Young Infant Mortality Associated with Preterm and Small-for-Gestational-Age Births in Rural Bangladesh: A Prospective Cohort Study.

OBJECTIVE: To assess the relative risk of mortality in infants born preterm and small for gestational age (SGA) during the first and second months of life in rural Bangladesh. STUDY DESIGN: We analyzed data from a cohort of pregnant women and their babies in Sylhet, Bangladesh, assembled between 2011 and 2014. Community health workers visited enrolled babies up to 10 times from birth to age 59 days. Survival status was recorded at each visit. Gestational age was estimated from mother's reported last menstrual period. Birth weights were measured within 72 hours of delivery. SGA was defined using the INTERGROWTH-21st standard. We estimated unadjusted and adjusted hazard ratios (HRs) and corresponding 95% CIs for babies born preterm and SGA separately for the first and second month of life using bivariate and multivariable weighted Cox regression models. RESULTS: The analysis included 17 643 singleton live birth babies. Compared with infants born at term-appropriate for gestational age, in both unadjusted and adjusted analyses, infants born preterm-SGA had the greatest risk of death in the first (HR 13.25, 95% CI 8.65-20.31; adjusted HR 12.05, 95% CI 7.82-18.57) and second month of life (HR 4.65, 95% CI 1.93-11.23; adjusted HR 4.1, 95% CI 1.66-10.15), followed by infants born preterm-appropriate for gestational age and term-SGA. CONCLUSIONS: The risk of mortality in infants born preterm and/or SGA is increased and extends through the second month of life. Appropriate interventions to prevent and manage complications caused by prematurity and SGA could improve survival during and beyond the neonatal period.

Early to mid-pregnancy HbA1c levels and its association with adverse pregnancy outcomes in three low middle-income countries in Asia and Sub-Saharan Africa.

BACKGROUND: Hyperglycemia during pregnancy leads to adverse maternal and fetal outcomes. Thus, strict monitoring of blood glucose levels is warranted. This study aims to determine the association of early to mid-pregnancy HbA1c levels with the development of pregnancy complications in women from three countries in South Asia and Sub-Saharan Africa. METHODS: We performed a secondary analysis of the AMANHI (Alliance for Maternal and Newborn Health Improvement) cohort, which enrolled 10,001 pregnant women between May 2014 and June 2018 across Sylhet-Bangladesh, Karachi-Pakistan, and Pemba Island-Tanzania. HbA1c assays were performed at enrollment (8 to < 20 gestational weeks), and epidemiological data were collected during 2-3 monthly household visits. The women were followed-up till the postpartum period to determine the pregnancy outcomes. Multivariable logistic regression models assessed the association between elevated HbA1c levels and adverse events while controlling for potential confounders. RESULTS: A total of 9,510 pregnant women were included in the analysis. The mean HbA1c level at enrollment was found to be the highest in Bangladesh (5.31 ± 0.37), followed by Tanzania (5.22 ± 0.49) and then Pakistan (5.07 ± 0.58). We report 339 stillbirths and 9,039 live births. Among the live births were 892 preterm births, 892 deliveries via cesarean section, and 532 LGA babies. In the multivariate pooled analysis, maternal HbA1c levels of ≥ 6.5 were associated with increased risks of stillbirths (aRR = 6.3, 95% CI = 3.4,11.6); preterm births (aRR = 3.5, 95% CI = 1.8-6.7); and Large for Gestational Age (aRR = 5.5, 95% CI = 2.9-10.6). CONCLUSION: Maternal HbA1c level is an independent risk factor for predicting adverse pregnancy outcomes such as stillbirth, preterm birth, and LGA among women in South Asia and Sub-Saharan Africa. These groups may benefit from early interventional strategies.

