Prelacteal feeding is not associated with infant size at 3 months in rural Bangladesh: a prospective cohort study

BACKGROUND

Early and exclusive breastfeeding may reduce neonatal and post-neonatal mortality in low-resource settings. However, prelacteal feeding (PLF), the practice of giving food or liquid before breastfeeding is established, is still a barrier to optimal breastfeeding practices in many South Asian countries. We used a prospective cohort study to assess the association between feeding non-breastmilk food or liquid in the first three days of life and infant size at 3-5 months of age.

METHODS

The analysis used data from 3,332 mother-infant pairs enrolled in a randomized controlled trial in northwestern rural Bangladesh conducted from 2018 to 2019. Trained interviewers visited women in their households during pregnancy to collect sociodemographic data. Project staff were notified of a birth by telephone and interviewers visited the home within approximately three days and three months post-partum. At each visit, interviewers collected data on breastfeeding practices and anthropometric measures. Infant length and weight measurements were used to produce length-for-age (LAZ), weight-for-age (WAZ), and weight-for-length (WLZ) Z-scores. We used multiple linear regression to assess the association between anthropometric indices and PLF practices, controlling for household wealth, maternal age, weight, education, occupation, and infant age, sex, and neonatal sizes.

RESULTS

The prevalence of PLF was 23%. Compared to infants who did not receive PLF, infants who received PLF may have a higher LAZ (Mean difference (MD) = 0.02 [95% CI: -0.04, 0.08]) score, a lower WLZ (MD=-0.06 [95% CI: -0.15, 0.03]) score, and a lower WAZ (MD=-0.02 [95% CI: -0.08, 0.05]) score at 3-5 months of age, but none of the differences were statistically significant. In the adjusted model, female sex, larger size during the neonatal period, higher maternal education, and wealthier households were associated with larger infant size.

CONCLUSION

PLF was a common practice in this setting. Although no association between PLF and infant growth was identified, we cannot ignore the potential harm posed by PLF. Future studies could assess infant size at an earlier time point, such as 1-month postpartum, or use longitudinal data to assess more subtle differences in growth trajectories with PLF.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03683667 and NCT02909179.

Accuracy of a smartphone application for blood pressure estimation in Bangladesh, South Africa, and Tanzania

Undetected and unmonitored hypertension carries substantial mortality and morbidity, especially during pregnancy. We assessed the accuracy of OptiBPTM, a smartphone application for estimating blood pressure (BP), across diverse settings. The study was conducted in community settings: Gaibandha, Bangladesh and Ifakara, Tanzania for general populations, and Kalafong Provincial Tertiary Hospital, South Africa for pregnant populations. Based on guidance from the International Organization for Standardization (ISO) 81,060-2:2018 for non-invasive BP devices and global consensus statement, we compared BP measurements taken by two independent trained nurses on a standard auscultatory cuff to the BP measurements taken by a research version of OptiBPTM called CamBP. For ISO criterion 1, the mean error was 0.5 ± 5.8 mm Hg for the systolic blood pressure (SBP) and 0.1 ± 3.9 mmHg for the diastolic blood pressure (DBP) in South Africa; 0.8 ± 7.0 mmHg for the SBP and -0.4 ± 4.0 mmHg for the DBP in Tanzania; 3.3 ± 7.4 mmHg for the SBP and -0.4 ± 4.3 mmHg for the DBP in Bangladesh. For ISO criterion 2, the average standard deviation of the mean error per subject was 4.9 mmHg for the SBP and 3.4 mmHg for the DBP in South Africa; 6.3 mmHg for the SBP and 3.6 mmHg for the DBP in Tanzania; 6.4 mmHg for the SBP and 3.8 mmHg for the DBP in Bangladesh. OptiBPTM demonstrated accuracy against ISO standards in study populations, including pregnant populations, except in Bangladesh for SBP (criterion 2). Further research is needed to improve performance across different populations and integration within health systems.

The Pregnancy, Arsenic, and Immune Response (PAIR) Study in rural northern Bangladesh

BACKGROUND

Arsenic exposure and micronutrient deficiencies may alter immune reactivity to influenza vaccination in pregnant women, transplacental transfer of maternal antibodies to the foetus, and maternal and infant acute morbidity.

