BackgroundThe objectives of this study are to document the trend on utilisation of four or more (4+) antenatal care (ANC) over the last 22 years period and to explore the determinants and inequity of 4+ ANC utilisation as reported by the last two Bangladesh Demographic and Health surveys (BDHS) (2011 and 2014).MethodsThe data related to ANC have been extracted from the BDHS data set which is available online as an open source. STATA 13 software was used for organising and analysing the data. The outcome variable considered for this study was utilisation of 4+ ANC. Trends of 4+ ANC were measured in percentage and predictors for 4+ ANC were measured through bivariate and multivariable analysis. The concentration index was estimated for assessing inequity in 4+ ANC utilisation.ResultsUtilisation of 4+ ANC has increased by about 26% between the year 1994 and 2014. Higher level of education, residing in urban region and richest wealth quintile were found to be significant predictors. The utilisation of 4+ ANC has decreased with increasing parity and maternal age. The inequity indices showed consistent inequities in 4+ ANC utilisation, and such inequities were increased between 2011 and 2014.ConclusionsIn Bangladesh, the utilisation of any ANC rose steadily between 1994 and 2014, but progress in terms of 4+ ANC utilisation was much slower as the expectation was to achieve the national set target (50%: 4+ ANC utilisation) by 2016. Socio-economic inequities were observed in groups that failed to attend a 4+ ANC visit. Policymakers should pay special attention to increase the 4+ ANC coverage where this study can facilitate to identify the target groups whom need to be intervened on priority basis.

ObjectiveTo examine the effect of short (<36 months) and long (≥60 months) birth intervals on adverse pregnancy outcomes in Bangladesh.Design, setting and participantsWe analysed data from six Bangladesh Demographic and Health Surveys (1996–1997, 1999–2000, 2004, 2007, 2011 and 2014). We included all singleton non-first live births, most recently born to mothers within 5 years preceding each survey (n=21 382). We defined birth interval according to previous research which suggests that a birth interval between 36 and 59 months is the most ideal interval. Bivariate and multivariable analyses were conducted to obtain the crude and adjusted ORs (aOR) respectively to assess the odds of first-day neonatal death, early neonatal death and small birth size for both short (<36 months) and long (≥60 months) spacing between births.Main outcome measuresFirst-day neonatal death, early neonatal death and small birth size.ResultsIn the multivariable analysis, compared with births spaced 36–59 months, infants with a birth interval of <36 months had increased odds of first-day neonatal death (aOR: 2.11, 95% CI: 1.17 to 3.78) and early neonatal death (aOR: 1.58, 95% CI: 1.13 to 2.22). Compared with births spaced 36–59 months, infants with a birth interval of ≥60 months had increased odds of first-day neonatal death (aOR: 2.02, 95% CI: 1.10 to 3.73) and small birth size (aOR: 1.17, 95% CI: 1.02 to 1.34). When there was a history of any previous pregnancy loss, there was an increase in the odds of first-day and early neonatal death for both short and long birth intervals, although it was not significant.ConclusionsBirth intervals shorter than 36 months and longer than 59 months are associated with increased odds of adverse pregnancy outcomes. Care-providers, programme managers and policymakers could focus on promoting an optimal birth interval between 36 and 59 months in postpartum family planning.

BackgroundPerinatal mortality is a devastating pregnancy outcome affecting millions of families in many low and middle-income countries including Nepal. This paper examined the more distant factors associated with perinatal mortality in Nepal.MethodsA sample of 23,335 pregnancies > 28 weeks’ gestation from the Nepal Demographic and Health Survey datasets for the period (2001–2016) was analysed. Perinatal Mortality (PM) is defined as the sum of stillbirth (fetal deaths in pregnancies > 28 weeks’ gestation) and early neonatal mortality (deaths within the first week of life), while Extended Perinatal Mortality (EPM) is denoted as the sum of stillbirth and neonatal mortality (deaths within the first 28 days of life). Rates of PM and EPM were calculated. Logistic regression generalized linear latent and mixed models (GLLAMM) that adjusted for clustering and sampling weight was used to examine the factor associated with perinatal mortality.ResultsOver the study period, the PMR was 42 [95% Confidence Interval (CI): 39, 44] per 1000 births for the five-year before each survey; while corresponding EPMR was 49 (95% CI, 46, 51) per 1000 births. Multivariable analyses revealed that women residing in the mountains, who did not use contraceptives, women aged 15–18 years or 19–24 years, and women having no education were associated with increased PM and EPM. The study also identified households using biomass as cooking fuel, and households who reported unimproved sanitation or open defecation were significantly more likely to experience PM and EPM.ConclusionsInterventions aimed to improve use of contraceptives, and reduce biomass as a source of cooking fuel are needed to achieve the recommended target of < 12 perinatal deaths per 1000 births by 2030.Electronic supplementary materialThe online version of this article (10.1186/s12884-019-2234-6) contains supplementary material, which is available to authorized users.

