Pandemic Now and Then: A Historical Perspective of Non-Pharmaceutical Interventions Adopted In Covid-19

The coronavirus disease 2019 (COVID-19), first reported in Wuhan, China is now a major global health threat - a pandemic. Public health control measures are the cornerstones in the fight against COVID-19 in the absence of an effective vaccine or proven treatment. The aim of this review was to explore the historical use case of various public health measures adopted today to tackle COVID-19 spread. Although our knowledge about this novel coronavirus transmission is evolving over time, the fundamental non-pharmaceutical interventions e.g., handwashing, wearing a mask, physical distancing, isolation, quarantine and border control which are adopted globally at present are not new. This review highlighted that historically and religiously similar approaches were practised in the medieval past for controlling disease outbreaks. The successful implementation of the public health control measures largely depends on health systems resilience, community engagement and changes in population behaviour. Combined global efforts are essential to strengthen health systems, improve the capability of research and transparent information sharing with both public and international bodies to combat the pandemic.

Distribution of commensal rodents in rain-fed and irrigated areas of Swat district, Khyber Pakhtunkhwa, Pakistan

Distribution pattern and relative abundance of the agricultural rodent pests of rain-fed and irrigated areas of district Swat Khyber Pakhtunkhwa, Pakistan were recorded from April 2011 to November 2013 using wire mesh live traps. A total of 350 rodents (269 Rattus rattus and 81 Mus musculus) were captured under 2268 trap nights (trap success: 0.15). Regression of daily captures on cumulative captures revealed an estimate of 350 rodents from all the sampled structures with an average of 21.8 rodents per crop field. House rats (R. rattus; 76.8% of captures) were numerically dominant in almost all types of agricultural fields, and were significantly different from the mice (Mus musculus; 23.1% of captures). Both species were found together in some fields. The sex ratio revealed that males outnumbered the females in both of the reported species.

Bovine Lactoferrin to Prevent Neonatal Infections in Low-Birth-Weight Newborns in Pakistan: Protocol for a Three-Arm Double-Blind Randomized Controlled Trial

Background

Sepsis is a common and severe complication in premature neonates, particularly those born with low birth weights (<2500 g). Neonatal sepsis is steadily emerging as a leading cause of neonatal mortality in Pakistan. Lactoferrin is a natural product with broad-spectrum antimicrobial properties and glycoprotein that is actively involved in innate immune host responses. Clinical trials have revealed its protective effect on sepsis, but lactoferrin dosage, duration, and role in the prevention of sepsis are still uncertain.

Objective

We aimed to establish the efficacy of bovine lactoferrin in the prevention of late-onset sepsis and to determine the optimal dose and method of administering bovine lactoferrin that may contribute to improvement in overall survival of low birth weight infants.

Methods

We will implement the study in 2 phases at the Aga Khan University Hospital. The first phase, which we have completed, was formative research. This phase mainly focused on a qualitative exploration of perceptions about feeding and caring practices of low birth weight newborns and a trial of improved practices for the preparation and administration of bovine lactoferrin to newborns. The second phase is a 3-arm double-blind randomized controlled trial. In this phase, we randomly allocated 2 different daily oral prophylactic doses of bovine lactoferrin (150 mg or 300 mg) and placebo to 300 low–birth weight neonates starting within the first 72 hours of birth and continuing for the first 28 days of life.

Results

The study protocol was approved by the Ethics Review Committee of Aga Khan University on August 16, 2017. Data collection began in April 2018 and was completed in September 2020. Data analyses are yet to be completed. We expect the results to be published in peer-reviewed journals by autumn of 2021.

Conclusions

This intervention, if effective, has the potential to be translated into a safe, affordable, and widely utilized treatment to prevent sepsis and, subsequently, may improve the survival outcomes of low birth weight neonates in Pakistan and other low- and middle-income countries.

Trial Registration

ClinicalTrials.gov NCT03431558; https://clinicaltrials.gov/ct2/show/NCT03431558

International Registered Report Identifier (IRRID)

PRR1-10.2196/23994

Factors associated with delayed initiation of breastfeeding in health facilities: secondary analysis of Bangladesh demographic and health survey 2014

Background

Irrespective of the place and mode of delivery, ‘delayed’ initiation of breastfeeding beyond the first hour of birth can negatively influence maternal and newborn health outcomes. In Bangladesh, 49% of newborns initiate breastfeeding after the first hour. The rate is higher among deliveries at a health facility (62%). This study investigates the maternal, health service, infant, and household characteristics associated with delayed initiation of breastfeeding among health facility deliveries in Bangladesh.

Methods

We used data from the 2014 Bangladesh Demographic and Health Survey. We included 1277 last-born children born at a health facility in the 2 years preceding the survey. ‘Delayed’ breastfeeding was defined using WHO recommendations as initiating after 1 h of birth. We performed univariate and multivariable logistic regression to determine factors associated with delayed initiation.

Results

About three-fifth (n = 785, 62%) of the children born at a health facility delayed initiation of breastfeeding beyond 1 h. After adjusting for potential confounders, we found delayed initiation to be common among women, who delivered by caesarean section (adjusted Odds Ratio (aOR): 2.93; 95% CI 2.17, 3.98), and who were exposed to media less than once a week (aOR: 1.53; 95% CI 1.07, 2.19). Women with a higher body mass index had an increased likelihood of delaying initiation (aOR: 1.05; 95% CI 1.01, 1.11). Multiparous women were less likely to delay (aOR: 0.71; 95% CI 0.53, 0.96).

Conclusions

Delayed initiation of breastfeeding following caesarean deliveries continues to be a challenge, but several other health facility and maternal factors also contributed to delayed initiation. Interventions to promote early breastfeeding should include strengthening the capacity of healthcare providers to encourage early initiation, especially for caesarean deliveries.

Determinants of low breastfeeding self-efficacy amongst mothers of children aged less than six months: results from the BADUTA study in East Java, Indonesia

Background

Despite the increasing rate of exclusive breastfeeding in Indonesia, there is still a need for supportive interventions. The breastfeeding self-efficacy of mothers is a key factor positively associated with optimum breastfeeding practices. Our analysis aims to assess the determinants of low breastfeeding self-efficacy amongst a sample of women with children aged under 6 months in Malang and Sidoarjo Districts, East Java, Indonesia.

Methods

We used information from 1210 mothers of children aged < 6 months recruited in the BADUTA study conducted in 2015–2016 in Malang and Sidoarjo Districts. The outcome variable in this analysis was mothers’ self-efficacy for breastfeeding using the 14 statements in the Breastfeeding Self-Efficacy-Short Form. We evaluated 17 potential predictors of breastfeeding self-efficacy, organized into six sub-groups of variables: (1) context/demographic; (2) household factors; (3) maternal characteristics; (4) child characteristics; (5) breastfeeding practices; and (6) antenatal and delivery care. Logistic regression analyses were employed to examine factors associated with mothers’ self-efficacy with breastfeeding.

Results

More than half of the women in this study had a low level of self-efficacy. One of the factors associated with low breastfeeding self-efficacy found in this study was mothers’ problems related to breastfeeding. Mothers who had problems with breastfeeding not related to illness (adjusted odds ratio [aOR] 3.27; 95% CI 2.45, 4.36) or problems related to both illness and non-illness conditions (aOR 3.57; 95% CI 1.37, 9.33) had higher odds of low breastfeeding self-efficacy than those who did not have any problems. Compared to mothers who completed university education, there was a significantly higher odds of low breastfeeding self-efficacy in mothers who completed primary school or lower (aOR 1.88; 95% CI 1.16, 3.05); completed junior high school (aOR 2.27; 95% CI 1.42, 3.63); and completed senior high school (aOR 1.94; 95% CI 1.29, 2.91). Other significant predictors of low breastfeeding self-efficacy were mothers not exposed to any breastfeeding interventions (aOR 1.87; 95% CI 1.09, 3.22); working outside the house (aOR 1.69; 95% CI 1.23, 2.32); not obtaining any advice on breastfeeding (aOR 1.40; 95% CI 1.08, 1.82); with low knowledge of breastfeeding (aOR 1.38; 95% CI 1.03, 1.84); and delivered by Caesarean section (aOR 1.34; 95% CI 1.05, 1.70).

