Prediction of gestational age with symphysis-fundal height and estimated uterine volume in a pregnancy cohort in Sylhet, Bangladesh.

OBJECTIVE: To improve the accuracy of the prediction of gestational age (GA) before birth with the standardised measurement of symphysis-fundal height (SFH), estimation of uterine volume, and statistical modelling including maternal anthropometrics and other factors. DESIGN: Prospective pregnancy cohort study. SETTING: Rural communities in Sylhet, Bangladesh. PARTICIPANTS: 1516 women with singleton pregnancies with early pregnancy ultrasound dating (<20 weeks); 1486 completed follow-up. METHODS: SFH and abdominal girth were measured at subsequent antenatal care (ANC) visits by community health workers at 24 to 28, 32 to 36, and/or >37 weeks gestation. An estimated uterine volume (EUV) was calculated from these measures. Data on pregnancy characteristics and other maternal anthropometrics were also collected. PRIMARY OUTCOME MEASURE: GA at subsequent ANC visits, as defined by early ultrasound dating. RESULTS: 1486 (98%) women had at least one subsequent ANC visit, 1102 (74%) women had two subsequent ANC visits, and 748 (50%) had three visits. Using the common clinical practice of approximating the GA (in weeks) with the SFH measurement (cm), SFH systematically underestimated GA in late pregnancy (mean difference -4.4 weeks, 95% limits of agreement -12.5 to 3.7). For the classification of GA <28 weeks, SFH <26 cm had 85% sensitivity and 81% specificity; and for GA <34 weeks, SFH <29 cm had 83% sensitivity and 71% specificity. EUV had similar diagnostic accuracy. Despite rigorous statistical modelling of SFH, accounting for repeated longitudinal measurements and additional predictors, the best model without including a known last menstrual period predicted 95% of pregnancy dates within ±7.4 weeks of early ultrasound dating. CONCLUSIONS: We were unable to predict GA with a high degree of accuracy before birth using maternal anthropometric measures and other available maternal characteristics. Efforts to improve GA dating in low- and middle-income countries before birth should focus on increasing coverage and training of ultrasonography. TRIAL REGISTRATION NUMBER: NCT01572532.

Prevalence and factors associated with hypertension among adults in rural Sylhet district of Bangladesh: a cross-sectional study.

OBJECTIVES: Low-income and middle-income countries are undergoing epidemiological transition, however, progression is varied. Bangladesh is simultaneously experiencing continuing burden of communicable diseases and emerging burden of non-communicable diseases (NCDs). For effective use of limited resources, an increased understanding of the shifting burden and better characterisation of risk factors of NCDs, including hypertension is needed. This study provides data on prevalence and factors associated with hypertension among males and females 35 years and older in rural Bangladesh. METHODS: This is a population-based cross-sectional study conducted in Zakiganj and Kanaighat subdistricts of Sylhet district of Bangladesh. Blood pressure was measured and data on risk factors were collected using STEPS instrument from 864 males and 946 females aged 35 years and older between August 2017 and January 2018. Individuals with systolic blood pressure of ≥140 mm Hg or diastolic blood pressure of ≥90 mm Hg or taking antihypertensive drugs were considered hypertensive. Bivariate and multivariate analyses were performed to identify factors associated with hypertension. RESULTS: The prevalence of hypertension was 18.8% (95% CI 16.3 to 21.5) and 18.7% (95% CI 16.3 to 21.3) in adult males and females, respectively. Among those who were hypertensive, the prevalence of controlled, uncontrolled and unaware/newly identified hypertension was 23.5%, 25.9% and 50.6%, respectively among males and 38.4%, 22.6% and 39.0%, respectively among females. Another 22.7% males and 17.8% females had prehypertension. Increasing age and higher waist circumference (≥90 cm for males and ≥80 cm for females) were positively associated with hypertension both in males (OR 4.0, 95% CI 2.5 to 6.4) and females (OR 2.8, 95% CI 2.0 to 4.1). CONCLUSIONS: In view of the high burden of hypertension and prehypertension, a context-specific scalable public health programme including behaviour change communications, particularly to increase physical activity and consumption of healthy diet, as well as identification and management of hypertension needs to be developed and implemented.

Rates and determinants of neonatal mortality in two rural sub-districts of Sylhet, Bangladesh.