OBJECTIVES

The Pregnancy, Arsenic, and Immune Response (PAIR) Study was designed to assess whether arsenic exposure and micronutrient deficiencies alter maternal and newborn immunity and acute morbidity following maternal seasonal influenza vaccination during pregnancy.

POPULATION

The PAIR Study recruited pregnant women across a large rural study area in Gaibandha District, northern Bangladesh, 2018-2019.

DESIGN

Prospective, longitudinal pregnancy and birth cohort.

METHODS

We conducted home visits to enrol pregnant women in the late first or early second trimester (11-17 weeks of gestational age). Women received a quadrivalent seasonal inactivated influenza vaccine at enrolment. Follow-up included up to 13 visits between enrolment and 3 months postpartum. Arsenic was measured in drinking water and maternal urine. Micronutrient deficiencies were assessed using plasma biomarkers. Vaccine-specific antibody titres were measured in maternal and infant serum. Weekly telephone surveillance ascertained acute morbidity symptoms in women and infants.

PRELIMINARY RESULTS

We enrolled 784 pregnant women between October 2018 and March 2019. Of 784 women who enrolled, 736 (93.9%) delivered live births and 551 (70.3%) completed follow-up visits to 3 months postpartum. Arsenic was detected (≥0.02 μg/L) in 99.7% of water specimens collected from participants at enrolment. The medians (interquartile ranges) of water and urinary arsenic at enrolment were 5.1 (0.5, 25.1) μg/L and 33.1 (19.6, 56.5) μg/L, respectively. Water and urinary arsenic were strongly correlated (Spearman's ⍴ = 0.72) among women with water arsenic ≥ median but weakly correlated (⍴ = 0.17) among women with water arsenic < median.

CONCLUSIONS

The PAIR Study is well positioned to examine the effects of low-moderate arsenic exposure and micronutrient deficiencies on immune outcomes in women and infants.

REGISTRATION

NCT03930017.

Digitalization of routine health information systems: Bangladesh, Indonesia, Pakistan

Objective

To describe a systematic process of transforming paper registers into a digital system optimized to enhance service provision and fulfil reporting requirements.

Methods

We designed a formative study around primary health workers providing reproductive, maternal, newborn and child health services in three countries in Bangladesh, Indonesia and Pakistan. The study ran from November 2014 to June 2018. We developed a prototype digital application after conducting a needs assessment of health workers' responsibilities, workflows, routine data requirements and service delivery needs. Methods included desk reviews, focus group discussions, in-depth interviews; data mapping of paper registers; observations of health workers; co-design workshops with health workers; and usability testing. Finally, we conducted an observational feasibility assessment to monitor uptake of the application.

Findings

Researchers reviewed a total of 17 paper registers across the sites, which we transformed into seven modules within a digital application running on mobile devices. Modules corresponded to the services provided, including household enumeration, antenatal care, family planning, immunization, nutrition and child health. A total of 65 health workers used the modules during the feasibility assessment, and average weekly form submissions ranged from 8 to 234, depending on the health worker and their responsibilities. We also observed variability in the use of modules, requiring consistent monitoring support for health workers.

Conclusion

Lessons learnt from this study shaped key global initiatives and resulted in a software global good. The deployment of digital systems requires well-designed applications, change management and strengthening human resources to realize and sustain health system gains.

mCARE, a digital health intervention package on pregnancy surveillance and care-seeking reminders from 2018 to 2027 in Bangladesh: a model-based cost-effectiveness analysis

OBJECTIVE

We estimated the cost-effectiveness of a digital health intervention package (mCARE) for community health workers, on pregnancy surveillance and care-seeking reminders compared with the existing paper-based status quo, from 2018 to 2027, in Bangladesh.

INTERVENTIONS

The mCARE programme involved digitally enhanced pregnancy surveillance, individually targeted text messages and in-person home-visit to pregnant women for care-seeking reminders for antenatal care, child delivery and postnatal care.

STUDY DESIGN

We developed a model to project population and service coverage increases with annual geographical expansion (from 1 million to 10 million population over 10 years) of the mCARE programme and the status quo.

