing food groups were vegetables (dark and light) and tubers, and food items were colocasia, potato, beans, brinjal, and ripe tomatoes. On the other hand, the major retinol-contributing food groups were fish, eggs, and milk, and food items were small fish, Rui (carp) fish, and cow's milk. It was also observed that the consumption of food items from ß-carotene and retinol-contributing food groups did not differ significantly among the three groups of respondents, but the variations in the amount of the different food items consumed were significant. Dietary vitamin A intake is low among pregnant women in the South-West region of Bangladesh. Hence, they are at a greater risk of adverse materno-fetal health outcomes associated with vitamin A deficiency.

The Bangladesh Maternal Health Voucher Scheme: impact on completeness of antenatal care provision.

This study aimed to assess completeness of antenatal care coverage following implementation of a voucher scheme for maternal health in Bangladesh. The investigation used interview data from a survey conducted in Bangladesh in 2017 of 2400 randomly selected women aged 15-49 with children aged 0-23 months in four geographical areas where voucher scheme implementation was underway. Of these women, 1944 had attended at least one antenatal clinic visit so were included in the analysis. A 'completeness index' for antenatal visits was constructed as an outcome variable based on recall of thirteen elements of care. Bivariate analysis against independent variables of interest was carried out and multivariate linear regression models developed to examine the influence of voucher scheme participation on completeness of antenatal care adjusting for socio-demographic characteristics. Voucher scheme membership was associated with higher 'completeness index' scores, with a mean score of 185.2±101.0 for voucher recipients and 139.6 ± 93.3 for non-recipients (p<0.001). Scheme membership reduced the differentials associated with health facility type and socioeconomic status. Women from the lowest socioeconomic group who were voucher recipients received substantially more components of antenatal care (mean score: 159.6±82.1) compared with non-recipients (mean score: 115.7±83.0). This favourable effect of voucher scheme membership on the most vulnerable socioeconomic group remained significant after adjusting for educational status. The Bangladesh voucher scheme model has the potential to maximize gains in maternal and newborn health through enhancing the completeness of service provision.

Correction to: Association of Time since Migration from Rural to Urban Slums and Maternal and Child Outcomes: Dhaka (North and South) and Gazipur City Corporations.

There is an error in Fig 2 in this article: There should not be a box indicating p-values.

Association of Time since Migration from Rural to Urban Slums and Maternal and Child Outcomes: Dhaka (North and South) and Gazipur City Corporations.

This study analyzes data from a new Urban Health and Demographic Surveillance (UHDSS) in five slums in Dhaka (North and South) and Gazipur City Corporations to examine the relationship between migration status and maternal and child health service utilization. Migration status was determined by duration in urban slums (<= 9.99 years, 10-19.99 years, 20+ years, and urban-born). Compared to those born in the city, migrants were characterized by significant disadvantages in every maternal, neonatal, and child health (MNCH) indicator under study, including antenatal care, facility-based delivery, doctor-assisted delivery, child immunization, caesarean-section delivery, and use of modern contraceptives. We found that the level of service coverage among migrants gradually converged-but did not fully converge-to that of the urban-born with increasing duration in the city. We observed a strong positive association between wealth and total MNCH coverage, with a more modest association with higher levels of schooling attainment. Women who were engaged in market employment were less likely to receive adequate coverage, suggesting a tradeoff between livelihood attainment and mother-and-child health. After controlling for these socioeconomic and neighborhood variations in coverage, the duration gradient was diminished but still significant. In line with existing studies of healthcare access, this study highlights the persistent and widespread burden of unequal access to maternal and child health care facing migrants to slum areas, even relative to the overall disadvantages experienced in informal settlements.

Does healthcare voucher provision improve utilisation in the continuum of maternal care for poor pregnant women? Experience from Bangladesh.

Background: Improving maternal health is a major development goal, with ambitious targets set for high-mortality countries like Bangladesh. Following a steep decline in the maternal mortality ratio over the past decade in Bangladesh, progress has plateaued at 196/100,000 live births. A voucher scheme was initiated in 2007 to reduce financial, geographical and institutional barriers to access for the poorest.Objective: The current paper reports the effect of vouchers on the use of continuum of maternal care.Methods: Cross-sectional surveys were carried out in the Chattogram and Sylhet divisions of Bangladesh in 2017 among 2400 women with children aged 0-23 months. Using Cluster analysis utilisation groups for antenatal care, facility delivery and postnatal care were formed. Clusters were regressed on voucher receipt to identify the underlying relationship between voucher receipt and utilisation of care while controlling for possible confounders.Results: Four clusters with varying levels of utilisation were identified. A significantly higher proportion of voucher-recipients belonged to the high-utilisation cluster compared to non-voucher recipients (43.5% vs. 15.4%). For the poor voucher recipients, the probability of belonging to the high-utilisation cluster was higher compared to poor non-voucher recipients (33.3% vs. 6.8%) and the probability of being in the low-utilisation cluster was lower than poor non-voucher recipients (13.3% vs. 55.4%).Conclusion: The voucher programme enhanced uptake of the complete continuum of maternal care and the benefits extended to the most vulnerable women. However, a lack of continued transition through the continuum of maternal care was identified. This insight can assist in designing effective interventions to prevent intermittent or interrupted care-seeking. Programmes that improve access to quality healthcare in pregnancy, childbirth and the postnatal period can have wide-ranging benefits. A coherent continuum-based approach to understanding maternal care-seeking behaviour is thus expected to have a greater impact on maternal, newborn and child health outcomes.

