Correlations among the maternal healthcare services in Bangladesh: An application of joint modelling technique.

Background: Caesarean section (C-section) in Bangladesh have received great attention as the number has been amplified during the last two decades. The question arises whether this rise has a correlation with other maternal healthcare services and/or has been influenced by their predictors. Objective: The main objectives of this study are to assess correlations among the maternal healthcare indicators-antenatal care use, childbirth in private facilities, and childbirth through C-section-and identify their associated predictors in Bangladesh through the development of an appropriate cluster-adjusted joint model that accounts for inter-correlation among the indicators in the same cluster. Design: The 2019 Bangladesh Multiple Indicator Cluster Survey data have been utilized in this study. Separate generalized linear mixed models developed for the three outcome variables are combined into a joint model by letting cluster-specific random effects be in association. Findings: The joint model shows that the number of antenatal cares is fairly positively correlated with delivery in private facilities and C-section, while the latter two are strongly positively correlated. Household socio-economic condition, women and their partners' education, women's exposure to mass media, place of residence, religion, and regional settings have significant influence on the joint likelihood of receiving antenatal care, choosing a private health facility for birth, and opting for C-section birth. Key conclusions and implications: The rising rate of C-section delivery over time is alarming for Bangladesh to achieve the World Health Organization target of 10-15 %. The joint model reveals that the rising rate of C-sections may be correlated with the choice of a private health facility as the delivery place. The study findings also suggest that maternal childbirth care is private-dominant and predominantly utilized by urban women with better education and higher socio-economic status. The policy should focus on strengthening the public health sector while also keeping importance in increasing coverage of maternal care services among the less well-off.

An overview of diarrhea among infants and under-five in Punjab-Pakistan.

BACKGROUND: Diarrhea, pneumonia, malnutrition, tuberculosis, measles, and fever are the leading causes of mortality in children under five-years of age (0-59 months), whereas diarrhea alone is the world's second-biggest cause of mortality in this population. This study is particularly important for Pakistan as it focuses on one of the main causes of infant mortality, diarrhea, which is a major challenge for Pakistan to achieve the Sustainable Development Goals to reduce infant mortality to 12/1000 live births by 2030. AIM: This study was planned to investigate the various household, parental, environmental, and child-related factors causing diarrheal diseases in children aged 0-59 months in Punjab Pakistan. METHODS: The study used the data of 38,405 households from the Multiple Indicator Cluster Survey (MICS) 2017-18, directed by the Punjab Bureau of Statistics. Comprehensive descriptive statistics, i.e., cross-tabulations and logistic regression were used for the detailed analysis. FINDINGS: The results showed that infants are more probable to get diarrhea than older children. A wide range of influences were found to affect the probability of a child getting diarrhea, including child-specific, mother-specific and environment-specific ones. One prominent finding was that, at the mother level, the education of the mother played a significant role in reducing diarrhea among children under five-years of age (0-59 months). DISCUSSION: The results of the study contribute to the literature by highlighting that it is an interplay of factors that result in diarrhea. Hence, improving the source of drinking water, e.g., tap water and bottled water, can decrease the occurrence of diarrhea, especially in poor households. It was also revealed that households with a toilet facility of flush have less probability of their children being diagnosed with diarrhea than toilet facilities in open drains and fields. On the child level, results suggested that birth order matters as well, with the firstborn child having a lower probability of contracting diarrhea than siblings born after. APPLICATION TO PRACTICE: Interventions targeting infants and mothers of infants aimed at reducing diarrhea are expected to be very effective to reduce child mortality, one of the main child health challenges faced by Pakistan.

Relationship between low birth weight and infant mortality: evidence from National Family Health Survey 2019-21, India.

