Thinness and fecundability: Time to pregnancy after adolescent marriage in rural Bangladesh.

Undernutrition may affect fecundability, but few studies have quantified this relationship. In rural Bangladesh, where newlywed couples face strong pressures to become pregnant, we assessed fecundability, estimated by time to pregnancy (TTP), and its association with preconceptional thinness among nulligravid, newlywed female adolescents. During 2001-2002, 5,516 newlywed women aged 12-19 years participated in a home-based, 5-weekly surveillance system for 5-6 years to enrol pregnant women into an antenatal vitamin A or ß-carotene supplementation trial. Thinness was defined as a left mid-upper arm circumference (MUAC) ≤21.5 versus >21.5 cm. At each visit, staff obtained a monthly history of menstruation. Report of amenorrhea prompted a human chorionic gonadotropin urine test to confirm pregnancy. We derived hazard ratios (with 95% confidence intervals [CI]) for pregnancy and Kaplan-Meier curves for TTP. Ages of women at marriage and pregnancy detection (mean ± standard deviation) were 15.3 ± 1.9 and 17.0 ± 1.9 years, respectively. A total of 82.7% of thinner and 87.3% of better nourished women became pregnant. The unadjusted and multivariable relative hazard of ever becoming pregnant was 0.84 (95% CI [0.78, 0.89]) and 0.86 (95% CI [0.81, 0.92]), respectively, and TTP was 12 weeks longer (median [95% CI]: 63 [58-68] vs. 51 [49-54]) in women whose MUAC was ≤21.5 versus >21.5 cm. In rural Bangladesh, thin adolescent newlywed girls have a lower probability of becoming pregnant and experience a longer time to pregnancy.

Unintended pregnancy is a risk factor for depressive symptoms among socio-economically disadvantaged women in rural Bangladesh.

BACKGROUND: Little is known about the relation between unwanted pregnancy and intention discordance and maternal mental health in low-income countries. The study aim was to evaluate maternal and paternal pregnancy intentions (and intention discordance) in relation to perinatal depressive symptoms among rural Bangladeshi women. METHODS: Data come from a population-based, community trial of married rural Bangladeshi women aged 13-44. We examined pregnancy intentions among couples and pregnancy-intention discordance, as reported by women at enrollment soon after pregnancy ascertainment, in relation to depressive symptoms in the third trimester of pregnancy (N = 14,629) and six months postpartum (N = 31,422). We calculated crude and adjusted risk ratios for prenatal and postnatal depressive symptoms by pregnancy intentions. RESULTS: In multivariable analyses, women with unwanted pregnancies were at higher risk of prenatal (Adj. RR = 1.60, 95% CI: 1.37-1.87) and postnatal depressive symptoms (Adj. RR = 1.32, 95% CI: 1.21-1.44) than women with wanted pregnancies. Women who perceived their husbands did not want the pregnancy also were at higher risk for prenatal (Adj. RR = 1.42, 95% CI: 1.22-1.65) and postnatal depressive symptoms (Adj. RR = 1.30, 95% CI: 1.19-1.41). Both parents not wanting the pregnancy was associated with prenatal and postnatal depressive symptoms (Adj. RR = 1.34, 95% CI: 1.19-1.52; Adj. RR = 1.13, 95% CI: 1.06-1.21, respectively), compared to when both parents wanted it. Adjusting for socio-demographic and pregnancy intention variables simultaneously, maternal intentions and pregnancy discordance were significantly related to prenatal depressive symptoms, and perception of paternal pregnancy unwantedness and couple pregnancy discordance, with postnatal depressive symptoms. CONCLUSIONS: Maternal, paternal and discordant couple pregnancy intentions, as perceived by rural Bangladeshi women, are important risk factors for perinatal maternal depressive symptoms.

Identifying maternal and infant factors associated with newborn size in rural Bangladesh by partial least squares (PLS) regression analysis.

Birth weight, length and circumferences of the head, chest and arm are key measures of newborn size and health in developing countries. We assessed maternal socio-demographic factors associated with multiple measures of newborn size in a large rural population in Bangladesh using partial least squares (PLS) regression method. PLS regression, combining features from principal component analysis and multiple linear regression, is a multivariate technique with an ability to handle multicollinearity while simultaneously handling multiple dependent variables. We analyzed maternal and infant data from singletons (n = 14,506) born during a double-masked, cluster-randomized, placebo-controlled maternal vitamin A or ß-carotene supplementation trial in rural northwest Bangladesh. PLS regression results identified numerous maternal factors (parity, age, early pregnancy MUAC, living standard index, years of education, number of antenatal care visits, preterm delivery and infant sex) significantly (p<0.001) associated with newborn size. Among them, preterm delivery had the largest negative influence on newborn size (Standardized ß = -0.29 - -0.19; p<0.001). Scatter plots of the scores of first two PLS components also revealed an interaction between newborn sex and preterm delivery on birth size. PLS regression was found to be more parsimonious than both ordinary least squares regression and principal component regression. It also provided more stable estimates than the ordinary least squares regression and provided the effect measure of the covariates with greater accuracy as it accounts for the correlation among the covariates and outcomes. Therefore, PLS regression is recommended when either there are multiple outcome measurements in the same study, or the covariates are correlated, or both situations exist in a dataset.

