Search results for: Dilshad Sharmin Chowdhury

Authors: Priyanka Dutta Chowdhury

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A globalized connected world, calling loud for a composite culture, was still not able to erase the pain of a desired nationalism based on cultural identity. In the South Asian region, the random drawing of the boundaries without taking the ethnic aspect into consideration have always challenged the very basis of the existence of certain groups. The urge to reunify with the fellow brothers on both sides of the border have always called for a chaos and schism in the countries of this region. Sometimes this became a tool to bargain with the state and find a favorable position in the power structure on the basis of cultural identity. In Pakistan and Afghanistan, the Pakhtuns who are divided across the border of the two countries, from the inception of creation of Pakistan have posed various challenges and hampered the growth of a consolidated nation. The Pakhtuns or Pashtuns of both Pakistan and Afghanistan have a strong cultural affinity which blurs their physical distancing and calls for a nationalism based on this ethnic affiliation. Both the sides wanted to create Pakhtunistan unifying all the Pakhtuns of the region. For long, this group have denied to accept the Durand line separating the two. This was an area of concern especially for the Pakhtuns of Pakistan torn between the decision either to join Afghanistan, create a nation of their own or be a part of Pakistan. This ethnic issue became a bone of contention between the two countries. Later, though well absorbed and recognized in the respective countries, they have fought for their identity and claimed for a dominant position in the politics of the nations. Because of the porous borders often influx of refugees was seen especially during Afghan Wars and later many extremists’ groups were born from them especially the Taliban. In the recent string of events, when the Taliban, who are mostly Pakhtuns ethnically, came in power in Afghanistan, a wave of sympathy arose in Pakistan. This gave a strengthening position to the religious Pakhtuns across the border. It is to be noted here that a fragmented Pakhtun identity between the religious and seculars were clearly visible, voicing for their place in the political hierarchy of the country with a vision distinct from each other especially in Pakistan. In this context the paper tries to evaluate the reasons for this cultural turmoil between the countries and this ethnic group. It also aims to analyze the concept of how the identity politics still holds its relevance in the contemporary world. Additionally, the recent trend of fragmented identity points towards instrumentalization of this ethnic groups, who are engaged in the bargaining process with the state for a robust position in the power structure. In the end, the paper aims to deduct from the theoretical conditions of identity politics, whether this is a primordial or a situational tool to have a visibility in the power structure of the contemporary world.

Keywords: cultural identity, identity politics, instrumentalization of identity pakhtuns, power structure

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Authors: Debasish Chowdhury, Sunil Mekale, Sarvanamurthy Sakthivel, Sukhvinder Kaur, Rambabu Khambampati, Ashok Agarwal

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Introduction: The migrant intervention in India was initiated during the National AIDS Control Program (NACP) Phase-2 (2002-2007). HIV Sentinel surveillance Studies (HSS) conducted in 2012-13 indicated higher HIV prevalence among migrants (0.99%) compared to general populations (0.35%). Migrants continue to bear a heightened risk of HIV infection which results from the condition and structure of the migration process. USAID PHFI-PIPPSE project in collaboration with the National AIDS Control Organization (NACO) developed a unique system called Migrant Service Delivery System (MSDS) to capture migrants profile with respect to their risk profile and to provide tailor made services to them. Description: MSDS is a web-based system, designed and implemented to increase service uptake among migrants through evidence based planning. 110 destination migrants Targeted Intervention (TI) from 11 states were selected for study with varied target populations in terms of occupations; to understand occupation related risk behaviors among the migrants. Occupation wise registration data of high risk vulnerable migrants were analyzed through MSDS for the period April 2014–June 2016. Analysis was made on specific indicators among these occupational groups to understand the risk behavior and their vulnerability to HIV and STIs. Findings: Out of total HIV positive migrant’s workers (N= 847) enrolled in MSDS HIV rate is found to be highest among Auto-Rickshaw (18.66%) followed by Daily wage laborers (14.46%), Loom workers (10.73%), Industrial workers (10.04%) and Construction worker 7.93%. With 45.14% positivity, industrial workers are found to be most vulnerable to Sexually Transmitted Infections (STIs) (N=10057) among all occupational categories followed by loom workers (16.28%), Skilled worker (Furniture, Jeweler)-7.14%, daily wage laborers (5.45%). Conclusion: MSDS is an effective tool to assess migrants’ risk and their vulnerability to HIV for designing evidence informed program. This system calls for a replication across all destination TIs by NACO for differential strategies for different occupation groups to ensure better yield through scientific planning of intervention among high risk and high vulnerable migrants.