MAJOR OUTCOMES

For this modelling study, we used Lives Saved Tool to estimate the number of deaths and disability-adjusted life years (DALYs) that would be averted by 2027, if the coverage of health interventions was increased in mCARE programme and the status quo, respectively. Economic costs were captured from a societal perspective using an ingredients approach and expressed in 2018 US dollars. Probabilistic sensitivity analysis was undertaken to account for parameter uncertainties.

RESULTS

We estimated the mCARE programme to avert 3076 deaths by 2027 at an incremental cost of $43 million relative to the status quo, which is translated to $462 per DALY averted. The societal costs were estimated to be $115 million for mCARE programme (48% of which are programme costs, 35% user costs and 17% provider costs). With the continued implementation and geographical scaling-up, the mCARE programme improved its cost-effectiveness from $1152 to $462 per DALY averted from 5 to 10 years.

CONCLUSION

Mobile phone-based pregnancy surveillance systems with individually scheduled text messages and home-visit reminder strategies can be highly cost-effective in Bangladesh. The cost-effectiveness may improve as it promotes facility-based child delivery and achieves greater programme cost efficiency with programme scale and sustainability.

Effects of a Water, Sanitation and Hygiene Mobile Health Program on Diarrhea and Child Growth in Bangladesh: A Cluster-Randomized Controlled Trial of the CHoBI7 Mobile Health Program

Background

The Cholera Hospital-Based Intervention for 7 Days (CHoBI7) mobile health (mHealth) program was a cluster-randomized controlled trial of diarrhea patient households conducted in Dhaka, Bangladesh.

Methods

Patients were block-randomized to 3 arms: standard message on oral rehydration solution use; health facility delivery of CHoBI7 plus mHealth (no home visits); and health facility delivery of CHoBI7 plus 2 home visits and mHealth. The primary outcome was reported diarrhea in the past 2 weeks collected monthly for 12 months. The secondary outcomes were stunting, underweight, and wasting at a 12-month follow-up. Analysis was intention-to-treat.

Results

Between 4 December 2016 and 26 April 2018, 2626 participants in 769 households were randomly allocated to 3 arms: 849 participants to the standard message arm, 886 to mHealth with no home visits arm, and 891 to the mHealth with 2 home visits. Children <5 years had significantly lower 12-month diarrhea prevalence in both the mHealth with 2 home visits arm (prevalence ratio [PR]: 0.73 [95% confidence interval {CI}, .61–.87]) and the mHealth with no home visits arm (PR: 0.82 [95% CI, .69–.97]). Children <2 years were significantly less likely to be stunted in both the mHealth with 2 home visits arm (33% vs 45%; odds ratio [OR]: 0.55 [95% CI, .31–.97]) and the mHealth with no home visits arm (32% vs 45%; OR: 0.54 [95% CI, .31–.96]) compared with children in the standard message arm.

Conclusions

The CHoBI7 mHealth program lowered pediatric diarrhea and stunting among diarrhea patient households.

Clinical Trials Registration

NCT04008134.

Process evaluation for the delivery of a water, sanitation and hygiene mobile health program: findings from the randomised controlled trial of the CHoBI7 mobile health program

OBJECTIVE

The Cholera-Hospital-Based Intervention for 7-days (CHoBI7) mobile health (mHealth) program delivers mobile messages to diarrhoea patient households promoting water treatment and handwashing with soap. The randomised controlled trial (RCT) of the CHoBI7 mHealth program demonstrated this intervention was effective in significantly reducing diarrhoea and stunting amoung young children. The objective of this study was to assess the implementation of the CHoBI7 mHealth program in delivering mHealth messages during this RCT.

METHODS

517 diarrhoea patient households with 1777 participants received weekly text, voice and interactive voice response (IVR) messages from the CHoBI7 mHealth program over the 12-month program period. The program process evaluation indicators were the following: the percentage of CHoBI7 mHealth messages received and fully listened to by program households (program fidelity and dose), and household members reporting receiving and sharing an mHealth message from the program in the past two weeks (program reach).

RESULTS

Ninety two percent of text messages were received by program households. Eighty three percent of voice and 86% of IVR messages sent were fully listened to by at least one household member. Eighty one percent of IVR quiz responses from households were answered correctly. Program households reported receiving a CHoBI7 mHealth message in the past two weeks at 79% of monthly household visits during the 12-month program. Seventy seven percent of participants reported sharing a program message with a spouse, 55% with a neighbour and 49% with a child during the program period.