Conclusions

Multipronged breastfeeding education programs and support are required to improve women’s self-efficacy with breastfeeding. Improved access to breastfeeding counselors, active support for mothers following cesarean delivery, and increased supporting facilities at workplaces are essential to improve self-efficacy with breastfeeding.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00357-5.

Shonjibon cash and counselling: a community-based cluster randomised controlled trial to measure the effectiveness of unconditional cash transfers and mobile behaviour change communications to reduce child undernutrition in rural Bangladesh

Background

Undernutrition is strongly associated with poverty - levels of undernutrition are higher in poor countries than in better-off countries. Social protection especially cash transfer is increasingly recognized as an important strategy to accelerate progress in improving maternal and child nutrition. A critical method to improve nutrition knowledge and influence feeding practices is through behaviour change communication intervention. The Shonjibon Cash and Counselling study aims to assess the effectiveness of unconditional cash transfers combined with a mobile application on nutrition counselling and direct counselling through mobile phone in reducing the prevalence of stunting in children at 18 months.

Method

The study is a longitudinal cluster randomised controlled trial, with two parallel groups, and cluster assignment by groups of villages. The cohort of mother-child dyads will be followed-up over the intervention period of approximately 24 months, starting from recruitment to 18 months of the child’s age. The study will take place in north-central Bangladesh. The primary trial outcome will be the percentage of stunted children at 18 m as measured in follow up assessments starting from birth. The secondary trial outcomes will include differences between treatment arms in (1) Mean birthweight, percentage with low birthweight and small for gestational age (2) Mean child length-for age, weight for age and weight-for-length Z scores (3) Prevalence of child wasting (4) Percentage of women exclusively breastfeeding and mean duration of exclusive breastfeeding (5) Percentage of children consuming > 4 food groups (6) Mean child intake of energy, protein, carbohydrate, fat and micronutrients (7) Percentage of women at risk of inadequate nutrient intakes in all three trimesters (8) Maternal weight gain (9) Household food security (10) Number of events for child suffering from diarrhoea, acute respiratory illness and fever (11) Average costs of mobile phone BCC and cash transfer, and benefit-cost ratio for primary and secondary outcomes.

Discussion

The proposed trial will provide high-level evidence of the efficacy and cost-effectiveness of mobile phone nutrition behavior change communication, combined with unconditional cash transfers in reducing child undernutrition in rural Bangladesh.

Trial registration

The study has been registered in the Australian New Zealand Clinical Trials Registry (ACTRN12618001975280).

Immune response in COVID-19: A review

The immune system protects against viruses and diseases and produces antibodies to kill pathogens. This review presents a brief overview of the immune system regarding its protection of the human body from COVID-19; illustrates the process of the immune system, how it works, and its mechanism to fight virus; and presents information on the most recent COVID-19 treatments and experimental data. Various types of potential challenges for the immunes system are also discussed. At the end of the article, foods to consume and avoid are suggested, and physical exercise is encouraged. This article can be used worldwide as a state of the art in this critical moment for promising alternative solutions related to surviving the coronavirus.

Traditional practices during pregnancy and birth, and perceptions of perinatal losses in women of rural Pakistan

OBJECTIVE

Understanding the sociocultural context and local practices during pregnancy and birth is imperative to identify factors related to perinatal mortality in countries where its burden is high. This study aims to explore the pregnancy and birth related cultural practices and the perceptions of women with a recent perinatal death in Sindh province, Pakistan.

DESIGN

This qualitative exploratory study consisted of in-depth interviews with women who had experienced a perinatal death in the year preceding the study. Women were identified and recruited with the help of lady health workers. After consent, women were interviewed in their homes and in their own language (Sindhi) by a local female interviewer.

SETTING AND PARTICIPANTS

Interviews were conducted with women from predominantly rural district of the southern province of Sindh in Pakistan between May and August 2018. The data were coded both inductively and deductively and then analysed using themes.

FINDINGS

Twenty-five women were interviewed. Traditional home remedies were commonly used to alleviate pregnancy symptoms such as general aches and pains. The health providers often delayed the information about the perinatal deaths in health facilities, which saddened the women. Most women had fatalistic opinions about what caused their losses, and explained the cause based on their own interpretation, which were not necessarily consistent with known causes of perinatal death. The women also desired to use contraception and believed that it would prevent future pregnancy loss; however, many women were unable to make that decision themselves.

CONCLUSIONS AND IMPLICATIONS

The high use of traditional home-based remedies may be a proxy measure for poor access to formal healthcare services. Many women described poor acknowledgement of their grief which may be harmful. Women's knowledge about the causes of perinatal mortality in general was very low, improving this knowledge may help women to seek appropriate healthcare services during pregnancy.

Evaluation of a Package of Behaviour Change Interventions (Baduta Program) to Improve Maternal and Child Nutrition in East Java, Indonesia: Protocol for an Impact Study

BACKGROUND

Over the past decade, the prevalence of stunting has been close to 37% in children aged <5 years in Indonesia. The Baduta program, a multicomponent package of interventions developed by the Global Alliance for Improved Nutrition, aims to improve maternal and infant nutrition in Indonesia.

OBJECTIVE

This study aims to assess the impact of the Baduta program, a package of health system strengthening and behavior change interventions, compared with the standard village health services on maternal and child nutrition.

METHODS

The impact evaluation uses a cluster randomized controlled trial design with 2 outcome assessments. The first uses cross-sectional surveys of mothers of children aged 0-23 months and pregnant women before and after the interventions. The second is a cohort study of pregnant women followed until their child is 18 months from a subset of clusters. We will also conduct a process evaluation guided by the program impact pathway to assess coverage, fidelity, and acceptance. The study will be conducted in the Malang and Sidoarjo districts of East Java, Indonesia. The unit of randomization is the subdistricts. As random allocation of interventions to only 6 subdistricts is feasible, we will use constrained randomization to ensure balance of baseline covariates. The first intervention will be health system strengthening, including the Baby-Friendly Hospital Initiative, and training on counseling for appropriate infant and young child feeding (IYCF). The second intervention will be nutrition behavior change that includes Emo-Demos; a national television (TV) advertising campaign; local screening TV spots; a free, text message service; and promotion of low-cost water filters and hygiene practices. The primary study outcome is child stunting (low length-for-age), and secondary outcomes include length-for-age Z scores, wasting (low weight-for-length), anemia, child morbidity, IYCF indicators, and maternal and child nutrient intakes. The sample size for each cross-sectional survey is 1400 mothers and their children aged <2 years and 200 pregnant women in each treatment group. The cohort evaluation requires a sample size of 340 mother-infant pairs in each treatment group. We will seek Gatekeeper consent and written informed consent from the participants. The intention-to-treat principle will guide our data analysis, and we will apply Consolidated Standards of Reporting Trials guidelines for clustered randomized trials in the analysis.

RESULTS

In February 2015, we conducted a baseline cross-sectional survey on 2435 women with children aged <2 years and 409 pregnant women. In February 2017, we conducted an end-line survey on 2740 mothers with children aged <2 years and 642 pregnant women. The cohort evaluation began in February 2015, with 729 pregnant women, and was completed in December 2016.

CONCLUSIONS

The results of the program evaluation will help guide policies to support effective packages of behavior change interventions to prevent child stunting in Indonesia.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/18521.

How Can We Improve the Consumption of a Nutritionally Balanced Maternal Diet in Rural Bangladesh? The Key Elements of the "Balanced Plate" Intervention

Social, cultural, environmental and economic factors closely regulate the selection, allocation and consumption of maternal diets. We developed a nutrition behaviour change intervention to promote a balanced diet in pregnancy through practical demonstration in rural Bangladesh and tested the impact with a cluster randomised controlled trial. This paper presents the findings of the process evaluation and describes the strategies that worked for intervention compliance. We conducted in-depth interviews with pregnant women, women who birthed recently, and their husbands; focus groups with mothers and mothers-in-law; key-informant interviews with community health workers, and observations of home visits. We identified six key areas within the intervention strategy that played a crucial role in achieving the desired adherence. These included practical demonstration of portion sizes; addressing local food perceptions; demystifying animal-source foods; engaging husbands and mothers-in-law; leveraging women’s social networks; and harnessing community health workers’ social role. Practical demonstration, opportunity to participate and convenience of making of the plate with the food available in their kitchen or neighbours’ kitchen were the most commonly mentioned reasons for acceptance of the intervention by the women and their families. The balanced plate intervention helped women through practical demonstration to learn about a balanced meal by highlighting appropriate portion sizes and food diversity. The women needed active involvement of community health workers in mobilising social support to create an enabling environment essential to bring changes in dietary behaviours. Future implementation of the intervention should tailor the strategies to the local context to ensure optimal adherence to the intervention.

