Neonatal mortality risks among preterm births in a rural Bangladeshi cohort.

BACKGROUND: Preterm birth leads to an estimated 35% of neonatal deaths worldwide. Our study analyses neonatal mortality risks among preterm births in rural Bangladesh. METHODS: Trained community health workers (CHW) prospectively collected data between June 2007 and September 2009. RESULTS: Among 32 126 livebirths, 22.3% were preterm (delivered at <37 weeks gestation) and almost half (46.4%) of all neonatal deaths occurred among preterm babies. Preterm babies who were born as the first child {[risk ratio (RR) 1.4; 95% confidence interval (CI) 1.1, 1.8]} and in the poorest households [RR 1.7; 95% CI 1.2, 2.4] were at higher mortality risk. Birth and newborn care preparedness was associated with lower risk of mortality [RR 0.3; 95% CI 0.2, 0.4] while preterm infants who had symptoms of infection [RR 5.6; 95% CI 4.3, 7.1] or whose mother suffered antenatal complications [RR 1.4; 95% CI 1.1, 1.8] were at higher mortality risk. Elimination of excess neonatal deaths caused by preterm would decrease population-level neonatal mortality rate by 31.0% [95% CI 27.60%, 34.5%]. CONCLUSION: Given that 87% of preterm births and 60% of preterm deaths were in late or moderate preterm infants, and that 87% preterm babies received a visit from CHW within third day of life, a home-based essential care package delivered by CHWs for sick preterm infants, specifically focused on birth preparedness, skin-to-skin care, immediate breast feeding, early recognition of danger signs, and linked through referral to intensive and quality care in health facilities, could be an effective approach in low resource settings.

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.

Determinants and pattern of care seeking for preterm newborns in a rural Bangladeshi cohort.

BACKGROUND: Despite the increased burden of preterm birth and its complications, the dearth of care seeking data for preterm newborns remains a significant knowledge gap. Among preterm babies in rural Bangladesh, we examined: 1) determinants and patterns of care seeking, and 2) risk analysis for care-seeking from qualified and unqualified providers. METHOD: Trained community health workers collected data prospectively from 27,460 mother-liveborn baby pairs, including 6,090 preterm babies, between June 2007 and September 2009. Statistical analyses included binomial and multinomial logistic regressions. RESULTS: Only one-fifth (19.7%) of preterm newborns were taken to seek either preventive or curative health care. Among care-seeker preterm newborns, preferred providers included homeopathic practitioners (50.0%), and less than a third (30.9%) sought care from qualified providers. Care-seeking from either unqualified or qualified providers was significantly lower for female preterm babies, compared to male babies [Relative Risk Ratio (RRR) for unqualified care: 0.68; 95% Confidence Interval (CI): 0.58, 0.80; RRR for qualified care: 0.52; 95% CI: 0.41, 0.66]. Among preterm babies, care-seeking was significantly higher among caregivers who recognized symptoms of illness [RR: 2.14; 95% CI: 1.93, 2.38] or signs of local infection (RR: 2.53; 95% CI: 2.23, 2.87), had a history of child death [RR: 1.21; 95% CI: 1.07, 1.37], any antenatal care (ANC) visit [RR: 1.41; 95% CI: 1.25, 1.59]. Birth preparedness (RRR: 1.24; 95% CI: 1.09, 1.68) and any ANC visit (RRR: 1.73; 95% CI: 1.50, 2.49) were also associated with increased likelihood of care seeking for preterm babies from qualified providers. CONCLUSION: To improve care seeking practices for preterm babies and referral of sick newborns to qualified providers/facilities, we recommend: 1) involving community-preferred health care providers in community-based health education and awareness raising programs; 2) integrating postnatal care seeking messages into antenatal counselling; and 3) further research on care seeking practices for preterm babies.

The effect of cord cleansing with chlorhexidine on neonatal mortality in rural Bangladesh: a community-based, cluster-randomised trial.