CONCLUSION

There was high fidelity, dose and reach of mobile messages delivered for the CHoBI7 mHealth program. This study presents an approach for process evaluation that can be implemented to evaluate future mHealth programs.

Impact of Protein Supplementation and Presumptive Treatment for Enteric Pathogens on Infant Growth from 6–12 Months of Age: Results of a Cluster-Randomized Controlled Trial

Objectives

Intake of high-quality protein may be insufficient to support growth in the context of high enteric pathogen carriage and environmental enteric dysfunction. Our objective was to test whether supplemental protein, with or without presumptive treatment for enteric pathogens, would improve infant growth from 6–12 months of age.

Methods

We conducted a 2 × 4 factorial cluster-randomized trial in rural Bangladesh. The first factor was azithromycin treatment (10 mg/kg * 3 days) or placebo at 6 & 9 months of age. The second factor, delivered from 6–12 months of age, consisted of: supplemental protein as daily porridge (125 kcal/d, with 10 g protein/day as egg white powder) or a daily egg; an isocaloric daily porridge; or nutrition education alone. The present aim tested the impact of the protein-rich porridge, with or without azithromycin treatment. All infants born in the study area over a 9-mo period were eligible and consented at ∼3 mo of age. Trained field workers measured infant size at 6, 9, and 12 mo of age using standardized protocols. We used linear regression with generalized estimating equations to test the interventions’ impact on anthropometric indices, respectively, at 12 mo of age, controlling for baseline measures. Analysis was intention-to-treat.

Results

Overall, 2205 infants were enrolled from 282 clusters and exposed to both nutrition (1074 in protein arm from 140 clusters; 1074 in the isocaloric arm from 142 clusters) and presumptive treatment interventions. At baseline, 18.7%, 16.9%, and 6.4% of infants were stunted, underweight, and wasted, respectively. There was no statistical interaction between protein supplementation and azithromycin treatment for any of the anthropometric indices, so groups were combined. In the analysis of main effects, added protein had no impact on mean length-for-age (β = 0.01; 95% CI: −0.06, 0.08), weight-for-age (β = −0.002; 95% CI: −0.06, 0.05), or weight-for-length (β = −0.04; 95% CI: −0.12, 0.05) Z-scores at 12 mo of age.

Conclusions

Supplemental protein from 6–12 mo of age had no effect on mean linear or ponderal growth measured at 12 mo of age, irrespective of presumptive treatment for enteric pathogens with azithromycin.

Funding Sources

The Bill and Melinda Gates Foundation.

Trends in Prelacteal Feeding Practices in Rural Bangladesh from 2004–2019

Objectives

Our objective was to assess changes in prelacteal feeding practices in rural Bangladesh over a 15-year period, from ∼2004 to ∼2019, and to identify household, maternal, and infant characteristics associated with that trend.

Methods

The analysis used data from 21,804 infants enrolled in a cluster-randomized controlled trial of newborn vitamin A supplementation from 2004–2006, and from 4631 infants enrolled in a cluster-randomized controlled trial of a digital health intervention from 2018–2019. In both studies, trained field workers collected data on household socioeconomic status and maternal demographic characteristics at the time of enrollment. Upon receiving notification of an infant's birth, field workers visited the home as soon as possible, collecting detailed data on breastfeeding initiation and any foods or liquids other than breast milk provided to the infant. Prelacteal feeding was defined as giving infants any food or liquid other than breast milk within first 3 days of life. We used bivariate and multivariate logistic regression analyses to examine the association between different household, maternal, and infant characteristics and prelacteal feeding. We then applied a regression decomposition method to understand the factors associated with the changing prevalence of prelacteal feeding over time.

Results

The prevalence of prelacteal feeding was 88.0% during the period of 2004–2006. Among women practicing prelacteal feeding, sugar/sugar candy water was the most commonly fed prelacteal (41.2%), followed by animal milk (40.0%), honey (35.4%), and drops (11.8%). By 2018–2019, the prevalence of prelacteal feeding had declined to 24.7%. Most frequently consumed prelacteals were most commonly sugar/sugar candy water (20.0%), honey (20.0%), animal milk (19.7%), and drops (14.3%). Final analysis will include examination of the changing factors associated with this decline including rising maternal education, improvements in socioeconomic status, and exposure to media.

