Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh.

There is an unmet need for phototherapy treatment in low- and middle-income countries (LMICs) to prevent disability and death of newborns with neonatal hyperbilirubinemia. Home phototherapy deployed by community health workers (CHWs) in LMICs may help increase access to essential newborn postnatal care in a more acceptable way for families and lead to an increase in indicated treatment rates for newborns with hyperbilirubinemia. We aimed to investigate the operational feasibility and acceptability of a CHW-led home phototherapy intervention in a rural sub-district of Bangladesh for families and CHWs where home delivery was common and a treatment facility for neonatal hyperbilirubinemia was often more than two hours from households. We enrolled 23 newborns who were ≥ 2 kg in weight and ≥ 35 weeks gestational age, without clinical danger signs, and met the American Academy of Pediatric treatment criteria for phototherapy for hyperbilirubinemia. We employed a mixed-method investigation to evaluate the feasibility and acceptability of home phototherapy through surveys, in-depth interviews and focus group discussions with CHWs, mothers, and grandparents. Mothers and family members found home phototherapy worked well, saved them money, and was convenient and easy to operate. CHWs found it feasible to deploy home phototherapy and identified hands-on training, mHealth job aids, a manageable workload, and prenatal education as facilitating factors for implementation. Feasibility and acceptability concerns were limited amongst parents and included: a lack of confidence in CHWs' skills, fear of putting newborn infants in a phototherapy device, and unreliable home power supply. CHW-led home phototherapy was acceptable to families and CHWs in rural Bangladesh. Further investigation should be done to determine the impact of home phototherapy on treatment rates and on preventing morbidity associated with neonatal hyperbilirubinemia. Clinical Trial (CT) registration ID: NCT03933423, full protocol can be accessed at https://doi.org/10.1186/s13102-024-00824-6 . Name of the trial registry: clinicaltrials.gov. Clinical Trial (CT) registration Date: 01/05/2019.

Perception and experiences of adolescent mothers and communities in caring for their preterm babies: findings from an in-depth study in rural Bangladesh.

BACKGROUND: A significant concern for Bangladesh is the high prevalence of adolescent pregnancy and the associated negative consequences for mother and baby, including a teen-related increased risk of preterm birth (PTB). Bangladesh also has one of the highest incidences of PTB (19%). Despite these high numbers of adolescent pregnancies and PTB, little is reported about the experiences of adolescent mothers in caring for their preterm babies, and the interventions needed to support them. The aim of this study was to explore gaps and opportunities for improved care for preterm babies among adolescent mothers and communities in rural Bangladesh. METHODS: We conducted a qualitative study in rural villages of Baliakandi sub-district of Bangladesh. Data collection involved in-depth interviews with adolescent mothers of premature and term babies, adult mothers with premature babies, and family members (n = 36); focus groups with community members (n = 5); and key informant interviews with healthcare providers (n = 13). Adolescent mothers with term and adult mothers with PTBs were included to elicit similarities and differences in understanding and care practices of PTB. A thematic approach was used for data analysis. RESULTS: We explored two major themes- perceptions and understanding of PTB; care practices and care-seeking for illnesses. We observed gaps and variations in understanding of preterm birth (length of gestation, appearance, causes, problems faced) and care practices (thermal management, feeding, weight monitoring) among all, but particularly among adolescents. Immediate natal and marital-kins were prominent in the narratives of adolescents as sources of informational and instrumental support. The use of multiple providers and delays in care-seeking from trained providers for sick preterm babies was noted, often modulated by the perception of severity of illness, cost, convenience, and quality of services. Health systems challenges included lack of equipment and trained staff in facilities to provide special care to preterm babies. CONCLUSION: A combination of factors including local knowledge, socio-cultural practices and health systems challenges influenced knowledge of, and care for, preterm babies among adolescent and adult mothers. Strategies to improve birth outcomes will require increased awareness among adolescents, women, and families about PTB and improvement in quality of PTB services at health facilities.

Burden of child mortality from malaria in high endemic areas: Results from the CHAMPS network using minimally invasive tissue sampling.

