Levels and trends in mortality and causes of death among women of reproductive age in Bangladesh: Findings from three national surveys.

Background: Information on the mortality rate and proportional cause-specific mortality is essential for identifying diseases of public health importance, design programmes, and formulating policies, but such data on women of reproductive age in Bangladesh is limited. Methods: We analysed secondary data from the 2001, 2010, and 2016 rounds of the nationally representative Bangladesh Maternal Mortality and Health Care Survey (BMMS) to estimate mortality rates and causes of death among women aged 15-49 years. We collected information on causes of death three years prior to each survey using a country-adapted version of the World Health Organization (WHO) verbal autopsy (VA) questionnaire. Trained physicians independently reviewed the VA questionnaire and assigned a cause of death using the International Classification of Diseases (ICD) codes. The analysis included mortality rates and proportional mortality showing overall and age-specific causes of death. Results: The overall mortality rates for women aged 15-49 years decreased over time, from 190 per 100 000 years of observation in the 2001 BMMS, to 121 per 100 000 in the 2010 BMMS, to 116 per 100 000 in the 2016 BMMS. Age-specific mortality showed a similar downward pattern. The three diseases contributing the most to mortality were maternal causes (13-20%), circulatory system diseases (15-23%), and malignancy (14-24%). The relative position of these three diseases changed between the three surveys. From the 2001 BMMS to the 2010 BMMS and subsequently to the 2016 BMMS, the number of deaths from non-communicable diseases (e.g. cardiovascular diseases and malignancies) increased from 29% to 38% to 48%. Maternal causes led to the highest proportion of deaths among 20-34-year-olds in all three surveys (25-32%), while suicide was the number one cause of death for teenagers (19-22%). Circulatory system diseases and malignancy were the two leading causes of death for older women aged 35-49 years (40%-67%). Conclusions: There was a gradual shift in the causes of death from communicable to non-communicable diseases among women of reproductive age in Bangladesh. Suicide as the primary cause of death among teenage girls demands urgent attention for prevention.

Disparities in Risks of Malaria Associated with Climatic Variability among Women, Children and Elderly in the Chittagong Hill Tracts of Bangladesh.

Malaria occurrence in the Chittagong Hill Tracts in Bangladesh varies by season and year, but this pattern is not well characterized. The role of environmental conditions on the occurrence of this vector-borne parasitic disease in the region is not fully understood. We extracted information on malaria patients recorded in the Upazila (sub-district) Health Complex patient registers of Rajasthali in Rangamati district of Bangladesh from February 2000 to November 2009. Weather data for the study area and period were obtained from the Bangladesh Meteorological Department. Non-linear and delayed effects of meteorological drivers, including temperature, relative humidity, and rainfall on the incidence of malaria, were investigated. We observed significant positive association between temperature and rainfall and malaria occurrence, revealing two peaks at 19 °C (logarithms of relative risks (logRR) = 4.3, 95% CI: 1.1-7.5) and 24.5 °C (logRR = 4.7, 95% CI: 1.8-7.6) for temperature and at 86 mm (logRR = 19.5, 95% CI: 11.7-27.3) and 284 mm (logRR = 17.6, 95% CI: 9.9-25.2) for rainfall. In sub-group analysis, women were at a much higher risk of developing malaria at increased temperatures. People over 50 years and children under 15 years were more susceptible to malaria at increased rainfall. The observed associations have policy implications. Further research is needed to expand these findings and direct resources to the vulnerable populations for malaria prevention and control in the Chittagong Hill Tracts of Bangladesh and the region with similar settings.

Variations in disability and quality of life with age and sex between eight lower income and middle-income countries: data from the INDEPTH WHO-SAGE collaboration.