Conclusions

The prevalence of prelacteal feeding has dropped considerably in rural Bangladesh since 2004.

Funding Sources

The Bill and Melinda Gates Foundation; United States Agency for International Development; Sight and Life.

Association Between Prelacteal Feeding and Infant Growth

Objectives

To assess the association between exposure to prelacteal feeding and infant growth from birth to 3 months of age.

Methods

We analyzed data from a cohort of mothers and infants (n = 2569) identified as part of ongoing pregnancy and birth surveillance in rural Gaibandha, Bangladesh. Trained interviewers visited women in their households during pregnancy to collect sociodemographic data. Project staff were notified of a birth by telephone and interviewers visited the home within three days post-partum, at one-week, and at three months. At each visit, interviewers collected detailed data on breastfeeding, any foods provided to the infant other than breast milk, and morbidity. Infant weight, length, and mid-upper arm circumference were measured according to standardized protocols at birth and three months of age. For analysis, we defined exposure to prelacteal feeding (PLF) as giving infants any food or liquid other than breastmilk within first 3 days of life. Infant length and weight measurements were used to produce length-for-age (LAZ), weight-for-age (WAZ), and weight-for-length (WLZ) Z-scores. Stunting, wasting, and underweight were defined as a LAZ, WLZ, or WAZ &lt; −2, respectively. We used multiple linear regression and multiple logistic regression to assess the association between anthropometric indices and PLF practices, controlling for low birthweight, infant sex, infant age, maternal education, maternal age, and wealth.

Results

The prevalence of PLF was 25.2%. The prevalence of stunting, wasting and underweight was 29.0%, 3.8% and 22.3%, respectively. For stunting (adjusted risk ratio (ARR) = 1.02 [95% CI: 0.89–1.16]) and wasting (ARR = 0.97 [95% CI: 0.63–1.50]), there were no differences between infants who received PLF and infants who did not receive any PLF. Infants who received PLF tended to have higher risk of underweight (ARR = 1.10 [95% CI: 0.95–1.28]). For LAZ, WAZ, and WLZ score, no differences were observed in the adjusted analysis between infants who received PLF and those who did not receive any PLF.

Conclusions

There was no association between exposure to PLF and infant growth from birth to 3 months of age. More research is needed to explore the potential effect of PLF on other outcomes.

Funding Sources

Bill & Melinda Gates Foundation; Johnson & Johnson; UBS Optimus Foundation.

The Effect of Eggs on Growth Among Infants 6–12 months of Age in Rural Bangladesh: A Cluster Randomized Controlled Trial

Objectives

To assess the impact of daily egg supplementation on infant growth from 6–12 months of age in Bangladesh.

Methods

A cluster randomized controlled trial was conducted in rural Bangladesh to test the effect of daily egg supplementation and nutrition education versus nutrition education alone on linear growth and stunting prevalence among infants. Infants were enrolled at 3 months of age and assigned to a trial arm based on their geographic sector of residence. Households were visited weekly to distribute eggs and monitor compliance starting at 6 months of age. Length, weight, head circumference, and mid upper arm circumference were measured at 6, 9, and 12 months, as well as dietary intake from home foods in the last 24 hours. Analyses were conducted on an intention-to-treat basis. Linear regression models were developed for continuous outcomes. For dichotomous outcomes, prevalence ratios were estimated using log-binomial regression models. Generalized estimating equations were used with all models to account for clustering. Each model was adjusted for the baseline measure of the outcome variable.

Results

Overall, 909 infants were enrolled in the treatment arm from 142 clusters and 842 infants in the control arm from 140 clusters. Prevalence of stunting at baseline was 19.4%, wasting was 6.7%, and underweight was 18.1%. After 6 months of supplementation, the intervention had no effect on mean length-for-age z-scores (β = 0.05, 95% CI: −0.12, 0.23) or prevalence of stunting (PR = 1.00, 95% CI: 0.90, 1.10). Infants in the egg arm had significantly higher mean weight-for-length z-scores (β = 0.11, 95% CI: 0.04, 0.18) and weight-for-age z-scores (β = 0.08, 95% CI: 0.03, 0.12), adjusting for baseline measures of the outcomes. Our presented results will include findings from mixed-effects regression analyses assessing the effect of the intervention on growth rate.