BACKGROUND: Malaria is a leading cause of childhood mortality worldwide. However, accurate estimates of malaria prevalence and causality among patients who die at the country level are lacking due to the limited specificity of diagnostic tools used to attribute etiologies. Accurate estimates are crucial for prioritizing interventions and resources aimed at reducing malaria-related mortality. METHODS: Seven Child Health and Mortality Prevention Surveillance (CHAMPS) Network sites collected comprehensive data on stillbirths and children <5 years, using minimally invasive tissue sampling (MITS). A DeCoDe (Determination of Cause of Death) panel employed standardized protocols for assigning underlying, intermediate, and immediate causes of death, integrating sociodemographic, clinical, laboratory (including extensive microbiology, histopathology, and malaria testing), and verbal autopsy data. Analyses were conducted to ascertain the strength of evidence for cause of death (CoD), describe factors associated with malaria-related deaths, estimate malaria-specific mortality, and assess the proportion of preventable deaths. FINDINGS: Between December 3, 2016, and December 31, 2022, 2673 deaths underwent MITS and had a CoD attributed from four CHAMPS sites with at least 1 malaria-attributed death. No malaria-attributable deaths were documented among 891 stillbirths or 924 neonatal deaths, therefore this analysis concentrates on the remaining 858 deaths among children aged 1-59 months. Malaria was in the causal chain for 42.9% (126/294) of deaths from Sierra Leone, 31.4% (96/306) in Kenya, 18.2% (36/198) in Mozambique, 6.7% (4/60) in Mali, and 0.3% (1/292) in South Africa. Compared to non-malaria related deaths, malaria-related deaths skewed towards older infants and children (p < 0.001), with 71.0% among ages 12-59 months. Malaria was the sole infecting pathogen in 184 (70.2%) of malaria-attributed deaths, whereas bacterial and viral co-infections were identified in the causal pathway in 24·0% and 12.2% of cases, respectively. Malnutrition was found at a similar level in the causal pathway of both malaria (26.7%) and non-malaria (30.7%, p = 0.256) deaths. Less than two-thirds (164/262; 62.6%) of malaria deaths had received antimalarials prior to death. Nearly all (98·9%) malaria-related deaths were deemed preventable. INTERPRETATION: Malaria remains a significant cause of childhood mortality in the CHAMPS malaria-endemic sites. The high bacterial co-infection prevalence among malaria deaths underscores the potential benefits of antibiotics for severe malaria patients. Compared to non-malaria deaths, many of malaria-attributed deaths are preventable through accessible malaria control measures.

Serosurveillance among urban slum and non-slum populations immunized with COVID-19 vaccines in Bangladesh.

Using two rounds of serosurveillance, we aimed to observe the COVID-19 vaccination status and the dynamics of antibody responses to different vaccines among urban slum and non-slum populations of Bangladesh. Adults (>18 years) and children (10-17 years) were enrolled in March and October 2022. Data including COVID-19 vaccine types and dosage uptake were collected. SARS-CoV-2 spike (S)-specific antibodies were measured in blood. The proportion of vaccinated children was significantly lower among slum than non-slum populations. Two doses of vaccines showed an increase in the level of anti-S-antibodies up to 2 months, followed by reduced levels at 2-6 months and a resurgence at 6-12 months. Children showed significantly higher anti-S-antibodies after two doses of the Pfizer-BioNTech vaccine than adults; however, after 6 months, the level of antibodies declined in younger children (10 - < 12 years). In a mixed vaccine approach, mRNA vaccines contributed to the highest antibody response whether given as the first two doses or as the third dose. Our findings emphasized the need for increasing the coverage of COVID-19 vaccination among slum children and booster dosing among all children. The use of mRNA vaccines in the mixed vaccination approach was found to be useful in boosting the antibody response to SARS-CoV-2.

The effectiveness of a government-sponsored health protection scheme in reducing financial risks for the below-poverty-line population in Bangladesh.

The Government of Bangladesh is piloting a non-contributory health protection scheme called Shasthyo Surokhsha Karmasuchi (SSK) to increase access to quality essential healthcare services for the below-poverty-line (BPL) population. This paper assesses the effect of the SSK scheme on out-of-pocket expenditure (OOPE) for healthcare, catastrophic health expenditure (CHE) and economic impoverishment of the enrolled population. A comparative cross-sectional study was conducted in Tangail District, where the SSK was implemented. From August 2019 to March 2020, a total of 2315 BPL households (HHs) (1170 intervention and 1145 comparison) that had at least one individual with inpatient care experience in the last 12 months were surveyed. A household is said to have incurred CHE if their OOPE for healthcare exceeds the total (or non-food) HH's expenditure threshold. Multiple regression analysis was performed using OOPE, incidence of CHE and impoverishment as dependent variables and SSK membership status, actual BPL status and benefits use status as the main explanatory variables. Overall, the OOPE was significantly lower (P < 0.01) in the intervention areas (Bangladeshi Taka (BDT) 23 366) compared with the comparison areas (BDT 24 757). Regression analysis revealed that the OOPE, CHE incidence at threshold of 10% of total expenditure and 40% of non-food expenditure and impoverishment were 33% (P < 0.01), 46% (P < 0.01), 42% (P < 0.01) and 30% (P < 0.01) lower, respectively, in the intervention areas than in the comparison areas. Additionally, HHs that utilized SSK benefits experienced even lower OOPE by 92% (P < 0.01), CHE incidence at 10% and 40% threshold levels by 72% (P < 0.01) and 59% (P < 0.01), respectively, and impoverishment by 27% at 10% level of significance. These findings demonstrated the significant positive effect of the SSK in reducing financial burdens associated with healthcare utilization among the enrolled HHs. This illustrates the importance of the nationwide scaling up of the scheme in Bangladesh to reduce the undue financial risk of healthcare utilization for those in poverty.

Trends and inequity in improved sanitation facility utilisation in Bangladesh: Evidence from Bangladesh Demographic and Health Surveys.