The City Under COVID-19: Podcasting As Digital Methodology

This critical commentary reflects on a rapidly mobilised international podcast project, in which 25 urban scholars from around the world provided audio recordings about their cities during COVID-19. New digital tools are increasing the speeds, formats and breadth of the research and communication mediums available to researchers. Voice recorders on mobile phones and digital audio editing on laptops allows researchers to collaborate in new ways, and this podcast project pushed at the boundaries of what a research method and community might be. Many of those who provided short audio 'reports from the field' recorded on their mobile phones were struggling to make sense of their experience in their city during COVID-19. The substantive sections of this commentary discuss the digital methodology opportunities that podcasting affords geographical scholarship. In this case the methodology includes the curated production of the podcast and critical reflection on the podcast process through collaborative writing. Then putting this methodology into action some limited reflections on cities under COVID-19 lockdown and social distancing initiatives around the world are provided to demonstrate the utility and limitations of this method.

Improving the Lifestyle of Adolescents Through Peer Education and Support in Vietnam: Protocol for a Pilot Cluster Randomized Controlled Trial

BACKGROUND

In Ho Chi Minh City, Vietnam, recent studies found a rapid increase in overweight and obesity in adolescents. There is a need for effective health promotion interventions to support healthy diets and encourage a physically active lifestyle. This study will help fill an evidence gap on effective interventions to prevent excess weight gain in adolescents and generate new insights about peer-led education to promote healthy lifestyles.

OBJECTIVE

We aim to assess the feasibility and acceptability of a combined peer-led and peer support intervention among junior high school students in Ho Chi Minh City. Additionally, the efficacy of the intervention on adolescents' dietary practices and time spent on physical activity will also be measured in this pilot study.

METHODS

The Peer Education and Peer Support (PEPS) project is a pilot cluster randomized controlled trial with 2 intervention and 2 control schools. The intervention consists of 4 weekly education sessions of why and how to choose healthy food and drinks and how to be more physically active. Additionally, the intervention includes a school-based and online support system to help maintain student engagement during the intervention. We will use in-depth interviews with students, peer leaders, teachers, and parents; focus group discussions with peer educators; and direct observation of the school environment and peer leaders' interactions with the students. Acceptability and feasibility of the intervention will be assessed. We will also quantitatively assess limited efficacy by measuring changes in student' physical activity levels and dietary behaviors.

RESULTS

We delivered the peer education intervention at the start of each school year over 3 months for all new grade 6 adolescents in the selected schools, followed by peer support and home engagement activities over 6 months until the end of the school year. There was a baseline assessment and 2 post-intervention assessments: the first immediately after the intervention to assess the short-term impact and the second at the end of the school year to assess the sustained impact on changes in adiposity, diet, and physical activity.

CONCLUSIONS

The findings of this study will be used to develop a larger-scale cluster randomized controlled trial to examine the impact of a multicomponent, school- and home-based health promotion intervention. The trial will use innovative peer education methods to reduce overweight and obesity and improve dietary choices and physical activity levels in Vietnamese adolescents.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12619000421134; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376690&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15930.

"In the Past, the Seeds I Planted often Didn't Grow." A Mixed-Methods Feasibility Assessment of Integrating Agriculture and Nutrition Behaviour Change Interventions with Cash Transfers in Rural Bangladesh

Combining agriculture with behaviour change communication and other nutrition-sensitive interventions could improve feeding practices to reduce maternal and child undernutrition. Such integrated intervention requires rigorous design and an appropriate implementation strategy to generate an impact. We assessed feasibility and acceptability of an intervention package that combines nutrition counselling, counselling and support for home-gardening, and unconditional cash transfers delivered to women on a mobile platform for improving maternal and child nutrition behaviours among low-income families in rural Bangladesh. We used mixed-methods including in-depth interviews with women (20), key-informant interviews with project workers (6), and a cross sectional survey of women (60). Women well-accepted the intervention and reported to be benefited by acquiring new skills and information on home gardening and nutrition. They established homestead gardens of seasonal vegetables successfully and were able to find a solution for major challenges. All women received the cash transfer. Ninety-one percent of women spent the cash for buying foods, 20% spent it on purchasing seeds or fertilizers and 57% used it for medical and livelihood purchases. Project staff and mobile banking agent reported no difficulty in cash transfer. Combining nutrition-specific and -sensitive interventions is a feasible and acceptable approach. Using mobile technologies can provide additional benefits for the intervention to reach the disadvantage families in rural settings.

What Worked for Improving Balanced Maternal Dietary Intake in Rural Bangladesh? Implications for New Programs

Objectives

To assess the strategies that worked to motivate the women and families to adhere to a nutrition behavior change intervention trial that aimed to promote balanced diet in pregnancy in rural Bangladesh.

Methods

We designed this process evaluation as part of a cluster randomized controlled trial. We conducted in-depth interviews with pregnant women, recently-delivered women, and husbands; focus groups with mothers and mothers-in-law; and key-informant interviews with Shasthya Kormis (community health workers) who provided the balanced plate nutrition intervention.

Results

The novel finding in the study was that the balanced plate nutrition education helped women through practical demonstration to learn about a balanced meal considering appropriate portion sizes and diversity of foods. We also found that pregnant women needed active involvement of community health workers in mobilizing social support to create an enabling environment essential to bring changes in dietary behavior with self-motivation. Practical demonstration, opportunity to participate and convenience of making of the plate with the food available in own or neighbors’ kitchen were the most commonly mentioned reasons of acceptance of the intervention to the women and families. We identified six key areas within the intervention strategy that played crucial role in achieving desired adherence. These include: practical demonstration of portion sizes engaging the end-users; addressing local food perceptions; demystifying animal-source foods; engaging husbands and mothers-in-law; leveraging women's social networks; and harnessing community health workers’ social role.

Conclusions

Programs to improve maternal nutritious food consumption should focus on promoting diet through practical demonstration of portion sizes through active engagement of the women and family instead of replicating the conventional information-based counseling.

Funding Sources

The University of Sydney Faculty of Medicine and Health.

Understanding pathways leading to stillbirth: The role of care-seeking and care received during pregnancy and childbirth in Kabul province, Afghanistan

BACKGROUND

The underlying pathways leading to stillbirth in low- and middle-income countries are not well understood. Context-specific understanding of how and why stillbirths occur is needed to prioritise interventions and identify barriers to their effective implementation and uptake.

AIM

To explore the contribution of contextual, individual, household-level and health system factors to stillbirth in Afghanistan.

METHODS

Using a qualitative approach, we conducted semi-structured in-depth interviews with women and men that experienced stillbirth, female elders, community health workers, healthcare providers, and government officials in Kabul province, Afghanistan between October-November 2017. We used thematic analysis to identify contributing factors and developed a conceptual map describing possible pathways to stillbirth.

FINDINGS

We found that low utilisation and access to healthcare was a key contributing factor, as were unmanaged conditions in pregnancy that increased women's risk of complications and stillbirth. Sociocultural factors related to the treatment of women and perceptions about medical interventions deprived women of interventions that could potentially prevent stillbirth. The quality of care from public and private providers during pregnancy and childbirth was a recurring concern exacerbated by health system constraints that led to unnecessary delays; while environmental factors linked to the ongoing conflict were also perceived to contribute to stillbirth. These pathways were underscored by social, cultural, economic factors and individual perceptions that contributed to the three-delays.

DISCUSSION

Efforts are needed at the community-level to facilitate care-seeking and raise awareness of stillbirth risk factors and the facility-level to strengthen antenatal and childbirth care quality, ensure culturally appropriate and respectful care, and reduce treatment delays.