Socio-demographic, health and institutional determinants of caesarean section among the poorest segment of the urban population: Evidence from selected slums in Dhaka, Bangladesh.

Caesarean sections (CS) is the most common lifesaving surgeries for obstructed labour and other emergency obstetrical conditions. The WHO had recommended ideal rate for CS to be between 5% and 15%. The rate higher than 15% indicates overused other than lifesaving. Bangladesh has experienced a dramatic increase in CS delivery from 4% in 2004 to 23% in 2014. This increase is elevated by the several factors including maternal education, maternal request or elective CS, and by the urban richest population. However, little is known about the use CS by the urban poorest population. Therefore, the study aimed to examine and identify the factors associated with CS among the urban disadvantaged section of the population. A total of 1063 randomly chosen women aged 15-49 years from the population of 121,912 residing five-different slums were interviewed during November-December 2016. CS delivery was considered as outcome variable. Both bivariate and multivariable statistical analyses were carried-out. We performed logistic regression analyses to examine the net-effect of independent variables on outcome variable. Over 25% of total deliveries and 50% of facility-based deliveries were CS. The odds of CS delivery was 3.4-fold greater among better-off women than poorest. Women who had 4 + ANC checks-up during pregnancy had a 2-fold higher odds of CS delivery than women of ANC check-up. In private facilities, 76% of births were delivered as CS, followed by 51% in public facilities and 24% in NGO facilities. The likelihood of CS delivery in private facilities was 9.2-fold greater than NGO facilities after controlling for women socio-demographic, pregnancy and delivery characteristics. Thus, the high use of CS is largely associated with private facility, ANC visits and household wealth. Therefore, the Government of Bangladesh should take immediate actions by designing new policies and regulations to ensure CS for the lifesaving condition, not for financial gain.

Who enrols in voluntary micro health insurance schemes in low-resource settings? Experience from a rural area in Bangladesh.

BACKGROUND: Micro health insurance (MHI) has proved to be a potential health-financing tool for many developing countries. Bangladesh also included MHI in its current health-financing strategy which aims to achieve universal health coverage. However, low uptake, low renewal and high dropouts have historically challenged financial sustainability of these schemes. OBJECTIVE: This study aims to identify factors influencing people from low-resource settings, particularly those from Bangladesh, to enrol in MHI schemes. METHODS: The study analyses the 'Amader Shasthya' MHI scheme operating in Chakaria, a sub-district under Cox's Bazar district, Bangladesh. A household survey was carried out during May-June 2016 among 2,000 households from the scheme coverage area. The Outreville's insurance-demand framework was used to identify enrolment influencing factors. Multivariate logistic regression analysis was carried out to identify significant influencing factors of enrolment. RESULTS: Enrolment influencing factors were identified in four dimensions: economic, socio-cultural, demographic and structural. Households with the main income earner having 10+ years of schooling (odds 1.9 [CI 1.2-2.9] compared to illiterate), having financial literacy (odds 1.5 [CI 1.2-1.8] compared to financially illiterate) and being a public/private service holder (odds 1.6 [CI 1.1-2.4] compared to menial labour) were more likely to enrol. Membership in development programmes of NGOs also influenced enrolment decision significantly (odds 1.3 [CI 1.0-1.5]). The presence of chronic illness in household encouraged enrolment (odds 1.5 [CI 1.2-1.8]). Households living closer to health centres were more likely to enrol (odds 2.1 [CI 1.6-2.7]) compared to those living further away. CONCLUSION: The findings are expected to have significant implications in terms of designing similar health insurance schemes, particularly in terms of designing demand-driven and context adapted schemes that have greater potential to attract a larger client pool, ensure effective risk pooling and eventually expedite the achievement of universal health coverage in low-resource settings.

Sociodemographic and geographical inequalities in under- and overnutrition among children and mothers in Bangladesh: a spatial modelling approach to a nationally representative survey.

