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In Tanzania, the coverage of four or more antenatal care (ANC 4) visits among pregnant women has declined over time. We conducted an exploratory analysis to identify factors associated with utilization of ANC 4 and ANC 4 decline among pregnant women over time. We used data from 8035 women who delivered within two years preceding Tanzania Demographic and Health Surveys conducted in 1999, 2004/05 and 2010. Multivariate logistic regression models were used to examine the association between all potential factors and utilization of ANC 4; and decline in ANC 4 over time. Factors positively associated with ANC 4 utilization were higher quality of services, testing and counseling for HIV during ANC, receiving two or more doses of SP (Sulphadoxine Pyrimethamine)/Fansidar for preventing malaria during ANC and higher educational status of the woman. Negatively associated factors were residing in a zone other than Eastern zone, never married woman, reported long distance to health facility, first ANC visit after four months of pregnancy and woman's desire to avoid pregnancy. The factors significantly associated with decline in utilization of ANC 4 were: geographic zone and age of the woman at delivery. Strategies to increase ANC 4 utilization should focus on improvement in quality of care, geographic accessibility, early ANC initiation, and services that allow women to avoid pregnancy. The interconnected nature of the Tanzanian Health System is reflected in ANC 4 decline over time where introduction of new programs might have had unintended effects on existing programs. An in-depth assessment of the recent policy change towards Focused Antenatal Care and its implementation across different geographic zones, including its effect on the perception and understanding among women and performance and counseling by health providers can help explain the decline in ANC 4.

Neonatal infections cause a significant proportion of deaths in the first week of life, yet little is known about risk factors and pathways of transmission for early-onset neonatal sepsis globally. We aimed to estimate the risk of neonatal infection (excluding sexually transmitted diseases [STDs] or congenital infections) in the first seven days of life among newborns of mothers with bacterial infection or colonization during the intrapartum period. We searched PubMed, Embase, Scopus, Web of Science, Cochrane Library, and the World Health Organization Regional Databases for studies of maternal infection, vertical transmission, and neonatal infection published from January 1, 1960 to March 30, 2013. Studies were included that reported effect measures on the risk of neonatal infection among newborns exposed to maternal infection. Random effects meta-analyses were used to pool data and calculate the odds ratio estimates of risk of infection. Eighty-three studies met the inclusion criteria. Seven studies (8.4%) were from high neonatal mortality settings. Considerable heterogeneity existed between studies given the various definitions of laboratory-confirmed and clinical signs of infection, as well as for colonization and risk factors. The odds ratio for neonatal lab-confirmed infection among newborns of mothers with lab-confirmed infection was 6.6 (95% CI 3.9-11.2). Newborns of mothers with colonization had a 9.4 (95% CI 3.1-28.5) times higher odds of lab-confirmed infection than newborns of non-colonized mothers. Newborns of mothers with risk factors for infection (defined as prelabour rupture of membranes [PROM], preterm <37 weeks PROM, and prolonged ROM) had a 2.3 (95% CI 1.0-5.4) times higher odds of infection than newborns of mothers without risk factors. Neonatal infection in the first week of life is associated with maternal infection and colonization. High-quality studies, particularly from settings with high neonatal mortality, are needed to determine whether targeting treatment of maternal infections or colonization, and/or prophylactic antibiotic treatment of newborns of high risk mothers, may prevent a significant proportion of early-onset neonatal sepsis. Please see later in the article for the Editors' Summary.

Preterm birth (PTB) and its complications are the leading causes of under-five year old child deaths, accounting worldwide for an estimated one million deaths annually. The etiology of PTB is complex and multifactorial. Exposures to environmental metals or metalloids are pervasive and prenatal exposures to them are considered important in the etiology of PTB. We conducted a scoping review to determine the extent of prenatal exposures to four metals/metalloids (lead, mercury, cadmium and arsenic) and their association with PTB. We reviewed original research studies published in PubMed, Embase, the Cochrane Library, Scopus, POPLINE and the WHO regional indexes from 2000 to 2019; 36 articles were retained for full text review. We documented a higher incidence of PTB with lead and cadmium exposures. The findings for mercury and arsenic exposures were inconclusive. Metal-induced oxidative stress in the placenta, epigenetic modification, inflammation, and endocrine disruptions are the most common pathways through which heavy metals and metalloids affect placental functions leading to PTB. Most of the studies were from the high-income countries, reflecting the need for additional data from low-middle-income countries, where PTB rates are higher and prenatal exposure to metals are likely to be just as high, if not higher.