BACKGROUND: Disability and quality of life are key outcomes for older people. Little is known about how these measures vary with age and gender across lower income and middle-income countries; such information is necessary to tailor health and social care policy to promote healthy ageing and minimise disability. METHODS: We analysed data from participants aged 50 years and over from health and demographic surveillance system sites of the International Network for the Demographic Evaluation of Populations and their Health Network in Ghana, Kenya, Tanzania, South Africa, Vietnam, India, Indonesia and Bangladesh, using an abbreviated version of the WHO Study on global AGEing survey instrument. We used the eight-item WHO Quality of Life (WHOQoL) tool to measure quality of life and theWHO Disability Assessment Schedule, version 2 (WHODAS-II) tool to measure disability. We collected selected health status measures via the survey instrument and collected demographic and socioeconomic data from linked surveillance site information. We performed regression analyses to quantify differences between countries in the relationship between age, gender and both quality of life and disability, and we used anchoring vignettes to account for differences in interpretation of disability severity. RESULTS: We included 43 935 individuals in the analysis. Mean age was 63.7 years (SD 9.7) and 24 434 (55.6%) were women. In unadjusted analyses across all countries, WHOQoL scores worsened by 0.13 points (95% CI 0.12 to 0.14) per year increase in age and WHODAS scores worsened by 0.60 points (95% CI 0.57 to 0.64). WHODAS-II and WHOQoL scores varied markedly between countries, as did the gradient of scores with increasing age. In regression analyses, differences were not fully explained by age, socioeconomic status, marital status, education or health factors. Differences in disability scores between countries were not explained by differences in anchoring vignette responses. CONCLUSIONS: The relationship between age, sex and both disability and quality of life varies between countries. The findings may guide tailoring of interventions to individual country needs, although these associations require further study.

Improving performance of the Tariff Method for assigning causes of death to verbal autopsies.

BACKGROUND: Reliable data on the distribution of causes of death (COD) in a population are fundamental to good public health practice. In the absence of comprehensive medical certification of deaths, the only feasible way to collect essential mortality data is verbal autopsy (VA). The Tariff Method was developed by the Population Health Metrics Research Consortium (PHMRC) to ascertain COD from VA information. Given its potential for improving information about COD, there is interest in refining the method. We describe the further development of the Tariff Method. METHODS: This study uses data from the PHMRC and the National Health and Medical Research Council (NHMRC) of Australia studies. Gold standard clinical diagnostic criteria for hospital deaths were specified for a target cause list. VAs were collected from families using the PHMRC verbal autopsy instrument including health care experience (HCE). The original Tariff Method (Tariff 1.0) was trained using the validated PHMRC database for which VAs had been collected for deaths with hospital records fulfilling the gold standard criteria (validated VAs). In this study, the performance of Tariff 1.0 was tested using VAs from household surveys (community VAs) collected for the PHMRC and NHMRC studies. We then corrected the model to account for the previous observed biases of the model, and Tariff 2.0 was developed. The performance of Tariff 2.0 was measured at individual and population levels using the validated PHMRC database. RESULTS: For median chance-corrected concordance (CCC) and mean cause-specific mortality fraction (CSMF) accuracy, and for each of three modules with and without HCE, Tariff 2.0 performs significantly better than the Tariff 1.0, especially in children and neonates. Improvement in CSMF accuracy with HCE was 2.5%, 7.4%, and 14.9% for adults, children, and neonates, respectively, and for median CCC with HCE it was 6.0%, 13.5%, and 21.2%, respectively. Similar levels of improvement are seen in analyses without HCE. CONCLUSIONS: Tariff 2.0 addresses the main shortcomings of the application of the Tariff Method to analyze data from VAs in community settings. It provides an estimation of COD from VAs with better performance at the individual and population level than the previous version of this method, and it is publicly available for use.

A shortened verbal autopsy instrument for use in routine mortality surveillance systems.