OBJECTIVE: To investigate the sociodemographic and geographical variation in under- and overnutrition prevalence among children and mothers. DESIGN: Data from the 2014 Bangladesh Demographic and Health Survey were analysed. Stunting and wasting for children and BMI<18·5 kg/m2 for mothers were considered as undernutrition; overweight was considered as overnutrition for both children and mothers. We estimated the prevalence and performed simple logistic regression analyses to assess the associations between outcome variables and predictors. Bayesian spatial models were applied to estimate region-level prevalence to identify the regions (districts) prone to under- and overnutrition.Settings/SubjectsChildren aged<5 years and their mothers aged 15-49 years in Bangladesh. RESULTS: A significant difference (P<0·001) was observed in both under- and overnutrition prevalence between poor and rich. A notable regional variation was also observed in under- and overnutrition prevalence. Stunting prevalence ranged from 20·3 % in Jessore to 56·2 % in Sunamgonj, wasting from 10·6 % in Dhaka to 19·2 % in Bhola, and overweight from 0·8 % in Shariatpur to 2·6 % in Dhaka. Of the sixty-four districts, twelve had prevalence of stunting and thirty-two districts had prevalence of wasting higher than the WHO critical threshold levels. Similarly, fifty-three districts had prevalence of maternal underweight higher than the national level. In contrast, the prevalence of overweight was comparatively high in the industrially equipped metropolitan districts. CONCLUSIONS: Observed sociodemographic and geographical inequalities imply slow progress in the overall improvement of both under- and overnutrition. Therefore, effective intervention programmes and policies need to be designed urgently targeting the grass-roots level of such regions.

Socioeconomic inequalities in under-five mortality in rural Bangladesh: evidence from seven national surveys spreading over 20 years.

BACKGROUND: Socioeconomic inequality in health and mortality remains a disturbing reality across nations including Bangladesh. Inequality drew renewed attention globally. Bangladesh though made impressive progress in health, it makes an interesting case for learning. This paper examined the trends and changing pattern of socioeconomic inequalities in under-five mortality in rural Bangladesh. It also examined whether mother's education had any effect in reducing socioeconomic inequalities. METHODS: Data from rural samples of seven Bangladesh Demographic Health Surveys, carried out so far, were used. Children born alive during 5 years preceding the surveys were included in the analysis. Univariate, bivariate and multivariate analyses were carried out. RESULTS: Under-five mortality rate steadily declined over the years from 128/1000 in 1994 to 48 in 2014. Females had 8% lower mortality rates than males. Children of mothers with no schooling had 1.88 times higher mortality than those whose mother had six or more years of schooling. Similarly, children from low asset category households had on an average 1.17 times higher mortality rate than those from high asset category households. Inequality by mother's education disappeared in the recent years, and inequality by household socioeconomic condition persisted all through. The pattern of inequality by sex, mother's education, and household socioeconomic status was not changed statistically significantly over the years, and mothers' education did not reduce socioeconomic inequalities. DISCUSSION: The reduction in mortality was consistent with changes in the proximate determinants of child survival in the country. Proximate determinants included maternal factors, environmental contamination, nutrient deficiency, personal illness control, and injury. Health and population programmes have been effective in increasing immunization coverage, use of ORS for managing diarrhoeal diseases, and increasing contraceptive use. Development activities on the other hand raised the literacy, especially among females, demand for modern health services, and reduction of poverty. However, socioeconomic inequality still exists in both under-five mortality and proximate determinants of child survival. CONCLUSIONS: The socioeconomic inequality in under-five mortality is showing resistance against further reduction. An assessment of the adequacy of the existing programmes taking the proximate determinants of child survival into consideration will be useful for further improvement.

Socioeconomic and programmatic determinants of renewal of membership in a voluntary micro health insurance scheme: evidence from Chakaria, Bangladesh.

BACKGROUND: Out-of-pocket (OOP) healthcare expenditure is a major obstacle for achieving universal health coverage in low-income countries including Bangladesh. Sixty-three percent of the USD 27 annual per-capita healthcare expenditure in Bangladesh comes from individuals' pockets. Although health insurance is a financial tool for reducing OOP, use of such tools in Bangladesh has been limited to some small-scale voluntary micro health insurance (MHI) schemes run by non-governmental organizations (NGO). The MHI, however, can orient people on health insurance concept and provide learning for product development, implementation, barriers to enrolment, membership renewal, and other operational challenges and solutions. Keeping this in mind, icddr,b in 2012 initiated a pilot MHI, Amader Shasthya, in Chakaria, Bangladesh. This paper explores the determinants of membership renewal in this scheme, which is a perpetual challenge for MHI. OBJECTIVE: Identify socioeconomic and programmatic determinants and their effects on membership renewal in a voluntary MHI scheme. METHODS: Data came from the online management information system of the scheme and Health and Demographic Surveillance System of Chakaria, covering the period February 2012-May 2015. Association between renewal and independent variables was examined using cross-tabular and logistic regression analyses. RESULTS: Nearly 20% of households in the catchment area ever enroled in the scheme, and 38% renewed membership over the initial 3 years of operation. Frequency of consultation with healthcare providers, benefits received, proximity of member's residence to health facility, socioeconomic status, educational level, and age of the household head showed significant positive association with renewal of membership. CONCLUSIONS: Villagers' enrolment in the scheme indicated that even in poor economic and literacy conditions people can be motivated to enrol in insurance schemes. Degree of service utilization and benefits received can greatly enhance the probability of membership renewal, which can be ensured with good quality of services and ease of access.