BACKGROUND: Low birth weight (LBW) predisposes physical and mental growth failure and premature death among infants. Studies report that LBW predominately explains infant mortality. However, existing studies rarely demonstrate the phenomenon of both observed and unobserved factors, which may influence the likelihood of birth and mortality outcomes simultaneously. In this study, we identified the spatial clustering of the prevalence of LBW along with its determinants. Further, the relationship between of LBW and infant mortality, considering the unobserved factors, has been explored in the study. METHODS: Data for this study have been extracted from the National Family Health Survey (NFHS) round 5, 2019-21. We used the directed acyclic graph model to identify the potential predictors of LBW and infant mortality. Moran's I statistics have been used to identify the high-risk areas of LBW. We applied conditional mixed process modelling in Stata software to account for the simultaneous nature of occurrences of the outcomes. The final model has been performed after imputing the missing data of LBW. RESULTS: Overall, in India, 53% of the mothers reported their babies' birth weight by seeing health card, 36% reported by recall, and about 10% of the LBW information was observed as missing. The state/union territory of Punjab and Delhi were observed to have the highest levels of LBW (about 22%) which is much higher than the national level (18%). The effect of LBW was more than four times larger compared to the effect in the analysis which does not account for the simultaneous occurrence of LBW and infant mortality (marginal effect; from 12 to 53%). Also, in a separate analysis, the imputation technique has been used to address the missing data. Covariates' effects showed that female children, higher order births, births that occur in Muslim and non-poor families and literate mothers were negatively associated with infant mortality. However, a significant difference was observed in the impact of LBW before and after imputing the missing values. CONCLUSIONS: The current findings showed the significant association of LBW with infant deaths, highlighting the importance of prioritising policies that help improve the birth weight of new-born children that may significantly reduce the infant mortality in India.

Identifying risk factors in explaining women's anaemia in limited resource areas: evidence from West Bengal of India and Bangladesh.

BACKGROUND: Anaemia among women is a public health problem with associated adverse outcomes for mother and child. This study investigates the determinants of women's anaemia in two Bengals; West Bengal (a province of India) and Bangladesh. These two spaces are inhabitated by Bengali speaking population since historic past. The study argues that open defecation, contraceptive method use and food consumption patterns are playing crucial role in explaining anaemia. METHODS: Using non-pregnant women belonging to different religious groups, we analyzed a total of 21,032 women aged 15-49 from the nationally representative cross-sectional surveys, i.e., Bangladesh Demographic Health Survey (BDHS-VI, 2011) and National Family Health Survey (NFHS round 4, 2015-16). We performed spatial, bivariate and logistic regression analyses to unfold the important risk factors of anaemia in two Bengals. RESULTS: The prevalence of anaemia was 64% in West Bengal and 41% in Bangladesh. The significant risk factors explaining anaemia were use of sterilization, vegetarian diet and open defecation. Further, women who used groundwater (tube well or well) for drinking suffered more from anaemia. Also, younger women, poor, less educated and having more children were highly likely to be anaemic. The study also indicates that those who frequently consumed non-vegetarian items and fruits in West Bengal and experienced household food security in Bangladesh were less prone to be anaemic. Hindus of West Bengal, followed by Muslims of that state and then Hindus of Bangladesh were at the higher risk of anaemia compared to Muslims of Bangladesh, indicating the stronger role of space over religion in addressing anaemia. Unlike West Bengal, Bangladesh observed distinct regional differences in women's anaemia. CONCLUSIONS: Propagating the choices of contraception mainly Pill/ injection/IUDs and making the availability of iron rich food along with a favourable community environment in terms of safe drinking water and improved sanitation besides better education and economic condition can help to tackle anaemia in limited-resource areas.

Disadvantaged neighborhoods, birth weight, and problem behavior in five- and six-year-old pre-school children: Evidence from a cohort born in Amsterdam.

RATIONALE: Low birth weight has been found to increase the problem behavior of children. Yet, little attention has been given to adequately account for the impact of the child's neighborhood on this relation. The residential neighborhood is a choice, based on factors that are usually not observed that may also influence birth weight and problem behavior. OBJECTIVE: Using a model that accounts for such endogeneity of both neighborhood choice and birth weight, we have analyzed behavioral problems in 4210 pre-school children between the ages of 5 and 6, birth weight, and neighborhood status, simultaneously. METHOD: The data used are from the Amsterdam Born Children and their Development (ABCD) cohort for whom a complete prospective record of birth outcomes, pregnancy, socio-demographic characteristics, and indicators of problem behavior are available. Neighborhood data obtained from Statistics Netherlands are merged with the ABCD data file. RESULTS: Our results suggest that ignoring endogeneity attenuates the effect of disadvantaged neighborhoods on both birth weight and problem behavior in pre-school children. Living in a disadvantaged neighborhood decreases the birth weight and increases the probability of problem behavior. Accounting for the endogeneity of neighborhood choice increases the estimated impacts (marginal effects: from -10% to -44% for birth weight and from 3% to 11% for problem behavior). Lower birth weight increases the probability of problem behavior, but it is only significant after adjusting for endogeneity. The coefficients of other factors have the expected associations with problem behavior. CONCLUSIONS: These significant effects of disadvantaged neighborhood on birth weight and problem behavior could inform policies and practices that improve neighborhood development for children born in Amsterdam.