BACKGROUND: Verbal autopsy (VA) is recognized as the only feasible alternative to comprehensive medical certification of deaths in settings with no or unreliable vital registration systems. However, a barrier to its use by national registration systems has been the amount of time and cost needed for data collection. Therefore, a short VA instrument (VAI) is needed. In this paper we describe a shortened version of the VAI developed for the Population Health Metrics Research Consortium (PHMRC) Gold Standard Verbal Autopsy Validation Study using a systematic approach. METHODS: We used data from the PHMRC validation study. Using the Tariff 2.0 method, we first established a rank order of individual questions in the PHMRC VAI according to their importance in predicting causes of death. Second, we reduced the size of the instrument by dropping questions in reverse order of their importance. We assessed the predictive performance of the instrument as questions were removed at the individual level by calculating chance-corrected concordance and at the population level with cause-specific mortality fraction (CSMF) accuracy. Finally, the optimum size of the shortened instrument was determined using a first derivative analysis of the decline in performance as the size of the VA instrument decreased for adults, children, and neonates. RESULTS: The full PHMRC VAI had 183, 127, and 149 questions for adult, child, and neonatal deaths, respectively. The shortened instrument developed had 109, 69, and 67 questions, respectively, representing a decrease in the total number of questions of 40-55%. The shortened instrument, with text, showed non-significant declines in CSMF accuracy from the full instrument with text of 0.4%, 0.0%, and 0.6% for the adult, child, and neonatal modules, respectively. CONCLUSIONS: We developed a shortened VAI using a systematic approach, and assessed its performance when administered using hand-held electronic tablets and analyzed using Tariff 2.0. The length of a VA questionnaire was shortened by almost 50% without a significant drop in performance. The shortened VAI developed reduces the burden of time and resources required for data collection and analysis of cause of death data in civil registration systems.

Chronic respiratory symptoms in children following in utero and early life exposure to arsenic in drinking water in Bangladesh.

BACKGROUND: Arsenic exposure via drinking water increases the risk of chronic respiratory disease in adults. However, information on pulmonary health effects in children after early life exposure is limited. METHODS: This population-based cohort study set in rural Matlab, Bangladesh, assessed lung function and respiratory symptoms of 650 children aged 7-17 years. Children with in utero and early life arsenic exposure were compared with children exposed to less than 10 µg/l in utero and throughout childhood. Because most children drank the same water as their mother had drunk during pregnancy, we could not assess only in utero or only childhood exposure. RESULTS: Children exposed in utero to more than 500 µg/l of arsenic were more than eight times more likely to report wheezing when not having a cold [odds ratio (OR) = 8.41, 95% confidence interval (CI): 1.66-42.6, P < 0.01] and more than three times more likely to report shortness of breath when walking on level ground (OR = 3.86, 95% CI: 1.09-13.7, P = 0.02) and when walking fast or climbing (OR = 3.19, 95% CI: 1.22-8.32, P < 0.01]. However, there was little evidence of reduced lung function in either exposure category. CONCLUSIONS: Children with high in utero and early life arsenic exposure had marked increases in several chronic respiratory symptoms, which could be due to in utero exposure or to early life exposure, or to both. Our findings suggest that arsenic in water has early pulmonary effects and that respiratory symptoms are a better marker of early life arsenic toxicity than changes in lung function measured by spirometry.

Challenges to evaluating respiratory syncytial virus mortality in Bangladesh, 2004-2008.

BACKGROUND: Acute lower respiratory illness is the most common cause of death among children, globally. Data are not available to make accurate estimates on the global mortality from respiratory syncytial virus (RSV), specifically. METHODS: Respiratory samples collected from children under 5 years of age during 2004 to 2008 as part of population-based respiratory disease surveillance in an urban community in Dhaka, Bangladesh were tested for RSV, human metapneumovirus (HMPV), human parainfluenza virus (PIV) types 1, 2, and 3, influenza and adenovirus by RT-PCR. Verbal autopsy data were used to identify children who died from respiratory illness in a nearby rural community. Significance of the correlation between detections and community respiratory deaths was determined using Spearman's coefficient. RESULTS: RSV activity occurred during defined periods lasting approximately three months but with no clear seasonal pattern. There was no significant correlation between respiratory deaths and detection of any of the respiratory viruses studied. CONCLUSION: Outbreaks of respiratory viruses may not be associated with deaths in children in the study site; however, the few respiratory deaths observed and community-to-community variation in the timing of outbreaks may have obscured an association. An accurate assessment of respiratory virus-associated deaths will require detections and death data to come from the same location and a larger study population.