Does the implementation of revised American College of Cardiology and American Heart Association (ACC/AHA) guidelines improve the identification of stillbirths and preterm births in hypertensive pregnancies: a population-based cohort study from South Asia and sub-Saharan Africa.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) are a significant cause of maternal mortality worldwide. The classification and treatment of hypertension in pregnancy remain debated. We aim to compare the effectiveness of the revised 2017 ACC/AHA blood pressure threshold in predicting adverse pregnancy outcomes. METHODS: We conducted a secondary data analysis of the Alliance for Maternal and Newborn Health Improvement (AMANHI) biorepository study, including 10,001 pregnant women from Bangladesh, Pakistan, and Tanzania. Blood pressure was measured using validated devices at different antenatal care visits. The blood pressure readings were categorized as: normal blood pressure (systolic blood pressure (sBP) < 120 mm Hg and diastolic blood pressure (dBP) < 80 mm Hg), elevated blood pressure (sBP 120-129 and dBP < 80), stage 1 hypertension (sBP 130-139 or dBP 80-89, or both), and stage 2 hypertension (sBP ≥ 140 or dBP ≥ 90, or both). We estimated risk ratios for stillbirths and preterm births, as well as diagnostic test properties of both the pre-existing JNC7 (≥ 140/90) and revised ACC/AHA (≥ 130/80) thresholds using normal blood pressure as reference group. RESULTS: From May 2014 to June 2018, blood pressure readings were available for 9,448 women (2,894 in Bangladesh, 2,303 in Pakistan, and 4,251 in Tanzania). We observed normal blood pressure in 70%, elevated blood pressure in 12.4%, stage 1 hypertension in 15.2%, and stage 2 hypertension in 2.5% of the pregnant women respectively. Out of these, 310 stillbirths and 9,109 live births were recorded, with 887 preterm births. Using the ACC/AHA criteria, the stage 1 hypertension cut-off revealed 15.3% additional hypertension diagnoses as compared to JNC7 criteria. ACC/AHA defined hypertension was significantly associated with stillbirths (RR 1.8, 95% CI 1.4, 2.3). The JNC 7 hypertension cut-off of ≥ 140/90 was significantly associated with a higher risk of preterm births (RR 1.6, 95% CI 1.2, 2.2) and stillbirths (RR 3.6, 95% CI 2.5, 5.3). Both criteria demonstrated low sensitivities (8.4 for JNC-7 and 28.1 for ACC/AHA) and positive predictive values (11.0 for JNC7 and 5.2 for ACC/AHA) in predicting adverse outcomes. CONCLUSION: The ACC/AHA criteria (≥ 130/80) identified additional cases of hypertension but had limited predictive accuracy for stillbirths and preterm births, highlighting the ongoing need for improved criteria in managing pregnancy-related hypertension.

Prevalence of and factors associated with insufficient physical activity among adolescents: evidence from a nationwide survey in Bangladesh.

The World Health Organization set a target of a 15% relative reduction in the prevalence of insufficient physical activity (IPA) by 2025 among adolescents and adults globally. In Bangladesh, there are no national estimates of the prevalence of IPA among adolescents. The aim of this study was to estimate the prevalence of and risk factors associated with IPA among adolescent girls and boys. Data for 4865 adolescent girls and 4907 adolescent boys, collected as a part of a National Nutrition Surveillance in 2018-19, were analysed for this study. A modified version of the Global Physical Activity Questionnaire (GPAQ) was used to collect physical activity data. The World Health Organization recommended cut-off points were used to estimate the prevalence of IPA. Bivariate and multivariable logistic regression was performed to identify factors associated with IPA. Prevalences of IPA among adolescent girls and boys were 50.3% and 29.0%, respectively, and the prevalence was significantly higher among early adolescents (10-14 years) than late adolescents (15-19 years) among both boys and girls. The IPA prevalence was highest among adolescents living in non-slum urban areas (girls: 77.7%; boys: 64.1%). For both boys and girls, younger age, non-slum urban residence, higher paternal education and increased television viewing time were significantly associated with IPA. Additionally, residing in slums was significantly associated with IPA only among the boys. Higher maternal education was associated with IPA only among the girls. This study identified several modifiable risk factors associated with IPA among adolescent boys and girls in Bangladesh. These factors should be addressed through comprehensive public health interventions to promote physical activity among adolescent girls and boys.

Direct maternal morbidity and the risk of pregnancy-related deaths, stillbirths, and neonatal deaths in South Asia and sub-Saharan Africa: A population-based prospective cohort study in 8 countries.

BACKGROUND: Maternal morbidity occurs several times more frequently than mortality, yet data on morbidity burden and its effect on maternal, foetal, and newborn outcomes are limited in low- and middle-income countries. We aimed to generate prospective, reliable population-based data on the burden of major direct maternal morbidities in the antenatal, intrapartum, and postnatal periods and its association with maternal, foetal, and neonatal death in South Asia and sub-Saharan Africa. METHODS AND FINDINGS: This is a prospective cohort study, conducted in 9 research sites in 8 countries of South Asia and sub-Saharan Africa. We conducted population-based surveillance of women of reproductive age (15 to 49 years) to identify pregnancies. Pregnant women who gave consent were include in the study and followed up to birth and 42 days postpartum from 2012 to 2015. We used standard operating procedures, data collection tools, and training to harmonise study implementation across sites. Three home visits during pregnancy and 2 home visits after birth were conducted to collect maternal morbidity information and maternal, foetal, and newborn outcomes. We measured blood pressure and proteinuria to define hypertensive disorders of pregnancy and woman's self-report to identify obstetric haemorrhage, pregnancy-related infection, and prolonged or obstructed labour. Enrolled women whose pregnancy lasted at least 28 weeks or those who died during pregnancy were included in the analysis. We used meta-analysis to combine site-specific estimates of burden, and regression analysis combining all data from all sites to examine associations between the maternal morbidities and adverse outcomes. Among approximately 735,000 women of reproductive age in the study population, and 133,238 pregnancies during the study period, only 1.6% refused consent. Of these, 114,927 pregnancies had morbidity data collected at least once in both antenatal and in postnatal period, and 114,050 of them were included in the analysis. Overall, 32.7% of included pregnancies had at least one major direct maternal morbidity; South Asia had almost double the burden compared to sub-Saharan Africa (43.9%, 95% CI 27.8% to 60.0% in South Asia; 23.7%, 95% CI 19.8% to 27.6% in sub-Saharan Africa). Antepartum haemorrhage was reported in 2.2% (95% CI 1.5% to 2.9%) pregnancies and severe postpartum in 1.7% (95% CI 1.2% to 2.2%) pregnancies. Preeclampsia or eclampsia was reported in 1.4% (95% CI 0.9% to 2.0%) pregnancies, and gestational hypertension alone was reported in 7.4% (95% CI 4.6% to 10.1%) pregnancies. Prolonged or obstructed labour was reported in about 11.1% (95% CI 5.4% to 16.8%) pregnancies. Clinical features of late third trimester antepartum infection were present in 9.1% (95% CI 5.6% to 12.6%) pregnancies and those of postpartum infection in 8.6% (95% CI 4.4% to 12.8%) pregnancies. There were 187 pregnancy-related deaths per 100,000 births, 27 stillbirths per 1,000 births, and 28 neonatal deaths per 1,000 live births with variation by country and region. Direct maternal morbidities were associated with each of these outcomes. CONCLUSIONS: Our findings imply that health programmes in sub-Saharan Africa and South Asia must intensify their efforts to identify and treat maternal morbidities, which affected about one-third of all pregnancies and to prevent associated maternal and neonatal deaths and stillbirths. TRIAL REGISTRATION: The study is not a clinical trial.