Risk of Depressive Symptoms Associated with Morbidity in Postpartum Women in Rural Bangladesh.

Objectives Depression following pregnancy is common, but its extent and association with maternal morbidity in the first 6 months postpartum have not been well described in low resource settings such as rural Bangladesh. Methods We used data from a population-based, community trial of approximately 39,000 married rural Bangladeshi women aged 13-44 between 2001 and 2007 to examine the relation between women's reported morbidity symptoms from childbirth to 3 months postpartum, and subsequent depressive symptoms assessed at 6 months postpartum. We calculated crude and adjusted risk ratios for depressive symptoms following women's reports of reproductive, urinary, neurologic, nutrition and other illness measures constructed based on symptomatic reporting. Results In models adjusted for sociodemographic factors and co-morbidities, all postpartum illnesses were associated with an increased relative risk [RR, with 95% confidence intervals (CI) excluding 1] of depressive symptoms by 6 months postpartum. These morbidities included uterine prolapse (RR 1.20, 95% CI 1.04-1.39), urinary tract infection (RR 1.24, 95% CI 1.11-1.38), stress related incontinence (SRI) (RR 1.49, 95% 1.33-1.67), simultaneous SRI and continuously dripping urine (RR 1.60-2.96), headache [RR 1.20 (95% CI 1.12-1.28)], convulsions (RR 1.67, 95%CI 1.36-2.06), night blindness (RR 1.33, 95% CI 1.19-1.49), anemia (RR 1.38, 95% CI 1.31-1.46), pneumonia (RR 1.24, 95% CI 1.12-1.37), gastroenteritis (RR 1.24, 95% CI 1.17-1.31) and hepatobiliary disease (RR 2.10, 96% CI 1.69-2.60). Conclusions for Practice Illnesses during the first three postpartum months were risk factors for depressive symptoms, with the strongest associations noted for convulsions and hepatobiliary disease. Symptoms of depression may be of particular concern among women suffering from physical illnesses. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT0019882.

Early newborn ritual foods correlate with delayed breastfeeding initiation in rural Bangladesh.

BACKGROUND: Early and exclusive breastfeeding may improve neonatal survival in low resource settings, but suboptimal breastfeeding still exists in areas with high infant mortality. Prelacteal feeding, the practice of giving a non-breastmilk food as a neonate's first food, has been associated with suboptimal breastfeeding practices. We examined the association of feeding a non-breastmilk food in the first three days of life (early neonatal food, or ENF) with time from birth to initiation of breastfeeding among 25,286 Bangladeshi mother-neonate pairs, in a secondary analysis of a randomized controlled trial in northwestern rural Bangladesh conducted from 2001-2007. METHODS: Trained interviewers assessed the demographic characteristics during pregnancy. At three months postpartum, the interviewers visited participants again and retrospectively assessed demographic and breastfeeding characteristics surrounding the birth. We assessed the relationship between ENF and time to initiation of breastfeeding in hours in both unadjusted and adjusted linear regression analyses. We also calculated reverse cumulative distribution curves for time to initiation of breastfeeding and analyses were stratified by an infant's ability to breastfeed normally at birth. RESULTS: The mean ± SD time from birth to initiation of breastfeeding was 30.6 ± 27.9 hours. Only 2,535 (10.0%) of women reported initiating breastfeeding in the first hour after birth and 10,207 (40.4%) reported initiating breastfeeding in the first 12 hours after birth. In adjusted linear regression analyses, feeding ENF was associated with a significant increase in time, in hours, to breastfeeding initiation both among children not able to breastfeed at birth (37.4; 95% CI 33.3, 41.5) and among children able to breastfeed at birth (13.3; 95% CI 12.7, 14.0). CONCLUSIONS: Feeding ENF was strongly associated with delayed initiation of breastfeeding, even after adjusting for other related factors and stratifying on the neonate's ability to suckle normally after birth. More research is needed to understand the impact of these findings on optimal breastfeeding in this setting. It is possible that ENF feeding and the ability to breastfeed immediately after birth are interrelated in their respective associations to suboptimal breastfeeding initiation. This study in a large population representative of other populations in rural South Asia, demonstrates significantly longer times to breastfeeding initiation than previously appreciated, with a possible important role of ENF feeding. TRIAL REGISTRATION: The randomized controlled trial on which this analysis is based, "Impact of Maternal Vitamin A or Beta-Carotene Supplementation on Maternal and Infant Mortality in Bangladesh", was registered with ClinicalTrials.gov as trial number ID GHS-A-00-03-00019-00 and identifier NCT00198822. The identifier was first received September 12, 2005 (retrospectively registered). The first participant was enrolled in August 2001.