BACKGROUND: Up to half of neonatal deaths in high mortality settings are due to infections, many of which can originate through the freshly cut umbilical cord stump. We aimed to assess the effectiveness of two cord-cleansing regimens with the promotion of dry cord care in the prevention of neonatal mortality. DESIGN: We did a community-based, parallel cluster-randomised trial in Sylhet, Bangladesh. We divided the study area into 133 clusters, which were randomly assigned to one of the two chlorhexidine cleansing regimens (single cleansing as soon as possible after birth; daily cleansing for 7 days after birth) or promotion of dry cord care. Randomisation was done by use of a computer-generated sequence, stratified by cluster-specific participation in a previous trial. All livebirths were eligible; those visited within 7 days by a local female village health worker trained to deliver the cord care intervention were enrolled. We did not mask study workers and participants to the study interventions. Our primary outcome was neonatal mortality (within 28 days of birth) per 1000 livebirths, which we analysed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT00434408. RESULTS: Between June, 2007, and September, 2009, we enrolled 29 760 newborn babies (10 329, 9423, and 10 008 in the multiple-cleansing, single-cleansing, and dry cord care groups, respectively). Neonatal mortality was lower in the single-cleansing group (22·5 per 1000 livebirths) than it was in the dry cord care group (28·3 per 1000 livebirths; relative risk [RR] 0·80 [95% CI] 0·65-0·98). Neonatal mortality in the multiple-cleansing group (26·6 per 1000 livebirths) was not statistically significantly lower than it was in the dry cord care group (RR 0·94 [0·78-1·14]). Compared with the dry cord care group, we recorded a statistically significant reduction in the occurrence of severe cord infection (redness with pus) in the multiple-cleansing group (risk per 1000 livebirths=4·2 vs risk per 1000 livebirths=1·2; RR 0·35 [0·15-0·81]) but not in the single-cleansing group (risk per 1000 livebirths=3·3; RR 0·77 [0·40-1·48]). INTERPRETATION: Chlorhexidine cleansing of a neonate's umbilical cord can save lives, but further studies are needed to establish the best frequency with which to deliver the intervention. FUNDING: United States Agency for International Development and Save the Children's Saving Newborn Lives program, through a grant from the Bill & Melinda Gates Foundation.

Economic evaluation of neonatal care packages in a cluster-randomized controlled trial in Sylhet, Bangladesh.

OBJECTIVE: To evaluate and compare the cost-effectiveness of two strategies for neonatal care in Sylhet division, Bangladesh. METHODS: In a cluster-randomized controlled trial, two strategies for neonatal care--known as home care and community care--were compared with existing services. For each study arm, economic costs were estimated from a societal perspective, inclusive of programme costs, provider costs and household out-of-pocket payments on care-seeking. Neonatal mortality in each study arm was determined through household surveys. The incremental cost-effectiveness of each strategy--compared with that of the pre-existing levels of maternal and neonatal care--was then estimated. The levels of uncertainty in our estimates were quantified through probabilistic sensitivity analysis. FINDINGS: The incremental programme costs of implementing the home-care package were 2939 (95% confidence interval, CI: 1833-7616) United States dollars (US$) per neonatal death averted and US$ 103.49 (95% CI: 64.72-265.93) per disability-adjusted life year (DALY) averted. The corresponding total societal costs were US$ 2971 (95% CI: 1844-7628) and US$ 104.62 (95% CI: 65.15-266.60), respectively. The home-care package was cost-effective--with 95% certainty--if healthy life years were valued above US$ 214 per DALY averted. In contrast, implementation of the community-care strategy led to no reduction in neonatal mortality and did not appear to be cost-effective. CONCLUSION: The home-care package represents a highly cost-effective intervention strategy that should be considered for replication and scale-up in Bangladesh and similar settings elsewhere.

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.

Levels, timing, and etiology of stillbirths in Sylhet district of Bangladesh.