Causes and incidence of community-acquired serious infections among young children in south Asia (ANISA): an observational cohort study.

BACKGROUND: More than 500 000 neonatal deaths per year result from possible serious bacterial infections (pSBIs), but the causes are largely unknown. We investigated the incidence of community-acquired infections caused by specific organisms among neonates in south Asia. METHODS: From 2011 to 2014, we identified babies through population-based pregnancy surveillance at five sites in Bangladesh, India, and Pakistan. Babies were visited at home by community health workers up to ten times from age 0 to 59 days. Illness meeting the WHO definition of pSBI and randomly selected healthy babies were referred to study physicians. The primary objective was to estimate proportions of specific infectious causes by blood culture and Custom TaqMan Array Cards molecular assay (Thermo Fisher, Bartlesville, OK, USA) of blood and respiratory samples. FINDINGS: 6022 pSBI episodes were identified among 63 114 babies (95·4 per 1000 livebirths). Causes were attributed in 28% of episodes (16% bacterial and 12% viral). Mean incidence of bacterial infections was 13·2 (95% credible interval [CrI] 11·2-15·6) per 1000 livebirths and of viral infections was 10·1 (9·4-11·6) per 1000 livebirths. The leading pathogen was respiratory syncytial virus (5·4, 95% CrI 4·8-6·3 episodes per 1000 livebirths), followed by Ureaplasma spp (2·4, 1·6-3·2 episodes per 1000 livebirths). Among babies who died, causes were attributed to 46% of pSBI episodes, among which 92% were bacterial. 85 (83%) of 102 blood culture isolates were susceptible to penicillin, ampicillin, gentamicin, or a combination of these drugs. INTERPRETATION: Non-attribution of a cause in a high proportion of patients suggests that a substantial proportion of pSBI episodes might not have been due to infection. The predominance of bacterial causes among babies who died, however, indicates that appropriate prevention measures and management could substantially affect neonatal mortality. Susceptibility of bacterial isolates to first-line antibiotics emphasises the need for prudent and limited use of newer-generation antibiotics. Furthermore, the predominance of atypical bacteria we found and high incidence of respiratory syncytial virus indicated that changes in management strategies for treatment and prevention are needed. Given the burden of disease, prevention of respiratory syncytial virus would have a notable effect on the overall health system and achievement of Sustainable Development Goal. FUNDING: Bill & Melinda Gates Foundation.

Pregnancy intervals after stillbirth, neonatal death and spontaneous abortion and the risk of an adverse outcome in the next pregnancy in rural Bangladesh.