Discovery of intestinal sodium-glucose transport was the basis for development of oral rehydration solution, and was hailed as potentially the most important medical advance of the 20th century. Before widespread use of oral rehydration solution, treatment for diarrhoea was restricted to intravenous fluid replacement, for which patients had to go to a health-care facility to access appropriate equipment. These facilities were usually neither available nor reasonable to use in the resource-poor settings most affected by diarrhoea. Use of oral rehydration solution has stagnated, despite being effective, inexpensive, and widely available. Thus, diarrhoea continues to be a leading cause of child death with consistent mortality rates during the past 5 years. New methods for prevention, management, and treatment of diarrhoea—including an improved oral rehydration formulation, zinc supplementation, and rotavirus vaccines—make now the time to revitalise efforts to reduce diarrhoea mortality worldwide.

The ‘continuum of care’ is proposed as a key framework for the delivery of maternal, neonatal and child health services. This study examined the extent of dropout as well as factors associated with retention across the MNCH continuum from antenatal care (ANC), through skilled birth attendance (SBA), to postnatal care (PNC). We analyzed data from 1931 women who delivered in the preceding 2–14 months, from a twostage cluster sampling household survey in four districts of Tanzania’s Morogoro region. The survey was conducted in 2011 as a part of a baseline for an independent evaluation of a maternal health program. Using the Anderson model of health care seeking, we fitted logistic models for three transition stages in the continuum. Only 10% of women received the ‘recommended’care package (4+ANC visits, SBA, and 1+PNC visit), while 1% reported not having care at any stage. Receipt of four ANC visits was positively associated with women being older in age (age 20–34 years—OR: 1.77, 95% CI: 1.22–2.56; age 35–49 years—2.03, 1.29–3.2), and knowledge of danger signs (1.75, 1.39–2.1). A pro-rich bias was observed in facility-based deliveries (proxy for SBA), with women from the fourth (1.66, 1.12–2.47) and highest quintiles of household wealth (3.4, 2.04–5.66) and the top tertile of communities by wealth (2.9, 1.14–7.4). Higher rates of facility deliveries were also reported with antenatal complications (1.37, 1.05–1.79), and 4+ANC visits (1.55, 1.14–2.09). Returning for PNC was highest among the wealthiest communities (2.25, 1.21–4.44); catchment areas of a new PNC program (1.89, 1.03–3.45); knowledge of danger signs (1.78, 1.13–2.83); community health worker counselling (4.22, 1.97–9.05); complicated delivery (3.25, 1.84–5.73); and previous health provider counselling on family planning (2.39, 1.71–3.35). Dropout from maternal care continuum is high, especially for the poorest, in rural Tanzania. Interactions with formal health system and perceived need for future services appear to be important factors for retention. ”连续照护”是孕产妇、新生儿和儿童健康服务提供的关键框 架。MNCH 连续照护是从产前护理 （ANC） 、熟练助产护 理 （SBA） 到产后护理（PNC） 的连续过程, 本研究调查中途 退出 MNCH连续照护和继续使用的相关因素。 