Keywords: migrants, migrant service delivery system, risk, vulnerability

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Authors: Itee Chowdhury, Shikha Modi

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Introduction: Cancer is beginning to outpace cardiovascular disease as a cause of death affecting every major organ system with profound implications for perioperative management. Breast cancer is the most common cancer in women in India, accounting for 27% of all cancers. The small changes in analgesic management of cancer patients can greatly improve prognosis and reduce the risk of postsurgical cancer recurrence as opioid-based analgesia has a deleterious effect on cancer outcomes. Shortened postsurgical recovery time facilitates earlier return to intended oncological therapy maximising the chance of successful treatment. Literature reveals that the role of BIS since FDA approval has been assessed in various types of surgeries, but clinical data on its use in oncosurgical patients are scanty. Our study focuses on the role of BIS-guided anaesthesia for breast cancer surgery patients. Methods: A prospective randomized controlled study in patients aged 36-55years scheduled for modified radical mastectomy was conducted in 51 patients in each group who met the inclusion and exclusion criteria, and randomization was done by sealed envelope technique. In BIS guided anaesthesia group (B), sevoflurane was titrated to keep the BIS value 45-60, and thereafter if the patient showed hypertension/tachycardia, an opioid was given. In standard anaesthesia care (group C), sevoflurane was titrated to keep MAC in the range of 0.8-1, and fentanyl was given if the patient showed hypertension/tachycardia. Intraoperative opioid consumption was calculated. Postsurgery recovery characteristics, including Aldrete score, were assessed. Patients were questioned for pain, PONV, and recall of the intraoperative event. A comparison of age, BMI, ASA, recovery characteristics, opioid, and VAS score was made using the non-parametric Mann-Whitney U test. Categorical data like intraoperative awareness of surgery and PONV was studied using the Chi-square test. A comparison of heart rate and MAP was made by an independent sample t-test. #ggplot2 package was used to show the trend of the BIS index for all intraoperative time points for each patient. For a statistical test of significance, the cut-off p-value was set as <0.05. Conclusions: BIS monitoring led to reduced opioid consumption and early recovery from anaesthesia in breast cancer patients undergoing MRM resulting in less postoperative nausea and vomiting and less pain intensity in the immediate postoperative period without any recall of the intraoperative event. Thus, the use of a Bispectral index monitor allows for tailoring of anaesthesia administration with a good outcome.

Keywords: bispectral index, depth of anaesthesia, recovery, opioid consumption

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Authors: S. Chowdhury, A. Corlett

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Large tsunamis strike the British Columbia coast every few hundred years. The Cascadia Subduction Zone, which extends along the Pacific coast from Vancouver Island to Northern California is one of the most seismically active regions in Canada. Significant earthquakes have occurred in this region, including the 1700 Cascade Earthquake with an estimated magnitude of 9.2. Based on geological records, experts have predicted a 'great earthquake' of a similar magnitude within this region may happen any time. This earthquake is expected to generate a large tsunami that could impact the coastal communities on Vancouver Island. Since many of these communities are in remote locations, they are more likely to be vulnerable, as the post-earthquake relief efforts would be impacted by the damage to critical road infrastructures. To assess the coastal vulnerability within these communities, a hydrodynamic model has been developed using MIKE-21 software. We have considered a 500 year probabilistic earthquake design criteria including the subsidence in this model. The bathymetry information was collected from Canadian Hydrographic Services (CHS), and National Oceanic Atmospheric and Administration (NOAA). The arial survey was conducted using a Cessna-172 aircraft for the communities, and then the information was converted to generate a topographic digital elevation map. Both survey information was incorporated into the model, and the domain size of the model was about 1000km x 1300km. This model was calibrated with the tsunami occurred off the west coast of Moresby Island on October 28, 2012. The water levels from the model were compared with two tide gauge stations close to the Vancouver Island and the output from the model indicates the satisfactory result. For this study, the design water level was considered as High Water Level plus the Sea Level Rise for 2100 year. The hourly wind speeds from eight directions were collected from different wind stations and used a 200-year return period wind speed in the model for storm events. The regional model was set for 12 hrs simulation period, which takes more than 16 hrs to complete one simulation using double Xeon-E7 CPU computer plus a K-80 GPU. The boundary information for the local model was generated from the regional model. The local model was developed using a high resolution mesh to estimate the coastal flooding for the communities. It was observed from this study that many communities will be effected by the Cascadia tsunami and the inundation maps were developed for the communities. The infrastructures inside the coastal inundation area were identified. Coastal vulnerability planning and resilient design solutions will be implemented to significantly reduce the risk.

