Delivery practices of traditional birth attendants in Dhaka slums, Bangladesh

This paper describes associations among delivery-location, training of birth attendants, birthing practices, and early postpartum morbidity in women in slum areas of Dhaka, Bangladesh. During November 1993-May 1995, data on delivery-location, training of birth attendants, birthing practices, delivery-related complications, and postpartum morbidity were collected through interviews with 1,506 women, 489 home-based birth attendants, and audits in 20 facilities where the women from this study gave birth. Associations among maternal characteristics, birth practices, delivery-location, and early postpartum morbidity were specifically explored. Self-reported postpartum morbidity was associated with maternal characteristics, delivery-related complications, and some birthing practices. Dais with more experience were more likely to use potentially-harmful birthing practices which increased the risk of postpartum morbidity among women with births at home. Postpartum morbidity did not differ by birth-location. Safe motherhood programmes must develop effective strategies to discourage potentially-harmful home-based delivery practices demonstrated to contribute to morbidity.

Invasive pneumococcal disease burden and implications for vaccine policy in urban Bangladesh

We undertook active population-based surveillance in 5,000 urban households among children < 5 years old to determine invasive pneumococcal disease (IPD) incidence, serotype distribution, clinical presentation, and antimicrobial resistance, which have not been previously described in population-based studies from the region. IPD was documented by blood culture isolation. From 01 April 2004 to 31 March 2006, 5,903 blood cultures were collected from 6,167 eligible children. Streptococcus pneumoniae was isolated from 34 pneumococcal patients; IPD was clinically associated with pneumonia (24%), upper respiratory infection (62%), and febrile syndromes (14%). Overall, IPD and 13-valent serotype-related IPD incidences were 447 and 276 episodes/100,000 child-years, respectively. Peak IPD incidence occurred during the cool dry seasons. Penicillin, cotrimoxazole, chloramphenicol, and ciprofloxacin resistances were 2.9%, 82.4%, 14.7%, and 24.1%, respectively. Current conjugate vaccines should substantially reduce IPD, childhood pneumonia, and antimicrobial resistance in Bangladesh.

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

CONTEXT

Although the reduction of maternal mortality levels is a key Millennium Development Goal, community-based evidence on obstetric complications and maternal care-seeking behavior remains limited in low-resource countries.

METHODS

This study presents an overview of key findings from the 2001 Bangladesh Maternal Health Services and Maternal Mortality Survey of ever-married women aged 13-49. The survey collected data on the prevalence of obstetric complications, women's knowledge of life-threatening complications, treatment-seeking behavior and reasons for delay in seeking medical care.

RESULTS

Bangladeshi women report low but increasing use of antenatal care, as well as low rates of delivery in a health facility or with the assistance of a skilled provider. Although almost half of women reported having one or more complications during pregnancy that they perceived as life threatening, only one in three sought treatment from a qualified provider. More than three-fourths of women with the time-sensitive complications of convulsions or excessive bleeding either failed to seek any treatment or sought treatment from an unqualified provider. The principal reason cited for failing to seek care for life-threatening complications was concern over medical costs, and pronounced socioeconomic disparities were found for maternal care-seeking behavior in both urban and rural Bangladesh.

CONCLUSIONS

Despite these gaps in access to skilled delivery and effective emergency obstetric care, some progress has been made in reducing maternal mortality levels. Improved obstetric care and declining levels of fertility and unwanted pregnancy may have played critical roles in addressing the maternal health care needs of Bangladeshi women.

Setting priorities in global child health research investments: addressing values of stakeholders

AIM

To identify main groups of stakeholders in the process of health research priority setting and propose strategies for addressing their systems of values.

METHODS

In three separate exercises that took place between March and June 2006 we interviewed three different groups of stakeholders: 1) members of the global research priority setting network; 2) a diverse group of national-level stakeholders from South Africa; and 3) participants at the conference related to international child health held in Washington, DC, USA. Each of the groups was administered different version of the questionnaire in which they were asked to set weights to criteria (and also minimum required thresholds, where applicable) that were a priori defined as relevant to health research priority setting by the consultants of the Child Health and Nutrition Research initiative (CHNRI).