BACKGROUND: Studies have revealed associations between preceding short and long birth-to-birth or birth-to-pregnancy intervals and poor pregnancy outcomes. Most of these studies, however, have examined the effect of intervals that began with live births. Using data from Bangladesh, we examined the effect of inter-outcome intervals (IOI) starting with a non-live birth or neonatal death, on outcomes in the next pregnancy. Pregnancy spacing behaviors in rural northeast Bangladesh have changed little since 2004. METHODS: We analyzed pregnancy histories for married women aged 15-49 years who had outcomes between 2000 and 2006 in Sylhet, Bangladesh. We examined the effects of the preceding outcome and the IOI length on the risk of stillbirth, neonatal death and spontaneous abortion using multinomial logistic regression models. RESULTS: Data included 64,897 pregnancy outcomes from 33,495 mothers. Inter-outcome intervals of 27-50 months and live births were baseline comparators. Stillbirths followed by IOI's <=6 months, 7-14 months or overall <=14 months had increased risks for spontaneous abortion with adjusted relative risk ratios (aRRR) and 95% confidence intervals = 29.6 (8.09, 108.26), 1.84 (0.84, 4.02) and 2.53 (1.19, 5.36), respectively. Stillbirths followed by IOIs 7-14 months had aRRR 2.00 (1.39, 2.88) for stillbirths. Neonatal deaths followed by IOIs <=6 months had aRRR 28.2 (8.59, 92.63) for spontaneous abortion. Neonatal deaths followed by IOIs 7-14 and 15-26 months had aRRRs 3.08 (1.82, 5.22) and 2.32 (1.38, 3.91), respectively, for stillbirths; and aRRRs 2.81 (2.06, 3.84) and 1.70 (1.24, 3.84), respectively, for neonatal deaths. Spontaneous abortions followed by IOIs <=6 months and 7-14 months had, respectively, aRRRs 23.21 (10.34, 52.13) and 1.80 (0.98, 3.33) for spontaneous abortion. CONCLUSION: In rural northeast Bangladesh, short inter-outcome intervals after stillbirth, neonatal death and spontaneous abortion were associated with a high risk of a similar outcome in the next pregnancy. These findings are aligned with other studies from Bangladesh. Two studies from similar settings have found benefits of waiting six months before conceiving again, suggesting that incorporating this advice into programs should be considered. Further research is warranted to confirm these findings.

Urinary tract infections in pregnancy in a rural population of Bangladesh: population-based prevalence, risk factors, etiology, and antibiotic resistance.

BACKGROUND: Urinary tract infection (UTI) in pregnancy, including asymptomatic bacteriuria, is associated with maternal morbidity and adverse pregnancy outcomes, including preterm birth and low birthweight. In low-middle income countries (LMICs), the capacity for screening and treatment of UTIs is limited. The objective of this study was to describe the population-based prevalence, risk factors, etiology and antimicrobial resistance patterns of UTIs in pregnancy in Bangladesh. METHODS: In a community-based cohort in Sylhet district, Bangladesh, urine specimens were collected at the household level in 4242 pregnant women (< 20 weeks gestation) for culture and antibiotic susceptibility testing. Basic descriptive analysis was performed, as well as logistic regression to calculate adjusted odds ratios (aOR) for UTI risk factors. RESULTS: The prevalence of UTI was 8.9% (4.4% symptomatic UTI, 4.5% asymptomatic bacteriuria). Risk factors for UTI in this population included maternal undernutrition (mid-upper arm circumference <23 cm: aOR= 1.29, 95% CI: 1.03-1.61), primiparity (aOR= 1.45, 95% CI: 1.15-1.84), and low paternal education (no education: aOR= 1.56, 95% CI: 1.09-2.22). The predominant uro-pathogens were E. coli (38% of isolates), Klebsiella (12%), and staphyloccocal species (23%). Group B streptococcus accounted for 5.3% of uro-pathogens. Rates of antibiotic resistance were high, with only two-thirds of E. coli susceptible to 3rd generation cephalosporins. CONCLUSIONS: In Sylhet, Bangladesh, one in 11 women had a UTI in pregnancy, and approximately half of cases were asymptomatic. There is a need for low-cost and accurate methods for UTI screening in pregnancy and efforts to address increasing rates of antibiotic resistance in LMIC.

Prevalence of and risk factors for abnormal vaginal flora and its association with adverse pregnancy outcomes in a rural district in north-east Bangladesh.

INTRODUCTION: The role of screening and treatment for abnormal vaginal flora (AVF) on adverse pregnancy outcomes remains unclear. Using data from women who participated in a population-based cluster randomized trial who were screened and treated for AVF, we report risk factors for AVF and association of persistent AVF with adverse perinatal outcomes. MATERIAL AND METHODS: Pregnant women (n = 4221) <19 weeks of gestation provided self-administered mid-vaginal swabs; smears were Nugent-scored. AVF was treated with oral clindamycin; if AVF was present 3 weeks after treatment, persistent AVF was re-treated. We examined risk factors for AVF and the association of persistent AVF with adverse pregnancy outcomes. RESULTS: The prevalence of AVF was 16.5%: 9.8% of women had bacterial vaginosis and 6.8% had intermediate flora. Lower economic and educational status of women were associated with increased risk of AVF. One-third of women with AVF had persistent abnormal flora; these women had a higher risk of a composite measure of adverse pregnancy outcomes from 20 to <37 weeks (preterm live birth, preterm still birth, late miscarriage) (relative risk [RR] 1.33, 95% confidence interval [CI] 1.07-1.65) and of late miscarriage alone (RR 4.15, 95% CI 2.12-8.12) compared to women without AVF. CONCLUSIONS: In this study in Sylhet District, Bangladesh, rates of AVF and persistent AVF were high and persistent AVF was associated with adverse pregnancy outcomes, with an especially high associated risk for late miscarriage. Further characterization of the microbiome and relative bacterial species density associated with persistent AVF is needed.