Improved sanitation is indispensable to human health. However, lack of access to improved sanitation remains one of the most daunting public health challenges of the twenty-first century in Bangladesh. The aim of the study was to describe the trends in access to improved sanitation facilities following the inequity gap among households in different socioeconomic groups in Bangladesh. Data from the Bangladesh Demographic and Health Survey (BDHS) 2007, 2011, 2014, and 2017-18 were extracted for this study. Inequity in access to improved sanitation was calculated using rich-poor ratio and concentration index to determine the changes in inequity across the time period. In Bangladesh, the proportion of households with access to improved sanitation increased steadily from 25.4% to 45.4% between 2007 and 2014, but slightly decreased to 44.0% in 2017-18. Age, educational status, marital status of household head, household wealth index, household size, place of residence, division, and survey year were significantly associated with the utilisation of improved sanitation. There is a pro-rich situation, which means that utilisation of improved sanitation was more concentrated among the rich across all survey years (Concentration Index ranges: 0.40 to 0.27). The government and other relevant stakeholders should take initiatives considering inequity among different socioeconomic groups to ensure the use of improved sanitation facilities for all, hence achieving universal health coverage.

Stillbirths and Neonatal Deaths Caused by Group B Streptococcus in Africa and South Asia Identified Through Child Health and Mortality Prevention Surveillance (CHAMPS).

Background: Invasive Group B Streptococcus (GBS) is a common cause of early-onset neonatal sepsis and is also associated with stillbirth. This study aimed to determine the proportion of stillborn infants and infants who died between 0 and 90 days attributable to GBS using postmortem minimally invasive tissue sampling (MITS) in 7 low- and middle-income countries (LMICs) participating in Child Health and Mortality Prevention Surveillance (CHAMPS). Methods: Deaths that occurred between December 2016 and December 2021 were investigated with MITS, including culture for bacteria of blood and cerebrospinal fluid (CSF), multipathogen polymerase chain reaction on blood, CSF, and lung tissue and histopathology of lung, liver, and brain. Data collection included clinical record review and verbal autopsy. Expert panels reviewed all information and assigned causes of death. Results: We evaluated 2966 deaths, including stillborn infants (n = 1322), infants who died during first day of life (0 to <24 hours, n = 597), early neonatal deaths (END) (1 day to <7 days; END; n = 593), and deaths from 7 to 90 days (n = 454). Group B Streptococcus was determined to be in the causal pathway of death for 2.7% of infants (79 of 2, 966; range, 0.3% in Sierra Leone to 7.2% in South Africa), including 2.3% (31 of 1322) of stillbirths, 4.7% (28 of 597) 0 to <24 hours, 1.9% (11 of 593) END, and 2.0% (9 of 454) of deaths from 7 to 90 days of age. Among deaths attributed to GBS with birth weight data available, 61.9% (39 of 63) of decedents weighed <2500 grams at birth. Group B Streptococcus sepsis was the postmortem diagnosis for 100% (31 of 31) of stillbirths. For deaths <90 days, postmortem diagnoses included GBS sepsis (83.3%, 40 of 48), GBS meningitis (4.2%, 2 of 48), and GBS pneumonia (2.1%, 1 of 48). Conclusions: Our study reveals significant heterogeneity in the contribution of invasive GBS disease to infant mortality across different countries, emphasizing the need for tailored prevention strategies. Moreover, our findings highlight the substantial impact of GBS on stillbirths, shedding light on a previously underestimated aspect in LMICs.

Evaluating the impact of e-registration and mHealth on institutional delivery in hazard-prone areas of Bangladesh: A protocol for a non-randomized controlled cluster trial.

Despite substantial progress, Bangladesh still has a high rate of maternal deaths owing to difficulties during pregnancy, delivery, and the postpartum period. Increasing facility delivery is mandatory to reach the goal of bringing down the MMR to <70 deaths/100,000 live births by 2030. In the era of digitalization, the introduction of e-registration and mHealth may aid the government in reaching this target. The southern part of Bangladesh is a hazard-prone area, where service uptake from institutions is low. This study aims to determine the effect of an e-registration tracking system and mHealth counseling on institutional deliveries to pregnant mothers in hazard-prone areas of southern Bangladesh. We will conduct an open-label, two-arm, non-randomized controlled cluster trial for six months and use three hazard-prone areas for intervention and another three hazard-prone areas for control. We will collect data at baseline and end-line of the study period using a structured questionnaire. We will enroll at least 268 pregnant mothers from the intervention and 268 pregnant mothers from the control areas after screening based on the inclusion and exclusion criteria. Pregnancy information will be obtained from the Family Welfare Assistant register. The respondents of the intervention arm will be registered in the e-Registration system, and receive voice call and text messages from the midwives to have their deliveries done in healthcare facilities. We will follow the participants until their delivery and exclude those respondents from the study who will have post-dated delivery, migrate out, lost to follow-up, or die during the study period. Random-intercept mixed-effect logistic regression will be performed to explain the relationship of e-registration and mHealth package with institutional delivery. Institutional delivery is still uncommon in Southern Bangladesh despite several interventions. Innovative approaches like e-registration and mHealth counseling may be helpful to bring women to health facilities. The findings from the study might enable the policy makers of Bangladesh to integrate the intervention package into the existing healthcare system. This experiment is registered in the open science framework. Clinical trial registration: Registration number: DOI 10.17605/OSF.IO/YZE5C) and https://www.clinicaltrials.gov/ (registration number: NCT05398978.