Keywords: tsunami, coastal flooding, coastal vulnerable, earthquake, Vancouver, wave propagation

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Authors: A. K. M. Zakir Hossain, Faruk-Ul Islam, Muhammad Alamgir Chowdhury, Kazi Morshed Alam, Md. Rashidul Islam, Muhammad Humayun Kabir, Noshin Ara Tunazzina, Taufiqur Rahman, Md. Ashik Mia, Ashaduzzaman Sagar

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The jute retting process is one of the key factors for the excellent jute fibre production as well as maintaining water quality. The traditional method of jute retting is time-consuming and hampers the fish cultivation by polluting the water body. Therefore, a low cost, time-saving, environment-friendly, and improved technique is essential for jute retting to overcome this problem. Thus the study was focused to compare the extent of water pollution and fibre quality of two retting systems, i.e., traditional retting practices over-improved retting method (macha retting) by assessing different physico-chemical and microbiological properties of water and fibre quality parameters. Water samples were collected from the top and bottom of the retting place at the early, mid, and final stages of retting from four districts of Bangladesh viz., Gaibandha, Kurigram, Lalmonirhat, and Rangpur. Different physico-chemical parameters of water samples viz., pH, dissolved oxygen (DO), conductivity (CD), total dissolved solids (TDS), hardness, calcium, magnesium, carbonate, bicarbonate, chloride, phosphorus and sulphur content were measured. Irrespective of locations, the DO of the final stage retting water samples was very low as compared to the mid and early stage, and the DO of traditional jute retting method was significantly lower than the improved macha method. The pH of the water samples was slightly more acidic in the traditional retting method than that of the improved macha method. Other physico-chemical parameters of the water sample were found higher in the traditional method over-improved macha retting in all the stages of retting. Bacterial species were isolated from the collected water samples following the dilution plate technique. Microbiological results revealed that water samples of improved macha method contained more bacterial species that are supposed to involve in jute retting as compared to water samples of the traditional retting method. The bacterial species were then identified by the sequencing of 16SrDNA. Most of the bacterial species identified belong to the genera Pseudomonas, Bacillus, Pectobacterium, and Stenotrophomonas. In addition, the tensile strength of the jute fibre was tested, and the results revealed that the improved macha method showed higher mechanical strength than the traditional method in most of the locations. The overall results indicate that the water and fibre quality were found better in the improved macha retting method than the traditional method. Therefore, a time-saving and cost-friendly improved macha retting method can be widely adopted for the jute retting process to get the quality jute fiber and to keep the environment clean and safe.