Correction: Trends, prevalence and determinants of childhood chronic undernutrition in regional divisions of Bangladesh: Evidence from demographic health surveys, 2011 and 2014.

[This corrects the article DOI: 10.1371/journal.pone.0220062.].

Trends, prevalence and determinants of childhood chronic undernutrition in regional divisions of Bangladesh: Evidence from demographic health surveys, 2011 and 2014.

BACKGROUND: Undernutrition, an important indicator for monitoring progress of development goals, is a matter of concern in many developing countries, including Bangladesh. Despite regional differences in chronic undernutrition in Bangladesh, regional determinants among children under the age of five were not extensively explored. DATA AND METHODS: Using combined repeated cross-sectional nationwide Bangladesh Demographic and Health Surveys (BDHS 2011 and 2014) and employing bivariate and logistic regression analyses, we estimated prevalence, changes and variations in regional determinants of stunting among children aged 6-59 months over two time periods 2011 and 2014. RESULTS: Our benchmark results suggested that the children from Rajshahi, Khulna, Rangpur, Chittagong and Dhaka tend to be significantly less stunted by 51% (p = 0.000; CI = [0.38, 0.63]), 44% (p = 0.000; CI = [0.44, 0.71]), 26% (p = 0.012; CI = [0.58, 0.93]), 23% (p = 0.012; CI = [0.62, 0.95]) and 22% (p = 0.033; [0.63, 0.97]) respectively, against Sylhet in 2011. With the exception of Dhaka, no region showed significant differences in the odds of stunting over two time periods 2011 and 2014, i.e. only Dhaka revealed significant difference by 30% reductions in the odds of stunting in 2014. Also, rural children were less likely to be stunted (by 19%) of the urban counterparts. Regional covariates of stunting differ. However, children's age, household wealth, mother's height, and parental education were important determinants of stunting in Bangladesh. CONCLUSION: Dhaka made an impressive improvement in child nutrition, thus contributed largely to the reduction of stunting levels in Bangladesh for 2014 over 2011. Sylhet and Barisal require strong push to improve nutritional status of children. Further decline is possible through region-specific multipronged interventions that can address area-specific covariates to break the cycle of undernutrition like strengthening economic and educational status, emphasizing the role of father to augment their knowledge in varying aspects like family planning, reduction of fertility and by improving mother's health.

District level estimates and mapping of prevalence of diarrhoea among under-five children in Bangladesh by combining survey and census data.

The demand for district level statistics has increased tremendously in Bangladesh due to existence of decentralised approach to governance and service provision. The Bangladesh Demographic Health Surveys (BDHS) provide a wide range of invaluable data at the national and divisional level but they cannot be used directly to produce reliable district-level estimates due to insufficient sample sizes. The small area estimation (SAE) technique overcomes the sample size challenges and can produce reliable estimates at the district level. This paper uses SAE approach to generate model-based district-level estimates of diarrhoea prevalence among under-5 children in Bangladesh by linking data from the 2014 BDHS and the 2011 Population Census. The diagnostics measures show that the model-based estimates are precise and representative when compared to the direct survey estimates. Spatial distribution of the precise estimates of diarrhoea prevalence reveals significant inequality at district-level (ranged 1.1-13.4%) with particular emphasis in the coastal and north-eastern districts. Findings of the study might be useful for designing effective policies, interventions and strengthening local-level governance.

Relationships between infant mortality, birth spacing and fertility in Matlab, Bangladesh.