RESULTS

At the global level, the wide and diverse group of respondents placed the greatest importance (weight) to the criterion of maximum potential for disease burden reduction, while the most stringent threshold was placed on the criterion of answerability in an ethical way. Among the stakeholders' representatives attending the international conference, the criterion of deliverability, answerability, and sustainability of health research results was proposed as the most important one. At the national level in South Africa, the greatest weight was placed on the criterion addressing the predicted impact on equity of the proposed health research.

CONCLUSIONS

Involving a large group of stakeholders when setting priorities in health research investments is important because the criteria of relevance to scientists and technical experts, whose knowledge and technical expertise is usually central to the process, may not be appropriate to specific contexts and in accordance with the views and values of those who invest in health research, those who benefit from it, or wider society as a whole.

Setting priorities in global child health research investments: assessment of principles and practice

This article reviews theoretical and practical approaches for setting priorities in global child health research investments. It also provides an overview of previous attempts to develop appropriate tools and methodologies to define priorities in health research investments. A brief review of the most important theoretical concepts that should govern priority setting processes is undertaken, showing how different perspectives, such as medical, economical, legal, ethical, social, political, rational, philosophical, stakeholder driven, and others will necessarily conflict each other in determining priorities. We specially address present research agenda in global child health today and how it relates to United Nation's (UN) Millennium Development Goal 4, which is to reduce child mortality by two-thirds between 1990 and 2015. The outcomes of these former approaches are evaluated and their benefits and shortcomings presented. The case for a new methodology for setting priorities in health research investments is presented, as proposed by Child Health and Nutrition Research Initiative, and a need for its implementation in global child health is outlined. A transdisciplinary approach is needed to address all the perspectives from which investments into health research can be seen as priorities. This prioritization requires a process that is transparent, systematic, and that would take into account many perspectives and build on advantages of previous approaches.

Setting priorities in child health research investments for South Africa

Nearly 100,000 children under 5 years die annually in South Africa. This paper defines health research priorities to address this unacceptably high mortality rate.

Depressive symptoms among rural Bangladeshi mothers: implications for infant development

OBJECTIVE

To examine how maternal depressive symptoms are related to infant development among low-income infants in rural Bangladesh and to examine how the relationship is affected by maternal perceptions of infant irritability and observations of caregiving practices.

METHODS

Development was measured among 221 infants at 6 and 12 months with the Bayley Scales II. Mothers reported on their depressive symptoms and on perceptions of their infant's temperament, and a home visit was made to complete the HOME Inventory.

RESULTS

Half (52%) the mothers reported depressive symptoms. In bivariate analyses, maternal depressive symptoms were related to low scores on the Bayley Scales. Infants whose mothers reported depressive symptoms and perceived their infants to be irritable acquired fewer cognitive, motor, and Orientation/Engagement skills between 6-12 months than infants whose mothers reported neither or only one condition. The relationship linking maternal depressive symptoms and perceived infant irritability with infant cognitive skills was partially mediated by parental responsiveness and opportunities for play in the home.

CONCLUSIONS

The intergenerational risks of maternal depressive symptoms on infant development extend to rural Bangladesh and are accentuated when mothers perceive their infants as irritable. Mothers who report depressive symptoms and infant irritability may lack the capacity to provide responsive, developmentally-oriented caregiving environments.