INTRODUCTION: Reducing neonatal mortality rate (NMR) is a challenge in many low- and middle-income countries including Bangladesh. In 2014, the estimated NMR in this country was 28 per 1,000 live births. This rate is higher in rural regions compared to the national average. Currently, Sylhet Division has the highest NMR in Bangladesh. Investigating rates and determinants of neonatal mortality in rural regions of this high-risk division is particularly important to implement evidence-based programs. This study examined rates and determinants of neonatal deaths in a large rural cohort in Sylhet Division. METHODS: We analyzed data from a multi-country cohort study, Aetiology of Neonatal Infections in South Asia. From November 2011 to December 2013, this study was conducted in two rural sub-districts in Sylhet Division. Community health workers followed 28,960 pregnant women and their newborns up to two months postpartum and collected data on pregnancy outcomes and newborns' survival status. The NMR was obtained by dividing total number of neonatal deaths with all studied newborns. Logistic regression was employed to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for factors associated with neonatal mortality. Stata 14.0 was used for data analysis. RESULTS: This study analyzed data of 21,227 newborns. The NMR was 43.4 (95% CI: 39.3-48.0) per 1,000 live births (N = 922). Multivariable analysis showed that the odds of neonatal mortality were significantly higher among male newborns (AOR: 1.5, 95% CI: 1.2-1.8), babies born before 34 weeks of gestation (AOR: 5.0, 95% CI: 4.1-6.1), those who were twins or triplets (AOR: 6.2, 95% CI: 3.6-10.9), and first-born child (AOR: 2.9, 95% CI: 1.6-5.3). Additionally, maternal age 30-35 years (AOR: 1.4, 95% CI: 1.-1.8), history of child death (AOR: 1.6, 95% CI: 1.2-2.2), and delivery complications (AOR: 2.1, 95% CI: 1.6-2.6) had positive associations with neonatal deaths. CONCLUSION: Public health programs in Bangladesh need to adopt a comprehensive strategy to address the individual, maternal, and intrapartum factors associated with neonatal mortality in rural regions. Interventions should aim to prioritize managing pre-term deliveries, first-born child, and delivery complications among pregnant women.

Effect of a package of integrated demand- and supply-side interventions on facility delivery rates in rural Bangladesh: Implications for large-scale programs.

BACKGROUND: According to the Bangladesh Demographic and Health Survey 2014, only approximately 37 percent of women deliver in a health facility. Among the eight administrative divisions of Bangladesh, the facility delivery rate is lowest in the Sylhet division (22.6 percent) where we assessed the effect of integrated supply- and demand-side interventions on the facility-based delivery rate. METHODS: Population-based cohort data of pregnant women from an ongoing maternal and newborn health improvement study being conducted in a population of ~120,000 in Sylhet district were used. The study required collection and processing of biological samples immediately after delivery. Therefore, the project assembled various strategies to increase institutional delivery rates. The supply-side intervention included capacity expansion of the health facilities through service provider refresher training, 24/7 service coverage, additions of drugs and supplies, and incentives to the providers. The demand-side component involved financial incentives to cover expenses, a provision of emergency transport, and referral support to a tertiary-level hospital. We conducted a before-and-after observational study to assess the impact of the intervention in a total of 1,861 deliveries between December 2014 and November 2016. RESULTS: Overall, implementation of the intervention package was associated with 52.6 percentage point increase in the proportions of facility-based deliveries from a baseline rate of 25.0 percent to 77.6 percent in 24 months. We observed lower rates of institutional deliveries when only supply-side interventions were implemented. The proportion rose to 47.1 percent and continued increasing when the project emphasized addressing the financial barriers to accessing obstetric care in a health facility. CONCLUSIONS: An integrated supply- and demand-side intervention was associated with a substantial increase in institutional delivery. The package can be tailored to identify which combination of interventions may produce the optimum result and be scaled. Rigorous implementation research studies are needed to draw confident conclusions and to provide information about the costs, feasibility for scale-up and sustainability.

Patterns and Determinants of Care-Seeking for Antepartum and Intrapartum Complications in Rural Bangladesh: Results from a Cohort Study.