Dietary Magnesium, Vitamin D, and Animal Protein Intake and Their Association to the Linear Growth Trajectory of Children from Birth to 24 Months of Age: Results From MAL-ED Birth Cohort Study Conducted in Dhaka, Bangladesh

BACKGROUND

Evidence suggests lack of understanding of the association of specific nutrients with different time points of linear growth trajectory.

OBJECTIVE

We investigated the role of dietary macro- and micronutrients on length-for-age z (LAZ) score trajectory of children across first 24 months of their life.

METHODS

The MAL-ED Bangladesh birth cohort study recruited 265 healthy newborn children after birth. The linear growth trajectory of those children was modeled using latent growth curve modeling (LGCM) technique.

RESULTS

Dietary magnesium intake at 9 to 11 months was positively associated (coefficient β = 0.006, P < .02) with LAZ at 12 months. Animal protein intake at 15 to 17 months, in turn, was positively associated (β = 0.03, P < .03) with LAZ at 18 months. However, vitamin D intake at 15 to 17 months was negatively associated (β = -0.06, P < .02) with LAZ at 18 months. Other micro- and macronutrients did not show any statistically significant association with the linear growth trajectory. We also found that birth weight (β = 0.91, P < .01), treating water (β = 0.35, P < 0.00), and maternal height (β = 3.4, P < .00) were positively associated with intercept. Gender had a significant negative association with the intercept, but a positive association with the slope (β = -0.39, P < .01; β = 0.08, P < .04), respectively. Conversely, birth weight had negative association with the slope (β = -0.12, P < .01).

CONCLUSIONS

Dietary magnesium and animal protein were positively and vitamin D was negatively associated with the linear growth trajectory. Maternal height, birth weight, gender, and treatment of drinking water also played significant roles in directing the trajectory.

A Feasibility Study Assessing Acceptability and Supply Issues of Distributing LPG Cookstoves and Gas Cylinders to Pregnant Women Living in Rural Bangladesh for Poriborton: The CHANge Trial

Our aim was to develop a protocol for a cluster randomised controlled trial to assess the impact of liquid petroleum gas (LPG) cooking compared to usual cooking on perinatal mortality in pregnant women in rural Bangladesh. We, therefore, aimed to assess the feasibility of the planned trial and the barriers/facilitators of distributing LPG to rural households. We conducted a feasibility study in rural Bangladesh using an iterative design. We included pregnant women, their families, and local LPG stakeholders. We distributed LPG to households for 3 months (3 cylinders) and assessed process issues, acceptability, and cooking/food behaviours. We interviewed LPG stakeholders, and conducted focus groups and in-depth interviews with the users. The initial distribution and uptake of LPG were hampered by process issues, most of these were due to the nonestablished supply chain in the study area. LPG cooking was very acceptable and all users reported a preference for continued use, fuel-sparing was heavily practiced. Safety concerns were an initial issue. LPG stakeholders reported that LPG demand differed by season. This study demonstrated the feasibility of our planned trial and the need for safety messages. These results are relevant beyond our trial, including for programs of LPG fuel promotion.

Perceptions and practices related to birthweight in rural Bangladesh: Implications for neonatal health programs in low- and middle-income settings

BACKGROUND

Globally, low birthweight (LBW) infants (<2.5 kilograms) contribute up to 80% of neonatal mortality. In Bangladesh, approximately 62% of all births occur at home and therefore, weighing newborns immediately after birth is not feasible. Thus, estimates of birthweight in Bangladesh are mostly obtained based on maternal perception of the newborn's birth size. Little is known about how birthweight is perceived in rural communities, and whether families associate birthweight with newborn's health status. Our objective was to explore families' perceptions of newborn's birthweight, and preventive and care practices for a LBW newborn in rural Bangladesh.

METHODS

We conducted a qualitative study in two rural settings of Bangladesh, including 32 in-depth interviews (11 with pregnant women, 12 with recently delivered women, 4 with husbands whose wives were pregnant or had a recent birth, 5 with mothers-in-law whose daughters-in-law were pregnant or had a recent birth), 2 focus group discussions with husbands and 4 key-informant interviews with community health workers. We used thematic analysis to analyse the data.

RESULTS

Most participants did not consider birthweight a priority for assessing a newborn's health status, although there was a desire for a healthy newborn. Recognition of different categories of birthweight was subjective and often included several physical descriptors including birth size of the newborn. LBW was not considered as a criterion of a newborn's illness unless the newborn appeared unwell. Maternal poor nutrition, inadequate diet in pregnancy, anaemia, illness during pregnancy, short stature, twin births and influence of supernatural spirit were identified as the major causes of LBW. Women's preventive practices for LBW or small newborns were predominantly constrained by a lack of awareness of birthweight and fear of caesarean section. As an effort to avoid caesarean section during birth, several women tended to perform potentially harmful practices in order to give birth to a small size newborn; such as avoiding nutritious food and eating less in pregnancy. Common practices to treat a LBW or small newborn who appeared ill included breastfeeding, feeding animal milk, feeding sugary water, feeding formula, oil massage, keeping the small newborn warm and seeking care from formal and informal care providers including a spiritual leader. Maternal lack of decision-making power, financial constraint, home birth and superstition were the major challenges to caring for a LBW newborn.

CONCLUSION

Birthweight was not well-understood in the rural community, which highlighted substantial challenges to the prevention and care practices of LBW newborns. Community-level health education is needed to promote awareness related to the recognition of birthweight in rural settings.

Effectiveness of a mobile health intervention on infant and young child feeding among children ≤ 24 months of age in rural Islamabad over six months duration

Background: Childhood development is highly influenced by feeding practices at infancy and young age of the children. Unfortunately, according to the National Nutrition Survey (2011), the prevalence of exclusive breastfeeding in Pakistan was 21% at four months, and 13% at six months of age with 51.3% of mothers initiating semisolid foods to their children at the recommended 6-8 months of age. Pakistan Demographic & Health Survey (PDHS 2018) however; indicates that only 48% of infants are exclusively breastfed which has been improved from 38% as reported in the past five years but still more improvement is envisaged.

Methods: A quasi-experimental study design was employed for this post-intervention survey assessing effectiveness of mobile health (mhealth) regarding infant & young child feeding (IYCF) among pregnant and lactating mothers in Tarlai, Islamabad from May to June 2018. A total of 135 mothers who were earlier included in the intervention phase were recruited after obtaining verbal & written consent. The data was entered in EpiData (3.1) and analyzed in SPSS version 21.

Results: The mean age of these pregnant and lactating mothers was 30.5 years ± 4.5 SD with the majority of mothers in the age group of 25 to 29 years. After intervention, the overall knowledge of mothers regarding IYCF nutrition was raised among 94 mothers (69.6%) as compared to 74 (54.8%) mothers prior to the intervention. Overall attitude regarding IYCF was found to be positive among 86 (63.7%) of the mothers, whereas 88 (65.2%) of the mothers had good IYCF related practices.

Conclusion: Our post-intervention survey signifies the effectiveness of mhealth in raising knowledge, attitude, and practices of mothers regarding IYCF in rural Islamabad. However, implementation of mhealth in masses requires future research specifically to address cost-effectiveness of such interventions in maternal & child health programmes.

Assessing the Intergenerational Linkage between Short Maternal Stature and Under-Five Stunting and Wasting in Bangladesh

Short maternal stature is identified as a strong predictor of offspring undernutrition in low and middle-income countries. However, there is limited information to confirm an intergenerational link between maternal and under-five undernutrition in Bangladesh. Therefore, this study aimed to assess the association between short maternal stature and offspring stunting and wasting in Bangladesh. For analysis, this study pooled the data from four rounds of Bangladesh Demographic and Health Surveys (BDHS) 2004, 2007, 2011, and 2014 that included about 28,123 singleton children aged 0–59 months born to mothers aged 15–49 years. Data on sociodemographic factors, birth history, and anthropometry were analyzed using STATA 14.2 to perform a multivariable model using ‘Modified Poisson Regression’ with step-wise backward elimination procedures. In an adjusted model, every 1 cm increase in maternal height significantly reduced the risk of stunting (relative risks (RR) = 0.960; 95% confidence interval (CI): 0.957, 0.962) and wasting (RR = 0.986; 95% CI: 0.980, 0.992). The children of the short statured mothers (<145 cm) had about two times greater risk of stunting and three times the risk of severe stunting, 1.28 times the risk of wasting, and 1.43 times the risk of severe wasting (RR = 1.43; 95% CI: 1.11, 1.83) than the tall mothers (≥155 cm). These findings confirmed a robust intergenerational linkage between short maternal stature and offspring stunting and wasting in Bangladesh.