Keywords: jute retting methods, physico-chemical parameters, retting microbes, tensile strength, water quality

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Authors: Fouzia Khanam, Tridib Chowdhury, Belal Hossain, Sajedur Rahman, Mahfuzar Rahman

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Introduction: Over the last decades, the world has achieved a noticeable success in preventing malaria. Nevertheless, malaria, a vector-borne infectious disease, remains a major public health burden globally as well as in Bangladesh. To achieve the goal of eliminating malaria, BRAC, a leading organization of Bangladesh in collaboration with government, is distributing free LLIN to the 13 endemic districts of the country. The study was conducted with the aim of assessing the gap between coverage, access, and utilization of LLIN among the people of the 13 malaria endemic districts of Bangladesh. Methods: This baseline study employed a community cross-sectional design triangulated with qualitative methods to measure households’ ownership, access and use of 13 endemic districts. A multistage cluster random sampling was employed for the quantitative part and for qualitative part a purposive sampling strategy was done. Thus present analysis included 2640 households encompassing a total of 14475 populations. Data were collected using a pre-tested structured questionnaire through one on one face-to-face interview with respondents. All analyses were performed using STATA (Version 13.0). For the qualitative part participant observation, in-depth interview, focus group discussion, key informant interview and informal interview was done to gather the contextual data. Findings: According to our study, 99.8% of households possessed at least one-bed net in both study areas. 77.4% households possessed at least two LLIN and 43.2% households had access to LLIN for all the members. So the gap between coverage and access is 34%. 91.8% people in the 13 districts and 95.1% in Chittagong Hill Tracts areas reported having had slept under a bed net the night before interviewed. And despite the relatively low access, in 77.8% of households, all the members were used the LLIN the previous night. This higher utilization compared to access might be due to the increased awareness among the community people regarding LLIN uses. However, among those people with sufficient access to LLIN, 6% of them still did not use the LLIN which reflects the behavioral failure that needs to be addressed. The major reasons for not using LLIN, identified by both qualitative and quantitative findings, were insufficient access, sleeping or living outside the home, migration, perceived low efficacy of LLIN, fear of physical side effects or feeling uncomfortable. Conclusion: Given that LLIN access and use was a bit short of the targets, it conveys important messages to the malaria control program. Targeting specific population segments and groups for achieving expected LLIN coverage is very crucial. And also, addressing behavior failure by well-designed behavioral change interventions is mandatory.

Keywords: long lasting insecticide net, malaria, malaria control programme, World Health Organisation

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Authors: Sushmita Roy Chowdhury, Steve Holding, Sujoy Khan

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The immunogenic responses of the lung towards the fungus Aspergillus fumigatus may range from invasive aspergillosis in the immunocompromised, fungal ball or infection within a cavity in the lung in those with structural lung lesions, or allergic bronchopulmonary aspergillosis (ABPA). Patients with asthma or cystic fibrosis are particularly predisposed to ABPA. There are consensus guidelines that have established criteria for diagnosis of ABPA, but uncertainty remains on the serologic cut-off values that would increase the diagnostic specificity of ABPA. We retrospectively analyzed 80 patients with severe asthma and evidence of peripheral blood eosinophilia ( > 500) over the last 3 years who underwent all serologic tests to exclude ABPA. Total IgE, specific IgE and specific IgG levels against Aspergillus fumigatus were measured using ImmunoCAP Phadia-100 (Thermo Fisher Scientific, Sweden). The Modified ISHAM working group 2013 criteria (obligate criteria: asthma or cystic fibrosis, total IgE > 1000 IU/ml or > 417 kU/L and positive specific IgE Aspergillus fumigatus or skin test positivity; with ≥ 2 of peripheral eosinophilia, positive specific IgG Aspergillus fumigatus and consistent radiographic opacities) was used in the clinical workup for the final diagnosis of ABPA. Patients were divided into 3 groups - definite, possible, and no evidence of ABPA. Specific IgG Aspergillus fumigatus levels were not used to assign the patients into any of the groups. Of 80 patients (males 48, females 32; mean age 53.9 years ± SD 15.8) selected for the analysis, there were 30 patients who had positive specific IgE against Aspergillus fumigatus (37.5%). 13 patients fulfilled the Modified ISHAM working group 2013 criteria of ABPA (‘definite’), while 15 patients were ‘possible’ ABPA and 52 did not fulfill the criteria (not ABPA). As IgE levels were not normally distributed, median levels were used in the analysis. Median total IgE levels of patients with definite and possible ABPA were 2144 kU/L and 2597 kU/L respectively (non-significant), while median specific IgE Aspergillus fumigatus at 4.35 kUA/L and 1.47 kUA/L respectively were significantly different (comparison of standard deviations F-statistic 3.2267, significance level p=0.040). Mean levels of IgG anti-Aspergillus fumigatus in the three groups (definite, possible and no evidence of ABPA) were compared using ANOVA (Statgraphics Centurion Professional XV, Statpoint Inc). Mean levels of IgG anti-Aspergillus fumigatus (Gm3) in definite ABPA was 125.17 mgA/L ( ± SD 54.84, with 95%CI 92.03-158.32), while mean Gm3 levels in possible and no ABPA were 18.61 mgA/L and 30.05 mgA/L respectively. ANOVA showed a significant difference between the definite group and the other groups (p < 0.001). This was confirmed using multiple range tests (Fisher's least significant difference procedure). There was no significant difference between the possible ABPA and not ABPA groups (p > 0.05). The study showed that a sizeable proportion of patients with asthma are sensitized to Aspergillus fumigatus in this part of India. A higher cut-off value of Gm3 ≥ 80 mgA/L provides a higher serologic specificity towards definite ABPA. Long-term studies would provide us more information if those patients with 'possible' APBA and positive Gm3 later develop clear ABPA, and are different from the Gm3 negative group in this respect. Serologic testing with clear defined cut-offs are a valuable adjunct in the diagnosis of ABPA.