Depressive symptoms in mothers after perinatal and early infant loss in rural Bangladesh: a population-based study.

PURPOSE: We examined stillbirth and neonatal death as predictors of depressive symptoms in women experiencing these events during the first 6 months postpartum. METHODS: We performed secondary analyses using data from 41,348 married women aged 13-44 years, originally collected for the JiVitA-1 study (2001-2007) in northwest Bangladesh. Adjusted relative risk ratios were estimated to determine the associations between stillbirth and early infant death and women's risk of reported depressive symptoms (trichotomized 0, 1-2, 3-5) up to 6 months after the death. Adjusted risk ratios, comparing 0-2 versus 3-5 depressive symptoms, were used in stratified analyses. RESULTS: Women having fetal/infant deaths had elevated risk of experiencing 1-2 postpartum depressive symptoms (adj RRRs between 1.2 and 1.7) and of experiencing 3-5 postpartum depressive symptoms (adj RRRs between 1.9 and 3.3), relative to women without a fetal/infant death. Notably, those whose infants died in the early postneonatal period had over a three-fold risk of 3-5 depressive symptoms (adj relative risk ratio [RRR] = 3.3; 95% confidence interval [CI], 2.6-4.3) compared to a two-fold risk for women experiencing a stillbirth (adj RRR = 1.9; 95% CI, 1.7-2.1). After early postneonatal deaths, women with higher levels of education were more likely to suffer 3-5 depressive symptoms (adj relative risk [RR] = 10.6; 95% CI, 5.2-21.7, ≥10 years of education) compared to women with lower levels of education (adj RR = 2.0; 95% CI, 1.6-2.4, no education; adj RR = 2.2; 95% CI, 1.6-2.9, 1-9 years of education). CONCLUSIONS: Women's mental health needs should be prioritized in low-resource settings, where these outcomes are relatively common and few mental health services are available.

Excessive adiposity at low BMI levels among women in rural Bangladesh.

Asian populations have a higher percentage body fat (%BF) and are at higher risk for CVD and related complications at a given BMI compared with those of European descent. We explored whether %BF was disproportionately elevated in rural Bangladeshi women with low BMI. Height, weight, mid-upper arm circumference, triceps and subscapular skinfolds and bioelectrical impedance analysis (BIA) were measured in 1555 women at 3 months postpartum. %BF was assessed by skinfolds and by BIA. BMI was calculated in adults and BMI Z-scores were calculated for females <20 years old. Receiver operating characteristic (ROC) curves found the BMI and BMI Z-score cut-offs that optimally classified women as having moderately excessive adipose tissue (defined as >30 % body fat). Linear regressions estimated the association between BMI and BMI Z-score (among adolescents) and %BF. Mean BMI was 19·2 (sd 2·2) kg/m(2), and mean %BF was calculated as 23·7 (sd 4·8) % by skinfolds and 23·3 (sd 4·9) % by BIA. ROC analyses indicated that a BMI value of approximately 21 kg/m(2) optimised sensitivity (83·6 %) and specificity (84·2 %) for classifying subjects with >30 % body fat according to BIA among adults. This BMI level is substantially lower than the WHO recommended standard cut-off point of BMI ≥ 25 kg/m(2). The equivalent cut-off among adolescents was a BMI Z-score of -0·36, with a sensitivity of 81·3 % and specificity of 80·9 %. These findings suggest that Bangladeshi women exhibit excess adipose tissue at substantially lower BMI compared with non-South Asian populations. This is important for the identification and prevention of obesity-related metabolic diseases.

First-trimester plasma tocopherols are associated with risk of miscarriage in rural Bangladesh.

