A context-driven approach through stakeholder engagement to introduce a digital emergency obstetric and newborn care register into routine obstetric health care services in Bangladesh.

Background: Emergency obstetric and newborn care (EmONC) in Bangladesh focusses on maternal health, whereby it addresses childbirth and postpartum complications to ensure women's health and well-being. It was transitioned to a digital platform to overcome challenges with the paper-based EmONC register and we conducted implementation research to assess the outcome. Here we outline the stakeholder engagement process integral to the implementation research process. Methods: We adopted a four-step stakeholder engagement model based on the identification, sensitisation, involvement, and engagement of stakeholders. The approach was informed by previous experience, desk reviews, and expert consultations to ensure comprehensive engagement with stakeholders at multiple levels. Led by the Maternal Health Programme of the Government of Bangladesh, we involved high-power and high-interest stakeholders in developing a joint action plan for digitisation of the paper-based EmONC register. Finally, we demonstrated this digital EmONC register in real-life settings to stakeholders at different levels. Results: The successful demonstration process fostered government ownership and collaboration with multiple stakeholders, while laying the foundation for scalability and sustainability. Nevertheless, our experience highlighted that the stakeholder engagement process is context-driven, time-consuming, resource-intensive, iterative, and dynamic, and it requires involving stakeholders with varied expertise. Effective strategic planning, facilitation, and the allocation of sufficient time and resources are essential components for successful stakeholder engagement. Conclusions: Our experience demonstrates the potential of adopting the 'identification, sensitisation, involvement, and engagement' stakeholder engagement model. Success in implementing this model in diverse settings depends on leveraging knowledge gained during implementation, maintaining robust communication with stakeholders, and harnessing the patience and determination of the facilitating organisation.

Introducing a digital emergency obstetric and newborn care register for indoor obstetric patient management: An implementation research in selected public health care facilities of Bangladesh.

Background: Digital health records have emerged as vital tools for improving health care delivery and patient data management. Acknowledging the gaps in data recording by a paper-based register, the emergency obstetric and newborn care (EmONC) register used in the labour ward was digitised. In this study, we aimed to assess the implementation outcome of the digital register in selected public health care facilities in Bangladesh. Methods: Extensive collaboration with stakeholders facilitated the development of an android-based electronic register from the paper-based register in the labour rooms of the selected district and sub-district level public health facilities of Bangladesh. We conducted a study to assess the implementation outcome of introducing the digital EmONC register in the labour ward. Results: The digital register demonstrated high usability with a score of 83.7 according to the system usability scale, and health care providers found it highly acceptable, with an average score exceeding 95% using the technology acceptance model. The adoption rate reached an impressive 98% (95% confidence interval (CI) = 98-99), and fidelity stood at 90% (95% CI = 88-91) in the digital register, encompassing more than 80% of data elements. Notably, fidelity increased significantly over the implementation period of six months. The digital system proved a high utility rate of 89% (95% CI = 88-91), and all outcome variables exceeded the predefined benchmark. Conclusions: The implementation outcome assessment underscores the potential of the digital register to enhance maternal and newborn health care in Bangladesh. Its user-friendliness, improved data completeness, and high adoption rates indicate its capacity to streamline health care data management and improve the quality of care.

Stakeholder engagement to introduce a standardised register for improved inpatient care of newborns and sick children in Bangladesh.

Background: Despite a global decrease of 59% in under-five mortality rates from 1990 to 2021, child survival remains a pressing issue. This holds true for Bangladesh, as well. In response, the Government of Bangladesh introduced a standardised register for strengthening the inpatient management of newborns and sick children in 2021. Methods: We employed a comprehensive four-phase stakeholder engagement process to implement an inpatient register for newborns and sick children. The first stage included identifying and prioritising potential stakeholders at the national and district levels. We identified eight organisations involved in newborn and child health and selected 24 participants from various other sectors for workshops aimed at raising awareness about the register's introduction. These stakeholders also participated in the register's design, development strategies planning, and implementation phases. These phases were led by the 'National Newborn Health and IMCI programme' with support from various partners. A technical working group reviewed existing registers and helped prepare training materials. Feedback from each workshop was crucial in finalising the register. Results: The Government of Bangladesh has recognised the need for an indoor register for newborns and sick children, which was to be established in collaboration with development partners. This initiative can enhance the quality of care for sick children and increase service provider accountability. Due to its successful implementation, it will continue to be used in the Kushtia and Dinajpur districts, with plans for a nationwide scale-up. The Government has allocated funds in the next health sector programme for orientation and register printing. A strengths, weaknesses, opportunities, and threats (SWOT) analysis of the stakeholder engagement process highlighted strengths such as a context-specific approach and collaborative engagement, as well as challenges such as time resource requirements. Conclusions: Implementing an inpatient register for newborns and sick children through stakeholder engagement can effectively improve child health care services. Aside from challenges such as resource intensiveness and stakeholder commitments, success depended on the organising authority's expertise in relationship building, budget allocation, time management, and workforce dedication. Therefore, strategic planning, staff recruitment, networking, and budgeting are crucial for successful stakeholder engagement and health care initiatives.