BACKGROUND: Lack of data is a critical barrier to addressing the problem of stillbirth in countries with the highest stillbirth burden. Our study objective was to estimate the levels, types, and causes of stillbirth in rural Sylhet district of Bangladesh. METHODS: A complete pregnancy history was taken from all women (n=39 998) who had pregnancy outcomes during 2003-2005 in the study area. Verbal autopsy data were obtained for all identified stillbirths during the period. We used pre-defined case definitions and computer programs to assign causes of stillbirth for selected causes containing specific signs and symptoms. Both non-hierarchical and hierarchical approaches were used to assign causes of stillbirths. RESULTS: A total of 1748 stillbirths were recorded during 2003-2005 from 48,192 births (stillbirth rate: 36.3 per 1000 total births). About 60% and 40% of stillbirths were categorized as antepartum and intrapartum, respectively. Maternal conditions, including infections, hypertensive disorders, and anemia, contributed to about 29% of total antepartum stillbirths. About 50% of intrapartum stillbirths were attributed to obstetric complications. Maternal infections and hypertensive disorders contributed to another 11% of stillbirths. A cause could not be assigned in nearly half (49%) of stillbirths. CONCLUSION: The stillbirth rate is high in rural Bangladesh. Based on algorithmic approaches using verbal autopsy data, a substantial portion of stillbirths is attributable to maternal conditions and obstetric complications. Programs need to deliver community-level interventions to prevent and manage maternal complications, and to develop strategies to improve access to emergency obstetric care. Improvements in care to avert stillbirth can be accomplished in the context of existing maternal and child health programs. Methodological improvements in the measurement of stillbirths, especially causes of stillbirths, are also needed to better define the burden of stillbirths in low-resource settings.

Factors affecting recruitment and retention of community health workers in a newborn care intervention in Bangladesh.

BACKGROUND: Well-trained and highly motivated community health workers (CHWs) are critical for delivery of many community-based newborn care interventions. High rates of CHW attrition undermine programme effectiveness and potential for implementation at scale. We investigated reasons for high rates of CHW attrition in Sylhet District in north-eastern Bangladesh. METHODS: Sixty-nine semi-structured questionnaires were administered to CHWs currently working with the project, as well as to those who had left. Process documentation was also carried out to identify project strengths and weaknesses, which included in-depth interviews, focus group discussions, review of project records (i.e. recruitment and resignation), and informal discussion with key project personnel. RESULTS: Motivation for becoming a CHW appeared to stem primarily from the desire for self-development, to improve community health, and for utilization of free time. The most common factors cited for continuing as a CHW were financial incentive, feeling needed by the community, and the value of the CHW position in securing future career advancement. Factors contributing to attrition included heavy workload, night visits, working outside of one's home area, familial opposition and dissatisfaction with pay. CONCLUSIONS: The framework presented illustrates the decision making process women go through when deciding to become, or continue as, a CHW. Factors such as job satisfaction, community valuation of CHW work, and fulfilment of pre-hire expectations all need to be addressed systematically by programs to reduce rates of CHW attrition.

Community-based health workers achieve high coverage in neonatal intervention trials: a case study from Sylhet, Bangladesh.

A large proportion of four million neonatal deaths occur each year during the first 24 hours of life. Research is particularly needed to determine the efficacy of interventions during the first 24 hours. Large cadres of community-based workers are required in newborn-care research both to deliver these interventions in a standardized manner in the home and to measure the outcomes of the study. In a large-scale community-based efficacy trial of chlorhexidine for cleansing the cord in north-eastern rural Bangladesh, a two-tiered system of community-based workers was established to deliver a package of essential maternal and newborn-care interventions and one of three umbilical cord-care regimens. At any given time, the trial employed approximately 133 community health workers--each responsible for 4-5 village health workers and a population of approximately 4,000. Over the entire trial period, 29,760 neonates were enrolled, and 87% of them received the intervention (their assigned cord-care regimen) within 24 hours of birth. Approaches to recruitment, training, and supervision in the study are described. Key lessons included the importance of supportive processes for community-based workers, including a strong training and field supervisory system, community acceptance of the study, consideration of the setting, study objectives, and human resources available.