The association between daily 500 mg calcium supplementation and lower pregnancy-induced hypertension risk in Bangladesh.

BACKGROUND: Evidence suggests that daily supplementation of 1500 to 2000 mg of calcium during pregnancy reduces pregnancy-induced hypertension (PIH). However, the evidence on the efficacy of low-dose calcium supplementation on PIH is limited. This paper assesses the longitudinal correlation between low-dose calcium intake (500 mg daily) and change in blood pressure during pregnancy among a homogeneous population in terms of hypertension and pre-eclampsia. METHODS: The study followed a retrospective cohort study design, and was carried out among 11,387 pregnant women from 10 rural upazilas (sub-districts) of Bangladesh where maternal nutrition initiative (MNI), implemented by Building Resources Across Communities (BRAC), was ongoing. The modified Poisson regression model was used to estimate the association (risk ratio) between consumption of calcium tablets and PIH. RESULTS: The present research found that women who consumed 500 mg/d calcium tablets for more than 6 months during their pregnancy had a 45% lower risk of developing hypertension compared to those who consumed less calcium (RR = 0.55, 95% CI = 0.33-0.93). CONCLUSIONS: Daily supplementation of 500 mg oral calcium during pregnancy for at least 180 tablets is associated with a considerably reduced risk of PIH, but this study is unable to confirm whether this association is causal. The causal relationship needs to be confirmed through a large scale randomized controlled trial.

Neonatal mortality within 24 hours of birth in six low- and lower-middle-income countries.

OBJECTIVE: To estimate neonatal mortality, particularly within 24 hours of birth, in six low- and lower-middle-income countries. METHODS: We analysed epidemiological data on a total of 149 570 live births collected between 2007 and 2013 in six prospective randomized trials and a cohort study from predominantly rural areas of Bangladesh, Ghana, India, Pakistan, the United Republic of Tanzania and Zambia. The neonatal mortality rate and mortality within 24 hours of birth were estimated for all countries and mortality within 6 hours was estimated for four countries with available data. The findings were compared with published model-based estimates of neonatal mortality. FINDINGS: Overall, the neonatal mortality rate observed at study sites in the six countries was 30.5 per 1000 live births (range: 13.6 in Zambia to 47.4 in Pakistan). Mortality within 24 hours was 14.1 per 1000 live births overall (range: 5.1 in Zambia to 20.1 in India) and 46.3% of all neonatal deaths occurred within 24 hours (range: 36.2% in Pakistan to 65.5% in the United Republic of Tanzania). Mortality in the first 6 hours was 8.3 per 1000 live births, i.e. 31.9% of neonatal mortality. CONCLUSION: Neonatal mortality within 24 hours of birth in predominantly rural areas of six low- and lower-middle-income countries was higher than model-based estimates for these countries. A little under half of all neonatal deaths occurred within 24 hours of birth and around one third occurred within 6 hours. Implementation of high-quality, effective obstetric and early newborn care should be a priority in these settings.

Screening and treatment of maternal genitourinary tract infections in early pregnancy to prevent preterm birth in rural Sylhet, Bangladesh: a cluster randomized trial.

BACKGROUND: Approximately half of preterm births are attributable to maternal infections, which are commonly undetected and untreated in low-income settings. Our primary aim is to determine the impact of early pregnancy screening and treatment of maternal genitourinary tract infections on the incidence of preterm live birth in Sylhet, Bangladesh. We will also assess the effect on other adverse pregnancy outcomes, including preterm birth (stillbirth and live birth), late miscarriage, maternal morbidity, and early onset neonatal sepsis. METHODS/DESIGN: We are conducting a cluster randomized controlled trial that will enroll 10,000 pregnant women in Sylhet district in rural northeastern Bangladesh. Twenty-four clusters, each with ~4000 population (120 pregnant women/year) and served by a community health worker (CHW), are randomized to: 1) the control arm, which provides routine antenatal and postnatal home-based care, or 2) the intervention arm, which includes routine antenatal and postnatal home-based care plus screening and treatment of pregnant women between 13 and 19 weeks of gestation for abnormal vaginal flora (AVF) and urinary tract infection (UTI). CHWs conduct monthly pregnancy surveillance, make 2 antenatal and 4 postnatal home visits for all enrolled pregnant women and newborns, and refer mothers or newborns with symptoms of serious illness to the government sub-district hospital. In the intervention clusters, CHWs perform home-based screening of AVF and UTI. Self-collected vaginal swabs are plated on slides, which are Gram stained and Nugent scored. Women with AVF (Nugent score ≥4) are treated with oral clindamycin, rescreened and retreated, if needed, after 3 weeks. Urine culture is performed and UTI treated with nitrofurantoin. Repeat urine culture is performed after 1 week for test of cure. Gestational age is determined by maternal report of last menstrual period at study enrollment using prospectively completed study calendars, and in a subset by early (<20 week) ultrasound. CHWs prospectively collect data on all pregnancy outcomes, maternal and neonatal morbidity and mortality. IMPLICATIONS/DISCUSSION: Findings will enhance our understanding of the burden of AVF and UTI in rural Bangladesh, the impact of a maternal screening-treatment program for genitourinary tract infections on perinatal health, and help formulate public health recommendations for infection screening in pregnancy in low-resource settings. TRIAL REGISTRATION: The study was registered on ClinicalTrials.gov:NCT01572532 on December 15, 2011. The study was funded by NICHD: R01HD066156 .