Introducing a standardised register for strengthening the inpatient management of newborns and sick children: Implementation research in selected health facilities of Bangladesh.

Background: It is imperative to maintain accurate documentation of clinical interventions aimed at enhancing the quality of care for newborns and sick children. The National Newborn Health and IMCI programme of Bangladesh led the development of a standardised register for managing newborns and sick children under five years of age during inpatient care through stakeholder engagement. We aimed to assess the implementation outcomes of the standardised register in the inpatient department. Methods: We conducted implementation research in two district hospitals and two sub-district hospitals of Kushtia and Dinajpur districts from November 2022 to January 2023 to assess the implementation outcomes of the standardised register. We assessed the following World Health Organization implementation outcome variables: usability, acceptability, adoption (actual use), fidelity (completeness and accuracy), and utility (quality of care) of the register against preset benchmarks. We collected data through structured interviews with health care providers; participant enrolment; and data extraction from inpatient registers and case record forms. Results: The average usability and acceptability scores among health care providers were 73 (standard deviation (SD) = 14) and 82 (SD = 14) out of 100, respectively. The inpatient register recorded 96% (95% confidence interval (CI) = 95-97) of under-five children who were admitted to the inpatient department (adoption - actual use). The proportions of completed data elements in the inpatient register were above the preset benchmark of 70% for all the assessed data elements except 'investigation done' (24%; 95% CI = 23-26) (fidelity - completeness). The percentage agreements between government-appointed nurses posted and study-appointed nurses were above the preset benchmark of 70% for all the reported variables (fidelity - accuracy). The kappa coefficient for the overall level of agreement between these two groups regarding reported variables indicated moderate to substantial agreement. The proportion of newborns with sepsis receiving injectable antibiotics was 62% (95% CI = 47-75) (utility - quality of care). We observed some variability in the completeness and accuracy of the inpatient register by district and facility type. Conclusions: The inpatient register was positively received by health care providers, with evaluations of implementation outcome variables showing encouraging results. Our findings could inform evidence-based decision-making on the implementation and scale-up of the inpatient register in Bangladesh, as well as other low- and middle-income countries.

Factors influencing delivery-related complications and their consequences in hard-to-reach areas of Bangladesh.

BACKGROUND AND OBJECTIVES: Bangladesh's high maternal mortality ratio is exacerbated by delivery-related complications, particularly in hard-to-reach (HtR) areas with limited healthcare access. Despite this, few studies have explored delivery-related complications and factors contributing to these complications among the disadvantaged population. This study aimed to investigate the factors contributing to delivery-related complications and their consequences among the mothers residing in the HtR areas of Bangladesh. METHODS: Data were collected using a cross-sectional study design from 13 HtR sub-districts of Bangladesh between September 2019 and October 2019. Data from 1,290 recently delivered mothers were analysed. RESULTS: Around 32% (95% CI: 29.7-34.8) of the mothers reported at least one delivery-related complication. Prolonged labour pain (21%) was the highest reported complication during the delivery, followed by obstructive labour (20%), fever (14%), severe headache (14%). Mothers with higher education, a higher number of antenatal care (ANC) visits, complications during ANC, employed, and first-time mothers had higher odds of reporting delivery-related complications. More than one-half (51%) of these mothers had normal vaginal delivery. Nearly one-fifth (20%) of mothers who reported delivery-related complications were delivered by unskilled health workers at homes. On the other hand, about one-fifth (19%) of the mothers without any complications during delivery had a caesarean delivery. Nine out of ten of these caesarean deliveries were done at the private facilities. CONCLUSION: Delivery-related complications are significantly related to a woman's reproductive history and other background characteristics. Unnecessary caesarean delivery is prominent at private facilities.

Evaluation of feasibility phase of adaptive version of locally made bubble continuous positive airway pressure oxygen therapy for the treatment of COVID-19 positive and negative adults with severe pneumonia and hypoxaemia.

