Knowledge, Attitude, and Practices Towards COVID-19 Among Pregnant and Postpartum Women in Rural Bangladesh: A Cross-Sectional Study.

OBJECTIVE: To identify knowledge, attitudes, and practices toward COVID-19 among pregnant and postpartum women in rural Bangladesh, and to assess any association with antenatal care attendance (ANC). METHODS: This cross-sectional study was conducted in Northern Bangladesh's Sherpur district with a sample of pregnant and post-partum women enrolled in 'Poriborton', a community-based cluster Randomised Controlled Trial. Knowledge, attitude, and practices toward COVID-19, and any association with antenatal care practices were assessed through face-to-face interviews using a structured questionnaire. Composite measures for knowledge, attitude, and practices of COVID-19 were generated. Specific knowledge on COVID-19 and the association of antenatal care were presented as descriptive statistics. An adjusted odds ratio was used to examine the association between categorical variables. RESULTS: Out of 4835 women, 34.0% correctly identified five or more COVID-19 symptoms, 31.8% knew three or more modes of coronavirus transmission, and 57.0% knew five or more preventive measures. Most (90.1%) had a "more positive attitude to testing" and 65.1% reported adequate practice of preventive measures. Women with adequate knowledge of COVID-19 were more likely to report both a positive attitude to testing (OR:2.96; 95% CI: 1.38-6.37) and adopt adequate practices of preventive measures (OR: 4.30;95% CI: 2.90-6.36). Education and being employed influenced KAP related to COVID-19. Only 14.9% were satisfied with their knowledge of COVID-19. Television was the main source of COVID-19-related specific information. CONCLUSIONS: We found that improved knowledge was associated with positive attitudes and behaviours that lead to the adoption of preventive measures. There was no association with ANC practices as attendance was very low in this region. The findings could be utilised to develop communication strategies for future public health emergencies in similar settings.

Reducing household air pollution exposure to improve early child growth and development; a randomized control trial protocol for the "Poriborton-Extension: The CHANge trial".

BACKGROUND: Globally, household air pollution (HAP) is a leading environmental cause of morbidity and mortality. Our trial aims to assess the impact of liquefied petroleum gas (LPG) for cooking to reduce household air pollution exposure on child health outcomes, compared to usual cooking practices in Bangladesh. The primary aim is to evaluate if reduced exposure to HAP through the provision of LPG for cooking from early gestation through to age 2 improves child anthropometry, health, and neuro-cognitive developmental outcomes, compared to children exposed to emissions from usual practice. METHODS: Two-arm parallel cluster randomized controlled trial (cCRT). We will extend the intervention and follow-up of our existing "Poriborton" trial. In a subset of the original surviving participants, we will supply LPG cylinders and LPG stoves (intervention) compared to usual cooking practices and extend the follow-up to 24 months of age. The expected final sample size, for both (intervention and control) is 1854 children with follow-up to 2 years of age available for analysis. DISCUSSION: This trial will answer important research gaps related to HAP and child health and neuro-cognitive developmental outcomes. This evidence will help to understand the impact of a HAP intervention on child health to inform policies for the adoption of clean fuel in Bangladesh and other similar settings. TRIAL REGISTRATION: The Poriborton: Change trial: Household Air Pollution and Perinatal and early Neonatal mortality is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001214224, original trial registered on 19th July 2018, extension approved on 23rd June 2021. www.anzctr.org.au .

Protocol for a cluster randomised controlled trial of LPG cookstoves compared to usual cooking practices to reduce perinatal mortality and morbidity in rural Bangladesh called Poriborton: the CHANge trial.