Although research on the fertility response to childhood mortality is widespread in demographic literature, very few studies focused on the two-way causal relationships between infant mortality and fertility. Understanding the nature of such relationships is important in order to design effective policies to reduce child mortality and improve family planning. In this study, we use dynamic panel data techniques to analyse the causal effects of infant mortality on birth intervals and fertility, as well as the causal effects of birth intervals on mortality in rural Bangladesh, accounting for unobserved heterogeneity and reverse causality. Simulations based upon the estimated model show whether (and to what extent) mortality and fertility can be reduced by breaking the causal links between short birth intervals and infant mortality. We find a replacement effect of infant mortality on total fertility of about 0.54 children for each infant death in the comparison area with standard health services. Eliminating the replacement effect would lengthen birth intervals and reduce the total number of births, resulting in a fall in mortality by 2.45 children per 1000 live births. These effects are much smaller in the treatment area with extensive health services and information on family planning, where infant mortality is smaller, birth intervals are longer, and total fertility is lower. In both areas, we find evidence of boy preference in family planning.

Cause-specific neonatal deaths in rural Bangladesh, 1987-2005: levels, trends, and determinants.

This paper reports on an analysis of neonatal mortality from communicable and non-communicable diseases in Bangladesh. The competing-risks model employed incorporated both observed and unobserved heterogeneity and allowed the two heterogeneity terms to be correlated. The data used came from the Health and Demographic Surveillance System, Matlab. The results confirm the conclusions of previous studies about the levels, trends, and causes of neonatal death in the Matlab area: the education of the mother helps protect her children from death from both communicable and non-communicable diseases; the children of a father in a low-status occupation are particularly vulnerable to death from communicable diseases; and children born to mothers aged less than 20 face a particularly high risk of dying from a non-communicable disease. The risks of dying from a communicable disease and from a non-communicable disease were both found to fall significantly as the distance to the nearest health centre decreased.

Contraceptive use, birth spacing, and child survival in Matlab, Bangladesh.

To reduce infant mortality through improved family planning, a better understanding of the factors driving contraceptive use and how this decision affects infant survival is needed. Using dynamic panel-data models of infant deaths, birth intervals, and contraceptive use, this study analyzes the causal effects of birth spacing on subsequent infant mortality and of infant mortality on the use of contraceptives and the length of the next birth interval. Data are drawn from the Health and Demographic Surveillance System in Matlab, Bangladesh, where almost 32,000 births have been observed from 1982 to 2005. Our main finding is that complete contraceptive use could reduce infant mortality of birth order two and higher by 7.9 percent. The net effect of complete contraceptive use on the total infant mortality rate is small (2.9 percent), however, because the favorable effect on higher order births is partly offset by the rise in the proportion of high-risk first births.

Infant death clustering in families: magnitude, causes, and the influence of better health services, Bangladesh 1982-2005.

This analysis of infant mortality in Bangladesh focuses on explaining death clustering within families, using prospective data from a rural region in Bangladesh, split into areas with and without extensive health services (the area covered by the International Centre for Diarrhoeal Disease Research and the comparison area, respectively). The modelling framework distinguishes between two explanations of death clustering: (observed and unobserved) heterogeneity across families and a causal 'scarring' effect of the death of one infant on the survival chances of the next to be born. Keeping observed and unobserved characteristics constant, we find scarring in the comparison area only. There the likelihood of infant death is about 29 per cent greater if the previous sibling died in infancy than otherwise. This effect mainly works through birth intervals: infant deaths are followed by shorter birth intervals, which increases the risk of infant death for the next child.

Impact monitoring of the national scale up of zinc treatment for childhood diarrhea in Bangladesh: repeat ecologic surveys.