Influence of iron and zinc status on cadmium accumulation in Bangladeshi women

Cadmium is a widespread environmental contaminant present in food. The absorption in the intestine increases in individuals with low iron stores, but the effect of zinc deficiency is not clear. The aim of the present study was to assess the influence of iron and zinc status on cadmium accumulation in pregnant Bangladeshi women. We measured cadmium in urine from 890 women using inductively coupled plasma mass spectrometry (ICPMS). Further, we also measured ferritin and zinc in plasma. The median cadmium concentration in urine was 0.59 microg/L (adjusted to mean specific gravity of 1.012 g/mL). Analysis of covariance (ANCOVA) showed that urinary cadmium was associated with plasma ferritin and plasma zinc via a significant interaction between dichotomized plasma ferritin and plasma zinc. The analysis was adjusted for age and socioeconomic status. Women with low iron stores and adequate zinc status had significantly higher urinary cadmium compared to women with both adequate iron stores and zinc status. There was no difference in urinary cadmium between women with both low iron stores and zinc status compared to those with both adequate iron stores and zinc status. In conclusion, low iron stores were associated with increased cadmium accumulation, but only at adequate zinc status.

Effectiveness of Haemophilus influenzae type B conjugate vaccine on prevention of pneumonia and meningitis in Bangladeshi children: a case-control study

BACKGROUND

Few Asian countries have introduced Haemophilus influenzae type b (Hib) conjugate vaccine because of its cost and uncertainty regarding disease burden.

METHODS

To estimate the effectiveness of Hib conjugate vaccine in preventing pneumonia and meningitis in children age <2 years, an incident case-control study was conducted in a birth cohort of about 68,000 infants in Dhaka city, Bangladesh. DPT vaccine was systematically replaced by a combined Hib-DPT vaccine in selected immunization centers of the study area. Four matched community- and 2 hospital-controls were randomly selected for each confirmed case of pneumonia and meningitis from the study area.

RESULTS

About 35% of the infants received each of the 3 doses of Hib-DPT vaccine. There were 2679 children who had a chest roentgenogram. For 475 children, a radiologist and a pediatrician independently identified substantial alveolar consolidation. Following at least 2 doses of Hib vaccine, the preventable fractions [95% confidence intervals (CI)] using community and hospital controls were 17% (-10% to 38%) and 35% (13% to 52%) respectively. Of these 475 cases, 2 radiologists with the World Health Organization concurred with the findings for 343 patients, yielding preventable fractions of 34% (6% to 53%) and 44% (20% to 61%). Fifteen confirmed Hib meningitis cases were identified; the preventable fractions (95% CI) using community and hospital controls, respectively, were 89% (28% to 100%) and 93% (53% to 100%).

CONCLUSIONS

The study documented that significant fractions of pneumonia and meningitis in Bangladeshi children age <2 years can be prevented by the Hib conjugate vaccine.

Increasing spectrum in antimicrobial resistance of Shigella isolates in Bangladesh: resistance to azithromycin and ceftriaxone and decreased susceptibility to ciprofloxacin

Antimicrobial resistance of Shigella isolates in Bangladesh, during 2001-2002, was studied and compared with that of 1991-1992 to identify the changes in resistance patterns and trends. A significant increase in resistance to trimethoprim-sulphamethoxazole (from 52% to 72%, p < 0.01) and nalidixic acid (from 19% to 51%, p < 0.01) was detected. High, but unchanged, resistance to tetracycline, ampicillin, and chloramphenicol, low resistance to mecillinam (resistance 3%, intermediate 3%), and to emergence of resistance to azithromycin (resistance 16%, intermediate 62%) and ceftriaxone/cefixime (2%) were detected in 2001-2002. Of 266 recent isolates, 63% were resistant to > or =3 anti-Shigella drugs (multidrug-resistant [MDR]) compared to 52% of 369 strains (p < 0.007) in 1991-1992. Of 154 isolates tested by E-test in 2001-2002, 71% were nalidixic acid-resistant (minimum inhibitory concentration [MIC] > or =32 microg/mL) and had 10-fold higher MIC90 (0.25 microg/mL) to ciprofloxacin than that of nalidixic acid-susceptible strains exhibiting decreased ciprofloxacin susceptibility, which were detected as ciprofloxacin-susceptible and nalidixic acid-resistant by the disc-diffusion method. These strains were frequently associated with MDR traits. High modal MICs were observed to azithromycin (MIC 6 microg/mL) and nalidixic acid (MIC 128 micdrog/mL) and low to ceftriaxone (MIC 0.023 microg/mL). Conjugative R-plasmids-encoded extended-spectrum beta-lactamase was responsible for resistance to ceftriaxone/cefixime. The growing antimicrobial resistance of Shigella is worrying and mandates monitoring of resistance. Pivmecillinam or ciprofloxacin might be considered for treating shigellosis with caution.