Keywords: allergic bronchopulmonary aspergillosis, Aspergillus fumigatus, asthma, IgE level

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Authors: Kenneth A. Rostowsky, Alexander S. Maher, Nahian F. Chowdhury, Andrei Irimia

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The clinical significance of cerebral microbleeds (CMBs) due to mild traumatic brain injury (mTBI) remains unclear. Here we use magnetic resonance imaging (MRI), diffusion tensor imaging (DTI) and connectomic analysis to investigate the statistical association between mTBI-related CMBs, post-TBI changes to the human connectome and neurological/cognitive deficits. This study was undertaken in agreement with US federal law (45 CFR 46) and was approved by the Institutional Review Board (IRB) of the University of Southern California (USC). Two groups, one consisting of 26 (13 females) mTBI victims and another comprising 26 (13 females) healthy control (HC) volunteers were recruited through IRB-approved procedures. The acute Glasgow Coma Scale (GCS) score was available for each mTBI victim (mean µ = 13.2; standard deviation σ = 0.4). Each HC volunteer was assigned a GCS of 15 to indicate the absence of head trauma at the time of enrollment in our study. Volunteers in the HC and mTBI groups were matched according to their sex and age (HC: µ = 67.2 years, σ = 5.62 years; mTBI: µ = 66.8 years, σ = 5.93 years). MRI [including T1- and T2-weighted volumes, gradient recalled echo (GRE)/susceptibility weighted imaging (SWI)] and gradient echo (GE) DWI volumes were acquired using the same MRI scanner type (Trio TIM, Siemens Corp.). Skull-stripping and eddy current correction were implemented. DWI volumes were processed in TrackVis (http://trackvis.org) and 3D Slicer (http://www.slicer.org). Tensors were fit to DWI data to perform DTI, and tractography streamlines were then reconstructed using deterministic tractography. A voxel classifier was used to identify image features as CMB candidates using Microbleed Anatomic Rating Scale (MARS) guidelines. For each peri-lesional DTI streamline bundle, the null hypothesis was formulated as the statement that there was no neurological or cognitive deficit associated with between-scan differences in the mean FA of DTI streamlines within each bundle. The statistical significance of each hypothesis test was calculated at the α = 0.05 level, subject to the family-wise error rate (FWER) correction for multiple comparisons. Results: In HC volunteers, the along-track analysis failed to identify statistically significant differences in the mean FA of DTI streamline bundles. In the mTBI group, significant differences in the mean FA of peri-lesional streamline bundles were found in 21 out of 26 volunteers. In those volunteers where significant differences had been found, these differences were associated with an average of ~47% of all identified CMBs (σ = 21%). In 12 out of the 21 volunteers exhibiting significant FA changes, cognitive functions (memory acquisition and retrieval, top-down control of attention, planning, judgment, cognitive aspects of decision-making) were found to have deteriorated over the six months following injury (r = -0.32, p < 0.001). Our preliminary results suggest that acute post-TBI CMBs may be associated with cognitive decline in some mTBI patients. Future research should attempt to identify mTBI patients at high risk for cognitive sequelae.