我们在坦桑尼亚莫罗戈罗省的四个区采用二阶段整群抽样住 户调查, 收集并分析了过去2-14个月分娩的 1931 位妇女的数 据并分析。该调查于 2011 年进行, 是一项孕产妇健康项目独 立评估基线调查的一部分。采用安德森模型分析求医行为, 建 立 Logistic 模型分析连续照护中的三个过渡阶段。 仅10%的妇女接受了推荐的整体护理 （4+ANC, SBA和1+PNC）, 1%的妇女未在任何阶段使用 MUCH 护理。接受四次 ANC 检查与年龄呈正相关（20–34 岁： OR=1.77, 95%CI 1.22–2.56； 35–49 岁： OR=2.03, 95%CI 1.29–3.2）, 与对危 险体征的了解也呈正相关 （1.75, 1.39–2.1） 。院内分娩 （SBA 的代理变量） 显示偏向富人的偏倚, 最富裕五分之一 和其次家庭的妇女院内分娩较高 （3.4, 2.04–5.66； 1.66, 1.12–2.47）, 最富裕的三分之一社区的妇女院内分娩也较高 （2.9, 1.14–7.4） 。 高院内分娩率还与产前并发症 （1.37, 1.05–1.79） 和接受4þ ANC 检查相关（1.55, 1.14–2.09） 。 与 返回医疗机构接受PNC 关联最强的是最富裕社区 （2.25, 1.21–4.44） ；新 PNC 项目服务地区 （1.89, 1.03–3.45） ； 了 解危险体征 （1.78, 1.13–2.83） ； 有社区卫生工作者咨询服务 （4.22, 1.97–9.05） ； 并发症分娩 （3.25, 1.84–5.73）； 和既 往计划生育咨询 （2.39, 1.71–3.35） 。 中途退出连续孕产妇保健的比例较高, 尤其是在坦桑尼亚贫困 人口和农村地区。与卫生体系的接触和对未来医疗服务需求 的预估可能是继续使用孕产妇保健的重要因素。 El ‘continuo de la atención’ se propone como un marco clave para la prestación de servicios de salud materna, neonatal e infantil (SMNI). Este estudio examinó el grado de deserción, así como los factores asociados con la retención a través del continuo de SMNI desde el cuidado prenatal (CPN), a través de la asistencia especializada en el parto (AEP), a la atención postnatal (APN). Analizamos los datos de 1931 mujeres que dieron a luz entre los 2 y 14 meses anteriores, de una encuesta de hogares de muestreo por grupos de dos etapas en cuatro distritos de la región de Morogoro en Tanzania. La encuesta se llevó a cabo en 2011 como parte de una línea de base para una evaluación independiente de un programa de salud materna. Usando el modelo de Anderson de la búsqueda de atención de salud, ajustamos los modelos logísticos para tres etapas de transición en el continuo. Sólo el 10% de las mujeres recibieron el paquete de atención “recomendado” (4+ visitas de CPN, AEP y 1 visita APN), mientras que el 1% informó que no había recibido atención en ninguna etapa. Haber recibido cuatro visitas de CPN se asoció positivamente con mujeres mayores en edad (edad 20-34 años—RP: 1.77, IC 95%: 1.22-2.56, edad 35 a 49 años—2.03, 1.29-3.2) y conocimiento de las señales de peligro (1.75, 1.39 – 2.1). Se observó un sesgo favorable a los ricos en los partos basados en instalaciones (lo cual representa la AEP), con las mujeres del cuarto quintil (1.66, 1.12-2.47) y el quintil más altos de la riqueza de los hogares (3.4, 2.04-5.66) y el tercio superior de las comunidades por riqueza (2.9, 1.14-7.4). También se reportaron tasas más altas de partos en instalaciones con complicaciones prenatales (1.37, 1.05-1.79), y 4+ visitas de CPN (1.55, 1.14- 2.09). El regreso a la APN fue mayor entre las comunidades más ricas (2.25, 1.21-4.44); áreas de captación de un nuevo programa de APN (1.89, 1.03-3.45); conocimiento de señales de peligro (1.78, 1.13-2.83); asesoramiento de trabajadores comunitarios de salud (4.22, 1.97-9.05); parto complicado (3.25, 1.84 – 5.73); y asesoramiento previo de proveedores de salud sobre planeación familiar (2.39, 1.71-3.35). La deserción del continuo de la atención materna es alta, especialmente para los más pobres, en las zonas rurales de Tanzania. Las interacciones con el sistema formal de la salud y la necesidad percibida de servicios futuros parecen ser factores importantes para la retención.