Invasive pneumococcal disease among children in rural Bangladesh: results from a population-based surveillance.

BACKGROUND: Streptococcus pneumoniae infection is recognized as a global priority public health problem, and conjugate vaccines have been shown to prevent vaccine-type invasive pneumococcal disease (IPD) in children. However, better estimates of the disease burden and reliable population-based data on serotype composition are needed for vaccine development and implementation in developing countries. METHODS: We initiated a population-based surveillance in the rural Bangladesh community of Mirzapur, covering a population of approximately 144,000. Village health care workers made weekly visits to approximately 12,000 children 1-59 months of age in the study area. Children with reported fever, cough, or difficulty breathing were assessed by the village health care workers using a clinical algorithm and were referred to the hospital if required. Children from the study area who were seen in the hospital underwent clinical examination and laboratory testing if they met standardized case definitions. IPD was confirmed by blood and/or cerebrospinal fluid culture results. Isolates were identified, tested for susceptibility to antibiotics, and serotyped in accordance with standard laboratory methods. We present here the results from the first 3 years of the surveillance (July 2004-June 2007). RESULTS: Village health care workers identified 5020 cases of possible severe pneumonia and/or very severe disease (165 cases per 1000 child-years)and 9411 cases of possible pneumonia (310 cases per 1000 child-years) as well as 2029 cases of suspected meningitis and/or very severe disease (67 cases per 1000 child-years) and 8967 cases of high fever and/or possible bacteremia (295 cases per 1000 child-years). Pneumonia was the single most common form of illness observed among 2596 hospitalizations (found in 977 [38%] of cases). We recovered 26 S. pneumoniae isolates (25 isolates from 6925 blood cultures and 1 isolate from 41 cerebrospinal fluid cultures), which gave an overall IPD incidence of 86 cases per 100,000 child-years. Invasive pneumococcal infection was common during infancy (with infants accounting for 23 of the 26 cases), and 50% of the total isolates were obtained from nonhospitalized patients who received a diagnosis of upper respiratory tract infection and fever. The most prevalent pneumococcal serotypes were serotypes 1, 5, 14, 18C, 19A, and 38. Ten of the 26 isolates were completely resistant to trimethoprim-sulfamethoxazole, and another 10 isolates had intermediate resistance. CONCLUSIONS: IPD contributes substantially to childhood morbidity in rural Bangladesh. S. pneumoniae can cause invasive but nonsevere disease in children, and IPD incidence can be seriously under reported if such cases are overlooked. The emerging high resistance to trimethoprim-sulfamethoxazole should be addressed. Data on serotype distribution would help to guide appropriate pneumococcal conjugate vaccine formulation.

Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial.

BACKGROUND: Neonatal mortality accounts for a high proportion of deaths in children under the age of 5 years in Bangladesh. Therefore the project for advancing the health of newborns and mothers (Projahnmo) implemented a community-based intervention package through government and non-government organisation infrastructures to reduce neonatal mortality. METHODS: In Sylhet district, 24 clusters (with a population of about 20 000 each) were randomly assigned in equal numbers to one of two intervention arms or to the comparison arm. Because of the study design, masking was not feasible. All married women of reproductive age (15-49 years) were eligible to participate. In the home-care arm, female community health workers (one per 4000 population) identified pregnant women, made two antenatal home visits to promote birth and newborn-care preparedness, made postnatal home visits to assess newborns on the first, third, and seventh days of birth, and referred or treated sick neonates. In the community-care arm, birth and newborn-care preparedness and careseeking from qualified providers were promoted solely through group sessions held by female and male community mobilisers. The primary outcome was reduction in neonatal mortality. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, number 00198705. FINDINGS: The number of clusters per arm was eight. The number of participants was 36059, 40159, and 37598 in the home-care, community-care, and comparison arms, respectively, with 14 769, 16 325, and 15 350 livebirths, respectively. In the last 6 months of the 30-month intervention, neonatal mortality rates were 29.2 per 1000, 45.2 per 1000, and 43.5 per 1000 in the home-care, community-care, and comparison arms, respectively. Neonatal mortality was reduced in the home-care arm by 34% (adjusted relative risk 0.66; 95% CI 0.47-0.93) during the last 6 months versus that in the comparison arm. No mortality reduction was noted in the community-care arm (0.95; 0.69-1.31). INTERPRETATION: A home-care strategy to promote an integrated package of preventive and curative newborn care is effective in reducing neonatal mortality in communities with a weak health system, low health-care use, and high neonatal mortality.