Keywords: traumatic brain injury, magnetic resonance imaging, diffusion tensor imaging, connectomics

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Authors: Sricheta Chowdhury

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To require a woman to choose between her work and her personal life is the most acute form of discrimination that can be meted out against her. No woman should be given a choice to choose between her motherhood and her career at Bar, yet that is the most detrimental discrimination that has been happening in Indian Bar, which no one has questioned so far. The falling number of women in practice is a reality that isn’t garnering much attention given the sharp rise in women studying law but is not being able to continue in the profession. Moving from a colonial misogynist whim to a post-colonial “new-age construct of Indian woman” façade, the policymakers of the Indian Judiciary have done nothing so far to decolonize itself from its rudimentary understanding of ‘equality of gender’ when it comes to the legal profession. Therefore, when Indian jurisprudence was (and is) swooning to the sweeping effect of transformative constitutionalism in the understanding of equality as enshrined under the Indian Constitution, one cannot help but question why the legal profession remained out of brushing effect of achieving substantive equality. The Airline industry’s discriminatory policies were not spared from criticism, nor were the policies where women’s involvement in any establishment serving liquor (Anuj Garg case), but the judicial practice did not question the stereotypical bias of gender and unequal structural practices until recently. That necessitates the need to examine the existing Bar policies and the steps taken by the regulatory bodies in assessing the situations that are in favor or against the purpose of furthering women’s issues in present-day India. From a comparative feminist point of concern, South Africa’s pro-women Bar policies are attractive to assess their applicability and extent in terms of promoting inclusivity at the Bar. This article intends to tap on these two countries’ potential in carving a niche in giving women an equal platform to play a substantive role in designing governance policies through the Judiciary. The article analyses the current gender composition of the legal profession while endorsing the concept of substantive equality as a requisite in designing an appropriate appointment process of the judges. It studies the theoretical framework on gender equality, examines the international and regional instruments and analyses the scope of welfare policies that Indian legal and regulatory bodies can undertake towards a transformative initiative in re-modeling the Judiciary to a more diverse and inclusive institution. The methodology employs a comparative and analytical understanding of doctrinal resources. It makes quantitative use of secondary data and qualitative use of primary data collected for determining the present status of Indian women legal practitioners and judges. With respect to quantitative data, statistics on the representation of women as judges and chief justices and senior advocates from their official websites from 2018 till present have been utilized. In respect of qualitative data, results of the structured interviews conducted through open and close-ended questions with retired lady judges of the higher judiciary and senior advocates of the Supreme Court of India, contacted through snowball sampling, are utilized.

Keywords: gender, higher judiciary, legal profession, representation, substantive equality

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Authors: Farhana Karim, Abdullah N. S. Khan, Mohiuddin A. K. Chowdhury, Nabila Zaka, Alexander Manu, Shams El Arifeen, Sk Masum Billah