BACKGROUND: Household air pollution is a leading health risk for global morbidity and mortality and a major health risk in South Asia. However, there are no prospective investigations of the impact of household air pollution on perinatal morbidity and mortality. Our trial aims to assess the impact of liquefied petroleum gas (LPG) for cooking to reduce household air pollution exposure on perinatal morbidity and mortality compared to usual cooking practices in Bangladesh. HYPOTHESIS: In a community-based cluster randomised controlled trial of pregnant women cooking with LPG throughout pregnancy, perinatal mortality will be reduced by 35% compared with usual cooking practices in a rural community in Bangladesh. METHODS: A two-arm community-based cluster randomised controlled trial will be conducted in the Sherpur district, Bangladesh. In the intervention arm, pregnant women receive an LPG cookstove and LPG in cylinders supplied throughout pregnancy until birth. In the control or usual practice arm, pregnant women continue their usual cooking practices, predominately traditional stoves with biomass fuel. Eligible women are pregnant women with a gestational age of 40-120 days, aged between 15 and 49 years, and permanent residents of the study area. The primary outcome is the difference in perinatal mortality between the LPG arm and the usual cooking arm. Secondary outcomes include (i) preterm birth and low birth weight, (ii) personal level exposure to household air pollution, (iii) satisfaction and acceptability of the LPG stove and stove use, and (iv) cost-effectiveness and cost-utility in reducing perinatal morbidity and mortality. We follow up all women and infants to 45 days after the birth. Personal exposure to household air pollution is assessed at three-time points in a sub-sample of the study population using the MicroPEM™. The total required sample size is 4944 pregnant women. DISCUSSION: This trial will produce evidence of the effectiveness of reduced exposure to household air pollution through LPG cooking to reduce perinatal morbidity and mortality compared to usual cooking practices. This evidence will inform policies for the adoption of clean fuel in Bangladesh and other similar settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618001214224 . Prospectively registered on 19 July 2019.

Pregnant Women's Exposure to Household Air Pollution in Rural Bangladesh: A Feasibility Study for Poriborton: The CHANge Trial.

The use of liquefied petroleum gas (LPG) for cooking is a strategy to reduce household air pollution (HAP) exposure and improve health. We conducted this feasibility study to evaluate personal exposure measurement methods to representatively assess reductions in HAP exposure. We enrolled 30 pregnant women to wear a MicroPEM for 24 h to assess their HAP exposure when cooking with a traditional stove (baseline) and with an LPG stove (intervention). The women wore the MicroPEM an average of 77% and 69% of the time during the baseline and intervention phases, respectively. Mean gravimetric PM2.5 mass and black carbon concentrations were comparable during baseline and intervention. Temporal analysis of the MicroPEM nephelometer data identified high PM2.5 concentrations in the afternoon, late evening, and overnight during the intervention phase. Likely seasonal sources present during the intervention phase were emissions from brick kiln and rice parboiling facilities, and evening kerosene lamp and mosquito coil use. Mean background adjusted PM2.5 concentrations during cooking were lower during intervention at 71 µg/m3, versus 105 µg/m3 during baseline. Representative real-time personal PM2.5 concentration measurements supplemented with ambient PM2.5 measures and surveys will be a valuable tool to disentangle external sources of PM2.5, other indoor HAP sources, and fuel-sparing behaviors when assessing the HAP reduction due to intervention with LPG stoves.

Overweight and obesity among urban women with iron deficiency anaemia in Bangladesh.

In this study, we aimed to determine the prevalence and factors associated with overweight and obesity among nonpregnant and nonlactating (NPNL) women of reproductive age with iron deficiency anaemia (IDA) in urban Bangladesh. We obtained data from the baseline assessment of a randomized control trial conducted among 525 women of reproductive age (18-49 years) with IDA (Hb < 12 gdl-1 and serum ferritin <30 µg L-1 ). The study was carried out in Mirpur, Dhaka, Bangladesh, between December 2017 and January 2019. We collected information on women's socio-demographic characteristics and anthropometry. Body mass index (BMI) was calculated using the following formula: weight in kilograms per height in square metres. BMI ≥ 25-29.9 kg m-2 was considered as overweight, whereas BMI ≥ 30 kg m-2 as obese. A multivariable logistic regression model was used to ascertain the risk factors of overweight and obesity. The prevalence of overweight and obesity was 29.9% (95% CI: 26.0-34.0) and 13.1% (95% CI: 10.4-16.3), respectively. The combined prevalence of overweight and obesity was 43.0% (95% CI: 38.7-47.4). The multivariable analysis showed married women (aOR: 4.4; CI: 1.8-11.1), women aged 30-49 years (aOR: 7.6; CI: 2.4-24.1), unemployed women (aOR 1.5; CI: 1.0-2.4) and women from the wealthier households (aOR 3.9; CI: 2.3-6.8) had the highest risk of being overweight and obese compared with their counterparts. Both age and household wealth statuses showed dose-response relationships. Combination of overweight and obesity with IDA poses a particular challenge for public health interventions. The policymakers should consider what new interventions and policy initiatives are needed to address this combination of overweight and obesity with IDA.