IntroductionStillbirth has a long-lasting impact on parents and families. This study examined socio-economic predictors associated with stillbirth in Nepal for the year 2001, 2006 and 2011.MethodsThe Nepalese Demographic and Health Survey (NDHS) data for the period (2001–2011) were pooled to estimate socio-economic predictors associated with stillbirths in Nepal using binomial logistic regression while taking clustering and sampling weights into account.ResultsA total of 18,386 pregnancies of at least 28 weeks gestation were identified. Of these pregnancies, 335 stillbirths were reported. Stillbirth increased significantly among women that lived in the hills ecological zones (aRR 1.38, 95% CI 1.02, 1.87) or in the mountains ecological zones (aRR 1.71, 95% CI 1.10, 2.66). Women with no schooling (aRR 1.72, 95% CI 1.10, 2.69), women with primary education (aRR 1.81, 95% CI 1.11, 2.97); open defecation (aRR 1.48, 95% CI 1.00, 2.18), and those whose major occupation was agriculture (aRR 1.80, 95% CI 1.16, 2.78) are more likely to report higher stillbirth.ConclusionsLow levels of education, ecological zones and open defecation were found to be strong predictors of stillbirth. Access to antenatal care services and skilled birth attendants for women in the mountainous and hilly ecological zones of Nepal is needed to further reduce stillbirth and improved services should also focus on women with low levels of education.

This study examines the association between household air pollution from use of polluting cooking fuels and perinatal mortality in Bangladesh. We analysed the data from the Bangladesh Demographic and Health Surveys (BDHS) 2004, 2007, 2011, and 2014. The two outcome variables were stillbirth and early neonatal mortality. The exposure variable was type of primary cooking fuel used in the household (clean vs. polluting). Bivariate and multivariable analyses were conducted to obtain the crude and adjusted odds ratio (aOR), respectively. In the adjusted model, the exposure to polluting fuels was associated with early neonatal mortality (aOR: 1.46, 95% confidence interval [CI]: 1.01-2.10), but not with stillbirth (aOR: 1.25, 95% CI: 0.85-1.84). The effect of cooking with agricultural crop waste was greater for stillbirth (aOR: 1.76, 95% CI: 1.10-2.80) and for early neonatal mortality (aOR: 1.78, 95% CI: 1.13-2.80) which was also associated with wood as the main fuel (aOR: 1.52, 95% CI: 1.04-2.21). Using polluting fuels in an indoor kitchen was associated with an increased odds of stillbirth (aOR: 4.12, 95% CI: 1.49-11.41). Cooking with polluting fuels is associated with perinatal mortality. The combined association of polluting cooking fuels and indoor kitchen location was greater for stillbirth. This effect and the effect of different fuel types need further investigation. Although this is a large sample, there are some limitations with the BDHS data in both recording the exposure and the outcomes. A large prospective trial is needed to determine the precise effect size.

BackgroundGlobally, low birthweight (LBW) infants (<2.5 kilograms) contribute up to 80% of neonatal mortality. In Bangladesh, approximately 62% of all births occur at home and therefore, weighing newborns immediately after birth is not feasible. Thus, estimates of birthweight in Bangladesh are mostly obtained based on maternal perception of the newborn’s birth size. Little is known about how birthweight is perceived in rural communities, and whether families associate birthweight with newborn’s health status. Our objective was to explore families’ perceptions of newborn’s birthweight, and preventive and care practices for a LBW newborn in rural Bangladesh.MethodsWe conducted a qualitative study in two rural settings of Bangladesh, including 32 in-depth interviews (11 with pregnant women, 12 with recently delivered women, 4 with husbands whose wives were pregnant or had a recent birth, 5 with mothers-in-law whose daughters-in-law were pregnant or had a recent birth), 2 focus group discussions with husbands and 4 key-informant interviews with community health workers. We used thematic analysis to analyse the data.ResultsMost participants did not consider birthweight a priority for assessing a newborn’s health status, although there was a desire for a healthy newborn. Recognition of different categories of birthweight was subjective and often included several physical descriptors including birth size of the newborn. LBW was not considered as a criterion of a newborn’s illness unless the newborn appeared unwell. Maternal poor nutrition, inadequate diet in pregnancy, anaemia, illness during pregnancy, short stature, twin births and influence of supernatural spirit were identified as the major causes of LBW. Women’s preventive practices for LBW or small newborns were predominantly constrained by a lack of awareness of birthweight and fear of caesarean section. As an effort to avoid caesarean section during birth, several women tended to perform potentially harmful practices in order to give birth to a small size newborn; such as avoiding nutritious food and eating less in pregnancy. Common practices to treat a LBW or small newborn who appeared ill included breastfeeding, feeding animal milk, feeding sugary water, feeding formula, oil massage, keeping the small newborn warm and seeking care from formal and informal care providers including a spiritual leader. Maternal lack of decision-making power, financial constraint, home birth and superstition were the major challenges to caring for a LBW newborn.ConclusionBirthweight was not well-understood in the rural community, which highlighted substantial challenges to the prevention and care practices of LBW newborns. Community-level health education is needed to promote awareness related to the recognition of birthweight in rural settings.