Effectiveness of home-based management of newborn infections by community health workers in rural Bangladesh.

BACKGROUND: : Infections account for about half of neonatal deaths in low-resource settings. Limited evidence supports home-based treatment of newborn infections by community health workers (CHW). METHODS: : In one study arm of a cluster randomized controlled trial, CHWs assessed neonates at home, using a 20-sign clinical algorithm and classified sick neonates as having very severe disease or possible very severe disease. Over a 2-year period, 10,585 live births were recorded in the study area. CHWs assessed 8474 (80%) of the neonates within the first week of life and referred neonates with signs of severe disease. If referral failed but parents consented to home treatment, CHWs treated neonates with very severe disease or possible very severe disease with multiple signs, using injectable antibiotics. RESULTS: : For very severe disease, referral compliance was 34% (162/478 cases), and home treatment acceptance was 43% (204/478 cases). The case fatality rate was 4.4% (9/204) for CHW treatment, 14.2% (23/162) for treatment by qualified medical providers, and 28.5% (32/112) for those who received no treatment or who were treated by other unqualified providers. After controlling for differences in background characteristics and illness signs among treatment groups, newborns treated by CHWs had a hazard ratio of 0.22 (95% confidence interval [CI] = 0.07-0.71) for death during the neonatal period and those treated by qualified providers had a hazard ratio of 0.61 (95% CI = 0.37-0.99), compared with newborns who received no treatment or were treated by untrained providers. Significantly increased hazards ratios of death were observed for neonates with convulsions (hazard ratio [HR] = 6.54; 95% CI = 3.98-10.76), chest in-drawing (HR = 2.38, 95% CI = 1.29-4.39), temperature <35.3 degrees C (HR = 3.47, 95% CI = 1.30-9.24), and unconsciousness (HR = 7.92, 95% CI = 3.13-20.04). CONCLUSIONS: : Home treatment of very severe disease in neonates by CHWs was effective and acceptable in a low-resource setting in Bangladesh.

Validation of community health workers' assessment of neonatal illness in rural Bangladesh.

OBJECTIVE: To estimate the validity (sensitivity, specificity, and positive and negative predictive values) of a clinical algorithm as used by community health workers (CHWs) to detect and classify neonatal illness during routine household visits in rural Bangladesh. METHODS: CHWs evaluated breastfeeding and symptoms and signs of illness in 395 neonates selected randomly from neonatal illness surveillance during household visits on postnatal days 0, 2, 5 and 8. Neonates classified with very severe disease (VSD) were referred to a community-based hospital. Within 12 hours of CHW assessments, physicians independently evaluated all neonates seen in a given day by one CHW, randomly chosen from among 36 project CHWs. Physicians recorded symptoms and signs of illness, classified the illness, and determined whether the newborn needed referral-level care at the hospital. Physicians' identification and classification were used as the gold standard in determining the validity of CHWs' identification of symptoms and signs of illness and its classification. FINDINGS: CHWs' classification of VSD showed a sensitivity of 73%, a specificity of 98%, a positive predictive value of 57% and a negative predictive value of 99%. A maternal report of any feeding problem as ascertained by physician questioning was significantly associated (P < 0.001) with 'not sucking at all' and 'not attached at all' or 'not well attached' as determined clinically by CHWs during feeding assessment. CONCLUSION: CHWs identified with high validity the neonates with severe illness needing referral-level care. Home-based illness recognition and management, including referral of neonates with severe illness by CHWs, is a promising strategy for improving neonatal health and survival in low-resource developing country settings.