Early initiation of breastfeeding and severe illness in the early newborn period: An observational study in rural Bangladesh

BACKGROUND

In Bangladesh, neonatal sepsis is the cause of 24% of neonatal deaths, over 65% of which occur in the early-newborn stage (0-6 days). Only 50% of newborns in Bangladesh initiated breastfeeding within 1 hour of birth. The mechanism by which early initiation of breastfeeding reduces neonatal deaths is unclear, although the most likely pathway is by decreasing severe illnesses leading to sepsis. This study explores the effect of breastfeeding initiation time on early newborn danger signs and severe illness.

METHODS AND FINDINGS

We used data from a community-based trial in Bangladesh in which we enrolled pregnant women from 2013 through 2015 covering 30,646 newborns. Severe illness was defined using newborn danger signs reported by The Young Infants Clinical Science Study Group. We categorized the timing of initiation as within 1 hour, 1 to 24 hours, 24 to 48 hours, ≥48 hours of birth, and never breastfed. The analysis includes descriptive statistics, risk attribution, and multivariable mixed-effects logistic regression while adjusting for the clustering effects of the trial design, and maternal/infant characteristics. In total, 29,873 live births had information on breastfeeding among whom 19,914 (66.7%) initiated within 1 hour of birth, and 4,437 (14.8%) neonates had a severe illness by the seventh day after birth. The mean time to initiation was 3.8 hours (SD 16.6 hours). The proportion of children with severe illness increased as the delay in initiation increased from 1 hour (12.0%), 24 hours (15.7%), 48 hours (27.7%), and more than 48 hours (36.7%) after birth. These observations would correspond to a possible reduction by 15.9% (95% CI 13.2-25.9, p < 0.001) of severe illness in a real world population in which all newborns had breastfeeding initiated within 1 hour of birth. Children who initiated after 48 hours (odds ratio [OR] 4.13, 95% CI 3.48-4.89, p < 0.001) and children who never initiated (OR 4.77, 95% CI 3.52-6.47, p < 0.001) had the highest odds of having severe illness. The main limitation of this study is the potential for misclassification because of using mothers' report of newborn danger signs. There could be a potential for recall bias for mothers of newborns who died after being born alive.

CONCLUSIONS

Breastfeeding initiation within the first hour of birth is significantly associated with severe illness in the early newborn period. Interventions to promote early breastfeeding initiation should be tailored for populations in which newborns are delivered at home by unskilled attendants, the rate of low birth weight (LBW) is high, and postnatal care is limited.

TRIAL REGISTRATION

Trial Registration number: anzctr.org.au ID ACTRN12612000588897.

Use of small intestinal submucosa for corporal body grafting in cases of epispadias and epispadias/exstrophy complex

BACKGROUND

Male epispadias is a rare congenital urogenital anomaly in which the meatus is ectopically located along the dorsal midline of the penile shaft. In cases associated with severe curvature, functional and cosmetic outcomes could be accomplished by lengthening the shorter dorsal surface with the use of corporal grafting. Various graft materials have been used in the past for hypospadias repair including tunica vaginalis, dermis, and small intestinal submucosa (SIS). The use of SIS grafting for corporoplasty during epispadias repair has rarely been described in the literature.

OBJECTIVE

To report the experience in the management of dorsal corporal body grafting using SIS in children with severe penile curvature due to epispadias.

STUDY DESIGN

The authors retrospectively reviewed the charts of all patients with epispadias or bladder exstrophy/epispadias complex and severe dorsal chordee (>40°) who underwent epispadias repair with single-layer SIS for corporal body grafting. Clinical variables, surgical technique, and outcomes were analyzed.

RESULTS

A total of nine consecutive patients underwent staged epispadias repair with dorsal corporal single-layer SIS grafting (summary figure). Of these, four (44.4%) had primary penopubic epispadias, one (11.1%) had mid-shaft epispadias, and four (44.4%) had bladder exstrophy/epispadias complex. The mean age at surgery was 13.4 ± 6 months. After phalloplasty with SIS grafting, there were no reported complications related to the graft during the post-operative period or follow-up visits.

DISCUSSION

Although traditional techniques for epispadias repair allow some degree of corporal lengthening, they also result in abrupt medial rotation of the corporal bodies leading to torqueing and potential unsatisfactory cosmetic results. In contrast, the authors use single-layer SIS for corporal body grafting, and this study technique results in a more gradual inward rotation thus allowing more anatomical accuracy. Furthermore, an advantage of the use of SIS over other grafting materials is that there is no need to harvest an autologous graft such as tunica vaginalis or dermis.

CONCLUSION

Epispadias repair using single-layer SIS corporal body grafting is an effective, safe, and feasible method, which provides satisfactory cosmesis and correction of dorsal curvature in congenital epispadias in children. Furthermore, a more normal penis appearance, without a decrease in the corporal length or diameter, is achieved with this technique.

How community and healthcare provider perceptions, practices and experiences influence reporting, disclosure and data collection on stillbirth: Findings of a qualitative study in Afghanistan

Quality concerns exist with stillbirth data from low- and middle-income countries including under-reporting and misclassification which affect the reliability of burden estimates. This is particularly problematic for household survey data. Disclosure and reporting of stillbirths are affected by the socio-cultural context in which they occur and societal perceptions around pregnancy loss. In this qualitative study, we aimed to understand how community and healthcare providers' perceptions and practices around stillbirth influence stillbirth data quality in Afghanistan. We collected data through 55 in-depth interviews with women and men that recently experienced a stillbirth, female elders, community health workers, healthcare providers, and government officials in Kabul province, Afghanistan between October-November 2017. The results showed that at the community-level, there was variation in local terminology and interpretation of stillbirth which did not align with the biomedical categories of stillbirth and miscarriage and could lead to misclassification. Specific birth attendant practices such as avoiding showing mothers their stillborn baby had implications for women's ability to recall skin appearance and determine stillbirth timing; however, parents who did see their baby, had a detailed recollection of these characteristics. Birth attendants also unintentionally misclassified birth outcomes. We found several practices that could potentially reduce under-reporting and misclassification of stillbirth; these included the cultural significance of ascertaining signs of life after birth (which meant families distinguished between stillbirths and early neonatal deaths); the perceived value and social recognition of a stillborn; and openness of families to disclose and discuss stillbirths. At the facility-level, we identified that healthcare provider's practices driven by institutional culture and demands, family pressure, and socio-cultural influences, could contribute to under-reporting or misclassification of stillbirths. Data collection methodologies need to take into consideration the socio-cultural context and investigate thoroughly how perceptions and practices might facilitate or impede stillbirth reporting in order to make progress on data quality improvements for stillbirth.

M-SAKHI-Mobile health solutions to help community providers promote maternal and infant nutrition and health using a community-based cluster randomized controlled trial in rural India: A study protocol

Reduction of childhood stunting is difficult to achieve by interventions that focus only on improving nutrition during infancy. Comprehensive interventions that extend through the continuum of care from pregnancy to infancy are needed. Mobile phones are now successfully being used for behaviour change communication to improve health. We present the methodology of an mHealth intervention "Mobile Solutions Aiding Knowledge for Health Improvement" (M-SAKHI) to be delivered by rural community health workers or Accredited Social Health Activists (ASHAs) for rural women, below or up to 20 weeks of pregnancy through delivery until their infant is 12 months of age. This protocol paper describes the cluster randomized controlled trial to evaluate the effectiveness of M-SAKHI. The primary objective of the trial is to reduce the prevalence of stunting (height-for-age < -2 z-score) in children at 18 months of age by 8% in the intervention as compared with control. The secondary objectives include evaluating the impact on maternal dietary diversity, birth weight, infant and young child feeding practices, infant development, and child morbidity, along with a range of intermediate outcomes for maternal, neonatal, and infant health. A total of 297 ASHAs, five trained counsellors, and 2,501 participants from 244 villages are participating in this study. The outcome data are being collected by 51 field research officers. This study will provide evidence regarding the efficacy of M-SAKHI to reduce stunting in young children in rural India, and if effective, the cost-effectiveness of M-SAKHI.