Asthma in rural Bangladeshi children

OBJECTIVE

Although bronchial asthma causes a great deal of morbidity among children in Bangladesh, few epidemiological studies addressed this problem. The study aims to determine the prevalence of wheezing and its association with environmental and host factors.

METHODS

A total of 1587 children aged 60-71 mth living in 50 villages in rural Bangladesh at Matlab was studied. Trained field workers interviewed caretakers of these children to diagnose wheezing using an adopted questionnaire of the International Studies of Asthma and Allergies in Childhood (ISAAC). History of pneumonia among wheezing and non-wheezing children during their childhood was obtained from the surveillance records.

RESULTS

The prevalence of wheezing in the last 12 mth prior to survey was 16.1% (95% CI: 14.3%, 18.0%), significantly higher among children who had attacks of pneumonia during their infancy compared to children who did not (23.0% vs 14.6%, p< 0.0001). Risk factors associated with wheezing were pneumonia at ages 0-12 m (OR= 1.50, 95% CI 1.08, 2.10) and 13-24 m (OR= 2.12, 1.46, 3.08), maternal asthma (OR=3.01, 95% CI 2.02, 4.47), paternal asthma (OR= 3.12, 95% CI 1.85, 5.26), maternal eczema (OR=1.81, 95% CI 1.14, 2.87) and family income 100 pounds US$ (OR for US$ 51-99= 1.63, 95% CI 1.05, 2.53; OR for US$ 50 pounds = 2.12, 95% CI 1.31, 3.44).

CONCLUSION

Our results suggest that wheezing is a significant cause of morbidity among children in rural Bangladesh. Greater efforts are needed to prevent pneumonia among children during their infancy to reduce the chances of subsequent development of wheezing.

A population-based study of hospital admission incidence rate and bacterial aetiology of acute lower respiratory infections in children aged less than five years in Bangladesh

The research was carried out to study the rate of population-based hospital admissions due to acute lower respiratory infections (ALRIs) and bacterial aetiology of ALRIs in children aged less than five years in Bangladesh. A cohort of children aged less than five years in a rural surveillance population in Matlab, Bangladesh, was studied for two years. Cases were children admitted to the Matlab Hospital of ICDDR,B with a diagnosis of severe ALRIs. Bacterial aetiology was determined by blood culture. Antimicrobial resistance patterns of Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae (Spn) isolates were determined using the disc-diffusion method. In total, 18,983 children aged less than five years contributed to 24,902 child-years of observation (CYO). The incidence of ALRI-related hospital admissions was 50.2 per 1,000 CYO. The incidences of ALRI were 67% higher in males than in females and were higher in children aged less than two years than in older children. About 34% of the cases received antibiotics prior to hospitalization. Of 840 blood samples cultured, 39.4% grew a bacterial isolate; 11.3% were potential respiratory pathogens, and the rest were considered contaminants. The predominant isolates were Staphylococcus aureus (4.5%). Hib (0.4%) and Spn (0.8%) were rarely isolated; however, resistance of both these pathogens to trimethoprim-sulphamethoxazole was common. The rate of ALRI-related hospitalizations was high. The high rate of contamination, coupled with high background antibiotic use, might have contributed to an underestimation of the burden of Hib and Spn. Future studies should use more sensitive methods and more systematically look for resistance patterns of other pathogens in addition to Hib and Spn.

Childhood pneumonia and diarrhoea: setting our priorities right

Childhood pneumonia and diarrhoeal disease cause almost half of all child deaths globally. Effective interventions against these conditions are available and could prevent about two-thirds of these deaths. We argue that part of the reason for the lack of success in delivering these interventions is the lack of attention to implementation challenges. We present a novel research priority setting model that shifts the emphasis from generation of new knowledge and publication to potential public-health outcomes, and propose a framework by which this new model can be put into operation. We believe that only in this way will proper attention be given to delivery of proven interventions to reduce the high childhood mortality caused by pneumonia and diarrhoea.