Community-based validation of assessment of newborn illnesses by trained community health workers in Sylhet district of Bangladesh.

OBJECTIVES: To validate trained community health workers' recognition of signs and symptoms of newborn illnesses and classification of illnesses using a clinical algorithm during routine home visits in rural Bangladesh. METHODS: Between August 2005 and May 2006, 288 newborns were assessed independently by a community health worker and a study physician. Based on a 20-sign algorithm, sick neonates were classified as having very severe disease, possible very severe disease or no disease. The physician's assessment was considered as the gold standard. RESULTS: Community health workers correctly classified very severe disease in newborns with a sensitivity of 91%, specificity of 95% and kappa value of 0.85 (P < 0.001). Community health workers' recognition showed a sensitivity of more than 60% and a specificity of 97-100% for almost all signs and symptoms. CONCLUSION: Community health workers with minimal training can use a diagnostic algorithm to identify severely ill newborns with high validity.

Impact of 4.0% chlorhexidine cleansing of the umbilical cord on mortality and omphalitis among newborns of Sylhet, Bangladesh: design of a community-based cluster randomized trial.

BACKGROUND: The World Health Organization recommends dry cord care for newborns but this recommendation may not be optimal in low resource settings where most births take place in an unclean environment and infections account for up to half of neonatal deaths. A previous trial in Nepal indicated that umbilical cord cleansing with 4.0% chlorhexidine could substantially reduce mortality and omphalitis risk, but policy changes await additional community-based data. METHODS: The Projahnmo Chlorhexidine study was a three-year, cluster-randomized, community-based trial to assess the impact of three cord care regimens on neonatal mortality and omphalitis. Women were recruited mid-pregnancy, received a basic package of maternal and neonatal health promotion messages, and were followed to pregnancy outcome. Newborns were visited at home by local village-based workers whose areas were randomized to either 1) single- or 2) 7-day cord cleansing with 4.0% chlorhexidine, or 3) promotion of dry cord care as recommended by WHO. All mothers received basic messages regarding hand-washing, clean cord cutting, and avoidance of harmful home-base applications to the cord. Death within 28 days and omphalitis were the primary outcomes; these were monitored directly through home visits by community health workers on days 1, 3, 6, 9, 15, and 28 after birth. DISCUSSION: Due to report in early 2010, the Projahnmo Chlorhexidine Study examines the impact of multiple or single chlorhexidine cleansing of the cord on neonatal mortality and omphalitis among newborns of rural Sylhet District, Bangladesh. The results of this trial will be interpreted in conjunction with a similarly designed trial previously conducted in Nepal, and will have implications for policy guidelines for optimal cord care of newborns in low resource settings in Asia. TRIAL REGISTRATION: ClinicalTrials.gov (NCT00434408).

Universal Health Coverage in Bangladesh: Activities, Challenges, and Suggestions.

Catastrophic health expenditure forces 5.7 million Bangladeshis into poverty. Inequity is present in most of health indicators across social, economic, and demographic parameters. This study explores the existing health policy environment and current activities to further the progress towards Universal Health Coverage (UHC) and the challenges faced in these endeavors. This qualitative study involved document reviews (n=22) and key informant interviews (KII, n=15). Thematic analysis of texts (themes: activities around UHC, implementation barriers, suggestions) was done using the manual coding technique. We found that Bangladesh has a comprehensive set of policies for UHC, e.g., a health-financing strategy and staged recommendations for pooling of funds to create a national health insurance scheme and expand financial protection for health. Progress has been made in a number of areas including the roll out of the essential package of health services for all, expansion of access to primary health care services (support by donors), and the piloting of health insurance which has been piloted in three sub districts. Political commitment for these areas is strong. However, there are barriers pertaining to the larger policy level which includes a rigid public financing structure dating from the colonial era. While others pertain to the health sector's implementation shortfalls including issues of human resources, political interference, monitoring, and supervision, most key informants discussed demand-side barriers too, such as sociocultural disinclination, historical mistrust, and lack of empowerment. To overcome these, several policies have been recommended, e.g., redesigning the public finance structure, improving governance and regulatory mechanism, specifying code of conduct for service providers, introducing health-financing reform, and collaborating with different sectors. To address the implementation barriers, recommendations include improving service quality, strengthening overall health systems, improving health service management, and improving monitoring and supervision. Addressing demand-side barriers, such as patient education and community empowerment, is also needed. Research and advocacy are required to address crosscutting barriers such as the lack of common understanding of UHC.