Effect of an integrated maternal and neonatal health intervention on maternal healthcare utilisation addressing inequity in Rural Bangladesh.

BACKGROUND: Although Bangladesh has made significant improvements in maternal, neonatal, and child health, the disparity between rich and poor remains a matter of concern. OBJECTIVE: The study aimed to increase coverage of skilled maternal healthcare services while minimising the inequity gap among mothers in different socioeconomic groups. METHODS: We implemented an integrated maternal and neonatal health (MNH) intervention between 2009 and 2012, in Shahjadpur sub-district of Sirajganj district, Bangladesh. The study was quasi-experimental in design for the evaluation. Socioeconomic status was derived from household assets using principal component analysis. Inequity in maternal healthcare utilisation was calculated using rich-poor ratio and concentration index to determine the changes in inequity between the baseline and the endline time period. RESULT: The baseline and endline surveys included 3,158 (mean age 23.5 years) and 3,540 (mean age 24.3 years) recently delivered mothers respectively. Reduction in the rich-poor ratio was observed in the utilisation of skilled 4+ antenatal care (ANC) (2.4:1 to 1.1:1) and related concentration index decreased from 0.220 to 0.013 (p < 0.001). The rich-poor ratio for skilled childbirth reduced from 1.7:1 to 1.0:1 and the related concentration index declined from 0.161 to -0.021 (p < 0.001). A similar reduction was also observed in the utilisation of skilled postnatal care (PNC); where the rich-poor gap decreased from 2.5:1 to 1.0:1 and the related concentration index declined from 0.197 to -0.004 (p < 0.001). CONCLUSION: The MNH intervention was successful in reducing inequity in receiving skilled 4+ ANC, delivery, and PNC in rural Bangladesh.

Risk factors for COVID-19 mortality among telehealth patients in Bangladesh: A prospective cohort study.

BACKGROUND AND OBJECTIVE: Estimating the contribution of risk factors of mortality due to COVID-19 is particularly important in settings with low vaccination coverage and limited public health and clinical resources. Very few studies of risk factors of COVID-19 mortality used high-quality data at an individual level from low- and middle-income countries (LMICs). We examined the contribution of demographic, socioeconomic and clinical risk factors of COVID-19 mortality in Bangladesh, a lower middle-income country in South Asia. METHODS: We used data from 290,488 lab-confirmed COVID-19 patients who participated in a telehealth service in Bangladesh between May 2020 and June 2021, linked with COVID-19 death data from a national database to study the risk factors associated with mortality. Multivariable logistic regression models were used to estimate the association between risk factors and mortality. We used classification and regression trees to identify the risk factors that are the most important for clinical decision-making. FINDINGS: This study is one of the largest prospective cohort studies of COVID-19 mortality in a LMIC, covering 36% of all lab-confirmed COVID-19 cases in the country during the study period. We found that being male, being very young or elderly, having low socioeconomic status, chronic kidney and liver disease, and being infected during the latter pandemic period were significantly associated with a higher risk of mortality from COVID-19. Males had 1.15 times higher odds (95% Confidence Interval, CI: 1.09, 1.22) of death compared to females. Compared to the reference age group (20-24 years olds), the odds ratio of mortality increased monotonically with age, ranging from an odds ratio of 1.35 (95% CI: 1.05, 1.73) for ages 30-34 to an odds ratio of 21.6 (95% CI: 17.08, 27.38) for ages 75-79 year group. For children 0-4 years old the odds of mortality were 3.93 (95% CI: 2.74, 5.64) times higher than 20-24 years olds. Other significant predictors were severe symptoms of COVID-19 such as breathing difficulty, fever, and diarrhea. Patients who were assessed by a physician as having a severe episode of COVID-19 based on the telehealth interview had 12.43 (95% CI: 11.04, 13.99) times higher odds of mortality compared to those assessed to have a mild episode. The finding that the telehealth doctors' assessment of disease severity was highly predictive of subsequent COVID-19 mortality, underscores the feasibility and value of the telehealth services. CONCLUSIONS: Our findings confirm the universality of certain COVID-19 risk factors-such as gender and age-while highlighting other risk factors that appear to be more (or less) relevant in the context of Bangladesh. These findings on the demographic, socioeconomic, and clinical risk factors for COVID-19 mortality can help guide public health and clinical decision-making. Harnessing the benefits of the telehealth system and optimizing care for those most at risk of mortality, particularly in the context of a LMIC, are the key takeaways from this study.

Levels and determinants of quality antenatal care in Bangladesh: Evidence from the Bangladesh Demographic and Health Survey.