Background: Bubble continuous positive airway pressure (bCPAP) oxygen therapy has been shown to be safe and effective in treating children with severe pneumonia and hypoxaemia in Bangladesh. Due to lack of adequate non-invasive ventilatory support during coronavirus disease 2019 (COVID-19) crisis, we aimed to evaluate whether bCPAP was safe and feasible when adapted for use in adults with similar indications. Methods: Adults (18-64 years) with severe pneumonia and moderate hypoxaemia (80 to <90% oxygen saturation (SpO2) in room air) were provided bCPAP via nasal cannula at a flow rate of 10 litres per minute (l/min) oxygen at 10 centimetres (cm) H2O pressure, in two tertiary hospitals in Dhaka, Bangladesh. Qualitative interviews and focus group discussions, using a descriptive phenomenological approach, were performed with patients and staff (n = 39) prior to and after the introduction (n = 12 and n = 27 respectively) to understand the operational challenges to the introduction of bCPAP. Results: We enrolled 30 adults (median age 52, interquartile range (IQR) 40-60 years) with severe pneumonia and hypoxaemia and/or acute respiratory distress syndrome (ARDS) irrespective of coronavirus disease 2019 (COVID-19) test results to receive bCPAP. At baseline mean SpO2 on room air was 87% (±2) which increased to 98% (±2), after initiation of bCPAP. The mean duration of bCPAP oxygen therapy was 14.4 ± 24.8 hours. There were no adverse events of note, and no treatment failure or deaths. Operational challenges to the clinical introduction of bCPAP were lack of functioning pulse oximeters, difficult nasal interface fixation among those wearing nose pin, occasional auto bubbling or lack of bubbling in water-filled plastic bottle, lack of holder for water-filled plastic bottle, rapid turnover of trained clinicians at the hospitals, and limited routine care of patients by hospital clinicians particularly after official hours. Discussion: If the tertiary hospitals in Bangladesh are supplied with well-functioning good quality pulse oximeters and enhanced training of the doctors and nurses on proper use of adapted version of bCPAP, in treating adults with severe pneumonia and hypoxaemia with or without ARDS, the bCPAP was found to be safe, well tolerated and not associated with treatment failure across all study participants. These observations increase the confidence level of the investigators to consider a future efficacy trial of adaptive bCPAP oxygen therapy compared to WHO standard low flow oxygen therapy in such patients. Conclusion: s Although bCPAP oxygen therapy was found to be safe and feasible in this pilot study, several challenges were identified that need to be taken into account when planning a definitive clinical trial.

Trends and inequity in improved sanitation facility utilisation in Bangladesh: Evidence from Bangladesh Demographic and Health Surveys.

Improved sanitation is indispensable to human health. However, lack of access to improved sanitation remains one of the most daunting public health challenges of the twenty-first century in Bangladesh. The aim of the study was to describe the trends in access to improved sanitation facilities following the inequity gap among households in different socioeconomic groups in Bangladesh. Data from the Bangladesh Demographic and Health Survey (BDHS) 2007, 2011, 2014, and 2017-18 were extracted for this study. Inequity in access to improved sanitation was calculated using rich-poor ratio and concentration index to determine the changes in inequity across the time period. In Bangladesh, the proportion of households with access to improved sanitation increased steadily from 25.4% to 45.4% between 2007 and 2014, but slightly decreased to 44.0% in 2017-18. Age, educational status, marital status of household head, household wealth index, household size, place of residence, division, and survey year were significantly associated with the utilisation of improved sanitation. There is a pro-rich situation, which means that utilisation of improved sanitation was more concentrated among the rich across all survey years (Concentration Index ranges: 0.40 to 0.27). The government and other relevant stakeholders should take initiatives considering inequity among different socioeconomic groups to ensure the use of improved sanitation facilities for all, hence achieving universal health coverage.

Disparities in the maternal healthcare continuum among Bangladeshi women: evidence from nationally representative surveys.

INTRODUCTION: Utilisation of maternal healthcare is low, and it consistently decreases across antenatal to postnatal period in Bangladesh. However, there is paucity of knowledge in Bangladesh to understand gaps and associated factors in seeking continuum of maternal healthcare along the pathway. Therefore, we aimed to assess the trend in socioeconomic and demographic factors and wealth inequity in maternal CoC using the Bangladesh Multiple Indicator Cluster Survey (MICS). METHODS: We performed a secondary analysis on nationally representative data from the last two MICS survey, carried out in 2012-13 and 2019. The study included women of reproductive age (15-49 years) with a live birth within two years preceding the survey. Total of 7,950 and 9,183 respondents were identified from these two surveys, respectively. We used multivariable logistic regression and concentration index to examine the covariates and inequity, respectively, in the utilisation of CoC. RESULTS: Utilisation of ≥4 antenatal care, skilled delivery, and postnatal care for both mother and newborn increased from 13 percent in 2012-13 to 25 percent in 2019 survey. Moreover, wealth inequity persists favouring the rich in utilisation of CoC in Bangladesh. Women belonging to wealthier quintile, urban areas, and non-Muslim families, with higher education, a household head with higher education, media use, and fewer children were most likely to avail complete CoC in both the surveys. CONCLUSION: Overall utilisation of maternal CoC increased between 2012 and 13 and 2019, however, women in Bangladesh still lack the CoC with persistent wealth inequality. Integrated provision of ANC, delivery by SBA, and PNC should be introduced, comprising both private and public health facilities, and targeting women in poor and rural communities. Efforts should also focus on women's education, autonomy, fertility rate, and exposure to media.