Association of antenatal care with facility delivery and perinatal survival - a population-based study in Bangladesh.

BACKGROUND: Antenatal Care (ANC) during pregnancy can play an important role in the uptake of evidence-based services vital to the health of women and their infants. Studies report positive effects of ANC on use of facility-based delivery and perinatal mortality. However, most existing studies are limited to cross-sectional surveys with long recall periods, and generally do not include population-based samples. METHODS: This study was conducted within the Health and Demographic Surveillance System (HDSS) of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) in Matlab, Bangladesh. The HDSS area is divided into an icddr,b service area (SA) where women and children receive care from icddr,b health facilities, and a government SA where people receive care from government facilities. In 2007, a new Maternal, Neonatal, and Child Health (MNCH) program was initiated in the icddr,b SA that strengthened the ongoing maternal and child health services including ANC. We estimated the association of ANC with facility delivery and perinatal mortality using prospectively collected data from 2005 to 2009. Using a before-after study design, we also determined the role of ANC services on reduction of perinatal mortality between the periods before (2005 - 2006) and after (2008-2009) implementation of the MNCH program. RESULTS: Antenatal care visits were associated with increased facility-based delivery in the icddr,b and government SAs. In the icddr,b SA, the adjusted odds of perinatal mortality was about 2-times higher (odds ratio (OR) 1.91; 95% confidence intervals (CI): 1.50, 2.42) among women who received ≤1 ANC compared to women who received ≥3 ANC visits. No such association was observed in the government SA. Controlling for ANC visits substantially reduced the observed effect of the intervention on perinatal mortality (OR 0.64; 95% CI: 0.52, 0.78) to non-significance (OR 0.81; 95% CI: 0.65, 1.01), when comparing cohorts before and after the MNCH program initiation (Sobel test of mediation P < 0.001). CONCLUSIONS: ANC visits are associated with increased uptake of facility-based delivery and improved perinatal survival in the icddr,b SA. Further testing of the icddr,b approach to simultaneously improving quality of ANC and facility delivery care is needed in the existing health system in Bangladesh and in other low-income countries to maximize health benefits to mothers and newborns.

Estimating the burden of maternal and neonatal deaths associated with jaundice in Bangladesh: possible role of hepatitis E infection.

OBJECTIVES: We estimated the population-based incidence of maternal and neonatal mortality associated with hepatitis E virus (HEV) in Bangladesh. METHODS: We analyzed verbal autopsy data from 4 population-based studies in Bangladesh to calculate the maternal and neonatal mortality ratios associated with jaundice during pregnancy. We then reviewed the published literature to estimate the proportion of maternal deaths associated with liver disease during pregnancy that were the result of HEV in hospitals. RESULTS: We found that 19% to 25% of all maternal deaths and 7% to 13% of all neonatal deaths in Bangladesh were associated with jaundice in pregnant women. In the published literature, 58% of deaths in pregnant women with acute liver disease in hospitals were associated with HEV. CONCLUSIONS: Jaundice is frequently associated with maternal and neonatal deaths in Bangladesh, and the published literature suggests that HEV may cause many of these deaths. HEV is preventable, and studies to estimate the burden of HEV in endemic countries are urgently needed.

Injury deaths among people with epilepsy in rural Bangladesh: a retrospective population-based study.