BACKGROUND: Tocopherols were discovered for their role in animal reproduction, but little is known about the contribution of deficiencies of vitamin E to human pregnancy loss. OBJECTIVE: We sought to determine whether higher first-trimester concentrations of α-tocopherol and γ-tocopherol were associated with reduced odds of miscarriage (pregnancy losses <24 wk of gestation) in women in rural Bangladesh. DESIGN: A case-cohort study in 1605 pregnant Bangladeshi women [median (IQR) gestational age: 10 wk (8-13 wk)] who participated in a placebo-controlled vitamin A- or ß-carotene-supplementation trial was done to assess ORs of miscarriage in women with low α-tocopherol (<12.0 µmol/L) and γ-tocopherol (<0.81 µmol/L; upper tertile cutoff of the γ-tocopherol distribution in women who did not miscarry). RESULTS: In all women, plasma α- and γ-tocopherol concentrations were low [median (IQR): 10.04 µmol/L (8.07-12.35 µmol/L) and 0.66 µmol/L (0.50-0.95 µmol/L), respectively]. In a logistic regression analysis that was adjusted for cholesterol and the other tocopherol, low α-tocopherol was associated with an OR of 1.83 (95% CI: 1.04, 3.20), whereas a low γ-tocopherol concentration was associated with an OR of 0.62 (95% CI: 0.41, 0.93) for miscarriage. Subgroup analyses revealed that opposing ORs were evident only in women with BMI (in kg/m(2)) ≥18.5 and serum ferritin concentration ≤150 µg/L, although low BMI and elevated ferritin conferred stronger risk of miscarriage. CONCLUSIONS: In pregnant women in rural Bangladesh, low plasma α-tocopherol was associated with increased risk of miscarriage, and low γ-tocopherol was associated with decreased risk of miscarriage. Maternal vitamin E status in the first trimester may influence risk of early pregnancy loss. The JiVitA-1 study, from which data for this report were derived, was registered at clinicaltrials.gov as NCT00198822.

Plasma zinc, vitamin B(12) and α-tocopherol are positively and plasma γ-tocopherol is negatively associated with Hb concentration in early pregnancy in north-west Bangladesh.

OBJECTIVE: The objective of the current analysis was to explore the association of multiple micronutrients with Hb concentration among pregnant women in a South Asian setting, a topic that has not been adequately explored. DESIGN: Sociodemographic, anthropometric and micronutrient status (plasma ferritin, transferrin receptor, retinol, a- and g-tocopherol, folate, vitamin B12, Zn) and Hb concentration were assessed at early pregnancy. SETTING: The biochemical sub-study was nested within a double-blind, placebo-controlled, community-based vitamin A and b-carotene supplementation trial in rural north-western Bangladesh (JiVitA). All assessments were conducted before trial supplementation was initiated. SUBJECTS: A systematic sample of 285 women was selected from those enrolled in the biochemical sub-study. RESULTS: Seventeen per cent of women were mildly anaemic; moderate and severe anaemia was uncommon (2.1 %). a-Tocopherol, vitamin B12 and Zn deficiencies were common (43.5%, 19.7% and 14.7%, respectively); however, vitamin A, folate and Fe deficiencies were comparatively rare (7.4%, 2.8% and ,1%,respectively). Plasma Zn, vitamin B12 and a-tocopherol were positively associated and plasma g-tocopherol was negatively associated with Hb (P < 0.05) after adjustment for gestational age, inflammation status, season and nutritional status measured by mid-upper arm circumference. CONCLUSIONS: Among pregnant women in rural Bangladesh with minimal Fe deficiency, plasma Zn, vitamin B12, and a- and g-tocopherol concentrations were associated with Hb concentration. Appreciating the influence on Hb of micronutrients in addition to those with known associations with anaemia, such as Fe, folate, and vitamin A, is important when addressing anaemia in similar settings.

Effects of vitamin A and ß-carotene supplementation on birth size and length of gestation in rural Bangladesh: a cluster-randomized trial.

BACKGROUND: Micronutrient deficiencies may be related to poor fetal growth and short gestation. Few studies have investigated the contribution of maternal vitamin A deficiency to these outcomes. OBJECTIVE: In rural northwestern Bangladesh, we examined the effects of weekly antenatal vitamin A and ß-carotene supplementation on birth weight, length, circumferential body measures, and length of gestation. DESIGN: With the use of a cluster-randomized, placebo-controlled trial design, pregnant women were enrolled in the first trimester and began receiving their allocated supplements (vitamin A, ß-carotene, or placebo) weekly until 3 mo postpartum. Birth anthropometric measures were made at home. RESULTS: Of 13,709 newborns whose birth weight was measured within 72 h of birth, mean (±SD) weight was 2.44 ± 0.42 kg, the prevalence of low birth weight (LBW) was 54.4%, and that of small-for-gestational age (SGA) was 70.5%. Birth weight, length, and chest, head, and arm circumferences did not differ between supplementation and placebo groups nor did rates of LBW and SGA. Mean gestational age at birth was 38.3 ± 2.9 wk, and 25.6% of births occurred before 37 wk. Neither gestational age nor preterm birth rate differed with vitamin A or ß-carotene supplementation. CONCLUSIONS: In this rural South Asian population with a high burden of LBW and preterm birth but modest levels of maternal vitamin A deficiency, antenatal vitamin A or ß-carotene supplementation did not benefit these birth outcomes. Other nutritional and nonnutritional interventions should be examined to reduce risks of these adverse outcomes in rural South Asia. This trial was registered at clinicaltrials.gov as NCT00198822.