Assessing household fine particulate matter (PM2.5) through measurement and modeling in the Bangladesh cook stove pregnancy cohort study (CSPCS).

Biomass fuel burning is a significant contributor of household fine particulate matter (PM2.5) in the low to middle income countries (LMIC) and assessing PM2.5 levels is essential to investigate exposure-related health effects such as pregnancy outcomes and acute lower respiratory infection in infants. However, measuring household PM2.5 requires significant investments of labor, resources, and time, which limits the ability to conduct health effects studies. It is therefore imperative to leverage lower-cost measurement techniques to develop exposure models coupled with survey information about housing characteristics. Between April 2017 and March 2018, we continuously sampled PM2.5 in three seasonal waves for approximately 48-h (range 46 to 52-h) in 74 rural and semi-urban households among the participants of the Bangladesh Cook Stove Pregnancy Cohort Study (CSPCS). Measurements were taken simultaneously in the kitchen, bedroom, and open space within the household. Structured questionnaires captured household-level information related to the sources of air pollution. With data from two waves, we fit multivariate mixed effect models to estimate 24-h average, cooking time average, daytime and nighttime average PM2.5 in each of the household locations. Households using biomass cookstoves had significantly higher PM2.5 concentrations than those using electricity/liquefied petroleum gas (626 µg/m3 vs. 213 µg/m3). Exposure model performances showed 10-fold cross validated R2 ranging from 0.52 to 0.76 with excellent agreement in independent tests against measured PM2.5 from the third wave of monitoring and ambient PM2.5 from a separate satellite-based model (correlation coefficient, r = 0.82). Significant predictors of household PM2.5 included ambient PM2.5, season, and types of fuel used for cooking. This study demonstrates that we can predict household PM2.5 with moderate to high confidence using ambient PM2.5 and household characteristics. Our results present a framework for estimating household PM2.5 exposures in LMICs, which are often understudied and underrepresented due to resource limitations.

Community-based integrated intervention for skilled maternal health care utilization in riverine remote areas, Bangladesh.

INTRODUCTION: Despite the decrease in maternal mortality ratio, many women in Bangladesh are still at high-risk of death due to pregnancy-related morbidities. Increasing the rate of skilled maternal healthcare service utilization is effective to reduce maternal mortality rate. This paper examines the intervention effect of an integrated community-based maternal healthcare project implemented by a non-government organization, Friendship, aiming to provide maternal health services to women living in the remote riverine regions of Bangladesh. METHODS: We examined the skilled maternal healthcare service utilization before and after project implementation of the mothers with birth experience of 0-6 months from the intervention (N = 1,304) and comparison areas (N = 1,304). A difference-in-differences logistic model measured the effect of the intervention. RESULTS: After the intervention, mothers were three times more likely to receive ≥ 4 ANC visits from skilled providers (AOR: 2.9; 95 % CI: 2.1-4.2), 1.5 times more likely to have skilled birth attendants during deliveries (AOR: 1.5; 95 % CI: 1.1-2.1) and 1.5 times more likely to seek at least one PNC within 42 days after delivery (AOR: 1.5; 95 % CI: 1.1-2.2) as compared to the comparison group. CONCLUSION: The intervention showed positive effect on improving the ANC coverage, skilled delivery, and PNC among the mothers residing the remote riverine areas. Therefore, it opens up the opportunity for adaptation of such integrated community and facility-based interventions by other LMICs.

Research prioritisation on prevention and management of preterm birth in low and middle-income countries (LMICs) with a special focus on Bangladesh using the Child Health and Nutrition Research Initiative (CHNRI) method.

Background: Fifteen million babies are born preterm globally each year, with 81% occurring in low- and middle-income countries (LMICs). Preterm birth complications are the leading cause of newborn deaths and significantly impact health, quality of life, and costs of health services. Improving outcomes for newborns and their families requires prioritising research for developing practical, scalable solutions, especially in low-resource settings such as Bangladesh. We aimed to identify research priorities related to preventing and managing preterm birth in LMICs for 2021-2030, with a special focus on Bangladesh. Methods: We adopted the Child Health and Nutrition Research Initiative (CHNRI) method to set research priorities for preventing and managing preterm birth. Seventy-six experts submitted 490 research questions online, which we collated into 95 unique questions and sent for scoring to all experts. A hundred and nine experts scored the questions using five pre-selected criteria: answerability, effectiveness, deliverability, maximum potential for burden reduction, and effect on equity. We calculated weighted and unweighted research priority scores and average expert agreement to generate a list of top-ranked research questions for LMICs and Bangladesh. Results: Health systems and policy research dominated the top 20 identified priorities for LMICs, such as understanding and improving uptake of the facility and community-based Kangaroo Mother Care (KMC), promoting breastfeeding, improving referral and transport networks, evaluating the impact of the use of skilled attendants, quality improvement activities, and exploring barriers to antenatal steroid use. Several of the top 20 questions also focused on screening high-risk women or the general population of women, understanding the causes of preterm birth, or managing preterm babies with illnesses (jaundice, sepsis and retinopathy of prematurity). There was a high overlap between research priorities in LMICs and Bangladesh. Conclusions: This exercise, aimed at identifying priorities for preterm birth prevention and management research in LMICs, especially in Bangladesh, found research on improving the care of preterm babies to be more important in reducing the burden of preterm birth and accelerating the attainment of Sustainable Development Goal 3 target of newborn deaths, by 2030.