BACKGROUND: Accidental death in people with epilepsy (PWE) has been described in high income settings where the relative risk of death is known to be higher than in the standard population. Population-based studies of injury deaths among PWE in developing countries are uncommon. METHODS: A population-based verbal autopsy study in Matlab, Bangladesh, performed at a health and demographic surveillance system site (mean population 223,886 in 142 villages), was used to assess the possible causes of all deaths. All cases of accidental injury (2005-2008) were evaluated and compared between people with and without a diagnosis of epilepsy. RESULTS: There were 12 accidental deaths among PWE (8 females, age range 12-58 years old) out of a total of 316 deaths due to accidental injuries (3.8% of all injury deaths). Causes of mortality were drowning (n=10) and burns (n=2). The proportion of deaths due to drowning among PWE was significantly higher than that of the standard population (83% (10/12) vs. 7% (21/304), relative risk 12.6 (95% CI, 7.7-20.7, p<0.0001)). Mortality due to injury in PWE occurred at a younger age compared to people without epilepsy (mean difference 20.7 years (95% CI 6.7, 34.3), p<0.004). CONCLUSIONS: There is a high proportion of accidental deaths due to drowning in PWE in Bangladesh compared to the standard population. Given the risk of seasonal flooding and low level of formal education, programs targeting water safety for PWE at all ages should be emphasized, appropriate for level of ability.

Effectiveness of an integrated approach to reduce perinatal mortality: recent experiences from Matlab, Bangladesh.

BACKGROUND: Improving perinatal health is the key to achieving the Millennium Development Goal for child survival. Recently, several reviews suggest that scaling up available effective perinatal interventions in an integrated approach can substantially reduce the stillbirth and neonatal death rates worldwide. We evaluated the effect of packaged interventions given in pregnancy, delivery and post-partum periods through integration of community- and facility-based services on perinatal mortality. METHODS: This study took advantage of an ongoing health and demographic surveillance system (HDSS) and a new Maternal, Neonatal and Child Health (MNCH) Project initiated in 2007 in Matlab, Bangladesh in half (intervention area) of the HDSS area. In the other half, women received usual care through the government health system (comparison area). The MNCH Project strengthened ongoing maternal and child health services as well as added new services. The intervention followed a continuum of care model for pregnancy, intrapartum, and post-natal periods by improving established links between community- and facility-based services. With a separate pre-post samples design, we compared the perinatal mortality rates between two periods--before (2005-2006) and after (2008-2009) implementation of MNCH interventions. We also evaluated the difference-of-differences in perinatal mortality between intervention and comparison areas. RESULTS: Antenatal coverage, facility delivery and cesarean section rates were significantly higher in the post- intervention period in comparison with the period before intervention. In the intervention area, the odds of perinatal mortality decreased by 36% between the pre-intervention and post-intervention periods (odds ratio: 0.64; 95% confidence intervals: 0.52-0.78). The reduction in the intervention area was also significant relative to the reduction in the comparison area (OR 0.73, 95% CI: 0.56-0.95; P = 0.018). CONCLUSION: The continuum of care approach provided through the integration of service delivery modes decreased the perinatal mortality rate within a short period of time. Further testing of this model is warranted within the government health system in Bangladesh and other low-income countries.

Care seeking for fatal illness episodes in neonates: a population-based study in rural Bangladesh.

BACKGROUND: Poor neonatal health is a major contributor to under-five mortality in developing countries. A major constraint to effective neonatal survival programme has been the lack of population level data in developing countries. This study investigated the consultation patterns of caregivers during neonatal fatal illness episodes in the rural Matlab sub-district of eastern Bangladesh. METHODS: Neonatal deaths were identified through a population-based demographic surveillance system in Matlab ICDDR,B maternal and child health (MCH) project area and an adjoining government service area. Trained project staff administered a structured questionnaire on care seeking to mothers at home who had experienced a neonatal death. Univariate, bivariate and binary multivariate logistic regressions were performed to describe care seeking during the fatal illness episode. RESULTS: Of the 365 deaths recorded during 2003 and 2004, 84% died in the early (0-7 days) neonatal period, with the remaining deaths occurring over the subsequent 8 to 28 days. The first resort of care by parents was a qualified doctor or paramedic in 37% of cases, followed by traditional and unqualified health care providers in 25%, while 38% sought no care. Thus, almost two thirds (63%) of neonates who died received only traditional and unqualified care or no care at all during their final illness episode. About 22% sought care from more than one provider, including 6% from 3 or more providers. Such plurality in care seeking was more likely among male infants, in the late neonatal period, and in the MCH project area. CONCLUSIONS: The high proportion of neonatal deaths that had received traditional care or no medical care in a rural area of Bangladesh highlights the need to develop community awareness about prompt medical care seeking for neonatal illnesses and to improve access to effective health care. Integration of traditional care providers into mainstream health programs should also be considered.