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Breastfeeding, an integral part of newborn care, can reduce 55-87% of all-cause neonatal mortality and morbidity. Early initiation of breastfeeding within 1 hour of birth can avert 22% of newborn mortality. Only 45% of world’s newborns and 42% of newborns in South-Asia are put to the breast within one hour of birth. In Bangladesh, only a half of the mothers practice early initiation of breastfeeding which is less likely to be practiced if the baby is born in a health facility. This study aims to generate strong evidence for early initiation of breastfeeding practices in the government health facilities and to explore the associated factors influencing the practice. The study was conducted in selected health facilities in three neighbouring districts of Northern Bangladesh. Total 249 normal vaginal delivery cases were observed for 24 hours since the time of birth. The outcome variable was initiation of breastfeeding within 1 hour while the explanatory variables included type of health facility, privacy, presence of support person, stage of labour at admission, need for augmentation of labour, complications during delivery, need for episiotomy, spontaneous cry of the newborn, skin-to-skin contact with mother, post-natal contact with the service provider, receiving a post-natal examination and counselling on breastfeeding during postnatal contact. The simple descriptive statistics were employed to see the distribution of samples according to socio-demographic characteristics. Kruskal-Wallis test was carried out for testing the equality of medians among two or more categories of each variable and P-value is reported. A series of simple logistic regressions were conducted with all the potential explanatory variables to identify the determining factors for breastfeeding within 1 hour in a health facility. Finally, multiple logistic regression was conducted including the variables found significant at bi-variate analyses. Almost 90% participants initiated breastfeeding at the health facility and median time to initiate breastfeeding was 38 minutes. However, delivering in a sub-district hospital significantly delayed the breastfeeding initiation in comparison to delivering in a district hospital. Maintenance of adequate privacy and presence of separate staff for taking care of newborn significantly reduced the time in early breastfeeding initiation. Initiation time was found longer if the mother had an augmented labour, obstetric complications, and the newborn needed resuscitation. However, the initiation time was significantly early if the baby was put skin-to-skin on mother’s abdomen and received a postnatal examination by a provider. After controlling for the potential confounders, the odds of initiating breastfeeding within one hour of birth is higher if mother gives birth in a district hospital (AOR 3.0: 95% CI 1.5, 6.2), privacy is well-maintained (AOR 2.3: 95% CI 1.1, 4.5), babies cry spontaneously (AOR 7.7: 95% CI 3.3, 17.8), babies are put to skin-to-skin contact with mother (AOR 4.6: 95% CI 1.9, 11.2) and if the baby is examined by a provider in the facility (AOR 4.4: 95% CI 1.4, 14.2). The evidence generated by this study will hopefully direct the policymakers to identify and prioritize the scopes for creating and supporting early initiation of breastfeeding in the health facilities.

Keywords: Bangladesh, early initiation of breastfeeding, health facility, normal vaginal delivery, skin to skin contact

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Authors: Abdullah Nurus Salam Khan, Farhana Karim, Mohiuddin Ahsanul Kabir Chowdhury, S. Masum Billah, Nabila Zaka, Alexander Manu, Shams El Arifeen

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Globally, pre-eclampsia (PE) and ante-partum haemorrhage (APH) are two major causes of maternal mortality. Prompt identification and management of these conditions depend on competency of the birth attendants. Since these conditions are infrequent to be observed, clinical vignette based assessment could identify the extent of health worker’s competence in managing emergency obstetric care (EmOC). During June-August 2016, competence of 39 medical officers (MO) and 95 nurses working in obstetric ward of 15 government health facilities (3 district hospital, 12 sub-district hospital) was measured using clinical vignettes on PE and APH. The vignettes resulted in three outcome measures: total vignette scores, scores for diagnosis component, and scores for management component. T-test was conducted to compare mean vignette scores and linear regression was conducted to measure the strength and association of vignette scores with different cadres of health workers, facility’s readiness for EmOC and average annual utilization of normal deliveries after adjusting for type of health facility, health workers’ work experience, training status on managing maternal complication. For each of the seven component of EmOC items (administration of injectable antibiotics, oxytocic and anticonvulsant; manual removal of retained placenta, retained products of conception; blood transfusion and caesarean delivery), if any was practised in the facility within last 6 months, a point was added and cumulative EmOC readiness score (range: 0-7) was generated for each facility. The yearly utilization of delivery cases were identified by taking the average of all normal deliveries conducted during three years (2013-2015) preceding the survey. About 31% of MO and all nurses were female. Mean ( ± sd) age of the nurses were higher than the MO (40.0 ± 6.9 vs. 32.2 ± 6.1 years) and also longer mean( ± sd) working experience (8.9 ± 7.9 vs. 1.9 ± 3.9 years). About 80% health workers received any training on managing maternal complication, however, only 7% received any refresher’s training within last 12 months. The overall vignette score was 8.8 (range: 0-19), which was significantly higher among MO than nurses (10.7 vs. 8.1, p < 0.001) and the score was not associated with health facility types, training status and years of experience of the providers. Vignette score for management component (range: 0-9) increased with higher annual average number of deliveries in their respective working facility (adjusted β-coefficient 0.16, CI 0.03-0.28, p=0.01) and increased with each unit increase in EmOC readiness score (adjusted β-coefficient 0.44, CI 0.04-0.8, p=0.03). The diagnosis component of vignette score was not associated with any of the factors except it was higher among the MO than the nurses (adjusted β-coefficient 1.2, CI 0.13-2.18, p=0.03). Lack of competence in diagnosing and managing obstetric complication by the nurses than the MO is of concern especially when majority of normal deliveries are conducted by the nurses. Better EmOC preparedness of the facility and higher utilization of normal deliveries resulted in higher vignette score for the management component; implying the impact of experiential learning through higher case management. Focus should be given on improving the facility readiness for EmOC and providing the health workers periodic refresher’s training to make them more competent in managing obstetric cases.