Effect of an integrated maternal and neonatal health intervention on maternal healthcare utilisation addressing inequity in Rural Bangladesh.

BACKGROUND: Although Bangladesh has made significant improvements in maternal, neonatal, and child health, the disparity between rich and poor remains a matter of concern. OBJECTIVE: The study aimed to increase coverage of skilled maternal healthcare services while minimising the inequity gap among mothers in different socioeconomic groups. METHODS: We implemented an integrated maternal and neonatal health (MNH) intervention between 2009 and 2012, in Shahjadpur sub-district of Sirajganj district, Bangladesh. The study was quasi-experimental in design for the evaluation. Socioeconomic status was derived from household assets using principal component analysis. Inequity in maternal healthcare utilisation was calculated using rich-poor ratio and concentration index to determine the changes in inequity between the baseline and the endline time period. RESULT: The baseline and endline surveys included 3,158 (mean age 23.5 years) and 3,540 (mean age 24.3 years) recently delivered mothers respectively. Reduction in the rich-poor ratio was observed in the utilisation of skilled 4+ antenatal care (ANC) (2.4:1 to 1.1:1) and related concentration index decreased from 0.220 to 0.013 (p < 0.001). The rich-poor ratio for skilled childbirth reduced from 1.7:1 to 1.0:1 and the related concentration index declined from 0.161 to -0.021 (p < 0.001). A similar reduction was also observed in the utilisation of skilled postnatal care (PNC); where the rich-poor gap decreased from 2.5:1 to 1.0:1 and the related concentration index declined from 0.197 to -0.004 (p < 0.001). CONCLUSION: The MNH intervention was successful in reducing inequity in receiving skilled 4+ ANC, delivery, and PNC in rural Bangladesh.

Cohort profile: Bangladesh Cook Stove Pregnancy Cohort Study (CSPCS).

PURPOSE: The Cook Stove Pregnancy Cohort Study (CSPCS) was designed to assess the effects of biomass fuel use on household air pollution (HAP) as well as the effects of HAP (fine particulate matter, PM2.5) on birth outcomes and acute lower respiratory infection (ALRI) among infants in Bangladesh. PARTICIPANTS: We recruited 903 women within 18 weeks of pregnancy from rural and semiurban areas of Bangladesh between November 2016 and March 2017. All women and their infants (N=831 pairs) were followed until 12 months after delivery and a subset have undergone respiratory and gut microbiota analysis. METHODS: Questionnaires were administered to collect detailed sociodemographic, medical, nutritional and behavioural information on the mother-child dyads. Anthropometric measurements and biological samples were also collected, as well as household PM2.5 concentrations. FINDINGS TO DATE: Published work in this cohort showed detrimental effects of biomass fuel and health inequity on birth outcomes. Current analysis indicates high levels of household PM2.5 being associated with cooking fuel type and infant ALRI. Lastly, we identified distinct gut and respiratory microbial communities at 6 months of age. FUTURE PLANS: This study provides an economical yet effective framework to conduct pregnancy cohort studies determining the health effects of adverse environmental exposures in low-resource countries. Future analyses in this cohort include assessing the effect of indoor PM2.5 levels on (1) physical growth, (2) neurodevelopment, (3) age of first incidence and frequency of ALRI in infants and (4) the development of the respiratory and gut microbiome. Additional support has allowed us to investigate the effect of in utero exposure to metals on infant neurodevelopment in the first year of life.

Levels and determinants of quality antenatal care in Bangladesh: Evidence from the Bangladesh Demographic and Health Survey.