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.

Molecular basis of resistance displayed by highly ciprofloxacin-resistant Salmonella enterica serovar Typhi in Bangladesh

Highly ciprofloxacin-resistant (MIC, 512 microg/ml) strains of Salmonella enterica serovar Typhi were isolated from the blood of typhoid patients in Dhaka, Bangladesh. The strains were indistinguishable by their antibiograms, biotypes, and variable-number tandem repeat types and had matching point mutations at positions 83 and 87 of the gyrA gene. The isolation of these strains in an area of high endemicity indicates the need for continuous surveillance of antibiotic resistance of S. enterica serovar Typhi and for the rationalized use of ciprofloxacin.

Arsenic exposure in pregnancy: a population-based study in Matlab, Bangladesh

This study assessed the exposure of pregnant women to arsenic in Matlab, Bangladesh, an area with highly-elevated concentrations of arsenic in tubewells, by measuring concentrations of arsenic in urine. In a defined administrative area, all new pregnancies were identified by urine test in gestational week 6-8, and women were asked to participate in the assessment of arsenic exposure. Urine for analysis of arsenic was collected immediately and in gestational week 30. In total, 3,426 pregnant women provided urine samples during January 2002-March 2003. There was a considerable variation in urinary concentrations of arsenic (total range 1-1,470 microg/L, adjusted to specific gravity 1.012 g/mL), with an overall median concentration of 80 microg/L (25th and 75th percentiles were 37 and 208 microg/L respectively). Similar concentrations were found in gestational week 30, indicating no trend of decreasing exposure, despite the initiation of mitigation activities in the area. Arsenic exposure was negatively associated with socioeconomic classes and achieved educational level. There were marked geographical variations in exposure. The results emphasize the urgent need for efficient mitigation activities and investigations of arsenic-related reproductive effects.

Effect of prenatal food supplementation on birth weight: an observational study from Bangladesh

BACKGROUND

National nutrition programs in Bangladesh have included prenatal food supplementation to reduce maternal and child malnutrition. The knowledge base is weak regarding the effect of prenatal food supplementation on the birth weight (BW) of infants in populations in whom low BW is prevalent and regarding any variation in effect based on maternal nutritional status.

OBJECTIVE

We examined whether observational data support an effect of daily prenatal food supplementation on BW by considering the duration of supplementation and whether the effect is modified by maternal postpartum weight (a proxy of prepregnancy weight) groups.

DESIGN

A cohort of undernourished pregnant women (n = 777) who received prenatal food supplementation (608 kcal/d) was followed. The association between the uptake of food supplements and BW was analyzed after adjustment for potential confounders (n = 619 with complete information). Differential effects in lower and higher maternal postpartum weight groups were examined.

RESULTS

The average BW was 2521 g. On average, the women received daily supplements for 4 mo, which resulted in an increase in BW of 118 g (1.0 g/d). The strongest effect was found for births occurring in January and February. There was a linear dose-response relation between duration of supplementation and BW for women with higher postpartum weights (> or = 42 kg, above the median). In women with lower weights (< 42 kg, below median), a shorter duration of supplementation (< 4 mo) had no such dose-response relation with BW, but there was a linear dose-response relation for longer durations of supplementation.

CONCLUSIONS

The association between duration of prenatal food supplementation and BW varies with maternal postpartum weight. A large effect was observed after the season with food insecurity (mid-August to mid-November).