A comparison of physicians and medical assistants in interpreting verbal autopsy interviews for allocating cause of neonatal death in Matlab, Bangladesh: can medical assistants be considered an alternative to physicians?

OBJECTIVE: This study assessed the agreement between medical physicians in their interpretation of verbal autopsy (VA) interview data for identifying causes of neonatal deaths in rural Bangladesh. METHODS: The study was carried out in Matlab, a rural sub-district in eastern Bangladesh. Trained persons conducted the VA interview with the mother or another family member at the home of the deceased. Three physicians and a medical assistant independently reviewed the VA interviews to assign causes of death using the International Classification of Diseases - Tenth Revision (ICD-10) codes. A physician assigned cause was decided when at least two physicians agreed on a cause of death. Cause-specific mortality fraction (CSMF), kappa (k) statistic, sensitivity, specificity, and positive predictive values were applied to compare agreement between the reviewers. RESULTS: Of the 365 neonatal deaths reviewed, agreement on a direct cause of death was reached by at least two physicians in 339 (93%) of cases. Physician and medical assistant reviews of causes of death demonstrated the following levels of diagnostic agreement for the main causes of deaths: for birth asphyxia the sensitivity was 84%, specificity 93%, and kappa 0.77. For prematurity/low birth weight, the sensitivity, specificity, and kappa statistics were, respectively, 53%, 96%, and 0.55, for sepsis/meningitis they were 48%, 98%, and 0.53, and for pneumonia they were 75%, 94%, and 0.51. CONCLUSION: This study revealed a moderate to strong agreement between physician- assigned and medical assistant- assigned major causes of neonatal death. A well-trained medical assistant could be considered an alternative for assigning major causes of neonatal deaths in rural Bangladesh and in similar settings where physicians are scarce and their time costs more. A validation study with medically confirmed diagnosis will improve the performance of VA for assigning cause of neonatal death.

Protection from annual flooding is correlated with increased cholera prevalence in Bangladesh: a zero-inflated regression analysis.

BACKGROUND: Alteration of natural or historical aquatic flows can have unintended consequences for regions where waterborne diseases are endemic and where the epidemiologic implications of such change are poorly understood. The implementation of flood protection measures for a portion of an intensely monitored population in Matlab, Bangladesh, allows us to examine whether cholera outcomes respond positively or negatively to measures designed to control river flooding. METHODS: Using a zero inflated negative binomial model, we examine how selected covariates can simultaneously account for household clusters reporting no cholera from those with positive counts as well as distinguishing residential areas with low counts from areas with high cholera counts. Our goal is to examine how residence within or outside a flood protected area interacts with the probability of cholera presence and the effect of flood protection on the magnitude of cholera prevalence. RESULTS: In Matlab, living in a household that is protected from annual monsoon flooding appears to have no significant effect on whether the household experiences cholera, net of other covariates. However, counter-intuitively, among households where cholera is reported, living within the flood protected region significantly increases the number of cholera cases. CONCLUSIONS: The construction of dams or other water impoundment strategies for economic or social motives can have profound and unanticipated consequences for waterborne disease. Our results indicate that the construction of a flood control structure in rural Bangladesh is correlated with an increase in cholera cases for residents protected from annual monsoon flooding. Such a finding requires attention from both the health community and from governments and non-governmental organizations involved in ongoing water management schemes.

Earning their keep: the productivity of older women and men in rural Bangladesh.