BACKGROUND: Zinc treatment of childhood diarrhea has the potential to save 400,000 under-five lives per year in lesser developed countries. In 2004 the World Health Organization (WHO)/UNICEF revised their clinical management of childhood diarrhea guidelines to include zinc. The aim of this study was to monitor the impact of the first national campaign to scale up zinc treatment of childhood diarrhea in Bangladesh. METHODS/FINDINGS: Between September 2006 to October 2008 seven repeated ecologic surveys were carried out in four representative population strata: mega-city urban slum and urban nonslum, municipal, and rural. Households of approximately 3,200 children with an active or recent case of diarrhea were enrolled in each survey round. Caretaker awareness of zinc as a treatment for childhood diarrhea by 10 mo following the mass media launch was attained in 90%, 74%, 66%, and 50% of urban nonslum, municipal, urban slum, and rural populations, respectively. By 23 mo into the campaign, approximately 25% of urban nonslum, 20% of municipal and urban slum, and 10% of rural under-five children were receiving zinc for the treatment of diarrhea. The scale-up campaign had no adverse effect on the use of oral rehydration salt (ORS). CONCLUSIONS: Long-term monitoring of scale-up programs identifies important gaps in coverage and provides the information necessary to document that intended outcomes are being attained and unintended consequences avoided. The scale-up of zinc treatment of childhood diarrhea rapidly attained widespread awareness, but actual use has lagged behind. Disparities in zinc coverage favoring higher income, urban households were identified, but these were gradually diminished over the two years of follow-up monitoring. The scale up campaign has not had any adverse effect on the use of ORS. Please see later in the article for the Editors' Summary.

Inconsistencies in the relationship between contraceptive use and fertility in Bangladesh.

CONTEXT: Contraceptive prevalence increased by nine percentage points from 1993 to 2000 in Bangladesh, but there was almost no decline in the total fertility rate. METHODS: Data from the 1999-2000 Bangladesh Demographic and Health Survey and from the Matlab Demographic Surveillance System area collected between 1978 and 2001 were analyzed to explain the lack of change in fertility and to examine relationships among contraceptive prevalence, the abortion ratio, desired fertility and total fertility. RESULTS: After a maternal and child health and family planning program was initiated in part of Matlab in 1977, the total fertility rate in the intervention area declined from 4.8 in 1979 to 2.9 in 2000, while fertility in the comparison area dropped from 6.3 to 3.5. Over this period, contraceptive prevalence rose from 30% to 70% and from 16% to 50% in the two areas, respectively; meanwhile, the abortion ratio fell from 4.3 to 3.6 in the intervention area, but rose from around two to 8.2 in the comparison area. Trends in desired fertility in each area were similar, declining from about 4.0 children per woman in 1979 to about 2.5 children in 2000. Among women at each level of parity, fertility generally decreased as the number of sons increased, and fertility was highest for women without sons. CONCLUSIONS: Preference for male children and parental concern over infant and child mortality may partially explain the difference between desired family size and fertility. A reduction in breast-feeding and an increase in use of less-effective contraceptive methods might be responsible for the inconsistency in the relationship between contraceptive use and fertility.

Inequalities in reproductive healthcare utilization: evidence from Bangladesh Demographic and Health Survey 2004.

Utilization of reproductive healthcare services such as antenatal care (ANC), delivery place facilities and postnatal care (PNC) is essential and a basic need for mothers around the globe. However, in Bangladesh inequalities in many forms affect the use of these facilities. These inequalities include socio-economic status, age, education, household size, existence of living children, occupation and household location. Using the database from the Bangladesh Demographic and Health Survey (BDHS) 2004, this study investigated the inequalities and implications of receiving facility-based maternity care such as ANC, delivery place and PNC in Bangladesh. Based on our findings, it is assumed that with the current inequalities in wealth and education, less attention to mothers with bigger family size and to mothers those existing children, lack of facilities and awareness, in rural areas, increased use of reproductive healthcare is unlikely without a change in wealth inequalities and attention to more equity in the health sector. Bivariate and multivariate analyses were done for the study, including tests of significance. Overall, findings revealed significant socio-economic inequalities in the use of reproductive healthcare services. Use of services was much lower among the poor than the rich. These socio-economic inequalities may be reduced by expanding outreach health programs and bringing services closer to the disadvantaged (poor people). The study concluded that many of these inequalities are social constructs that can be reduced by prioritizing the needs of the poor and disadvantaged and adopting appropriate policy change options.

Childhood diarrhoea management practices in Bangladesh: private sector dominance and continued inequities in care.