Background: Neonatal mortality is high in Bangladesh. Most of the neonatal deaths are pre ventable through simple and costeffective essential newborn care interventions. Studies to document the determinants of unhealthy newborn care practices are scarce. Objective: The objective of this study is to describe the pattern of neonatal care practices and their determinants in rural Bangladesh. Methodology: This study is based on baseline data of a communitybased intervention to assess impact of limited postnatal care services on maternal and neonatal healthseeking behavior. Data from 510 women, who had a live birth at home 1 year prior to survey, of six randomly selected unions of an Upazila (subdistrict) were analyzed. Results: Majority of the respondents were at an age group of 20-34 years. Only 6% had deliv ery by skilled providers. Immediate drying and wrapping, and giving colostrums to newborns were almost universal. Unhealthy practices, like unclean cord care (42%), delayed initiation of breastfeeding (60%), use of prelacteals (36%), and early bathing (71%) were very common. Muslims were more likely to give early bath (adjusted odds ratio [OR]: 2.01; 95% confidence interval [CI]: 1.13-3.59; P=0.018) and delay in initiating breastfeeding (adjusted OR: 1.45; 95% CI: 1.18-1.78; P,0.001) to newborns. Practice of giving prelacteals was associated with teenage mothers (adjusted OR: 2.26; 95% CI: 1.19-4.28; P=0.013) and women's lack of education (adjusted OR: 2.64; 95% CI: 1.46-4.77; P=0.001). Conclusion: Unhealthy neonatal care practices are widespread in rural Bangladesh. Continued education to the community and home delivery attendants on essential newborn care could benefit newborn survival in Bangladesh.

Background and ObjectivesIn Bangladesh, postpartum hemorrhage (PPH) is the leading cause of maternal mortality accounting for 31% of all blood transfusions in the country. Although safe blood transfusion is one of the 8 signal functions of Comprehensive Emergency Obstetric Care (CEmOC) strategy, most of the designated public sector CEmOC facilities do not have on-site blood storage system. Emergent blood is mainly available from external blood banks. As a result, emergent patients are to rely on an unregulated network of brokers for blood which may raise question about blood safety. This study explored lived experiences of patients’ attendants, managers, providers, and blood brokers before and after the implementation of an on-line Blood Information and Management Application (BIMA) in regards to barriers and facilitators of blood transfusion for emergent patients.MethodsData were collected at Dhaka Medical College Hospital (DMCH), a tertiary-level teaching hospital before (January 2014) and after (March 2015) the introduction of an online BIMA system. Data collection methods included 24 key informant interviews (KIIs) and 40 in-depth interviews (IDIs). KIIs were conducted with formal health service providers, health managers and unlicensed blood brokers. IDIs were conducted with the relatives and husbands of women who suffered PPH, and needed emergency blood.ResultsPatients’ attendants were unaware of patients’ blood type and availability of blood in emergency situation. Newly introduced online BIMA system could facilitate blood transfusion process for poor patients at lower cost and during any time of day and night. However, service providers and service recipients were heavily dependent on a network of unlicensed blood brokers for required blood for emergent PPH patients. Blood collected through unlicensed blood brokers is un-screened, unregulated and probably unsafe. Blood brokers feel that they are providing a needed service, acknowledged a financial incentive and unaware about safety of blood that they supply.ConclusionsEnsuring safe and timely blood transfusion is necessary to end preventable maternal mortality. In a context where facilities have no on-site blood, and both providers and patient attendants are heavily dependent on an unregulated cadre of unlicensed blood brokers, access to timely safe blood transfusion is seriously threatened. BIMA is a promising intervention to reduce inefficiencies in obtaining blood, but steps must be taken to ensure buy-in from current purveyors of blood, and to increase the acceptance of the intervention.