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.

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.

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 .

Knowledge and involvement of husbands in maternal and newborn health in rural Bangladesh.

BACKGROUND: Access to skilled health services during pregnancy, childbirth and postnatal period for obstetric care is one of the strongest determinants of maternal and newborn health (MNH) outcomes. In many countries, husbands are key decision-makers in households, effectively determining women's access to health services. We examined husbands' knowledge and involvement regarding MNH issues in rural Bangladesh, and how their involvement is related to women receiving MNH services from trained providers. METHODS: We conducted a cross-sectional survey in two rural sub-districts of Bangladesh in 2014 adopting a stratified cluster sampling technique. Women with a recent birth history and their husbands were interviewed separately with a structured questionnaire. A total of 317 wife-husband dyads were interviewed. The associations between husbands accompanying their wives as explanatory variables and utilization of skilled services as outcome variables were assessed using multiple logistic regression analyses. RESULTS: In terms of MNH knowledge, two-thirds of husbands were aware that women have special rights related to pregnancy and childbirth and one-quarter could mention three or more pregnancy-, birth- and postpartum-related danger signs. With regard to MNH practice, approximately three-quarters of husbands discussed birth preparedness and complication readiness with their wives. Only 12% and 21% were involved in identifying a potential blood donor and arranging transportation, respectively. Among women who attended antenatal care (ANC), 47% were accompanied by their husbands. Around half of the husbands were present at the birthplace during birth. Of the 22% women who received postpartum care (PNC), 67% were accompanied by their husbands. Husbands accompanying their wives was positively associated with women receiving ANC from a medically trained provider (AOR 4.5, p < .01), birth at a health facility (AOR 1.5, p < .05), receiving PNC from a medically trained provider (AOR 48.8, p < .01) and seeking care from medically trained providers for obstetric complications (AOR 3.0, p < 0.5). CONCLUSION: Husbands accompanying women when receiving health services is positively correlated with women's use of skilled MNH services. Special initiatives should be taken for encouraging husbands to accompany their wives while availing MNH services. These initiatives should aim to increase men's awareness regarding MNH issues, but should not be limited to this.

Birth preparedness and complication readiness among women and couples and its association with skilled birth attendance in rural Bangladesh.

INTRODUCTION: Despite remarkable progress in maternal and neonatal health over past two decades, maternal and neonatal mortality in Bangladesh remain high, which is partially attributable to low use of skilled maternal and newborn health (MNH) services. Birth preparedness and complications readiness (BCPR) is recommended by the World Health Organization and by the Government of Bangladesh as a key intervention to increasing appropriate MNH services. This study aims to explore the status of BPCR in a hard-to-reach area of rural Bangladesh and to demonstrate how BPCR practices is associated with birth in the presence of a skilled birth attendant. METHODS: Data was collected using multistage cluster sampling-based household survey in two sub-districts of Netrokona, Bangladesh in 2014. Interviews were conducted among women with a recent birth history in 12-months and their husbands. Univariate, bivariate, and multivariable analysis using Stata 14.0 were performed from 317 couples. RESULTS: Mean age of respondents was 26.1 (SD ± 5.3) years. There was a significant difference in BPCR practice between women and couples for identification of the place of birth (84% vs. 75%), identification of a birth attendant (89% vs.72%), arranging transport for birth or emergencies (20% vs. 13%), and identification of a blood donor (15% vs. 8%). In multivariable analysis, odds of giving birth in presence of a skilled birth attendant consistently increased with higher completeness of preparedness (OR 3.3 for 3-5 BPCR components, OR 5.5 for 4-5 BPCR components, OR 10.4 for all 5 BPCR components). For different levels of completeness of BPCR practice, the adjusted odds ratios were higher for couple preparedness comparatively. CONCLUSIONS: BPCR is associated with birth in the presence of a skilled attendant and this effect is magnified when planning is carried out by the couple. Interventions aiming to increase BPCR practices should not focus on women only, as involving the couple is most likely lead to positive care-seeking practices.