BACKGROUND: Assessing the quality of antenatal care (ANC) is imperative for improving care provisions during pregnancy to ensure the health of mother and baby. In Bangladesh, there is a dearth of research on ANC quality using nationally representative data to understand its levels and determinants. Thus, the current study aimed to assess ANC quality and identify the sociodemographic factors associated with the usage of quality ANC services in Bangladesh. METHODS: Secondary data analysis was conducted using the last two Bangladesh Demographic and Health Surveys (BDHSs) from 2014 and 2017-18. A total of 8,277 ever-married women were included in the analysis (3,631 from 2014 and 4,646 from 2017-18). The quality ANC index was constructed using a principal component analysis on the following ANC components: weight and blood pressure measurements, blood and urine test results, counselling about pregnancy complications and completion of a minimum of four ANC visits, one of which was performed by a medically trained provider. Multinomial logistic regression was used to determine the strength of the association. RESULTS: The percentage of mothers who received all components of quality ANC increased from about 13% in 2014 to 18% in 2017-18 (p < 0.001). Women from the poorest group, those in rural areas, with no education, a high birth order and no media exposure were less likely to receive high-quality ANC than those from the richest group, those from urban areas, with a higher level of education, a low birth order and media exposure, respectively. CONCLUSION: Although the quality of ANC improved from 2014 to 2017-18, it remains poor in Bangladesh. Therefore, there is a need to develop targeted interventions for different socio-demographic groups to improve the overall quality of ANC. Future interventions should address both the demand and supply-side perspectives.

Impact of integrated community-facility interventions model on neonatal mortality in rural Bangladesh- a quasi-experimental study.

BACKGROUND: Neonatal mortality remains unacceptably high in many countries. WHO recommends that all newborns be assessed during the postnatal period and should seek prompt medical care if there is any danger sign. However, in many developing countries, only a small proportion of women receive postnatal care. Also, the quality of care in public health facilities is sub-optimal. METHODS: We designed an intervention package that included community health worker-assisted pregnancy and birth surveillance, post-natal visits to assess newborns on the first, third, seventh and twenty-eighth days of birth, referral for facility-based care, and establishing a newborn stabilization unit at the first level referral health facility. We did a quasi-experimental, propensity-score matched, controlled study in the Sylhet region of Bangladesh. We used a cross-sectional survey method at baseline and endline to measure the effect of our intervention. We considered two indicators for the primary outcome-(a) all-cause neonatal mortality rate and (b) case fatality of severe illness. Secondary outcomes were the proportion of neonates with signs and symptoms of severe illness who sought care in a hospital or a medically qualified provider. RESULTS: Our sample size was 9,940 live births (4,257 at baseline, 5,683 at end line). Our intervention was significantly associated with a 39% reduction (aRR = 0.61, 95% CI: 0.40-0.93; p = 0.046) in the risk of neonatal mortality and 45% reduction (aRR = 0.55, 95% CI: 0.35-0.86; p = 0.001) in the risk of case fatality of severe illness among newborns in rural Bangladesh. The intervention significantly increased the care-seeking for severe illness at the first-level referral facility (DID 36.6%; 95% CI % 27.98 to 45.22; p<0.001). INTERPRETATION: Our integrated community-facility interventions model resulted in early identification of severely sick neonates, early care seeking and improved treatment. The interventions led to a significant reduction in all-cause neonatal mortality and case fatality from severe illness.

Nutritional and dietary diversity status of under-5 children and adolescent girls among forcibly displaced Myanmar nationals living in Bhasan Char relocation camp, Bangladesh: a cross-sectional survey.

OBJECTIVE: To generate baseline evidence regarding the nutritional and dietary diversity status of under-5 children and adolescent girls among forcibly displaced Myanmar nationals (FDMN) relocated to Bhasan Char relocation camp of Bangladesh. DESIGN: Cross-sectional survey. SETTING: Bhasan Char relocation camp, Bangladesh, 7 November 2021-12 November 2021. PARTICIPANTS: 299 under-5 children (both male and female) and 248 adolescent girls (11-17 years) were surveyed. OUTCOME MEASURES: Anthropometric indices and nutritional status of the study participants. RESULTS: Nearly 17% of the adolescent girls were suffering from severe thinness/thinness, while 5% were overweight/obese. Severe thinness was more prevalent (2% vs 3.9%) in older adolescents (15-17 years) than their younger counterparts (11-14 years). The prevalence of severe stunting and stunting in adolescents were 14% (95% CI 11.21 to 16.87%) and 29% (95% CI 25.93 to 31.59%), respectively. One-third of the surveyed under-5 children were severely (8.50% (95% CI 5.60 to 11.33%)) or moderately (23.08% (95% CI 20.24 to 25.90%)) stunted, 27% were either severely (4.43% (95% CI 1.60 to 7.27%)) or moderately (22.98% (95% CI 20.15 to 25.81%)) underweight and 12% were severely (1.21% (95% CI 0.00 to 4.04%)) or moderately (10.88% (95% CI 8.05 to 13.72%)) wasted. The prevalence of moderate and severe acute malnutrition in children was low. Surveyed adolescents took a mean of 3.10 (SD 1.03) of nine food groups and 25% (95% CI 22.97 to 28.64%) of under-5 children took minimum diversified diet. The survey respondents mostly consumed carbohydrate-based poorly diversified diets. Nutritional status of the participants did not show any statistically significant association to the dietary diversity status. CONCLUSION: A significant number of surveyed under-5 children and adolescent girls of relocated FDMN living in Bhasan Char of Bangladesh were suffering from thinness, stunting, underweight and wasting. Dietary diversity was poor among the surveyed population.