Conclusions

The provision of a daily egg for 6 months to infants in rural Bangladesh had an effect on ponderal but not linear growth.

Funding Sources

Bill and Melinda Gates Foundation.

Predictors of neonatal mortality: development and validation of prognostic models using prospective data from rural Bangladesh

Objective

To assess the extent to which maternal histories of newborn danger signs independently or combined with birth weight and/or gestational age (GA) can capture and/or predict postsecond day (age>48 hours) neonatal death.

Methods

Data from a cluster-randomised trial conducted in rural Bangladesh were split into development and validation sets. The prompted recall of danger signs and birth weight measurements were collected within 48 hours postchildbirth. Maternally recalled danger signs included cyanosis (any part of the infant's body was blue at birth), non-cephalic presentation (part other than head came out first at birth), lethargy (weak or no arm/leg movement and/or cry at birth), trouble suckling (infant unable to suckle/feed normally in the 2 days after birth or before death, collected 1-month postpartum or from verbal autopsy). Last menstrual period was collected at maternal enrolment early in pregnancy. Singleton newborns surviving 2 days past childbirth were eligible for analysis. Prognostic multivariable models were developed and internally validated.

Results

Recalling ≥1 sign of lethargy, cyanosis, non-cephalic presentation or trouble suckling identified postsecond day neonatal death with 65.3% sensitivity, 60.8% specificity, 2.1% positive predictive value (PPV) and 99.3% negative predictive value (NPV) in the development set. Requiring either lethargy or weight <2.5 kg identified 89.1% of deaths (at 39.7% specificity, 1.9% PPV and 99.6% NPV) while lethargy or preterm birth (<37 weeks) captured 81.0% of deaths (at 53.6% specificity, 2.3% PPV and 99.5% NPV). A simplified model (birth weight, GA, lethargy, cyanosis, non-cephalic presentation and trouble suckling) predicted death with good discrimination (validation area under the receiver-operator characteristic curve (AUC) 0.80, 95% CI 0.73 to 0.87). A further simplified model (GA, non-cephalic presentation, lethargy, trouble suckling) predicted death with moderate discrimination (validation AUC 0.74, 95% CI 0.66 to 0.81).

Conclusion

Maternally recalled danger signs, coupled to either birth weight or GA, can predict and capture postsecond day neonatal death with high discrimination and sensitivity.

Antenatal care in rural Bangladesh: current state of costs, content and recommendations for effective service delivery

Background

Measurement of antenatal care (ANC) service coverage is often limited to the number of contacts or type of providers, reflecting a gap in the assessment of quality as well as cost estimations and health impact. The study aims to determine service subcomponents and provider and patient costs of ANC services and compares them between community (i.e. satellite clinics) and facility care (i.e. primary and secondary health centers) settings in rural Bangladesh.

Methods

Service contents and cost data were collected by one researcher and four interviewers in various community and facility health care settings in Gaibandha district between September and December 2016. We conducted structured interviews with organization managers, observational studies of ANC service provision (n = 70) for service contents and provider costs (service and drug costs) and exit interviews with pregnant women (n = 70) for patient costs (direct and indirect costs) in health clinics at community and facility levels. Fisher’s exact tests were used to determine any different patient characteristics between community and facility settings. ANC service contents were assessed by 63 subitems categorized into 11 groups and compared within and across community and facility settings. Provider and patient costs were collected in Bangladesh taka and analyzed as 2016 US Dollars (0.013 exchange rate).

Results

We found generally similar provider and patient characteristics between the community and facility settings except in clients’ gestational age. High compliance (> 50%) of service subcomponents were observed in blood pressure monitoring, weight measurement, iron and folate supplementation given, and tetanus vaccine, while lower compliance of service subcomponents (< 50%) were observed in some physical examinations such as edema and ultrasonogram and routine tests such as blood test and urine test. Average unit costs of ANC service provision were about double at the facility level ($2.75) compared with community-based care ($1.62). ANC patient costs at facilities ($2.66) were about three times higher than in the community ($0.78).