BACKGROUND: Assessing the quality of antenatal care (ANC) is imperative for improving care provisions during pregnancy to ensure the health of mother and baby. In Bangladesh, there is a dearth of research on ANC quality using nationally representative data to understand its levels and determinants. Thus, the current study aimed to assess ANC quality and identify the sociodemographic factors associated with the usage of quality ANC services in Bangladesh. METHODS: Secondary data analysis was conducted using the last two Bangladesh Demographic and Health Surveys (BDHSs) from 2014 and 2017-18. A total of 8,277 ever-married women were included in the analysis (3,631 from 2014 and 4,646 from 2017-18). The quality ANC index was constructed using a principal component analysis on the following ANC components: weight and blood pressure measurements, blood and urine test results, counselling about pregnancy complications and completion of a minimum of four ANC visits, one of which was performed by a medically trained provider. Multinomial logistic regression was used to determine the strength of the association. RESULTS: The percentage of mothers who received all components of quality ANC increased from about 13% in 2014 to 18% in 2017-18 (p < 0.001). Women from the poorest group, those in rural areas, with no education, a high birth order and no media exposure were less likely to receive high-quality ANC than those from the richest group, those from urban areas, with a higher level of education, a low birth order and media exposure, respectively. CONCLUSION: Although the quality of ANC improved from 2014 to 2017-18, it remains poor in Bangladesh. Therefore, there is a need to develop targeted interventions for different socio-demographic groups to improve the overall quality of ANC. Future interventions should address both the demand and supply-side perspectives.

Haemorrhage-related maternal mortality in Bangladesh: Levels, trends, time of death, and care-seeking practices based on nationally representative population-based surveys.

Background: Haemorrhage is a major cause of maternal deaths globally, most of which are preventable and predominantly happen in low and middle-income countries, including Bangladesh. We examine the current levels, trends, time of death, and care-seeking practices for haemorrhage-related maternal deaths in Bangladesh. Methods: We conducted a secondary analysis with data from the nationally representative 2001, 2010, and 2016 Bangladesh Maternal Mortality Surveys (BMMS). The cause of death information was collected through verbal autopsy (VA) interviews using a country-adapted version of the standard World Health Organization VA questionnaire. Trained physicians reviewed the VA questionnaire and assigned the cause of death using the International Classification of Diseases (ICD) codes. Results: Haemorrhage accounted for 31% (95% confidence interval (CI) = 24-38) of all maternal deaths in 2016 BMMS, which was 31% (95% CI = 25-41) in 2010 BMMS and 29% (95% CI = 23-36) in 2001 BMMS. The haemorrhage-specific mortality rate remained unchanged between 2010 BMMS (60 per 100 000 live births, uncertainty range (UR) = 37-82) and 2016 BMMS (53 per 100 000 live births, UR = 36-71). Around 70% of haemorrhage-related maternal deaths took place within 24 hours of delivery. Of those who died, 24% did not seek health care outside the home and 15% sought care from more than three places. Approximately two-thirds of the mothers who died due to haemorrhage gave birth at home. Conclusions: Postpartum haemorrhage remains the primary cause of maternal mortality in Bangladesh. To reduce these preventable deaths, the Government of Bangladesh and stakeholders should take steps to ensure community awareness about care-seeking during delivery.

Introducing pulse oximetry for outpatient management of childhood pneumonia: An implementation research adopting a district implementation model in selected rural facilities in Bangladesh.

Background: Pulse oximetry has potential for identifying hypoxaemic pneumonia and substantially reducing under-five deaths in low- and middle-income countries (LMICs) setting. However, there are few examples of introducing pulse oximetry in resource-constrained paediatric outpatient settings, such as Integrated Management of Childhood Illness (IMCI) services. Methods: The National IMCI-programme of Bangladesh designed and developed a district implementation model for introducing pulse oximetry in routine IMCI services through stakeholder engagement and demonstrated the model in Kushtia district adopting a health system strengthening approach. Between December 2020 and June 2021, two rounds of assessment were conducted based on WHO's implementation research framework and outcome variables, involving 22 IMCI service-providers and 1680 children presenting with cough/difficulty-in-breathing in 12 health facilities. The data collection procedures included structured-observations, re-assessments, interviews, and data-extraction by trained study personnel. Findings: We observed that IMCI service-providers conducted pulse oximetry assessments on all eligible children in routine outpatient settings, of which 99% of assessments were successful; 85% (95% CI 83,87) in one attempt, and 69% (95% CI 67,71) within one minute. The adherence to standard operating procedure related to pulse oximetry was 92% (95% CI 91,93), and agreement regarding identifying hypoxaemia was 97% (95% CI 96,98). The median performance-time was 36 seconds (IQR 20,75), which was longer among younger children (2-11 months: 44s, IQR 22,78; 12-59 months: 30s, IQR 18,53, p < 0.01) and among those classified as pneumonia/severe-pneumonia than as no-pneumonia (41s, IQR 22,70; 32s, IQR 20,62, p < 0.01). We observed improvements in almost all indicators in round-2. IMCI service-providers and caregivers showed positive attitudes towards using this novel technology for assessing their children. Interpretation: This implementation research study suggested the adoption, feasibility, fidelity, appropriateness, acceptability, and sustainability of pulse oximetry introduction in routine IMCI services in resource-poor settings. The learning may inform the evidence-based scale-up of pulse oximetry linked with an oxygen delivery system in Bangladesh and other LMICs. Funding: This research was funded by the UK National Institute for Health Research (NIHR) (Global Health Research Unit on Respiratory Health (RESPIRE); 16/136/109) using UK aid from the UK Government to support global health research.