Incidence and risk factors of neonatal infections in a rural Bangladeshi population: a community-based prospective study.

BACKGROUND: Infections cause about one fifth of the estimated 2.7 million annual neonatal deaths worldwide. Population-based data on burden and risk factors of neonatal infections are lacking in developing countries, which are required for the appropriate design of effective preventive and therapeutic interventions in resource-poor settings. METHODS: We used data from a community-based cluster-randomized trial conducted to evaluate the impact of two umbilical cord cleansing regimens with chlorhexidine solution on neonatal mortality and morbidity in a rural area of Sylhet District in Bangladesh. Newborns were assessed four times in the first 9 days of life by trained community health workers (CHWs) using a WHO IMCI-like clinical algorithm. Cumulative incidence of the first episode of infections in the first 9 days of life was estimated using survival analysis technique accounting for survival bias and competing risk of death before the occurrence of infection. A multivariable generalized estimating equation log-binomial regression model was used to identify factors independently associated with infections. RESULTS: Between 2007 and 2009, 30,267 newborns who received at least one postnatal assessment visit by a CHW within the first 9 days of life were included in this study. Cumulative incidence of infections in the first 9 days of life was 14.5% (95% CI 14.1-14.9%). Significant risk factors included previous child death in the family [RR 1.10 (95% CI 1.02-1.19)]; overcrowding [RR 1.14 (95% CI 1.04-1.25)]; home delivery [RR 1.86 (95% CI 1.58-2.19)]; unclean cord care [RR 1.15 (95% CI 1.03-1.28)]; multiple births [RR 1.34 (95% CI 1.15-1.56)]; low birth weight [reference: ≥ 2500 g, RR (95% CI) for < 1500, 1500-1999, and 2000-2499 g were 4.69 (4.01-5.48), 2.15 (1.92-2.42), and 1.15 (1.07-1.25) respectively]; and birth asphyxia [RR 1.65 (1.51-1.81)]. Higher pregnancy order lowered the risk of infections in the study population [compared to first pregnancy, RR (95% CI) for second, third, and ≥ fourth pregnancy babies were 0.93 (0.85-1.02), 0.88 (0.79-0.97), and 0.79 (0.71-0.87), respectively]. CONCLUSION: Neonatal infections and associated deaths can be reduced by identifying and following up high-risk mothers and newborns and promoting facility delivery and clean cord care in resource-poor countries like Bangladesh where the burden of clinically ascertained neonatal infections is high. Further research is needed to measure the burden of infections in the entire neonatal period, particularly in the second fortnight and its association with essential newborn care. TRIAL REGISTRATION: NCT00434408 . Registered February 9, 2007.

A cross-sectional study of partograph utilization as a decision making tool for referral of abnormal labour in primary health care facilities of Bangladesh.