Maternal morbidity in early pregnancy in rural northern Bangladesh.

OBJECTIVE: To determine the burden of maternal morbidity in early pregnancy in rural northern Bangladesh. METHODS: A cross-sectional analysis was performed on baseline morbidity data from 42 896 pregnant women enrolled in a vitamin A supplementation trial. One-week histories for 31 defined symptoms were collected at 5-12 weeks of gestation. Ten illnesses were defined, compatible with ICD-10 diagnoses and WHO definitions. Prevalence, duration, and treatment-seeking behaviors were determined for each symptom and illness. Risk of wasting malnutrition was compared between symptomatic and asymptomatic women. RESULTS: In total, 93.1% of women reported at least 1 symptom. The most frequent symptoms were poor appetite (53.3%), vaginal discharge (48.7%), and nausea (48.1%), each of which lasted 22-27 days. The most prevalent illnesses were anemia (36.4%), morning sickness (17.2%), excessive vomiting (7.0%), and reproductive tract infections (6.7%). Symptoms that prompted treatment seeking included jaundice, high-grade fever, and swelling of hands and face. Odds ratios for malnutrition were higher among women with symptoms of anemia (1.30; 95% confidence interval [CI], 1.24-1.36), vaginal discharge (1.37; 95% CI, 1.31-1.43), and high-grade fever (1.23; 95% CI, 1.10-1.37) than among those without symptoms. CONCLUSION: Women in rural Bangladesh report substantial morbidity in the first trimester.

Hepatitis E, a vaccine-preventable cause of maternal deaths.

Hepatitis E virus (HEV) is a major cause of illness and of death in the developing world and disproportionate cause of deaths among pregnant women. Although HEV vaccine trials, including trials conducted in populations in southern Asia, have shown candidate vaccines to be effective and well-tolerated, these vaccines have not yet been produced or made available to susceptible populations. Surveillance data collected during 2001-2007 from >110,000 pregnancies in a population of ≈650,000 women in rural Bangladesh suggest that acute hepatitis, most of it likely hepatitis E, is responsible for ≈9.8% of pregnancy-associated deaths. If these numbers are representative of southern Asia, as many as 10,500 maternal deaths each year in this region alone may be attributable to hepatitis E and could be prevented by using existing vaccines.

Care-seeking patterns for fatal non-communicable diseases among women of reproductive age in rural northwest Bangladesh.

BACKGROUND: Though non-communicable diseases contribute to an increasing share of the disease burden in South Asia, health systems in most rural communities are ill-equipped to deal with chronic illness. This analysis seeks to describe care-seeking behavior among women of reproductive age who died from fatal non-communicable diseases as recorded in northwest rural Bangladesh between 2001 and 2007. METHODS: This analysis utilized data from a large population-based cohort trial in northwest rural Bangladesh. To conduct verbal autopsies of women who died while under study surveillance, physicians interviewed family members to elicit the biomedical symptoms that the women experienced as well as a narrative of the events leading to deaths. We performed qualitative textual analysis of verbal autopsy narratives for 250 women of reproductive age who died from non-communicable diseases between 2001 and 2007. RESULTS: The majority of women (94%) sought at least one provider for their illnesses. Approximately 71% of women first visited non-certified providers such as village doctors and traditional healers, while 23% first sought care from medically certified providers. After the first point of care, women appeared to switch to medically certified practitioners when treatment from non-certified providers failed to resolve their illness. CONCLUSIONS: This study suggests that treatment seeking patterns for non-communicable diseases are affected by many of the sociocultural factors that influence care seeking for pregnancy-related illnesses. Families in northwest rural Bangladesh typically delayed seeking treatment from medically certified providers for NCDs due to the cost of services, distance to facilities, established relationships with non-certified providers, and lack of recognition of the severity of illnesses. Most women did not realize initially that they were suffering from a chronic illness. Since women typically reached medically certified providers in advanced stages of disease, they were usually told that treatment was not possible or were referred to higher-level facilities that they could not afford to visit. Women suffering from non-communicable disease in these rural communities need feasible and practical treatment options. Further research and investment in adequate, appropriate care seeking and referral is needed for women of reproductive age suffering from fatal non-communicable diseases in resource-poor settings.