Background Increasing the utilization of facility-based care for women and newborns in low-resource settings can reduce maternal and newborn morbidity and mortality. Men influence whether women and newborns receive care because they often control financial resources and household decisions. This influence can have negative effects if men misjudge or ignore danger signs or are unwilling or unable to pay for care. Men can also positively affect their families’ health by helping plan for delivery, supplementing women’s knowledge about danger signs, and supporting the use of facility-based care. Because of these positive implications, researchers have called for increased male involvement in maternal and newborn health. However, data gathered directly from men to inform programs are lacking. Methods This study draws on in-depth interviews with 27 men in Morogoro Region, Tanzania whose partners delivered in the previous 14 months. Debriefings took place throughout data collection. Interview transcripts were analyzed inductively to identify relevant themes and devise an analysis questionnaire, subsequently applied deductively to all transcripts. Results Study findings add a partner-focused dimension to the three delays model of maternal care seeking. Men in the study often, though not universally, described facilitating access to care for women and newborns at each point along this care-seeking continuum (deciding to seek care, reaching a facility, and receiving care). Specifically, men reported taking ownership of their role as decision makers and described themselves as supportive of facility-based care. Men described arranging transport and accompanying their partners to facilities, especially for non-routine care. Men also discussed purchasing supplies and medications, acting as patient advocates, and registering complaints about health services. In addition, men described barriers to their involvement including a lack of knowledge, the need to focus on income-generating activities, the cost of care, and policies limiting male involvement at facilities. Conclusion Men can leverage their influence over household resources and decision making to facilitate care seeking and navigate challenges accessing care for women and newborns. Examining these findings from men and understanding the barriers they face can help inform interventions that encourage men to be positively and proactively involved in maternal and newborn health.

Many infants with possible serious bacterial infections (PSBI) do not receive inpatient treatment because hospital care may not be affordable, accessible, or acceptable for families. In 2015, WHO issued guidelines for managing PSBI in young infants (0-59 days) with simpler antibiotic regimens when hospital care is not feasible. Bangladesh adopted WHO's guidelines for implementation in outpatient primary health centers. We report results of an implementation research study that assessed caregiver acceptability of the guidelines in three rural sub-districts of Bangladesh during early implementation (October 2015-August 2016). We included 19 outpatient primary health centers involved in the initial rollout of the infection management guidelines. We extracted data for all PSBI cases (N = 192) from facility registers to identify gaps in referral feasibility, simplified antibiotic treatment, and follow-up. Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with both caregivers (6 FGDs; 23 IDIs) and providers (2 FGDs; 28 IDIs) to assess caregiver acceptability of the guidelines. Referral to the hospital was not feasible for many families (83.3%; N = 160/192) and acceptance varied by infection severity. Barriers to referral feasibility included economic and household factors, and previous experiences with poor quality of care at the sub-district hospital. Conversely, providers and caregivers indicated high acceptability of simplified antibiotic treatment. 80% (N = 96/120) of infants with clinical severe infection for whom referral was not feasible returned to the facility for the second antibiotic injection. Some providers reported developing local solutions-including engaging informal providers in treatment of the infant-to address organizational barriers and promote treatment compliance. Follow-up of young infants receiving simplified treatment is critical, but only 67.4% (N = 87/129) of infants received fourth day follow-up. Some providers' reported deviations from the guidelines that shifted responsibility of follow-up to the caregiver, which may have contributed to lapses. Caregivers' perception of trust and communication with providers were influential in caregiver acceptability of care. Few caregivers accepted referral to the sub-district hospital, suggesting low acceptability of this option. When referral was not feasible, many caregivers reported satisfaction with simplified antibiotic treatment. Local solutions described by providers require further examination in this context to assess the safety and potential value of these strategies in outpatient treatment. Our findings suggest strengthening providers' interpersonal skills could improve caregiver acceptability of the guidelines.

ABSTRACT Background Acute lower respiratory tract infections (ALRIs) remain the leading infectious cause of death among children < 5 years, with viruses contributing to a large proportion of cases. Little is known about the epidemiology and etiology of viral ALRI in rural Bangladesh. Methods We enrolled 3‐ to 23‐month‐old children with ALRIs attending a subdistrict hospital outpatient clinic in Sylhet district in Bangladesh. Trained study physicians ascertained the cases and obtained nasopharyngeal swabs to detect 19 respiratory viruses by multiplex PCR using the Luminex Integrated System NxTAG Respiratory pathogen panel. Results Between August 2016 and September 2017, we enrolled 1477 children. Median age was 10 months; 58.1% were male. Forty‐seven percent presented during autumn (mid‐June to mid‐October). About a third had temperature ≥ 101°F, 95.4% had cough in the previous 3 days, 72.0% had fast breathing, and 80.0% had chest indrawing. Alveolar consolidation occurred in 23.9%, and 4.4% were hypoxemic (saturation < 90% on room air). Nineteen percent required hospitalization; 79.1% of them were discharged within 48 h. A respiratory virus was identified in 81.8%, majority (75.8%) with single virus isolation. Rhinoenterovirus was most commonly identified (HRV/HEV, 37.9%), followed by respiratory syncytial virus (RSV, 20.2%) and human metapneumovirus (hMPV, 11.7%). Rhinoenterovirus was detected year‐round; RSV was detected during August–November and hMPV during December–March. Conclusions Respiratory viruses were identified in a majority (82%) of children under 2 years of age presenting with ALRI in rural hospitals of Bangladesh. These findings have implications for future study and potentially for surveillance, antimicrobial stewardship, vaccine program planning, and policy.