Polycyclic aromatic hydrocarbon (PAH) exposure during pregnancy and child anthropometry from birth to 10 years of age: Sex-specific evidence from a cohort study in rural Bangladesh.

Polycyclic aromatic hydrocarbons (PAHs) have endocrine disrupting properties and they cross the placental barrier, but studies on gestational exposure and child anthropometry are inconclusive. We aimed to elucidate the impact of early gestational PAH exposure on anthropometry from birth to 10 years of age in 1295 mother-child pairs from a nested sub-cohort of the MINIMat trial in Bangladesh. Several PAH metabolites [1-hydroxyphenanthrene (1-OH-Phe), Σ2-,3-hydroxyphenanthrene (Σ2-,3-OH-Phe), 4-hydroxyphenanthrene (4-OH-Phe), 1-hydroxypyrene (1-OH-Pyr), Σ2-,3-hydroxyfluorene (Σ2-,3-OH-Flu)] were quantified in spot urine collected around gestational week 8 using LC-MS/MS. Child weight and height were measured at 19 occasions from birth to 10 years. Multivariable-adjusted regression models were used to assess associations of maternal PAH metabolites (log2-transformed) with child anthropometry. The median concentration of 1-OH-Phe, Σ2-,3-OH-Phe, 4-OH-Phe, 1-OH-Pyr and Σ2-,3-OH-Flu was 1.5, 1.9, 0.14, 2.5, and 2.0 ng/mL, respectively. All maternal urinary PAH metabolites were positively associated with newborn weight and length and all associations were more pronounced in boys than in girls (p interaction for all <0.14). In boys, the strongest associations were observed with Σ2-,3-OH-Phe and Σ2-,3-OH-Flu for which each doubling increased mean birth weight by 41 g (95% CI: 13; 69 and 12; 70) and length by 0.23 cm (0.075; 0.39) and 0.21 cm (0.045; 0.37), respectively. Maternal urinary PAH metabolites were not associated with child anthropometry at 10 years. In longitudinal analysis, however, maternal urinary PAH metabolites were positively associated with boys' weight-for-age (WAZ) and height-for-age Z-scores (HAZ) from birth to 10 years, but only the association of 4-OH-Phe with HAZ was significant (B: 0.080 Z-scores; 95% CI 0.013, 0.15). No associations were observed with girls' WAZ or HAZ. In conclusion, gestational PAH exposure was positively associated with fetal and early childhood growth, especially in boys. Further studies are needed to confirm causality and to explore long-term health effects.

Causes of death identified in neonates enrolled through Child Health and Mortality Prevention Surveillance (CHAMPS), December 2016 -December 2021.

Each year, 2.4 million children die within their first month of life. Child Health and Mortality Prevention Surveillance (CHAMPS) established in 7 countries aims to generate accurate data on why such deaths occur and inform prevention strategies. Neonatal deaths that occurred between December 2016 and December 2021 were investigated with MITS within 24-72 hours of death. Testing included blood, cerebrospinal fluid and lung cultures, multi-pathogen PCR on blood, CSF, nasopharyngeal swabs and lung tissue, and histopathology examination of lung, liver and brain. Data collection included clinical record review and family interview using standardized verbal autopsy. The full set of data was reviewed by local experts using a standardized process (Determination of Cause of Death) to identify all relevant conditions leading to death (causal chain), per WHO recommendations. For analysis we stratified neonatal death into 24-hours of birth, early (1-<7 days) and late (7-<28 days) neonatal deaths. We analyzed 1458 deaths, 41% occurring within 24-hours, 41% early and 18% late neonatal deaths. Leading underlying causes of death were complications of intrapartum events (31%), complications of prematurity (28%), infections (17%), respiratory disorders (11%), and congenital malformations (8%). In addition to the underlying cause, 62% of deaths had additional conditions and 14% had ≥3 other conditions in the causal chain. The most common causes considering the whole causal chain were infection (40%), prematurity (32%) and respiratory distress syndrome (28%). Common maternal conditions linked to neonatal death were maternal hypertension (10%), labour and delivery complications (8%), multiple gestation (7%), placental complications (6%) obstructed labour and chorioamnionitis (5%, each). CHAMPS' findings showing the full causal chain of events that lead to death, in addition to maternal factors, highlights the complexities involved in each death along with the multiple opportunities for prevention. Highlighting improvements to prenatal and obstetric care and infection prevention are urgently needed in high-mortality settings.

Factors Associated with Neonatal Survival in a Special Care Newborn Unit in a Tertiary Care Hospital in Bangladesh.