Iodine status in pregnancy and household salt iodine content in rural Bangladesh.

Adequate maternal iodine intake is essential during pregnancy for the development of the foetus. To assess the extent of iodine insufficiency and its association with household iodized salt in rural Bangladesh, we measured urinary iodine and household salt iodine content among pregnant women in early (≤16 weeks, n = 1376) and late (≥32 weeks, n = 1114) pregnancy. Salt (∼20 g) and a spot urine sample (∼10 mL) were collected from women participating in a randomized, placebo-controlled trial of vitamin A or beta-carotene supplementation in rural northwestern Bangladesh during home visits in early and late pregnancy. Salt iodine was analyzed by iodometric titration, and urinary iodine by the Ohashi method. Almost all salt samples had some detectable iodine, but over 75% contained <15 ppm. Median (interquartile range) urinary iodine concentrations were 66 (34-133) and 55 (28-110) µg L⁻¹ in early and late pregnancy, respectively; urinary iodine <150 µg L⁻¹ was found in ∼80% of women at both times in pregnancy. Although the risk of iodine insufficiency declined with increasing iodine content of household salt (P for trend <0.05), median urinary iodine did not reach 150 µg L⁻¹ until iodine in household salt was at least 32 ppm and 51 ppm during early and late pregnancy, respectively. Despite a national policy on universal salt iodization, salt iodine content remains insufficient to maintain adequate maternal iodine status throughout pregnancy in rural northern Bangladesh. Alternative measures like direct iodine supplementation during pregnancy could be considered to assure adequate iodine status during this high-risk period of life.

Maternal vitamin A and ß-carotene supplementation and risk of bacterial vaginosis: a randomized controlled trial in rural Bangladesh.

BACKGROUND: Bacterial vaginosis (BV) in pregnancy is linked to preterm birth, but its risk factors are not well understood. Micronutrient deficiencies may be associated with an increased risk of this condition. OBJECTIVE: We assessed the effect of weekly vitamin A or ß-carotene supplementation during pregnancy until 3 mo postpartum on BV risk in rural northeastern Bangladesh. DESIGN: In this cluster-randomized, placebo-controlled trial, 33 clusters (n = 33) were randomly assigned to 3 groups. Women (n = 1812) were examined for BV by using self-administered swabs and the Nugent scoring method in early pregnancy, at 32 wk of gestation, and at 3 mo postpartum. RESULTS: The prevalence of BV in early pregnancy, before supplementation, was 7.6% (95% CI: 6.3%, 9.1%) overall. Neither the prevalence nor the incidence of BV in the third trimester differed by supplement group. However, the prevalence (OR: 0.71; 95% CI: 0.52, 0.98) and incidence (RR: 0.58; 95% CI: 0.41, 0.81) of BV at 3 mo postpartum was lower among women in the vitamin A group (9.1% and 6.7%, respectively) than in the placebo group (12.4% and 11.8%, respectively), but not in the ß-carotene group. Both vitamin A and ß-carotene reduced the prevalence and incidence of BV at both time points (ie, third trimester and 3 mo postpartum) by 30-40% compared with placebo (all P < 0.05). CONCLUSIONS: Weekly vitamin A supplementation reduced the risk of maternal BV in this rural Bangladeshi population. Enhancement of vitamin A status before and during pregnancy may reduce the risk of BV in areas with vitamin A deficiency. This trial is registered at clinicaltrials.gov as NCT00198822.

Accounts of severe acute obstetric complications in rural Bangladesh.

BACKGROUND: As maternal deaths have decreased worldwide, increasing attention has been placed on the study of severe obstetric complications, such as hemorrhage, eclampsia, and obstructed labor, to identify where improvements can be made in maternal health. Though access to medical care is considered to be life-saving during obstetric emergencies, data on the factors associated with health care decision-making during obstetric emergencies are lacking. We aim to describe the health care decision-making process during severe acute obstetric complications among women and their families in rural Bangladesh. METHODS: Using the pregnancy surveillance infrastructure from a large community trial in northwest rural Bangladesh, we nested a qualitative study to document barriers to timely receipt of medical care for severe obstetric complications. We conducted 40 semi-structured, in-depth interviews with women reporting severe acute obstetric complications and purposively selected for conditions representing the top five most common obstetric complications. The interviews were transcribed and coded to highlight common themes and to develop an overall conceptual model. RESULTS: Women attributed their life-threatening experiences to societal and socioeconomic factors that led to delays in seeking timely medical care by decision makers, usually husbands or other male relatives. Despite the dominance of male relatives and husbands in the decision-making process, women who underwent induced abortions made their own decisions about their health care and relied on female relatives for advice. The study shows that non-certified providers such as village doctors and untrained birth attendants were the first-line providers for women in all categories of severe complications. Coordination of transportation and finances was often arranged through mobile phones, and referrals were likely to be provided by village doctors. CONCLUSIONS: Strategies to increase timely and appropriate care seeking for severe obstetric complications may consider targeting of non-certified providers for strengthening of referral linkages between patients and certified facility-based providers. Future research may characterize the treatments and appropriateness of emergency care provided by ubiquitous village doctors and other non-certified treatment providers in rural South Asian settings. In addition, future studies may explore the use of mobile phones in decreasing delays to certified medical care during obstetric emergencies.