In Bangladesh, being active and able to participate in productive activities is often essential to ensure ongoing health and survival. This study aims to describe and explore the patterns of participation in productive activities by older people in Matlab, a rural area of Bangladesh. Data from a cross sectional survey of people over 60 years of age was utilised. Six hundred and twenty five men and women participated in home based interviews providing information about their participation in productive activities including work, domestic activities and community groups. Overall, 94.4% of subjects reported participation in at least one productive activity. Men were the main participants in paid work and community groups, with 62% reporting engagement in paid work and 44% contributing to community groups. Both men (95.4%) and women (91.9%) reported performing at least one domestic activity. Performance of higher numbers of domestic tasks was associated with being younger, female, not requiring any assistance with self care, not married, not living with any children and earning between 100-999 Bangladesh Taka in the past month. Participation in community groups was low with only 26% of the sample reporting any involvement. This study indicates a high level of productivity in the older population in Matlab which benefits the individual, the family and the wider community. The safety and suitability of typical productive activities needs further investigation, in order to inform strategies protecting the older population from the effects of over work and harmful activities.

Spatio-temporal clustering of cholera: the impact of flood control in Matlab, Bangladesh, 1983-2003.

Introducing flood control to an area of endemic waterborne diseases could have significant impacts on spatio-temporal occurrence of cholera. Using 21-year data from Bangladesh, we conducted cluster analysis to explore changes in spatial and temporal distribution of cholera incidence since the construction of flood control structures. Striking changes in temporal cluster patterns emerged, including a shift from dry-season to rainy-season clusters following flood protection and delayed clustering inside the protected areas. Spatial differences in pre-flood protection and post-protection cholera clusters are weaker. Changes in spatio-temporal cholera clustering, associated with implementation of flood protection strategies, could affect local cholera prevention efforts.

Mainstreaming nutrition in maternal, newborn and child health: barriers to seeking services from existing maternal, newborn, child health programmes.

In the light of mainstreaming nutrition programs into health services, this review article approaches the issue of barriers to existing maternal child health programs from both theoretical and applied perspectives. It begins with a discussion of salient literature on models of health service utilization. The mid-section of the paper presents the results of a review of research studies that illuminate the barriers to care. Categorical themes emerged from the review of studies in the form of barriers based on geographic factors, temporal factors, a myriad of socio-cultural factors, financial factors and quality of care. The discussion focuses on the need to overcome existing restrictions to health services in order to facilitate initiatives to mainstream nutrition and achieve Millennium Development Goal #1.

The International Network on Public Health and Aging (INOPA): introducing a life course perspective to the public health agenda.

In this paper, we present an international network of researchers from projects examining the human aging process and its consequences. It is both vital and urgent to include aging and a life course perspective on the public health agenda, particularly in low-income countries. By announcing the network in a publication, we wish not just to position the network but, more importantly, to attract the attention of other potential collaborators either at the project, institutional, decision making, or applied level.

Maternal health and care-seeking behavior in Bangladesh: findings from a national survey.

CONTEXT: Although the reduction of maternal mortality levels is a key Millennium Development Goal, community-based evidence on obstetric complications and maternal care-seeking behavior remains limited in low-resource countries. METHODS: This study presents an overview of key findings from the 2001 Bangladesh Maternal Health Services and Maternal Mortality Survey of ever-married women aged 13-49. The survey collected data on the prevalence of obstetric complications, women's knowledge of life-threatening complications, treatment-seeking behavior and reasons for delay in seeking medical care. RESULTS: Bangladeshi women report low but increasing use of antenatal care, as well as low rates of delivery in a health facility or with the assistance of a skilled provider. Although almost half of women reported having one or more complications during pregnancy that they perceived as life threatening, only one in three sought treatment from a qualified provider. More than three-fourths of women with the time-sensitive complications of convulsions or excessive bleeding either failed to seek any treatment or sought treatment from an unqualified provider. The principal reason cited for failing to seek care for life-threatening complications was concern over medical costs, and pronounced socioeconomic disparities were found for maternal care-seeking behavior in both urban and rural Bangladesh. CONCLUSIONS: Despite these gaps in access to skilled delivery and effective emergency obstetric care, some progress has been made in reducing maternal mortality levels. Improved obstetric care and declining levels of fertility and unwanted pregnancy may have played critical roles in addressing the maternal health care needs of Bangladeshi women.