Feasibility of Integrating Agriculture and Nutrition Behavior Change Interventions with Cash Transfers in Rural Bangladesh: A Mixed-methods Assessment (P10-126-19)

Objectives

The study aims to assess the feasibility and acceptability of an intervention package that combines nutrition-specific (nutrition counseling) and nutrition-sensitive (counseling and support for agriculture and unconditional cash transfers) interventions delivered on a mobile phone platform for improving maternal and child nutrition behaviors among low-income families in rural Bangladesh.

Methods

The intervention included counseling on homestead gardening techniques and infant feeding by community level agriculture and nutrition workers using smartphone apps. Women received weekly individual counseling at home and group counselling fortnightly. Each participating woman received a monthly unconditional cash transfer of BDT 1200 through a mobile banking system (bKash) for six months. We collect data through in-depth interviews and a cross sectional survey of the participants and their family members.

Results

The women were interested in both agriculture and nutrition counseling and understood the messages. They established homestead gardens of seasonal vegetables successfully that included preparing beds, planting seedlings, nurturing the plans and harvesting. Seasonal rainfall and damage by hens and ducks were major challenges but most of the families were able to find a solution. Many women preferred to consume the vegetables they produced and spent the cash provided on purchasing other nutritious foods such as fruits, egg and milk for their children as advised in the counseling. The project implementation staff and the bKash agent did not report any difficulties in using the mobile banking system for cash transfer.

Conclusions

Combining nutrition-specific and nutrition-sensitive interventions is a feasible and acceptable approach to the community. Using mobile phone technologies can provide additional benefits for the intervention to reach the disadvantage families in rural settings of Bangladesh.

Funding Sources

Leveraging Agriculture for Nutrition in South Asia (LANSA).

How the Women and the Community Responded to an Antenatal Balanced Plate Nutrition Education Intervention? A Qualitative Process Assessment in Rural Bangladesh (P04-002-19)

Objectives

Acceptability to the beneficiaries is crucial for effectiveness of a community-based nutrition intervention. We conducted a process evaluation to explore the response of the women and the community to an antenatal balanced plate nutrition education intervention in rural Bangladesh.

Methods

We conducted in-depth interviews (IDI) to collect data from recently delivered women, their husbands, and older women ((mothers and mothers-in-law of the women) who received the intervention. Key informant interviews (KII) were conducted with BRAC Shasthya Kormis (community health workers) who provided balanced plate demonstration.

Results

We found that the balanced plate nutrition education helped women through practical demonstration to learn about a balanced meal considering appropriate portion sizes and diversity of foods. The family decision makers, such as husbands and mothers-in-law, considered adopting a healthier diet as a tactic to protect the newborn and the mother from health complications that might safeguard a healthier baby. We also found that rural Bangladeshi pregnant women needed the active involvement of CHWs in mobilizing social support to create an enabling environment essential to bring change in dietary habits with self-motivation.

Conclusions

A community-based balanced plate nutrition education aiming to increase birth weight was widely accepted by the beneficiaries. Practical demonstration of balanced plate with appropriate portion sizes involving the community health workers and family members enhanced the acceptance.

Funding Sources

Faculty of Medicine and Health, University of Sydney, Australia.

The Impact of an Antenatal Balanced Plate Nutrition Education Intervention on Infant Birthweight: A Cluster Randomized Controlled Trial in Rural Bangladesh (OR25-01-19)

Objectives

Low birthweight (LBW) is strongly associated with neonatal mortality. Evidence that nutrition education improves diet during pregnancy and reduces LBW is still weak. We investigated the effect of a nutrition education intervention for pregnant women in improving birthweight of infants. Our primary hypothesis was that women who receive the ‘balanced plate nutrition education’ during pregnancy would deliver babies 100 g heavier than those who receive standard nutrition education.

Methods

We conducted a parallel, two-arm, cluster-randomized controlled trial in Bangladesh, in which we randomly assigned 36 clusters in equal ratio to intervention or standard care. Participants in the intervention clusters received ‘balanced plate nutrition education’ with a practical demonstration from community health workers 4–7 times starting from the first trimester of pregnancy. The participants in the control clusters received standard nutrition education delivered by healthcare providers during antenatal care. Eligible participants were pregnant women of 12 weeks gestation or less. The primary outcome was mean birthweight and incidence of LBW (defined as birthweight less than 2500 gm). The trial is registered with number ACTRN12616000080426.

Results

We included all assigned participants in the intervention (445) and comparison (448) groups in the analyses (Figure 1). Baseline characteristics were balanced between the treatment groups (Table 1). The mean birthweight increased by 125.3 g (95% confidence interval (CI) 5·7, 244·9; P = 0·04) and the risk of LBW was reduced by 54% (relative risk (RR) 0·46; 95% CI 0·28, 0·78; P = 0·004) in the intervention compared to the comparison group (Table 2). In post hoc analyses amongst adolescent mothers we observed a significant improvement in birthweight and reduction in LBW (mean difference 297·3 g; 95% CI 85·0, 509·6; P = 0·006 and RR 0·31; 95% CI 0·12, 0·77; P = 0·01).

Conclusions

A community-based balanced plate nutrition education was effective in increasing birthweight and reducing the incidence of LBW in a rural population of Bangladesh.

A community-based, balanced-plate nutrition education was effective in increasing birthweight and reducing the incidence of low birthweight in a rural population of Bangladesh.

Funding Sources

James P. Grant School of Public Health; Bangladesh, and Sydney Medical School; Australia.

Supporting Tables, Images and/or Graphs

Risk of adverse pregnancy outcomes associated with short and long birth intervals in Bangladesh: evidence from six Bangladesh Demographic and Health Surveys, 1996-2014

OBJECTIVE

To examine the effect of short (<36 months) and long (≥60 months) birth intervals on adverse pregnancy outcomes in Bangladesh.

DESIGN, SETTING AND PARTICIPANTS

We analysed data from six Bangladesh Demographic and Health Surveys (1996-1997, 1999-2000, 2004, 2007, 2011 and 2014). We included all singleton non-first live births, most recently born to mothers within 5 years preceding each survey (n=21 382). We defined birth interval according to previous research which suggests that a birth interval between 36 and 59 months is the most ideal interval. Bivariate and multivariable analyses were conducted to obtain the crude and adjusted ORs (aOR) respectively to assess the odds of first-day neonatal death, early neonatal death and small birth size for both short (<36 months) and long (≥60 months) spacing between births.

MAIN OUTCOME MEASURES

First-day neonatal death, early neonatal death and small birth size.

RESULTS

In the multivariable analysis, compared with births spaced 36-59 months, infants with a birth interval of <36 months had increased odds of first-day neonatal death (aOR: 2.11, 95% CI: 1.17 to 3.78) and early neonatal death (aOR: 1.58, 95% CI: 1.13 to 2.22). Compared with births spaced 36-59 months, infants with a birth interval of ≥60 months had increased odds of first-day neonatal death (aOR: 2.02, 95% CI: 1.10 to 3.73) and small birth size (aOR: 1.17, 95% CI: 1.02 to 1.34). When there was a history of any previous pregnancy loss, there was an increase in the odds of first-day and early neonatal death for both short and long birth intervals, although it was not significant.

CONCLUSIONS

Birth intervals shorter than 36 months and longer than 59 months are associated with increased odds of adverse pregnancy outcomes. Care-providers, programme managers and policymakers could focus on promoting an optimal birth interval between 36 and 59 months in postpartum family planning.

Exploring the intergenerational effects of undernutrition: association of maternal height with neonatal, infant and under-five mortality in Bangladesh

Background

Global or regional evidence showed maternal height as a strong predictor of child survival. However, there is limited information that confirms the intergenerational effect of short maternal height on the risk of offspring mortality in Bangladesh. Therefore, this study aimed to examine the association of maternal height with neonatal, infant and under-five mortality in Bangladesh.