Newborn vitamin A supplementation does not affect nasopharyngeal carriage of Streptococcus pneumoniae in Bangladeshi infants at age 3 months.

Nasopharyngeal (NP) carriage of S. pneumoniae (Spn) is a risk factor for pneumococcal disease and its transmission. We assessed the impact of vitamin A (VA) supplementation shortly after birth in reducing Spn colonization in early infancy in rural Bangladesh. We recruited 500 infants participating in a cluster-randomized trial that reported a 15% reduction in mortality following receipt of an oral dose of VA (52.25 µmol) compared to placebo. NP specimens were collected at the age of 3 mo to study the effect of VA on the prevalence of culture-confirmed Spn. Analyses were conducted by intention to treat. Spn carriage prevalence did not differ between VA and placebo recipients [OR = 0.83 (95% CI: 0.55-1.27); P = 0.390]. Spn carriage at the age of 3 mo was not lowered by VA given at birth. Results are similar to those from an Indian study in which impact on Spn carriage was assessed at the age of 4 mo [OR = 0.73 (95% CI: 0.48-1.10); P = 0.128]. The point estimate of the pooled effect size for the 2 studies is OR = 0.78 [(95% CI: 0.58-1.04); P = 0.095], which may imply a modest impact on carriage. If so, then the evidence thus far would suggest that Spn carriage reduction is unlikely to be a primary ancillary benefit of newborn VA supplementation.

Bioelectrical impedance among rural Bangladeshi Women during pregnancy and in the postpartum period.

Properties of bioelectrical impedance analysis (BIA) reflect body-composition and may serve as stand-alone indicators of maternal health. Despite these potential roles, BIA properties during pregnancy and lactation in rural South Asian women have not been described previously, although pregnancy and infant health outcomes are often compromised. This paper reports the BIA properties among a large sample of pregnant and postpartum women of rural Bangladesh, aged 12-46 years, participating in a substudy of a community-based, placebo-controlled trial of vitamin A or beta-carotene supplementation. Anthropometry and single frequency (50 kHz) BIA were assessed in 1,435 women during the first trimester (< or =12 weeks gestation), in 1237 women during the third trimester (32-36 weeks gestation), and in 1,141 women at 12-18 weeks postpartum. Resistance and reactance were recorded, and impedance and phase angle were calculated. Data were examined cross-sectionally to maximize sample-size at each timepoint, and the factors relating to BIA properties were explored. Women were typically young, primiparous and lacking formal education (22.2 +/- 6.3 years old, 42.2% primiparous, and 39.7% unschooled among the first trimester participants). Weight (kg), resistance (omega), and reactance (omega) were 42.1 +/- 5.7, 688 +/- 77, and 73 +/- 12 in the first trimester; 47.7 +/- 5.9, 646 +/- 77, and 64 +/- 12 in the third trimester; and 42.7 +/- 5.6, 699 +/- 79, and 72 +/- 12 postpartum respectively. Resistance declined with age and increased with body mass index. Resistance was higher than that observed in other, non-Asian pregnant populations, likely reflecting considerably smaller body-volume among Bangladeshi women. Resistance and reactance decreased in advanced stage of pregnancy as the rate of gain in weight increased, returning to the first trimester values by the three months postpartum. Normative distributions of BIA properties are presented for rural Bangladeshi women across a reproductive cycle that may be related to pregnancy outcomes and ultimately be used for assessing body-composition in this population.

Effects of vitamin A or beta carotene supplementation on pregnancy-related mortality and infant mortality in rural Bangladesh: a cluster randomized trial.