BACKGROUND: Monitoring for disparities in health and services received based upon gender, income, and geography should continue as renewed efforts to reduce under-five mortality are made in response to millennium development goal #4. The purpose of this survey was to provide a nationally representative description of current childhood diarrhoea management practices and disparities in Bangladesh. METHODS: A nationally representative, cross-sectional, cluster-sample survey was carried out in randomly selected rural and urban populations across Bangladesh. The survey was completed over an 8 month period between November 2003 and June 2004. RESULTS: A total of 7308 children with a prevalent diarrhoeal illness episode within 560 clusters were identified and enrolled in the survey. In 61% of the cases help was sought from a health care provider, with over 90% practicing in the private sector. Caretaker practice disparities favouring males and higher income households were identified. Significant trends (P < 0.001) favouring higher income households were found for having sought help from any provider or a licensed doctor and for treating their child with oral rehydration solution or an antibiotic. Female children in urban households were less likely to be seen by a licensed allopath, adj OR 0.73 (95% CI 0.57, 0.94). Among rural households gender disparities were limited to females being less likely to receive an antibiotic, adj OR 0.74 (95% CI 0.65, 0.86). CONCLUSION: Households seeking help from a health provider overwhelmingly utilize the private sector in Bangladesh. Gender inequities in the utilization of licensed providers and purchase of antibiotics, favouring males were identified. Findings suggest that higher income, urban households tend to practice greater gender discrimination. In order to better understand health dynamics in urban populations, in particular slum-dwellers, there is a need to disaggregate survey data by household location.

Initiation of zinc treatment for acute childhood diarrhoea and risk for vomiting or regurgitation: a randomized, double-blind, placebo-controlled trial.

The childhood diarrhoea-management guidelines of the World Health Organization/United Nations Children's Fund (WHO/UNICEF) now include zinc treatment, 20 mg per day for 10 days. To determine if a dispersible zinc sulphate tablet formulation is associated with increased risk of vomiting or regurgitation following the initial, first treatment dose, a double-blind, placebo-controlled randomized clinical trial was carried out in the Dhaka hospital of ICDDR,B: Centre for Health and Population Research (n=800) and in an adjacent NGO outpatient clinic (n=800). Children were randomized to one of three groups: no treatment, placebo, or zinc sulphate tablet (20 mg). They were then observed for 60 minutes, and all vomiting or regurgitation episodes were recorded. When compared with placebo, zinc treatment resulted in an attributable risk increase of 14% for vomiting and 5.2% for regurgitation. The median time to vomiting among those receiving zinc was 9.6 minutes and was limited to one episode in 91.2% of the cases. Overall, the proportion of 60-minute post-treatment vomiting attributable to zinc, placebo, and the illness episode was estimated to be 40%, 26%, and 34% respectively. The dispersible zinc sulphate tablet formulation at a dose of 20 mg is associated with increased risks of vomiting and regurgitation. Both are transient side-effects.

Determinants of pill failure in rural Bangladesh.

The pill is the most popular family planning method in Bangladesh. However, the failure rate of this method in Matlab, a typical rural area, has been found to be very high. It is estimated that with the current level of failure of the pill and other temporary contraceptives in Matlab, it is unlikely that fertility in Bangladesh will come down to replacement level without a change in contraceptive method mix. It is, therefore, important to know the reasons for the high failure in pill use. Data for this study came from a case-control study in Matlab. A pill failure was considered a case, and no-failure was considered a control. The study included 167 cases and 167 controls. In addition, five focus group discussions were conducted to supplement the data collected from the cases and controls to gain a deeper understanding of pill failure. Results of the analysis of both quantitative and qualitative data suggested that the following were the risk factors for pill failure: no mobility of women, poor knowledge of women about the effectiveness and consequences of drop-out from pill use, weak confidence in the pill, a gap between the use of subsequence pill cycles, delay in starting the pill after menstruation for the first use, not taking any measures consistently for missing the pill, and not following the arrow sign given on the pill cycle. Extensive training of field workers and pill users, covering the reasons for pill failure identified in this study and strong supervision of the work of field workers, is likely to reduce the rate of pill failure in Bangladesh. Also, information, education and communication services for users, and management of side-effects, may be helpful in reducing pill failure.