Incidence and risk factors of preterm birth in a rural Bangladeshi cohort.

BACKGROUND: Globally, about 15 million neonates are born preterm and about 85% of global preterm birth occurs in Asia and Africa regions. We aimed to estimate the incidence and risk factors for preterm birth in a rural Bangladeshi cohort. METHODS: Between June 2007 and September 2009, community health workers prospectively collected data from 32,126 mother-live-born baby pairs on household socio-demographic status, pregnancy history, antenatal care seeking and newborn gestational age determined by recall of date of last menstrual period. RESULTS: Among all live births, 22.3% were delivered prior to 37 weeks of gestation (i.e. preterm); of which 12.3% were born at 35-36 weeks of gestation (late preterm), 7.1% were born at 32-34 weeks (moderate preterm), and 2.9% were born at 28-31 weeks of gestation (very preterm). Overall, the majority of preterm births (55.1%) were late preterm. Risk of preterm birth was lower among women with primary or higher level of education (RR: 0.92; 95% CI: 0.88, 0.97), women who sought antenatal care at least once during the index pregnancy (RR: 0.86; 95% CI: 0.83, 0.90), and women who had completed all birth preparedness steps (RR: 0.32; 95% CI: 0.30, 0.34). In contrast, risk of preterm birth was higher among women with a history of child death (RR: 1.05; 95% CI: 1.01, 1.10), who had mid-upper arm circumference (MUAC) ≤250 mm, indicative of under nutrition (for women having MUAC <214 mm the risk was higher; RR: 1.26; 95% CI: 1.17, 1.35), who reported an antenatal complication (RR: 1.32; 95% CI: 1.14, 1.53), and who received iron-folic acid supplementation for 2-6 months during the index pregnancy (RR: 1.33; 95% CI: 1.24, 1.44). CONCLUSIONS: In resource poor settings with high burden of preterm birth, alike Bangladesh, preterm birth risk could be reduced by close monitoring and/or frequent follow-up of women with history of child death and antenatal complications, by encouraging women to seek antenatal care from qualified providers, to adopt birth preparedness planning and to maintain good nutritional status. Additional research is needed to further explore the associations of antenatal iron supplementation and maternal nutritional status on preterm birth.

Factors associated with the malnutrition inflammation score (MIS) among hemodialysis patients in Dhaka city: a cross-sectional study in tertiary care hospitals.

Background: Chronic kidney disease (CKD) is a progressive disease that leads to end-stage renal disease (ESRD). Malnutrition increases the risk of mortality among patients with ESRD. This study aimed to determine malnutrition prevalence and associated factors among twice-weekly (n = 94/120) and thrice-weekly (n = 26/120) hemodialysis patients/HDP. Method: A cross-sectional study was conducted at two tertiary-level public hospitals in Dhaka city using a consecutive sampling technique from April to June 2021. Nutritional status was assessed by Malnutrition Inflammation Score (MIS). Multivariable ordinal logistic regression was performed to determine which socioeconomic, clinical, anthropometric, biochemical, and dietary factors are associated with MIS. Results: The prevalence of malnutrition was very high among HDP (severe 15.5%, mild/moderate 56.7%) with an average dialysis vintage of 28.7 months. Comorbidities (80.8%) and gastrointestinal symptoms/GIS (68.3%) were ubiquitous, and "dialysis frequencies" were not associated with MIS in bivariate analysis. Multivariable ordinal regression showed that anthropometric factors like mid-upper arm circumference/MUAC (adjusted odds ratio/AOR = 0.978), post-dialysis body mass index/BMI (AOR = 0.957), and biochemical parameters like albumin (AOR = 0.733) and TIBC/total iron binding capacity (AOR = 0.996) negatively (P < .05) associated with MIS. Moreover, having "no GIS" (AOR = 0.672, P < .001) was 33.0% less likely to be associated with MIS. Contrarily, as the month of dialysis increases, MIS increases by 22.0% (AOR = 1.22). Conclusion: Significant associations of clinical, anthropometric, and biochemical characteristics with MIS indicate the importance of routine screening of the nutritional status of patients with CKD to improve health status and prevent protein-energy wasting. The MIS could be a simple, noninvasive tool for testing nutritional status in patients with CKD.