Methods

It was a pooled analysis of data from four rounds of Bangladesh Demographic and Health Surveys 2004, 2007, 2011 and 2014. We included singleton children aged 0-59 months born to mothers aged 15-49 years (n = 29 698). Mothers were interviewed to collect data on maternal and child characteristics, and socio-demographic information. Maternal height was measured using an adjustable measuring board calibrated in millimetres. We used STATA V.14.2 and adjusted for the cluster sampling design. Multivariate 'Modified Poisson Regression' was performed using stepwise backward elimination procedures to examine the association between maternal height and child death.

Results

In the adjusted model, every 1 cm increase maternal height was associated with a reduced risk of neonatal mortality (relative risk (RR) = 0.973, 95% CI 0.960 to 0.986), infant mortality (RR = 0.980, 95% CI 0.969 to 0.991) and under-five mortality (RR = 0.982, 95% CI 0.972 to 0.992). Children of the shortest mothers (height<145 cm) had 1.73 times greater risk of neonatal mortality, about 1.60 times greater risk of infant mortality and 1.48 times greater risk of under-five mortality compared with those of tall mothers (height≥155 cm). Among the children of the shortest mothers (height<145 cm), the absolute probabilities for neonatal, infant and under-five mortality were 4.4%, 6.0% and 6.5%, respectively, while for the children of the tall mothers (height≥ 155 cm), the absolute probabilities for neonatal, infant and under-five mortality were 2.6%, 3.7 %, and 4.4%, respectively.

Conclusion

These findings suggest a robust intergenerational linkage between short maternal height and the risk of neonatal, infant and under-five mortally in Bangladesh.

Variations in perinatal mortality associated with different polluting fuel types and kitchen location in Bangladesh

This study examines the association between household air pollution from use of polluting cooking fuels and perinatal mortality in Bangladesh. We analysed the data from the Bangladesh Demographic and Health Surveys (BDHS) 2004, 2007, 2011, and 2014. The two outcome variables were stillbirth and early neonatal mortality. The exposure variable was type of primary cooking fuel used in the household (clean vs. polluting). Bivariate and multivariable analyses were conducted to obtain the crude and adjusted odds ratio (aOR), respectively. In the adjusted model, the exposure to polluting fuels was associated with early neonatal mortality (aOR: 1.46, 95% confidence interval [CI]: 1.01-2.10), but not with stillbirth (aOR: 1.25, 95% CI: 0.85-1.84). The effect of cooking with agricultural crop waste was greater for stillbirth (aOR: 1.76, 95% CI: 1.10-2.80) and for early neonatal mortality (aOR: 1.78, 95% CI: 1.13-2.80) which was also associated with wood as the main fuel (aOR: 1.52, 95% CI: 1.04-2.21). Using polluting fuels in an indoor kitchen was associated with an increased odds of stillbirth (aOR: 4.12, 95% CI: 1.49-11.41). Cooking with polluting fuels is associated with perinatal mortality. The combined association of polluting cooking fuels and indoor kitchen location was greater for stillbirth. This effect and the effect of different fuel types need further investigation. Although this is a large sample, there are some limitations with the BDHS data in both recording the exposure and the outcomes. A large prospective trial is needed to determine the precise effect size.

Mobile-Based Nutrition Counseling and Unconditional Cash Transfers for Improving Maternal and Child Nutrition in Bangladesh: Pilot Study

Background

Inappropriate feeding practices, inadequate nutrition knowledge, and insufficient access to food are major risk factors for maternal and child undernutrition. There is evidence to suggest that the combination of cash transfer and nutrition education improves child growth. However, a cost-effective delivery platform is needed to achieve complete, population-wide coverage of these interventions.

Objective

This study aimed to assess the feasibility, acceptability, and perceived appropriateness of an intervention package consisting of voice messaging, direct counseling, and unconditional cash transfers all on a mobile platform for changing perceptions on nutrition during pregnancy and the first year of a child’s life in a poor rural community in Bangladesh.

Methods

We conducted a mixed-methods pilot study. We recruited 340 pregnant or recently delivered, lactating women from rural Bangladesh. The intervention consisted of an unconditional cash transfer combined with nutrition counseling, both delivered on a mobile platform. The participants received a mobile phone and BDT 787 per month (US $10). We used a voice messaging service to deliver nutrition-related messages. We provided additional nutrition counseling through a nutrition counselor from a call center. We carried out cross-sectional surveys at baseline and at the end of the study, focus group discussions, and in-depth interviews with participants and their family members.

Results

Approximately 89% (245/275) of participants reported that they were able to operate the mobile phones without much trouble. Charging of the mobile handsets posed some challenges since only approximately 45% (124/275) households in our study had electricity at home. Approximately 26% (72/275) women reported they had charged their mobile phones at their neighbor’s house, while 34% (94/275) reported that they charged it at a marketplace. Less than 10% (22/275) of women reported difficulties understanding the voice messages or direct counseling through mobile phones, while only 3% (8/275) of women reported they had some problems withdrawing cash from the mobile bank agent. Approximately 87% (236/275) women reported spending the cash to purchase food for themselves and their children.

Conclusions

The nature of our study precludes any conclusion about the effectiveness of the intervention package. However, the high coverage of our intervention and the positive feedback from the mothers were encouraging and support the feasibility, acceptability, and appropriateness of this program. Further research is needed to determine the efficacy and cost-effectiveness of mobile-based nutrition counseling and unconditional cash transfers in improving maternal and child nutrition in Bangladesh.

Isolation and genome analysis of a lytic Pasteurella multocida Bacteriophage PMP-GAD-IND

Currently used alum precipitated and oil adjuvant vaccines against HS caused by Pasteurella multocida B:2, have side effects and short-lived immunity, leading to regular catastrophic outbreaks in bovines in Asian subcontinent. The need for the development of an improved vaccine with longer immunity and the ability to differentiate between vaccinated and infected is essential. Pasteurella phage isolated in present study belongs to family Siphoviridae. PMP-GAD-IND phage exhibited lytic activity against vaccine strain (P52) as well as several field strains of P. multocida (B:2), and fowl cholera agent (P. multocida A:1).The phage has a double stranded DNA (dsDNA) with a genome of 46 335 bp. The complete genome sequence of the Pasteurella multocida phage has been deposited in Gen Bank with accession no: KY203335. PMP-GAD-IND being a lytic phage with broad activity range has a potential to be used in therapy against multidrug resistant P. multocida infections.

SIGNIFICANCE AND IMPACT OF THE STUDY

The present work is a part of research for the development of an improved phage lysate marker vaccine and a companion DIVA assay against haemorhagic septicaemia. This study describes the isolation and genome analysis of PMP-GAD-IND a lytic Pasteurella multocida bacteriophage.

The GBA p.Trp378Gly mutation is a probable French-Canadian founder mutation causing Gaucher disease and synucleinopathies

Biallelic GBA mutations cause Gaucher disease (GD), and heterozygous carriers are at risk for synucleinopathies. No founder GBA mutations in French-Canadians are known. GBA was fully sequenced using targeted next generation and Sanger sequencing in French-Canadian Parkinson disease (PD) patients (n = 436), rapid eye movement (REM)-sleep behavior disorder (RBD) patients (n = 189) and controls (n = 891). Haplotype, identity-by-descent (IBD) and principal component analyses (PCA) were performed using single nucleotide polymorphism-chip data. Data on GD patients from Toronto and Montreal were collected from patients' files. A GBA p.Trp378Gly mutation was identified in two RBD and four PD patients (1% of all patients combined), and not in controls. The two RBD patients had converted to DLB within 3 years of their diagnosis. Haplotype, IBD and PCA analysis demonstrated that this mutation is from a single founder. Out of 167 GD patients screened, 15 (9.0%) carried the p.Trp378Gly mutation, all in trans with p.Asn370Ser. Three (20%) of the GD patients with the p.Trp378Gly mutation had developed Parkinsonism, and 11 patients had family history of PD. The p.Trp378Gly mutation is the first French-Canadian founder GBA mutation to be described, which leads to synucleinopathies and to GD type 1 when in compound heterozygosity with p.Asn370Ser.

How can mobile phones be used to improve nutrition service delivery in rural Bangladesh?