Conclusion

The study reveals a delay in pregnant women’s initial ANC care seeking, gaps in compliance of ANC subcomponents and difference of provider and patient costs between facility and community settings.

Costs and cost-effectiveness analyses of mCARE strategies for promoting care seeking of maternal and newborn health services in rural Bangladesh

Objective

We examined the incremental cost-effectiveness between two mHealth programs, implemented from 2011 to 2015 in rural Bangladesh: (1) Comprehensive mCARE package as an intervention group and (2) Basic mCARE package as a control group.

Methods

Both programs included a core package of census enumeration and pregnancy surveillance provided by an established cadre of digitally enabled community health workers (CHWs). In the comprehensive mCARE package, short message service (SMS) and home visit reminders were additionally sent to pregnant women (n = 610) and CHWs (n = 70) to promote the pregnant women’s care-seeking of essential maternal and newborn care services. Economic costs were assessed from a program perspective inclusive of development, start-up, and implementation phases. Effects were calculated as disability adjusted life years (DALYs) and the number of newborn deaths averted. For comparative purposes, we normalized our evaluation to estimate total costs and total newborn deaths averted per 1 million people in a community for both groups. Uncertainty was assessed using probabilistic sensitivity analyses with Monte Carlo simulation.

Results

The addition of SMS and home visit reminders based on a mobile phone-facilitated pregnancy surveillance system was highly cost effective at a cost per DALY averted of $31 (95% uncertainty range: $19–81). The comprehensive mCARE program had at least 88% probability of being highly cost-effective as compared to the basic mCARE program based on the threshold of Bangladesh’s GDP per capita.

Conclusion

mHealth strategies such as SMS and home visit reminders on a well-established pregnancy surveillance system may improve service utilization and program cost-effectiveness in low-resource settings.

Dietary patterns of >30,000 adolescents 9-15 years of age in rural Bangladesh

Little is known of the usual food intakes of rural adolescents in South Asia. This study describes dietary patterns, based on >91,000 7‐day food frequencies among 30,702 girls and boys, aged 9–15 years in rural northwest Bangladesh. Three intake assessments per child, taken across a calendar year, were averaged to represent individual annual intake patterns for 22 food groups. Latent class analysis was used to assign individuals to dietary patterns based on class membership probabilities. The following five dietary patterns (class membership probabilities) were identified: (1) “least diverse” (0.20); (2) “traditional” (0.28); (3) “low vegetable/low fish” (0.23), (4) “moderately high meat” (0.20); and (5) “most diverse” (0.09). The least diverse pattern had the lowest median consumption of most foods and traditional had a relatively higher intake of most vegetables and fish. The most diverse pattern consumed both healthy and processed foods much more often than other patterns. The two most diverse patterns (4 and 5) were associated with higher socioeconomic status, body mass index, height‐for‐age Z‐score, and male gender, and the least diverse pattern showed inverse associations with these characteristics. The most diverse pattern may represent an early wave of the nutrition transition in rural Bangladesh.

Micronutrient Status of Young Adolescents in Rural Bangladesh: The JiVitA-1 Birth Cohort (FS01-04-19)

Objectives

We assessed micronutrient status in young rural Bangladeshi adolescents to determine prevalence of deficiency by sex, age, season and dietary pattern.

Methods

In a birth cohort of >30,000 youth in whom data on health, development, and nutritional status was collected in 2015–2017, venous blood was drawn from a ∼3% subsample (n = 991, 9–13 years old). Participants’ mothers had been in a cluster-randomized, placebo-controlled trial of daily antenatal beta-carotene or vitamin A supplementation in 2001–2007. Hemoglobin (Hb) was obtained at blood draw; plasma ferritin, folate, cobalamin (B12), homocysteine (Hcy), thyroglobulin (Tg), and C-reactive protein (CRP) were measured by chemiluminescent immunoassay, 25-hydroxyvitamin D [25(OH)D] by commercial immunoassay, and zinc by atomic absorption spectrometry.