CONTEXT: Maternal vitamin A deficiency is a public health concern in the developing world. Its prevention may improve maternal and infant survival. OBJECTIVE: To assess efficacy of maternal vitamin A or beta carotene supplementation in reducing pregnancy-related and infant mortality. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized, double-masked, placebo-controlled trial among pregnant women 13 to 45 years of age and their live-born infants to 12 weeks (84 days) postpartum in rural northern Bangladesh between 2001 and 2007. Interventions Five hundred ninety-six community clusters (study sectors) were randomized for pregnant women to receive weekly, from the first trimester through 12 weeks postpartum, 7000 µg of retinol equivalents as retinyl palmitate, 42 mg of all-trans beta carotene, or placebo. Married women (n = 125,257) underwent 5-week surveillance for pregnancy, ascertained by a history of amenorrhea and confirmed by urine test. Blood samples were obtained from participants in 32 sectors (5%) for biochemical studies. MAIN OUTCOME MEASURES: All-cause mortality of women related to pregnancy, stillbirth, and infant mortality to 12 weeks (84 days) following pregnancy outcome. RESULTS: Groups were comparable across risk factors. For the mortality outcomes, neither of the supplement group outcomes was significantly different from the placebo group outcomes. The numbers of deaths and all-cause, pregnancy-related mortality rates (per 100,000 pregnancies) were 41 and 206 (95% confidence interval [CI], 140-273) in the placebo group, 47 and 237 (95% CI, 166-309) in the vitamin A group, and 50 and 250 (95% CI, 177-323) in the beta carotene group. Relative risks for mortality in the vitamin A and beta carotene groups were 1.15 (95% CI, 0.75-1.76) and 1.21 (95% CI, 0.81-1.81), respectively. In the placebo, vitamin A, and beta carotene groups the rates of stillbirth and infant mortality were 47.9 (95% CI, 44.3-51.5), 45.6 (95% CI, 42.1-49.2), and 51.8 (95% CI, 48.0-55.6) per 1000 births and 68.1 (95% CI, 63.7-72.5), 65.0 (95% CI, 60.7-69.4), and 69.8 (95% CI, 65.4-72.3) per 1000 live births, respectively. Vitamin A compared with either placebo or beta carotene supplementation increased plasma retinol concentrations by end of study (1.46 [95% CI, 1.42-1.50] µmol/L vs 1.13 [95% CI, 1.09-1.17] µmol/L and 1.18 [95% CI, 1.14-1.22] µmol/L, respectively; P < .001) and reduced, but did not eliminate, gestational night blindness (7.1% for vitamin A vs 9.2% for placebo and 8.9% for beta carotene [P < .001 for both]). CONCLUSION: Use of weekly vitamin A or beta carotene in pregnant women in Bangladesh, compared with placebo, did not reduce all-cause maternal, fetal, or infant mortality. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00198822.

A cluster-randomized, placebo-controlled, maternal vitamin A or beta-carotene supplementation trial in Bangladesh: design and methods.

BACKGROUND: We present the design, methods and population characteristics of a large community trial that assessed the efficacy of a weekly supplement containing vitamin A or beta-carotene, at recommended dietary levels, in reducing maternal mortality from early gestation through 12 weeks postpartum. We identify challenges faced and report solutions in implementing an intervention trial under low-resource, rural conditions, including the importance of population choice in promoting generalizability, maintaining rigorous data quality control to reduce inter- and intra- worker variation, and optimizing efficiencies in information and resources flow from and to the field. METHODS: This trial was a double-masked, cluster-randomized, dual intervention, placebo-controlled trial in a contiguous rural area of ~435 sq km with a population of ~650,000 in Gaibandha and Rangpur Districts of Northwestern Bangladesh. Approximately 120,000 married women of reproductive age underwent 5-weekly home surveillance, of whom ~60,000 were detected as pregnant, enrolled into the trial and gave birth to ~44,000 live-born infants. Upon enrollment, at ~ 9 weeks' gestation, pregnant women received a weekly oral supplement containing vitamin A (7000 ug retinol equivalents (RE)), beta-carotene (42 mg, or ~7000 ug RE) or a placebo through 12 weeks postpartum, according to prior randomized allocation of their cluster of residence. Systems described include enlistment and 5-weekly home surveillance for pregnancy based on menstrual history and urine testing, weekly supervised supplementation, periodic risk factor interviews, maternal and infant vital outcome monitoring, birth defect surveillance and clinical/biochemical substudies. RESULTS: The primary outcome was pregnancy-related mortality assessed for 3 months following parturition. Secondary outcomes included fetal loss due to miscarriage or stillbirth, infant mortality under three months of age, maternal obstetric and infectious morbidity, infant infectious morbidity, maternal and infant micronutrient status, fetal and infant growth and prematurity, external birth defects and postnatal infant growth to 3 months of age. CONCLUSION: Aspects of study site selection and its "resonance" with national and rural qualities of Bangladesh, the trial's design, methods and allocation group comparability achieved by randomization, field procedures and innovative approaches to solving challenges in trial conduct are described and discussed. This trial is registered with http://Clinicaltrials.gov as protocol NCT00198822.