BACKGROUND

Nutrition has been integrated within the health services in Bangladesh as it is an important issue for health and development. High penetration of mobile phones in the community and favourable policy and political commitment of the Government of Bangladesh has created possibilities of using Information Communication Technology such as mobile phones for nutrition programs. In this paper the implementation of nutrition services with a specific focus on infant and young child feeding was explored and the potential for using mobile phones to improve the quality and coverage of nutrition services was assessed.

METHODS

A qualitative study was conducted in Mirzapur and Chakaria sub-districts, Bangladesh from February-April 2014. We conducted 24 in-depth interviews (mothers of young children), 8 focus group discussions (fathers and grandmothers); and 13 key informant interviews (community health workers or CHWs). We also observed 4 facilities and followed 2 CHWs during their work day. The data was analyzed manually using pre-existing themes.

RESULTS

In this community, mothers demonstrated gaps in knowledge about IYCF. They depended on their social network and media for IYCF information. Although CHWs were trusted in the community, mothers and their family members did not consider them a good source of nutrition information as they did not talk about nutrition. In terms of ICTs, mobile phones were the most available and used by both CHWs and mothers. CHWs showed willingness to incorporate nutrition counselling through mobile phone as this can enhance their productivity, reduce travel time and improve service quality. Mothers were willing to receive voice calls from CHWs as long as the decision makers in the households were informed.

CONCLUSIONS

Our study indicated that there are gaps in IYCF related service delivery and there is a potential for using mobile phones to both strengthen the quality of service delivery as well as reaching out to the mothers in the community. It is important however, to consider the community readiness to accept the technology during the design and delivery of the intervention.

A community-based cluster randomised controlled trial in rural Bangladesh to evaluate the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality: the Shonjibon trial

BACKGROUND

Iron-deficiency is the most common nutritional deficiency globally. Due to the high iron requirements for pregnancy, it is highly prevalent and severe in pregnant women. There is strong evidence that maternal iron deficiency anaemia increases the risk of adverse perinatal outcomes. However, most of the evidence is from observational epidemiological studies except for a very few randomised controlled trials. IFA supplements have also been found to reduce the preterm delivery rate and neonatal mortality attributable to prematurity and birth asphyxia. These results combined indicate that IFA supplements in populations of iron-deficient pregnant women could lead to a decrease in the number of neonatal deaths mediated by reduced rates of preterm delivery. In this paper, we describe the protocol of a community-based cluster randomised controlled trial that aims to evaluate the impact of maternal antenatal IFA supplements on perinatal outcomes.

METHODS/DESIGN

The effect of the early use of iron-folic acid supplements on neonatal mortality will be examined using a community based, cluster randomised controlled trial in five districts with 30,000 live births. In intervention clusters trained BRAC village volunteers will identify pregnant women & provide iron-folic acid supplements. Groundwater iron levels will be measured in all study households using a validated test kit. The analysis will follow the intention to treat principle. We will compare neonatal mortality rates & their 95% confidence intervals adjusted for clustering between treatment groups in each groundwater iron-level group. Cox proportional hazards mixed models will be used for mortality outcomes & will include groundwater iron level as an interaction term in the mortality model.

DISCUSSION

This paper aims to describe the study protocol of a community based randomised controlled trial evaluating the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality. This study is critical because it will determine if antenatal IFA supplements commenced in the first trimester of pregnancy, rather than later, will significantly reduce neonatal deaths in the first month of life, and if this approach is cost-effective.

TRIAL REGISTRATION

This trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on 31 May 2012. The registration ID is ACTRN12612000588897 .

Perceptions and Practices Related to Obesity in Adolescent Students and Their Programmatic Implications: Qualitative Evidence from Ho Chi Minh City, Vietnam

Background Prevalence of obesity in children in Ho Chi Minh City is rising in the last 10 years. We conducted a formative study to explore the perceptions and practices related to obesity, diet and physical activity among the students in two junior high schools in two suburbs in Ho Chi Minh City to aid in the design of an intervention in preventing obesity among adolescent school children. Method We conducted in-depth interviews with twenty participants including students, their parents, physical education teachers and a representative of the Department of Education. Manually coded and organized data were analysed applying a thematic analysis approach to divulge trends, diversities and similarities among the emerging themes. Results The study revealed diversified perceptions of obesity, diet and physical activity and their relationship with adolescent obesity. The findings indicated low practice of physical activity among almost all students who participated in the study. The major barriers to obesity prevention included knowledge gaps, food environment in the school, devaluation of physical activity and academic burden. Conclusion The findings provide contextual insights to design a culturally appropriate and feasible intervention to tackle child and adolescent obesity by harnessing the perspectives of the target populations.

Household Food Security and Birth Size of Infants: Analysis of the Bangladesh Demographic and Health Survey 2011

BACKGROUND

More than one-third of the population in Bangladesh is affected by household food insecurity in a setting where child survival and well-being are under threat. The relation between household food security and birth size of infants is an important area to explore given its explicit effect on mortality and morbidity.

OBJECTIVE

Our study aims to estimate the association between household food security and birth size of infants.

METHODS

For the analysis we used a nationally representative cross-sectional survey of 8753 households with a live birth between 2006 and 2011, collected under the Bangladesh Demographic and Health Survey (BDHS) 2011. We investigated the association of small birth size with the following potential explanatory variables: sex of the child; birth interval; mother's age at birth, height, body mass index (BMI), anemia status, parity, previous pregnancy loss, antenatal care visits, exposure to television, and participation in health care decisions; cooking fuel; parents' education level; region; place of residence; and wealth index using Pearson's chi-square test. We then constructed a multivariable logistic regression model of birth size on food security after controlling for all potential confounders as well as the cluster sampling design. The odds ratio (OR) was reported for each of the covariates; a P value <0.05 was interpreted as statistically significant.

RESULTS

A total of 1485 (17.3%) children were reported as small at the time of birth and more than one-third of households (35.7%) experienced some degree of food insecurity. Mothers from food-insecure households had 38% higher odds of having small-size infants compared to food-secure households (adjusted OR: 1.38; 95% CI: 1.19, 1.59; P < 0.001).

CONCLUSION

Household food security is one of the key factors associated with small birth size. Interventions to increase birth size should target women belonging to food-insecure households.

Bladder exstrophy closure in the newborn period with external pelvic fixation performed without osteotomy: A preliminary report

BACKGROUND

Successful primary bladder closure is the most crucial element for urinary continence in patients with classic bladder exstrophy (CBE). In the newborn period, bladder closure can be performed in the first 48 h without pelvic osteotomy or external fixation, but requires postoperative lower extremity immobilization (i.e., spica cast, Bryant's or Buck's traction).

OBJECTIVE

To present a novel surgical approach for primary bladder closure for CBE using two-pin external fixation without pelvic osteotomy, and without postoperative lower extremity immobilization.

STUDY DESIGN

A retrospective chart review of patients with CBE was performed at the current institution from 2000 to 2016, including all primary bladder closures with external fixation and without osteotomy or lower extremity immobilization. Patients were discharged with the external fixator in place, which was later removed in clinic. Baseline clinical and demographic variables, and follow-up data were recorded.

RESULTS

Thirteen patients were analyzed; eight (61.5%) were male. Pre-operative intersymphysial distance was 3.68 ± 1.0 cm (2.0-5.0). Mean follow-up was 56.8 ± 40.3 months (10-131). One patient had a partial bladder neck dehiscence, due to pin displacement on postoperative day 1: he had the lowest gestational age of 34 weeks (Summary table).

DISCUSSION

This approach used external fixation to bring the pubic bones together intra-operatively, and to decrease the tension in closing the pelvic ring and abdominal wall without osteotomy. External fixation with osteotomy and long-term immobilization, or using a spica cast without osteotomy offered the added advantage of improved wound care, due to lack of lower limb immobilization, less patient discomfort, and facilitation of mother/caregiver and newborn bonding.

CONCLUSION

The two-pin external fixator without osteotomy as an adjunct to primary bladder closure in CBE patients was technically feasible. At the current institution this approach had an equivalent success rate to previous reports in the literature for primary bladder closure, decreased the length of hospital stay, and precluded the need for lower extremity immobilization. Early data for bladder capacity were encouraging.