A community-based cluster randomized controlled trial (cRCT) to evaluate the impact and operational assessment of "safe motherhood and newborn health promotion package": study protocol.

BACKGROUND: Despite considerable progress in reduction of both under-five and maternal mortality in recent decades, Bangladesh is still one of the low and middle income countries with high burden of maternal and neonatal mortality. The primary objective of the current study is to measure the impact of a comprehensive package of interventions on maternal and neonatal mortality. In addition, changes in coverage, quality and utilization of maternal and newborn health (MNH) services, social capital, and cost effectiveness of the interventions will be measured. METHODS: A community-based, cluster randomized controlled trial design will be adopted and implemented in 30 unions of three sub-districts of Chandpur district of Bangladesh. Every union, the lowest administrative unit of the local government with population of around 20,000-30,000, will be considered a cluster. Based on the baseline estimates, 15 clusters will be paired for random assignment as intervention and comparison clusters. The primary outcome measure is neonatal mortality, and secondary outcomes are coverage of key interventions like ANC, PNC, facility and skilled provider delivery. Baseline, midterm and endline household survey will be conducted to assess the key coverage of interventions. Health facility assessment surveys will be conducted periodically to assess facility readiness and utilization of MNH services in the participating health facilities. DISCUSSION: The current study is expected to provide essential strong evidences on the impact of a comprehensive package of interventions to the Bangladesh government, and other developmental partners. The study results may help in prioritizing, planning, and scaling-up of Safe Motherhood Promotional interventions in other geographical areas of Bangladesh as well as to inform other developing countries of similar settings. TRIAL REGISTRATION: NCT03032276 .

Determinants of hardship financing in coping with out of pocket payment for care seeking of under five children in selected rural areas of Bangladesh.

BACKGROUND: Around 63% of total health care expenditure in Bangladesh is mitigated through out of pocket payment (OOP). Heavy reliance on OOP at the time of care seeking poses great threat for financial impoverishment of the households. Households employ different strategies to cope with the associated financial hardship. OBJECTIVE: The aim of this paper is to understand the determinants of hardship financing in coping with OOP adopted for health care seeking of under five childhood illnesses in rural setting of Bangladesh. METHODS: A community based cross sectional survey was conducted during August to October, 2014 in 15 low performing sub-districts of northern and north-east regions of Bangladesh. Of the 7039 mothers of under five children surveyed, 1895 children who suffered from illness and sought care for their illness episodes were reported in this study. Descriptive statistics and ordinal regression analysis were conducted. RESULTS: A total number of 7,039 under five children reported to have suffered illness by their mothers. Among these children 37% suffered from priority illness. Care was sought for 88% children suffering from illnesses. Among them 26% went to a public or private sector medically trained provider. 5% of households incurred illness cost more than 10% of the household's monthly expenditure. The need for assistance was higher among those compared to others (31% vs 13%). Different financing mechanisms adopted to meet OOP are loan with interest (6%), loan without interest (9%) and financial help from relatives (6%) Need for financial assistance varied from 19% among households in the lowest quintile to 9% in the highest wealth. Ordinal regression analysis revealed that burden of hardship financing increases by 2.17 times when care is sought from a private trained provider compared to care seeking from untrained provider (CI: 1.49, 3.17). Similarly, for families that incur a health care expenditure that is more than 10% of their total monthly expenditure (CI:1.46, 3.88), the probability of falling into more severe financial burden increases by 2.4 times. We also found severity of the hardship financing to be around half for households with monthly income of more than BDT 7500 (OR = 0.56, CI: 0.37, 0.86). The burden increased by 2.10 times for households with a deficit (CI: 1.53, 2.88) between their monthly income and expenditure. The interaction between family income and severity of illness showed to significantly affect the scale of hardship financing. Children suffering from priority illness belonging to poor households were found have two times (CI: 1.09, 3.47) higher risks of suffering from hardship financing. CONCLUSION AND POLICY IMPLICATIONS: Findings from this study will help the policy makers to identify the target groups and thereby design effective health financing programs.