Success and time implications of SpO2 measurement through pulse oximetry among hospitalised children in rural Bangladesh: Variability by various device-, provider- and patient-related factors.

Background: Hypoxaemia is one of the strongest predictors of mortality among children with pneumonia. It can be identified through pulse oximetry instantaneously, which is a non-invasive procedure but can be influenced by factors related to the specific measuring device, health provider and patient. Following WHO's global recommendation in 2014, Bangladesh decided to introduce pulse oximetry in paediatric outpatient services, ie, the Integrated Management of Childhood Illness (IMCI) services in 2019. A national committee updated the existing IMCI implementation package and decided to test it by assessing the pulse oximetry performance of different types of assessors in real-life inpatient settings. Methods: We adopted an observational design and conducted a technology assessment among children admitted to a rural district hospital. Eleven nurses and seven paramedics received one-day training on pulse oximetry as assessors. Each assessor performed at least 30 pulse oximetry measurements on children with two types of handheld devices. The primary outcome of interest was obtaining a successful measurement of SpO2, defined as observing a stable (±1%) reading for at least 10 seconds. Performance time, ie, time taken to obtain a successful measurement of SpO2 was considered the secondary outcome of interest. In addition, we used Generalized Estimating Equation to assess the effect of different factors on the pulse oximetry performance. Results: The assessors obtained successful measurements of SpO2 in all attempts (n = 1478) except one. The median time taken was 30 (interquartile range (IQR) = 22-42) seconds, and within 60 seconds, 92% of attempts were successful. The odds of obtaining a successful measurement within 60 seconds were 7.3 (95% confidence interval (CI) = 3.7-14.2) times higher with a Masimo device than a Lifebox device. Similarly, assessors aged >25 years were 4.8 (95% CI = 1.2, 18.6) times more likely to obtain a successful measurement within 60 seconds. The odds of obtaining a successful measurement was 2.6 (95% CI = 1.6, 4.2) times higher among children aged 12-59 months compared to 2-11 months. Conclusions: Our study indicated that assessors could achieve the necessary skills to perform pulse oximetry successfully in real-life inpatient settings through a short training module, with some effect of device-, provider- and patient-related factors. The National IMCI Programme of Bangladesh can use these findings for finalising the national IMCI training modules and implementation package incorporating the recommendation of using pulse oximetry for childhood pneumonia assessment.

Introducing pulse oximetry in routine IMCI services in Bangladesh: A context-driven approach to influence policy and programme through stakeholder engagement.

Background: Pneumonia is the leading cause of under-five child deaths globally and in Bangladesh. Hypoxaemia or low (<90%) oxygen concentration in the arterial blood is one of the strongest predictors of child mortality from pneumonia and other acute respiratory infections. Since 2014, the World Health Organization recommends using pulse oximetry devices in Integrated Management of Childhood Illness (IMCI) services (outpatient child health services), but it was not routinely used in most health facilities in Bangladesh until 2018. This paper describes the stakeholder engagement process embedded in an implementation research study to influence national policy and programmes to introduce pulse oximetry in routine IMCI services in Bangladesh. Methods: Based on literature review and expert consultations, we developed a conceptual framework, which guided the planning and implementation of a 4-step stakeholder engagement process. Desk review, key informant interviews, consultative workshops and onsite demonstration were the key methods to involve and engage a wide range of stakeholders. In the first step, a comprehensive desk review and key informant interviews were conducted to identify stakeholder organisations and scored them based on their power and interest levels regarding IMCI implementation in Bangladesh. In the second step, two national level, two district level and five sub-district level sensitisation workshops were organised to orient all stakeholder organisations having high power or high interest regarding the importance of using pulse oximetry for pneumonia assessment and classification. In the third step, national and district level high power-high interest stakeholder organisations were involved in developing a joint action plan for introducing pulse oximetry in routine IMCI services. In the fourth step, led by a formal working group under the leadership of the Ministry of Health, we updated the national IMCI implementation package, including all guidelines, training manuals, services registers and referral forms in English and Bangla. Subsequently, we demonstrated its use in real-life settings involving various levels of (national, district and sub-district) stakeholders and worked alongside the government leaders towards carefully resuming activities despite the COVID-19 pandemic. Results: Our engagement process contributed to the national decision to introduce pulse oximetry in routine child health services and update the national IMCI implementation package demonstrating country ownership, government leadership and multi-partner involvement, which are steppingstones towards scalability and sustainability. However, our experience clearly delineates that stakeholder engagement is a context-driven, time-consuming, resource-intensive, iterative, mercurial process that demands meticulous planning, prioritisation, inclusiveness, and adaptability. It is also influenced by the expertise, experience and positionality of the facilitating organization. Conclusions: Our experience has demonstrated the value and potential of the approach that we adopted for stakeholder engagement. However, the approach needs to be conceptualised coupled with the allocation of adequate resources and time commitment to implement it effectively.