Results

Participants were short (height-for-age Z-score −1.59 ± 0.93 in boys, −1.65 ± 0.98 in girls) and thin (BMI-for-age Z-score −1.49 ± 1.06 in boys, −1.28 ± 1.08 in girls). Anemia (Hb <120 g/L, 11.4%) was common but iron deficiency (ferritin <15 μg/L, 0.5%) was not. Folate (<6.8 nmol/L, 3.3%) and vitamin B12 (<150 pmol/L, 5.2%) deficiencies, elevated Hcy (>18 μmol/L, 0.8%) and inflammation (CRP >5 mg/L, 3.3%) were uncommon. However, deficiencies of vitamin D (25(OH)D < 50 nmol/L, 43.0%), iodine (Tg > 40 µg/L, 21.9%), and zinc (<8.6 µmol/L, 18.8%) were prevalent. Only vitamin D deficiency was more prevalent in girls than boys (54.0% versus 31.4%, P < 0.0001), doubling in girls from 32.5% at 10 to 69.7% at 13 years of age. Vitamin D deficiency was highest in winter and zinc deficiency highest during the monsoon. In preliminary analyses, micronutrient deficiencies were not significantly associated with dietary intake patterns derived from three 7-day food frequencies collected over ∼1 year.

Conclusions

Young adolescents in rural northern Bangladesh experienced anemia and vitamin D, iodine and zinc deficiencies; however, iron, folate, and B12 deficiencies, hyperhomocysteinemia, and inflammation were uncommon. Further resolution of dietary data and exploration of other contextual features may reveal specific risk factors for micronutrient deficiencies, informing our understanding of adolescent nutritional status in this setting.

Funding Sources

The Bill and Melinda Gates Foundation, Sight and Life.

Micronutrient Status of Young Adolescents in Rural Bangladesh: The JiVitA-1 Birth Cohort (FS01-04-19)

Objectives

We assessed micronutrient status in young rural Bangladeshi adolescents to determine prevalence of deficiency by sex, age, season and dietary pattern.

Methods

In a birth cohort of >30,000 youth in whom data on health, development, and nutritional status was collected in 2015–2017, venous blood was drawn from a ∼3% subsample (n = 991, 9–13 years old). Participants’ mothers had been in a cluster-randomized, placebo-controlled trial of daily antenatal beta-carotene or vitamin A supplementation in 2001–2007. Hemoglobin (Hb) was obtained at blood draw; plasma ferritin, folate, cobalamin (B12), homocysteine (Hcy), thyroglobulin (Tg), and C-reactive protein (CRP) were measured by chemiluminescent immunoassay, 25-hydroxyvitamin D [25(OH)D] by commercial immunoassay, and zinc by atomic absorption spectrometry.

Results

Participants were short (height-for-age Z-score -1.59 ± 0.93 in boys, -1.65 ± 0.98 in girls) and thin (BMI-for-age Z-score -1.49 ± 1.06 in boys, -1.28 ± 1.08 in girls). Anemia (Hb < 120 g/L, 11.4%) was common but iron deficiency (ferritin < 15 μg/L, 0.5%) was not. Folate (< 6.8 nmol/L, 3.3%) and vitamin B12 (<150 pmol/L, 5.2%) deficiencies, elevated Hcy (>18 μmol/L, 0.8%) and inflammation (CRP >5 mg/L, 3.3%) were uncommon. However, deficiencies of vitamin D (25(OH) D < 50 nmol/L, 43.0%), iodine (Tg > 40 µg/L, 21.9%), and zinc (< 8.6 µmol/L, 18.8%) were prevalent. Only vitamin D deficiency was more prevalent in girls than boys (54.0% versus 31.4%, P < 0.0001), doubling in girls from 32.5% at 10 to 69.7% at 13 years of age. Vitamin D deficiency was highest in winter and zinc deficiency highest during the monsoon. In preliminary analyses, micronutrient deficiencies were not significantly associated with dietary intake patterns derived from three 7-day food frequencies collected over ∼1 year.

Conclusions

Young adolescents in rural northern Bangladesh experienced anemia and vitamin D, iodine and zinc deficiencies; however, iron, folate, and B12 deficiencies, hyperhomocysteinemia, and inflammation were uncommon. Further resolution of dietary data and exploration of other contextual features may reveal specific risk factors for micronutrient deficiencies, informing our understanding of adolescent nutritional status in this setting.

Funding Sources

The Bill and Melinda Gates Foundation, Sight and Life.