BACKGROUND: The burden of maternal complications during antepartum and intrapartum periods is high and care seeking from a trained provider is low, particularly in low middle income countries of sub-Saharan Africa and South Asia. Identification of barriers to access to trained care and development of strategies to address them will contribute to improvements in maternal health. Using data from a community-based cohort of pregnant women, this study identified the prevalence of antepartum and intrapartum complications and determinants of care-seeking for these complications in rural Bangladesh. METHODS: The study was conducted in 24,274 pregnant women between June 2011 and December 2013 in rural Sylhet district of Bangladesh. Women were interviewed during pregnancy to collect data on demographic and socioeconomic characteristics; prior miscarriages, stillbirths, live births, and neonatal deaths; as well as data on their ability to make decision to go to health center alone. They were interviewed within the first 7 days of child birth to collect data on self-reported antepartum and intrapartum complications and care seeking for those complications. Bivariate analysis was conducted to explore association between predisposing (socio-demographic), enabling (economic), perceived need, and service related factors with care-seeking for self-reported antepartum and intrapartum complications. Multivariable multinomial logistic regression was performed to examine the association of selected factors with care-seeking for self-reported antepartum and intrapartum complications adjusting for co-variates. RESULTS: Self-reported antepartum and intrapartum complications among women were 14.8% and 20.9% respectively. Among women with any antepartum complication, 58.9% sought care and of these 46.5% received care from a trained provider. Of the women with intrapartum complications, 61.4% sought care and of them 46.5% did so from a trained provider. Care-seeking for both antepartum and intrapartum complications from a trained provider was significantly higher for women with higher household wealth status, higher literacy level of both women and their husbands, and for those living close to a health facility (<10 km). Women's decision making ability to go to health centre alone was associated with untrained care only for antepartum complications, but was associated with both trained and untrained care for intrapartum complications. CONCLUSIONS: Nearly 40.0% of the women who experienced either an antepartum or intrapartum complications did not seek care from any provider and 11.5% -14.9% received care from untrained providers, primarily because of economic and geographic barriers to access. Development and evaluation of context specific, cost-effective, and sustainable strategies that will address these barriers to access to care for the maternal complications will enhance care seeking from trained health care providers and improve maternal health.

Centralized Data Management in a Multicountry, Multisite Population-based Study.

BACKGROUND: A centralized data management system was developed for data collection and processing for the Aetiology of Neonatal Infection in South Asia (ANISA) study. ANISA is a longitudinal cohort study involving neonatal infection surveillance and etiology detection in multiple sites in South Asia. The primary goal of designing such a system was to collect and store data from different sites in a standardized way to pool the data for analysis. METHODS: We designed the data management system centrally and implemented it to enable data entry at individual sites. This system uses validation rules and audit that reduce errors. The study sites employ a dual data entry method to minimize keystroke errors. They upload collected data weekly to a central server via internet to create a pooled central database. Any inconsistent data identified in the central database are flagged and corrected after discussion with the relevant site. The ANISA Data Coordination Centre in Dhaka provides technical support for operations, maintenance and updating the data management system centrally. Password-protected login identifications and audit trails are maintained for the management system to ensure the integrity and safety of stored data. CONCLUSION: Centralized management of the ANISA database helps to use common data capture forms (DCFs), adapted to site-specific contextual requirements. DCFs and data entry interfaces allow on-site data entry. This reduces the workload as DCFs do not need to be shipped to a single location for entry. It also improves data quality as all collected data from ANISA goes through the same quality check and cleaning process.

Implementation of the ANISA Protocol in Sylhet, Bangladesh: Challenges and Solutions.

BACKGROUND: Despite the high rate of deaths in young infants (0-59 days) attributable to infections in resource-poor countries, data on bacterial and viral etiologies of community-acquired infections in this age group are limited. These data are needed to develop appropriate preventive strategies and suitable antibiotic treatment regimens for reducing the number of young infant deaths from infections. The Aetiology of Neonatal Infection in South Asia (ANISA) study is designed to generate these critical data and is being implemented in Bangladesh, India and Pakistan. The Sylhet site in Bangladesh was selected because neonatal mortality is high in this country and particularly in Sylhet District. In this article, we describe the contextual challenges in implementing the ANISA study in Sylhet, as well as the strategies developed by our team to address these challenges. CONTEXTUAL CHALLENGES: The major challenge in implementing the ANISA protocol in Sylhet is conducting the first postnatal visit within 24 hours of birth. This problem stems from several social, cultural and geographical characteristics of the study population and its demographic profile. In this area, most births take place at home, referral compliance for newborn illness to health facilities is low and the blood culture contamination rate is high. Community mobilization, cellphone-based birth notification by families, delivery of quality services at study hospitals and referral support to families in need were some of the strategies adopted by the Sylhet site team for overcoming these challenges during study implementation. Quality control in specimen collection, transportation and processing also plays a role in ensuring satisfactory performance. CONCLUSION: Our research team, with support from the ANISA coordination center, has successfully addressed these challenges and is implementing the study protocol while maintaining the high quality benchmark set by the coordination center.