Healthcare seeking behavior and delays in case of Drug-Resistant Tuberculosis patients in Bangladesh: Findings from a cross-sectional survey.

The emergence of Drug-Resistant Tuberculosis (DR-TB) has become a major threat globally and Bangladesh is no exception. Delays in healthcare seeking, proper diagnosis and initiation of treatment cause continuous transmission of the resistant tubercule bacilli through the communities. This study aimed to assess the different health care-seeking behaviors and delays among DR-TB patients in Bangladesh. A prospective cross-sectional study was conducted from November to December 2018, among 92 culture positive and registered DR-TB patients in four selected hospitals in Bangladesh. Data were collected through face-to-face interviews with survey questionnaire as well as record reviews. Among the 92 study participants, the median patient delay was 7 (IQR 3, 15) days, the median diagnostic delay was 88 (IQR 36.5, 210), the median treatment delay was 7 (IQR 4,12) days, and the median total delay among DR-TB patients was 108.5 (IQR 57.5, 238) days. 81.32% sought initial care from informal healthcare providers. The majority (68.48%) of the informal healthcare providers were drug sellers while 60.87% of patients sought care from more than four healthcare points before being diagnosed with DR-TB. The initial care seeking from multiple providers was associated with diagnostic and total delays. In Bangladesh, DR-TB cases usually seek care from multiple providers, particularly from informal providers, and among them, alarmingly higher healthcare-seeking related delays were noted. Immediate measures should be taken both at the health system levels and, in the community, to curb transmission and reduce the burden of the disease.

Factors associated with fathers' involvement in infant and young child feeding and nurturing care in the urban slums of Bangladesh: A cross-sectional study.

Optimal infant and young child feeding (IYCF) and nurturing care during the first years of children's lives are crucial for ensuring their growth and development. The IYCF and nurturing practices are associated with a multifaceted interplay of context-specific factors where fathers' involvement is necessary. The aim of this study is to explore the current scenario of fathers' involvement in IYCF practices in the urban slums of Bangladesh. A cross-sectional survey among the residents of the Sat Tola slum in Dhaka, the capital of Bangladesh was conducted. To avoid social desirability bias, 361 mothers of children aged <24 months were interviewed regarding fathers' involvement. An operational definition of father's involvement was developed based on 11 criteria and then scoring was applied to classify 'Good Involvement' and associated factors were identified using multivariable logistic regression. Fathers' mean age was around 31 (SD ± 6.09) years and the majority of them (44.32%) completed primary education. Fathers had diversified occupations such as day laborer (32.41%), garment worker (22.71%), and business (14.96%). Factors that were significantly associated with the father's involvement in IYCF practices include educational status (aOR = 3.98, 95% CI = 1.91, 8.26, p < .00) and theiroccupational status (aOR = 0.34, 95% CI = 0.16, 0.70, p = .00). Fathers were more active for their first child (aOR: 1.99, 95% CI = 1.04, 3.79, p = .03). Having child in the age group of 14-20 months (aOR = 2.73, 95% CI = 1.32, 5.64, p = <.01) and wife in the age group of 21-30 years (aOR = 2.34, 95% CI = 1.20, 4.58, p = .01) were significantly associated. The study finding explored that fathers' education and occupation as well as mothers' age and education were significantly associated factors for fathers' involvement in the IYCF practices. Further longitudinal studies are recommended to establish the causal relationship between fathers' involvement with IYCF and their impact on child growth and development.

Antibiotics administration without prescription in Bangladesh.

Background: Antibiotic resistance is a global challenge. Therefore, adhering to proper antibiotic administration protocols is essential to mitigating the problem. This study investigated the prevalence, and factors associated with, antibiotics administration without prescription by registered doctors in Bangladesh. Method: This cross-sectional survey was carried out among 1102 adults. The outcome variable was antibiotics administration without prescription. The exploratory variables included the those relating to sociodemographics, attitudes, and knowledge (antibiotic-treatable diseases, types of disease specification, and antimicrobial drugs specifications). Descriptive and inferential statistics were performed, with a p-value of 0.05 considered significant with a 95% confidence interval. Results: The prevalence of antibiotics administration without prescription was found to be 37.02%. Age was significantly associated with the administration of antibiotics without prescription. Those who had taken antibiotics in the previous 2 months reported a significantly higher prevalence of antibiotics administration without prescription. The participants' attitudes toward antibiotics and knowledge of antibiotic-treatable diseases, types of disease, and antimicrobial drugs were significantly associated with antibiotics administration without prescription. Conclusion: These findings may assist in facilitating relevant initiatives to improve the magnitude of antibiotics utilization without prescription, and mitigate the emergence of antibiotic resistance in Bangladesh.

COVID-19 vaccination coverage is extremely low among older population in Bangladesh: findings from a cross-sectional study.