Women experience high rates of depression, particularly during pregnancy and the postpartum periods. Using population-based data from Bangladesh and Pakistan, we estimated the burden of antenatal depression, its risk factors, and its effect on preterm birth. The study uses the following data: maternal depression measured between 24 and 28 weeks of gestation using the 9-question Patient Health Questionnaire (PHQ-9); data on pregnancy including an ultrasound before 19 weeks of gestation; data on pregnancy outcomes; and data on woman's age, education, parity, weight, height, history of previous illness, prior miscarriage, stillbirth, husband's education, and household socioeconomic data collected during early pregnancy. Using PHQ-9 cutoff score of ≥12, women were categorized into none to mild depression or moderate to moderately severe depression. Using ultrasound data, preterm birth was defined as babies born <37 weeks of gestation. To identify risk ratios (RR) for antenatal depression, unadjusted and adjusted RR and 95% confidence intervals (CI) were calculated using log- binomial model. Log-binomial models were also used for determining the effect of antenatal depression on preterm birth adjusting for potential confounders. Data were analyzed using Stata version 16 (StataCorp LP). About 6% of the women reported moderate to moderately severe depressive symptoms during the antenatal period. A parity of ≥2 and the highest household wealth status were associated with an increased risk of depression. The overall incidence of preterm birth was 13.4%. Maternal antenatal depression was significantly associated with the risk of preterm birth (ARR, 95% CI: 1.34, 1.02-1.74). The increased risk of preterm birth in women with antenatal depression in conjunction with other significant risk factors suggests that depression likely occurs within a constellation of other risk factors. Thus, to effectively address the burden of preterm birth, programs require developing and providing integrated care addressing multiple risk factors.

Background The purpose of this study is to assess the prevalence and associated factors of physical and sexual intimate partner violence (IPV) among married women of reproductive age in a rural population in northeast Bangladesh. In addition, we examined women’s sharing and disclosure of violence experience with others. Methods This cross-sectional study uses data from a household survey of 3966 women conducted in 2014 in the Sylhet District of Bangladesh. Interviews were completed in respondent’s homes by trained local female interviewers. Results Twenty-nine percent (28.8%, 95% CI 27.4–30.3%) of the women reported ever experiencing physical or sexual IPV by their spouse; 13.2% (95% CI 12.1–14.3%) reported physical or sexual IPV in the past year. Of the 13.2%, 10.1% (95% CI 9.2–11.1%) reported experiencing physical IPV and 4.6% (95% CI 4.0–5.3%) reported sexual IPV. In a combined model, the adjusted odds of having experienced physical or sexual IPV in the past year were higher for women who were raised in households with history of IPV (AOR = 4.35, 95% CI 3.26–5.80); women with no formal education (AOR = 1.76, 95% CI 1.30–2.37); women whose husbands had no formal education (AOR = 1.63, 95% CI 1.22–2.17); Muslim (AOR = 1.63, 95% CI 1.03–2.57); women younger than age 30 (AOR = 1.53, 95% CI 1.11–2.12); and women who were members of an NGO or microcredit financial organization (AOR = 1.38, 95% CI 1.04–1.82). Wealth, parity, number of household members, and pregnancy status (pregnant, postpartum, neither pregnant nor postpartum) were not associated with physical or sexual IPV after adjusting for other factors. Data on disclosure was available for women who reported experiencing physical violence in the last year; only 31.8% of victims told someone about the violence they had experienced and 1% reported to police, clerics, health workers, or a counselor altogether. Conclusions In rural northeast Bangladesh, a high proportion of women of reproductive age experience physical or sexual IPV. Women do not often speak of these experiences, especially to anyone outside of family. Interventions aimed at preventing future IPV and addressing current IPV should focus on women who witnessed IPV in childhood, as well as younger women and less educated couples. Trial registration This study was registered as a Clinical Trial (Identifier: NCT01702402). https://clinicaltrials.gov/ct2/show/NCT01702402