Measuring coverage and quality of supportive care for inpatient neonatal infections: EN-BIRTH multi-country validation study.

Background: An estimated 7 million episodes of severe newborn infections occur annually worldwide, with half a million newborn deaths, most occurring in low- and middle-income countries. Whilst injectable antibiotics are necessary to treat the infection, supportive care is also crucial in ending preventable mortality and morbidity. This study uses multi-country data to assess gaps in coverage, quality, and documentation of supportive care, considering implications for measurement. Methods: The EN-BIRTH study was conducted in five hospitals in Bangladesh, Nepal, and Tanzania (July 2017-July 2018). Newborns with an admission diagnosis of clinically-defined infection (sepsis, meningitis, and/or pneumonia) were included. Researchers extracted data from inpatient case notes and interviews with women (usually the mothers) as the primary family caretakers after discharge. The interviews were conducted using a structured survey questionnaire. We used descriptive statistics to report coverage of newborn supportive care components such as oxygen use, phototherapy, and appropriate feeding, and we assessed the validity of measurement through survey-reports using a random-effects model to generate pooled estimates. In this study, key supportive care components were assessment and correction of hypoxaemia, hyperbilirubinemia, and hypoglycaemia. Results: Among 1015 neonates who met the inclusion criteria, 89% had an admission clinical diagnosis of sepsis. Major gaps in documentation and care practices related to supportive care varied substantially across the participating hospitals. The pooled sensitivity was low for the survey-reported oxygen use (47%; 95% confidence interval (CI) = 30%-64%) and moderate for phototherapy (60%; 95% CI = 44%-75%). The pooled specificity was high for both the survey-reported oxygen use (85%; 95% CI = 80%-89%) and phototherapy (91%; 95% CI = 82%-97%). Conclusions: The women's reports during the exit survey consistently underestimated the coverage of supportive care components for managing infection. We have observed high variability in the inpatient documents across facilities. A standardised ward register for inpatient small and sick newborn care may capture selected supportive care data. However, tracking the detailed care will require standardised individual-level data sets linked to newborn case notes. We recommend investments in assessing the implementation aspects of a standardised inpatient register in resource-poor settings.

Indirect effects of the early phase of the COVID-19 pandemic on the coverage of essential maternal and newborn health services in a rural subdistrict in Bangladesh: results from a cross-sectional household survey.

OBJECTIVE: This paper presents the effect of the early phase of COVID-19 on the coverage of essential maternal and newborn health (MNH) services in a rural subdistrict of Bangladesh. DESIGN: Cross-sectional household survey with random sampling. SETTING: Baliakandi subdistrict, Rajbari district, Bangladesh. PARTICIPANTS: Data were collected from women who were on the third trimester of pregnancy during the early phase of the pandemic (111) and pre-pandemic periods (115) to measure antenatal care (ANC) service coverage. To measure birth, postnatal care (PNC) and essential newborn care (ENC), data were collected from women who had a history of delivery during the early phase of the pandemic (163) and pre-pandemic periods (166). EXPOSURE: Early phase of the pandemic included a strict national lockdown between April and June 2020, and pre-pandemic was defined as August-October 2019. OUTCOME OF INTEREST: Changes in the coverage of selected MNH services (ANC, birth, PNC, ENC) during the early phase of COVID-19 pandemic compared with the pre-pandemic period, estimated by two-sample proportion tests. FINDINGS: Among women who were on the third trimester of pregnancy during the early phase of the pandemic period, 77% (95% CI: 70% to 85%) received at least one ANC from a medically trained provider (MTP) during the third trimester, compared with 83% (95% CI: 76% to 90%) during the pre-pandemic period (p=0.33). Among women who gave birth during the early phase of the pandemic period, 72% (95% CI: 66% to 79%) were attended by an MTP, compared with 63% (95% CI: 56% to 71%) during the pre-pandemic period (p=0.08). Early initiation of breast feeding was practised among 38% (95% CI: 31% to 46%) of the babies born during the early phase of the pandemic period. It was 37% (95% CI: 29% to 44%) during the pre-pandemic period (p=0.81). The coverage of ANC, birth, PNC and ENC did not differ by months of pandemic and pre-pandemic periods; only the coverage of at least one ANC from an MTP significantly differed among the women who were 7 months pregnant during the early phase of the pandemic (35%, 95% CI: 26% to 44%) and pre-pandemic (49%, 95% CI: 39% to 58%) (p=0.04). CONCLUSION: The effect of the early phase of the pandemic including lockdown on the selected MNH service coverage was null in the study area. The nature of the lockdown, the availability and accessibility of private sector health services in that area, and the combating strategies at the rural level made it possible for the women to avail the required MNH services.