This cross-sectional study was conducted in September 2021 among 1,045 Bangladeshi older adults aged 60 years or above to explore the COVID-19 vaccination coverage and its associated factors. We used a semi-structured questionnaire to collect data on participants' sociodemographic and lifestyle characteristics, and COVID-19 related information (selected based on an extensive literature review). A multinomial logistic regression model was used to identify the factors independently associated with vaccine receipt. Nearly, two-thirds of the participants (64.5%) were unvaccinated and 12.5% received a single dose. Among the unvaccinated, approximately 94% reported that there was a problem in accessing the vaccine. We found that participants with formal schooling had 42% lower risk of being unvaccinated (RRR (Relative Risk Ratio) = 0.58, 95% CI 0.42-0.80) or 39% lower risk of receiving a single dose (RRR = 0.61, 95% CI 0.39-0.96) than the participants having no formal schooling. The middle family monthly income groups had 65% higher risk (RRR = 1.65, 95% CI 1.17-2.32) and rural participants had 84% higher risk (RRR = 1.84, 95% CI 1.26-2.70) of not receiving vaccines compared to their counterparts. Also, the participants with non-communicable chronic conditions had a significantly lower risk of being unvaccinated (RRR = 0.49, 95% CI 0.35-0.68) or receiving a single dose (RRR = 0.49, 95% CI 0.31-0.77) compared to their counterparts. This finding may help strengthen the existing efforts to maximize vaccine coverage among older populations in Bangladesh and reach herd immunity to break the transmission chain and gain greater overall population protection more rapidly.

Association between preference and e-learning readiness among the Bangladeshi female nursing students in the COVID-19 pandemic: a cross-sectional study.

BACKGROUND: The COVID-19 pandemic jeopardized the traditional academic learning calendars due to the closing of all educational institutions across the globe. To keep up with the flow of learning, most of the educational institutions shifted toward e-learning. However, the students' e-learning preference and e-learning readiness did not identify, particularly among the Bangladeshi female nursing students, where those can pose serious challenges. A cross-sectional study was carried out among the female nursing students between December 26, 2020, and January 11, 2021. A total of 237 students were recruited who have enrolled in e-learning at least the last 30 days of the participation. Multivariable linear regression models were fitted to find the association of students' preference, e-learning readiness domains, and other variables. RESULTS: A cross-sectional study was conducted among the female nursing students to assess perceived e-learning readiness in the subdomains of readiness; availability, technology use, self-confidence, acceptance and training. The findings of the study revealed that the prevalence of preference for e-learning was 43.46%. The students did not prefer e-learning compared to 'prefer group' has significantly less availability of technology (ß = - 3.01, 95% CI - 4.46, - 1.56), less use of technology (ß = - 3.08, 95% CI - 5.11, - 1.06), less self-confidence (ß = - 4.50, 95% CI - 7.02, - 1.98), less acceptance (ß = - 5.96, 95% CI - 7.76, - 4.16) and less training need (ß = - 1.86, 95% CI - 2.67, - 1.06). The age, degree, residence, parents' highest education, having a single room, and having any eye problems were significantly associated with the variation of availability of technology, use of technology, self-confidence, acceptance, and training need of e-learning. CONCLUSIONS: The outcomes of the study could be helpful while developing an effective and productive e-learning infrastructure regarding the preparedness of nursing colleges for the continuation of academia in any adverse circumstances like the COVID-19 pandemic.

Associations between household air pollution and early child development among children aged 36-59 months in Bangladesh.

BACKGROUND: Household air pollution (HAP) from solid fuel use (SFU) for cooking may impact child health in low-resources countries. This study examined the associations between HAP and early childhood development (ECD) outcomes among children under 5 years of age in Bangladesh and explored potential effect modification by sex and urbanicity. METHODS: The study sample consisted of 9395 children aged 36-59 months in the households from the Bangladesh Multiple Indicator Cluster Survey 2019. SFU and levels of exposure to SFU (unexposed, moderately exposed and highly exposed) were used as proxies of HAP exposure. We estimated the covariate-adjusted prevalence ratios (aPRs) and 95% CIs for the associations between HAP and ECD outcomes using multilevel mixed-effects Poisson regression models with a robust variance estimator. RESULTS: 81.4% of children were exposed to SFU, and the prevalence of developmental delay (in Early Childhood Development Index) was 25.3%. Children exposed to SFU were 1.47 times more likely to have developmental delays (95% CI: 1.25, 1.73; p<0.001) compared with children with no SFU exposure. SFU was significantly associated with developmental delay in socioemotional (aPR: 1.17; 95% CI: 1.01, 1.36; p=0.035) and learning-cognitive (aPR: 1.90; 95% CI: 1.39, 2.60; p<0.001) domains. Similarly, children moderately exposed and highly exposed to HAP had higher prevalence of developmental delays than unexposed children. We did not observe effect modification by sex or urbanicity. CONCLUSION: Public health policies should promote the use of clean cooking fuels and cookstoves to reduce the high burden of HAP exposure in low-resource countries for helping younger children to meet their developmental milestones.