The 2020 neonatal mortality rate in Bangladesh was 17 deaths per 1,000 live births, higher than the 2030 Sustainable Development Goal target (12 deaths per 1,000 live births). Over the past decade, Bangladesh has established special care newborn units (SCANUs) in medical facilities countrywide to improve neonatal survival. We conducted a retrospective cohort study in the SCANU of a tertiary-level healthcare facility in Bangladesh to study neonatal survival and associated risk factors using descriptive statistics and logistic regression models. Of 674 neonates admitted to the unit between January and November 2018, 263 (39%) died in hospital, 309 (46%) were discharged against medical advice, 90 (13%) were discharged healthy, and 12 (2%) had other discharge statuses. The median duration of time spent in hospital was 3 days, and 60% were admitted at birth. Neonates delivered via Cesarean section (adjusted odds ratio [aOR]: 2.5; 95% CI: 1.2-5.6) had an increased odds of recovering and being discharged, whereas those diagnosed with prematurity and/or low birth weight at admission (aOR: 0.2; 95% CI: 0.1-0.4) had a decreased odds of doing so. The high mortality rate and large number of neonates discharged against medical advice suggest a need to investigate the etiology of death and the factors leading to children leaving hospital prior to recovery. Medical records lacked information on gestational age that could provide key insights about mortality risk and age of viability in this setting. Addressing these knowledge gaps in SCANUs may enable better support for the improvement of child survival.

Early Life Environmental Exposure to Cadmium, Lead, and Arsenic and Age at Menarche: A Longitudinal Mother-Child Cohort Study in Bangladesh.

BACKGROUND: Several metals act as endocrine disruptors, but there are few large longitudinal studies about associations with puberty onset. OBJECTIVES: We evaluated whether early life cadmium, lead, and arsenic exposure was associated with timing of menarche. METHODS: In a mother-child cohort in rural Bangladesh (n=935), the exposure was assessed by concentrations in maternal erythrocytes in early pregnancy and in girls' urine at 5 and 10 years of age using inductively coupled plasma mass spectrometry. The girls were interviewed twice, at average ages 13.3 [standard deviation (SD)=0.43] and 13.8 (SD=0.43) y, and the date of menarche, if present, was recorded. Associations were assessed using Kaplan-Meier analysis and multivariable-adjusted Cox regression. RESULTS: In total, 77% of the girls (n=717) had reached menarche by the second follow-up. The median age of menarche among all girls was 13.0 y (25th-75th percentiles: 12.4-13.7 y). At 10 years of age, median urinary cadmium was 0.25µg/L (5th-95th percentiles: 0.087-0.72µg/L), lead 1.6µg/L (0.70-4.2µg/L), and arsenic 54µg/L (19-395µg/L). Given the same age, girls in the highest quartile of urinary cadmium at 5 and 10 years of age had a lower rate of menarche than girls in the lowest quartile, with an adjusted hazard ratio of (HR) 0.80 (95% CI: 0.62, 1.01) at 5 years of age, and 0.77 (95% CI: 0.60, 0.98) at 10 years of age. This implies that girls in the highest cadmium exposure quartile during childhood had a higher age at menarche. Comparing girls in the highest to the lowest quartile of urinary lead at 10 years of age, the former had a higher rate of menarche [adjusted HR = 1.23 (95% CI: 0.97, 1.56)], implying lower age at menarche, whereas there was no association with urinary lead at 5 years of age. Girls born to mothers in the highest quartile of erythrocyte arsenic during pregnancy were less likely to have attained menarche than girls born to mothers in the lowest quartile [adjusted HR= 0.79 (95% CI: 0.62, 0.99)]. No association was found with girls' urinary arsenic exposure. DISCUSSION: Long-term childhood cadmium exposure was associated with later menarche, whereas the associations with child lead exposure were inconclusive. Maternal exposure to arsenic, but not cadmium or lead, was associated with later menarche. https://doi.org/10.1289/EHP11121.

Taking a Pulse on Community Participation in Maternal Health through Community Clinics in Bangladesh.

Bangladesh started institutionalising community participation by setting-up community clinics (CCs) during the mid-90 s. This paper presents the genealogy of CCs, the community participation mechanism embedded within CCs, and the case of 54 CCs in Brahmanbaria, through the lens of maternal health. We undertook a desk review to understand the journey of CCs. In 2018, we assessed the accessibility, readiness and functionality of CCs, and a household survey to know recently delivered women's perceptions of CC's community groups (CGs) and community support groups (CSGs). We performed multiple logistic regression to determine the association between the functionality of these groups and women's perception regarding these groups' activities on maternal health. The integration of community participation involving CCs started to roll out through the operationalisation of the Health and Population Sector Programme 1998-2003. In 2019, 13,907 CCs were operational. However, per our CC assessment, their accessibility and readiness were moderate but there were gaps in the functionality of the CCs. The perception of women regarding these groups' functionality was significantly better when the group members met regularly. The gaps in CCs are primarily induced by the shortcomings of its community participation model. Proper understanding is needed to address this problem which has many facets and layers, including political priorities, expectations, and provisions at a local level.