Keywords: Bangladesh, emergency obstetric care, clinical vignette, competence of health workers

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Authors: Mohiuddin Ahsanul Kabir Chowdhury, Nafisa Lira Huq, Afroza Khanom, Rafiqul Islam, Abdullah Nurus Salam Khan, Farhana Karim, Nabila Zaka, Shams El Arifeen, Sk. Masum Billah

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After having astounding achievements in reducing maternal mortality and achieving the target for Millennium Development Goal (MDG) 5, the Government of Bangladesh has set new target to reduce Maternal Mortality Ratio (MMR) to 70 per 100,000 live births aligning with targets of Sustainable Development Goals (SDGs). Aversion of deaths from maternal complication by ensuring quality health care could be an important path to accelerate the rate of reduction of MMR. This formative research was aimed at exploring the provision of quality maternal health services at different level of health facilities. The study was conducted in 1 district hospital (DH) and 4 Upazila health complexes (UHC) of Kurigram district of Bangladesh, utilizing both quantitative and qualitative research methods. We conducted 14 key informant interviews with facility managers and 20 in-depth interviews with health care providers and support staff. Besides, we observed 387 normal deliveries from which we found 17 cases of post partum haemorrhage (PPH) and 2 cases of eclampsia during the data collection period extended from July-September 2016. The quantitative data were analyzed by using descriptive statistics, and the qualitative component underwent thematic analysis with the broad themes of facility readiness for maternal complication management, and management of complications. Inadequacy in human resources has been identified as the most important bottleneck to provide quality care to manage maternal complications. The DH had a particular paucity of human resources in medical officer cadre where about 61% posts were unfilled. On the other hand, in the UHCs the positions mostly empty were obstetricians (75%, paediatricians (75%), staff nurses (65%), and anaesthetists (100%). The workload on the existing staff is increased because of the persistence of vacant posts. Unavailability of anesthetists and consultants does not permit the health care providers (HCP) of lower cadres to perform emergency operative procedures and forces them to refer the patients although referral system is not well organized in rural Bangladesh. Insufficient bed capacity, inadequate training, shortage of emergency medicines etc. are other hindrance factors for facility readiness. Among the 387 observed delivery case, 17 (4.4%) were identified as PPH cases, and only 2 cases were found as eclampsia/pre-eclampsia. The majority of the patients were treated with uterine message (16 out of 17, 94.1%) and injectable Oxytocin (14 out of 17, 82.4%). The providers of DH mentioned that they can manage the PPH because of having provision for diagnostic and blood transfusion services, although not as 24/7 services. Regarding management of eclampsia/pre-eclampsia, HCPs provided Diazepam, MgSO4, and other anti-hypertensives. The UHCs did not have MgSO4 at stock even, and one facility manager admitted that they treat eclampsia with Diazepam only. The nurses of the UHCs were found to be afraid to handle eclampsia cases. The upcoming interventions must ensure refresher training of service providers, continuous availability of essential medicine and equipment needed for complication management, availability of skilled health workforce, availability of functioning blood transfusion unit and pairing of consultants and anaesthetists to reach the newly set targets altogether.

Keywords: Bangladesh, health facilities, maternal complications, quality of care

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