Prevalence of sputum smear-positive tuberculosis in a rural area in Bangladesh

The objective of the study was to determine the prevalence of smear-positive tuberculosis (TB) in a rural area in Bangladesh at Matlab. A TB surveillance system was established among 106,000 people in rural Bangladesh at Matlab. Trained field workers interviewed all persons aged > or = 15 years to detect suspected cases of TB (cough > 21 days) and sputum specimens of suspected cases were examined for acid-fast bacilli (AFB). Of 59,395 persons interviewed, 4235 (7.1%) had a cough for > 21 days. Sputum specimens were examined for AFB from 3834 persons, 52 (1.4%) of them were positive for AFB. The prevalence of chronic cough and sputum positivity were significantly higher among males compared to females (P < 0.001). The population-based prevalence rate of smear-positive TB cases was 95/100,000 among persons aged > or = 15 years. Cases of TB clustered geographically (relative risk 5.53, 95% CI 3.19-9.59). The high burden of TB among rural population warrants appropriate measures to control TB in Bangladesh. The higher prevalence of persistent cough and AFB-positive sputum among males need further exploration. Factors responsible for higher prevalence of TB in clusters should be investigated.

How should we measure maternal mortality in the developing world? A comparison of household deaths and sibling history approaches

OBJECTIVE

A reduction in the maternal mortality ratio (MMR) is one of six health-related Millennium Development Goals (MDGs). However, there is no consensus about how to measure MMR in the many countries that do not have complete registration of deaths and accurate ascertainment of cause of death. In this study, we compared estimates of pregnancy-related deaths and maternal mortality in a developing country from three different household survey measurement approaches: a module collecting information on deaths of respondents' sisters; collection of information about recent household deaths with a time-of-death definition of maternal deaths; and a verbal autopsy instrument to identify maternal deaths.

METHODS

We used data from a very large nationally-representative household sample survey conducted in Bangladesh in 2001. A total of 104 323 households were selected for participation, and 99 202 households (95.1% of selected households, 98.8% of contacted households) were successfully interviewed.

FINDINGS

The sisterhood and household death approaches gave very similar estimates of all-cause and pregnancy-related mortality; verbal autopsy gave an estimate of maternal deaths that was about 15% lower than the pregnancy-related deaths. Even with a very large sample size, however, confidence intervals around mortality estimates were similar for all approaches and exceeded +/- 15%.

CONCLUSION

Our findings suggest that with improved training for survey data collectors, both the sisterhood and household deaths methods are viable approaches for measuring pregnancy-related mortality. However, wide confidence intervals around the estimates indicate that routine sample surveys cannot provide the information needed to monitor progress towards the MDG target. Other approaches, such as inclusion of questions about household deaths in population censuses, should be considered.

Prevalence of arsenic exposure and skin lesions. A population based survey in Matlab, Bangladesh

STUDY OBJECTIVE

To assess prevalence of arsenic exposure through drinking water and skin lesions, and their variation by geographical area, age, sex, and socioeconomic conditions.

DESIGN, SETTING, AND PARTICIPANTS

Skin lesion cases were identified by screening the entire population above 4 years of age (n = 166,934) living in Matlab, a rural area in Bangladesh, during January 2002 and August 2003. The process of case identification involved initial skin examinations in the field, followed by verification by physicians in a clinic, and final confirmation by two independent experts reviewing photographs. The tubewell water arsenic concentrations (n = 13,286) were analysed by atomic absorption spectrometry. Drinking water history since 1970 was obtained for each person. Exposure information was constructed using drinking water histories and data on water arsenic concentrations.

MAIN RESULTS

The arsenic concentrations ranged from <1 to 3644 microg/l, and more than 70% of functioning tubewells exceeded the World Health Organisation guideline of 10 microg/l. Arsenic exposure had increased steadily from 1970s to the late 1990s, afterwards a decrease could be noted. In total, 504 skin lesions cases were identified, and the overall crude prevalence was 3/1000. Women had significantly higher cumulative exposure to arsenic, while men had significantly higher prevalence of skin lesions (SMR 158, 95% CI 133 to 188). The highest prevalence occurred in 35-44 age groups for both sexes. Arsenic exposure and skin lesions had a positive association with socioeconomic groups and achieved educational level.

CONCLUSIONS

The result showed sex, age, and socioeconomic differentials in both exposure and skin lesions. Findings clearly showed the urgency of effective arsenic mitigation activities.