Chronic Kidney Disease Awareness Campaign and Mobile Health Education to Improve Knowledge, Quality of Life, and Motivation for a Healthy Lifestyle Among Patients With Chronic Kidney Disease in Bangladesh: Randomized Controlled Trial.

BACKGROUND: Chronic kidney disease (CKD) is linked to major health consequences and a poor quality of life. Despite the fact that CKD is becoming more prevalent, public knowledge of the disease remains low. OBJECTIVE: This study aimed to evaluate the outcome of a health education intervention designed to enhance knowledge, health-related quality of life (QOL), and motivation about healthy lifestyle among adults with CKD. METHODS: This study was a parallel-group (1:1), randomized controlled trial in the Mirzapur subdistrict of Bangladesh that compared 2 groups of patients with CKD. Adults with CKD (stages 1-3) were enrolled in November 2020 and randomly assigned the intervention or control group. The intervention group received health education through a CKD awareness campaign and mobile health technologies and was observed for 6 months, whereas the control group received standard treatment. The primary outcome was the evaluation of improved scores on the CKD knowledge questionnaire, and the secondary outcomes were improved QOL and changes in the levels of blood pressure (BP), BMI, serum creatinine, fasting blood sugar (FBS), hemoglobin, cholesterol, high-density lipoprotein cholesterol, triglyceride, serum uric acid, blood urea nitrogen (BUN), and albumin-to-creatinine ratio. RESULTS: The study enrolled 126 patients (control: n=63; intervention: n=63) and performed intention-to-treat analysis. The analyses included repeated measures ANOVA, and the results were observed to be significantly different from within groups (P<.001), between groups (P<.001), and the interaction of group × time factor (P<.001) for knowledge score. Diastolic BP and BMI showed significant differences arising from within groups (P<.001 and P=.01, respectively) and the interaction of group × time factor (P=.001 and P=.02, respectively); food salinity and hip circumferences showed significant differences arising from within groups (P=.001 and P=.03, respectively) and between groups (P=.001 and P=.02, respectively). Moreover, systolic BP and waist circumference showed significant differences from within groups (P<.001 and P=.003, respectively). However, no significant differences were found arising from within groups, between groups, and the interactions of group × time for QOL, urine salinity, and mid-upper arm circumference. Regarding the laboratory findings, from baseline to 6 months, the mean (SD) FBS decreased by 0.51 (3.77) mmol/L in the intervention group and 0.10 (1.44) mmol/L in the control group (P=.03); however, blood urea nitrogen increased by 3.64 (7.17) mg/dL in the intervention group and 1.68 (10.10) mg/dL in the control group (P=.01). CONCLUSIONS: The health education strategy, which included a campaign and mobile health, showed promise for enhancing CKD knowledge among patients with CKD. This strategy may also aid patients with CKD in controlling their FBS and BP. The combined health education initiatives give evidence for scaling them up in Bangladesh and possibly other low- and middle-income countries, particularly in rural and peri-urban settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT04094831; https://clinicaltrials.gov/ct2/show/NCT04094831. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/30191.

Birth and Death Notifications for Improving Civil Registration and Vital Statistics in Bangladesh: Pilot Exploratory Study.

BACKGROUND: Effective health policy formulation requires sound information of the numerical data and causes of deaths in a population. Currently, in Bangladesh, neither births nor deaths are fully and promptly registered. Birth registration in Bangladesh is around 54% nationally. Although the legal requirements are to register within 45 days of an event, only 4.5% of births and 35.9% of deaths were reported within the required time frame in 2020. This study adopted an innovative digital notification approach to improve the coverage of registration of these events at the community level. OBJECTIVE: Our primary objective was to assess (1) the proportion of events identified by the new notification systems (success rate) and the contribution of the different notifiers individually and in combination (completeness) and (2) the proportion of events notified within specific time limits (timeliness of notifications) after introducing the innovative approach. METHODS: We conducted a pilot study in 2016 in 2 subdistricts of Bangladesh to understand whether accurate, timely, and complete information on births and deaths can be collected and notified by facility-based service providers; community health workers, including those who routinely visit households; local government authorities; and key informants from the community. We designed a mobile technology-based platform, an app, and a call center through which the notifications were recorded. All notifications were verified through the confirmation of events by family members during visits to the concerned households. We undertook a household survey-based assessment at the end of the notification period. RESULTS: Our innovative system gathered 13,377 notifications for births and deaths from all channels, including duplicate reports from multiple sources. Project workers were able to verify 92% of the births and 93% of the deaths through household visits. The household survey conducted among a subsample of the project population identified 1204 births and 341 deaths. After matching the notifications with the household survey, we found that the system was able to capture over 87% of the births in the survey areas. Health assistants and family welfare assistants were the primary sources of information. Notifications from facilities were very low for both events. CONCLUSIONS: The Global Civil Registration and Vital Statistics: Scaling Up Investment Plan 2015-2024 and the World Health Organization reiterated the importance of building an evidence base for improving civil registration and vital statistics. Our pilot innovation revealed that it is possible to coordinate with the routine health information system to note births and deaths as the first step to ensure registration. Health assistants could capture more than half of the notifications as a stand-alone source.