Health literacy in a community with low levels of education: findings from Chakaria, a rural area of Bangladesh.

BACKGROUND: Health literacy (HL) helps individuals to make effective use of available health services. In low-income countries such as Bangladesh, the less than optimum use of services could be due to low levels of HL. Bangladesh's health service delivery is pluralistic with a mix of public, private and informally trained healthcare providers. Emphasis on HL has been inadequate. Thus, it is important to assess the levels of HL and service utilization patterns. The findings from this study aim to bridge the knowledge gap. MATERIALS AND METHODS: The data for this study came from a cross-sectional survey carried out in September 2014, in Chakaria, a rural area in Bangladesh. A total of 1500 respondents were randomly selected from the population of 80,000 living in the Chakaria study area of icddr, b (International Centre for Diarrhoeal Disease Research, Bangladesh). HL was assessed in terms of knowledge of existing health facilities and sources of information on health care, immunization, diabetes and hypertension. Descriptive and cross-tabular analyses were carried out. RESULTS: Chambers of the rural practitioners of allopathic medicine, commonly known as 'village doctors', were mentioned by 86% of the respondents as a known health service facility in their area, followed by two public sector community clinics (54.6%) and Union Health and Family Welfare Centres (28.6%). Major sources of information on childhood immunization were government health workers. Almost all of the respondents had heard about diabetes and hypertension (97.4% and 95.4%, respectively). The top three sources of information for diabetes were neighbours (85.7%), followed by relatives (27.9%) and MBBS (Bachelor of Medicine and Bachelor of Surgery) doctors (20.4%). For hypertension, the sources were neighbours (78.0%), followed by village doctors (38.2%), MBBS doctors (23.2%) and relatives (15%). The proportions of respondents who knew diabetes and hypertension control measures were 40.9% and 28.0%, respectively. More females knew about the control of diabetes (44.4% to 36.6%) and hypertension (31.1% to 24.2%) than males. CONCLUSIONS: A low level of HL in terms of modern health service facilities, diabetes and hypertension clearly indicated the need for a systematic HL programme. The relatively high levels of literacy concerning immunization show that it is possible to enhance HL in areas with low levels of education through systematic awareness-raising programmes, which could result in higher service coverage.

Prevalence, pattern and sociodemographic differentials in smokeless tobacco consumption in Bangladesh: evidence from a population-based cross-sectional study in Chakaria.

BACKGROUND: The health hazards associated with the use of smokeless tobacco (SLT) are similar to those of smoking. However, unlike smoking, limited initiatives have been taken to control the use of SLT, despite its widespread use in South and Southeast Asian countries including Bangladesh. It is therefore important to examine the prevalence of SLT use and its social determinants for designing appropriate strategies and programmes to control its use. OBJECTIVE: To investigate the use of SLT in terms of prevalence, pattern and sociodemographic differentials in a rural area of Bangladesh. DESIGN: Population-based cross-sectional household survey. SETTING AND PARTICIPANTS: A total of 6178 individuals aged ≥13 years from 1753 households under the Chakaria HDSS area were interviewed during October-November 2011. METHODS: The current use of SLT, namely sadapatha (dried tobacco leaves) and zarda (industrially processed leaves), was used as the outcome variable. The crude and net associations between the sociodemographic characteristics of respondents and the outcome variables were examined using cross-tabular and multivariable logistic regression analysis, respectively. RESULTS: 23% of the total respondents (men: 27.0%, women: 19.3%) used any form of SLT. Of the respondents, 10.4% used only sadapatha,13.6% used only zarda and 2.2% used both. SLT use was significantly higher among men, older people, illiterate, ever married, day labourers and relatively poorer respondents. The odds of being a sadapatha user were 3.5-fold greater for women than for men and the odds of being a zarda user were 3.6-fold greater for men than for women. CONCLUSIONS: The prevalence of SLT use was high in the study area and was higher among socioeconomically disadvantaged groups. The limitation of the existing regulatory measures for controlling the use of non-industrial SLT products should be understood and discussion for developing new strategies should be a priority.