BACKGROUND: In Bangladesh, female paramedics known as Family Welfare Visitors (FWVs), conduct normal deliveries in first-level primary care facilities, or Union Health and Family Welfare Centres (UH&FWC). Utilization of partographs allow for early identification of abnormal labour and referral for advanced care to Emergency Obstetric Care (EmOC) facilities. A systematic assessment of the quality of partograph utilization in clinical-decision making will contribute to understanding the use of the tool by health workers. METHODS: In 2013, the USAID supported MaMoni HSS project, led in country by Save the Children, trained FWVs on the use of partographs in five UH&FWCs in Habiganj district. As part of the follow-up after training, intrapartum case record forms, accompanying partographs, and referral registers for all obstetric cases managed in these five facilities from July 2013 to June 2014 were reviewed. Partographs were reviewed to identify abnormal labour cases based on pre-defined indications. All referred cases were ascertained from the case records in the referral registers. Five health workers were interviewed to assess their knowledge, attitude and experience in partograph use and to explore the challenges for referral decision making associated with the tool. RESULTS: A total of 1,198 deliveries were managed at the study sites, of which 663 presented with cervical dilatation of 8 cm or less. Partographs were initiated in 98% of these cases. Indication of abnormal labour was found in 71 partographs (11%) and among them, only 1 was referred to a higher-level facility. Foetal heart rate and cervical dilatation were appropriately recorded in 61% and 70% of the partographs, respectively. Interviews with health workers revealed poor interpretation of referral indications from the partographs. Limited accessibility to the nearest EmOC facility, inadequate time for referral, and non-compliance to referral by clients were identified by the interviewed health workers as the key barriers for referral decision making. CONCLUSIONS: Supporting the health workers at first-level primary care facilities to better interpret and act on partograph data in a timely manner, and strengthening the referral systems are needed to ensure that women in labour receive the prompt quality care they and their babies require to survive.

Trends in use of referral hospital services for care of sick newborns in a community-based intervention in Tangail District, Bangladesh.

The Projahnmo-II Project in Mirzapur upazila (sub-district), Tangail district, Bangladesh, is promoting care-seeking for sick newborns through health education of families, identification and referral of sick newborns in the community by community health workers (CHWs), and strengthening of neonatal care in Kumudini Hospital, Mirzapur. Data were drawn from records maintained by the CHWs, referral hospital registers, a baseline household survey of recently-delivered women conducted from March to June 2003, and two interim household surveys in January and September 2005. Increases were observed in self-referral of sick newborns for care, compliance after referral by the CHWs, and care-seeking from qualified providers and from the Kumudini Hospital, and decreases were observed in care-seeking from unqualified providers in the intervention arm. An active surveillance for illness by the CHWs in the home, education of families by them on recognition of danger signs and counselling to seek immediate care for serious illness, and improved linkages between the community and the hospital can produce substantial increases in care-seeking for sick newborns.

Population-based Incidence and Etiology of Community-acquired Neonatal Viral Infections in Bangladesh: A Community-based and Hospital-based Surveillance Study.

BACKGROUND: The etiology of >90% of cases of suspected neonatal infection remains unknown. We conducted community-based surveillance in conjunction with hospital-based surveillance in a rural region in Bangladesh from June 2006 to September 2007 to assess the incidence and etiology of community-acquired viral infections among neonates. METHODS: Community health workers (CHWs) assessed neonates at home on days 0, 2, 5 and 8 after birth and referred cases of suspected illness to the hospital (CHW surveillance). Among neonates with clinically suspected upper respiratory tract infection (URTI), pneumonia, sepsis and/or meningitis, virus identification studies were conducted on nasal wash, cerebrospinal fluid and/or blood specimens. In the hospital-based surveillance, similar screening was conducted among all neonates (referred by CHWs and self-referred) who were admitted to the hospital. RESULTS: CHW surveillance found an incidence rate of 15.6 neonatal viral infections per 1000 live births with 30% of infections identified on the day of birth. Among neonates with suspected sepsis, a viral etiology was identified in 36% of cases, with enterovirus accounting for two-thirds of those infections. Respiratory syncytial virus was the most common etiologic agent among those with viral pneumonia (91%) and URTI (68%). There was a low incidence (1.2%) of influenza in this rural population. CONCLUSION: Viral infections are commonly associated with acute newborn illness, even in the early neonatal period. The estimated incidence was 5-fold greater than reported previously for bacterial infections. Low-cost preventive measures for neonatal viral infections are urgently needed.