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Cycle 1

Principal Investigator: Anisur Rahman, International Centre for Diarrhoeal Disease Research (icddr,b)
NIH-Supported Collaborator: Randall Kuhn, University of Denver
Title of NIH Award: Long-term Effects of Health and Development Interventions in Rural Bangladesh
Project Dates: October 2013 - December 2017
Project Overview:
PH 1-125 Rahman National Workshop
A national workshop to finalize the intervention module was held on 27 May 2015. (photo courtesy of PI Anisur Rahman)

Despite widespread poverty and malnutrition, the overall progress to achieving the MDGs for child (MDG 4) and maternal (MDG 5) health in Bangladesh is encouraging (NIPORT 2011). However, maintaining the pace of mortality reduction is challenging. Neonatal deaths contribute about 43% of under-five mortality, and the pace of neonatal mortality reduction is slow in comparison to post-neonatal and childhood mortality reduction. In the rural Matlab Upazila (sub-district) of Bangladesh, icddr,b has long maintained a health and demographic surveillance system (HDSS), operated a field hospital, and tested intensive in-home outreach and service delivery strategies on maternal and child health. In 2007, icddr,b introduced a successful model of integrated Maternal, Neonatal, and Child Health (MNCH) into its existing intensive treatment area associated with a 36% reduction of perinatal mortality within a short time frame. We propose to extend these services to the remaining part of Matlab where the population receives care from government health facilities similar to the remaining parts of the country. The overall goal of this Maternal, Neonatal and Child Health Extension (MNCH-Ext) Project is to implement the available evidence-based maternal and neonatal interventions through a functional and responsive primary health care service delivery system to improve perinatal health in Matlab, Bangladesh. Proposed study interventions are to strengthen the primary health care systems through addressing the health system building blocks such as: improving governance, human resources (training and quality improvement), ensuring supplies, improving the health delivery system (through established linkages), improving information systems, and working with people for creating demand for uptake of interventions. Upon strengthening the health system, evidence-based interventions related to maternal, neonatal and child health services will be offered. The impact of intervention will be evaluated further based on a nested case-referent study. The study populations are women of reproductive age residing in the selected area of two sub-districts (Matlab South and Matlab North) in Chandpur, Bangladesh. This study will demonstrate that a successful service delivery model (family/community, outreach, facility) can be integrated into the existing government health system in a low cost sustainable way by strengthening that system to implement known, evidence-based interventions during pregnancy, delivery and post-natal periods.This will position the model for national scale-up to achieve Millennium Development Goals (MDGs) for maternal and child health in Bangladesh.

Overall Project Outcomes and Activities:

GAP analyses and recommendation: In the following months after approval for implementation of the study, the team dedicated themselves to conducting health facility survey and gap analysis which took place in November - December 2015. Related to gap analysis, they conducted a series of focus group discussions (FGDs) and in-depth interviews (IDIs) to understand the gaps related to the existing services. The participants included in the discussions and interviews selected from community and facility level health workers. The aims of these activities were: to understand the (i) existing gaps in the availability of evidence-based maternal and neonatal interventions; (ii) to identify the challenges for offering high-quality MNH interventions at community and facility levels; (iii) to determine the needs for introducing the high impact MNH interventions which are not existing in the current system; (iv) to identify the gaps in documentation and reporting of data. We conducted 7 FGDs (71 participated) and 12 IDIs.

Establishment of intervention:
The study was established to implement community and facility-based interventions. The community intervention was accomplished by engaging village health workers- Family Welfare Assistants (FWAs) and Health Assistants (HA) from the Director General of Family Planning (DGFP) and the Director General of Health Services (DGHS), respectively and covers the following interventions:
  1. Pregnancy identification
  2. Pregnancy Home Visits (PHV) 1 and PHV 2: PHV1 took place during 12-14 weeks of gestation, and the PHV2 visits during 32-34 weeks of gestation. During the visits the health workers assessed the pregnant women’s wellbeing and counseled on birth preparedness and maternal and neonatal danger signs.Postpartum Home Visits (PPHV) 1 and PPHV2: PPHV1 took place in 0-3 days of delivery and PPHV2 took place after 7 days. During these visits, the health workers also assessed the well-being of mothers and their babies, if needed provided appropriate management of sick mother and baby found.
  3. Distribution of delivery kit including the delivery mat to early diagnosis of post-partum hemorrhage.
  4. Distribution of misoprostol to be used during delivery.
  5. Distribution of health cards.
  6. Train FWAs and FHs from the intervention area on pregnancy identification and home visits.
Facility interventions:
  1. Facilitate 24 hour emergency obstetric care by training two for anesthesiology and two for obstetrics.
  2. Train the medical officers and nurses from two sub-district level hospitals from a tertiary level hospital on EmONC.
  3. Kangaroo mother training and establishment of KMC unity in the sub-district level facility.
  4. Helping Baby’s Breath training to all staff in the sub-district level hospitals.
  5. Training on ANC, PNC and normal delivery to health care providers from community clinics and Family Welfare centers.
Crosscutting: Establish a monthly meeting with health care providers from both health and family planning sectors.

Data collection: The project collected information related to the evaluation of the study by the base-line and end-line surveys. They surveyed to understand the pregnancy outcome listing and the current pattern of health care seeking behavior. This was needed to understand the distribution of stillbirth and neonatal mortality, and pattern of antenatal and delivery care among the women in the study areas. With the end-line survey, the team performed the data collection similar to the baseline survey to compare the study outcomes.

The gap analyses highlighted the need to: a) Implement appropriate methodology to determine accurate number of pregnancies within the study population; b) Work with opinion leaders within the government sector to encourage the idea that government sector can achieve high outcomes without additional resources. c) Have a clear check-list (and goals) of antenatal and post-natal care counseling and services available to all staff across the continuum of care; d) Establish accountability and reporting mechanisms based on this shared understanding; e) Determine if patient tracking /communication across different facilities is possible; f) Determine if/how to address lack of transportation for hospital referrals; g) Determine how to account for availability or lack thereof of C-section delivery at UHC.

The intention-to-treat analyses showed significant improvement in increasing the ANC coverage due to intervention. However, no association was observed in perinatal mortality rates.

Health Cycle 1 Recipients