BackgroundThe aim of this study was to examine the fertility differential of women age 15 to 49 using data from Bangladesh Demographic and Health Survey 2014- a survey of women who were born from 1963 to 1999.MethodsThe secondary data analysis was carried out using the BDHS 2014 in order to discuss differences in childbearing practices in Bangladesh. Descriptive statistics were used to analyze the data including education level, geographic location, and religion. A trend test used to assess the inferences.ResultsOn average, women had 2.3 children in the BDHS 2014; more than 90% of them gave birth to at least one child by age 49 and the average age of first birth was 18 years. Fertility of women strongly differed by education (p < 0.001). The percentage of women with secondary education who had no child was 50.3% and never attended school 8.4%;those with secondary education were six times as likely as those who never attended school to have no child and this pattern was stronger among urban compared with rural women.ConclusionsFertility differential becomes robust as education increases. Women’s fertility is also related to religion and residence, but these factors were not strongly related as those educational attainments.

Background: Hypertensive disorders in pregnancy, specifically pre-eclampsia and eclampsia (PE/E), are the second biggest killer of pregnant women globally and remains the least understood and most challenging maternal morbidity to manage. Although great strides were made in reducing maternal and newborn mortality between 1990 and 2015, this was clearly not enough to achieve the global health goals. To reduce maternal deaths: 1) early detection of PE needs to be improved; 2) effective management of PE/E needs to occur at lower health system levels and should encourage timely care-seeking; and 3) prioritizing the scale up of a comprehensive package of services near to where women live. Findings: This commentary describes a pragmatic approach to test scalable and sustainable strategies for expanding access to quality under-utilized maternal health commodities, interventions and services. We present a primary health care (PHC) PE/E Model based on implementation research on identified gaps in care in several countries, accepted global best practice and built on the basic premise that PHC providers can take on additional skills with adequate capacity building, coaching and supervision, and community members desire control over their own health. The PHC PE/E model displays the linkages and opportunities to prevent and treat PE/E in a simplified way; however, there are numerous interlinking factors, angles, and critical points to consider including leadership, policies and protocols; relevant medicines and commodities, ongoing capacity building strategies at lower levels and understanding what women and their communities want for safe pregnancies. Conclusion: The PHC model described here uses PE/E as an entry to improve the quality of ANC and by extension the pregnancy continuum. Bringing preventive and treatment services nearer to where pregnant women live makes sense.Abstract (Continued on next page)

Background While women in low- and middle-income countries face a range of barriers to accessing care for hypertensive disorders of pregnancy, there is little understanding of the pathways taken to overcome these constraints and reach the services they need. This study explores the perspectives of women and communities on the influences that impact care-seeking decisions and pathways to health services. Methods To understand individual perspectives, we conducted 22 in-depth interviews (IDIs) with pre-eclampsia and eclampsia survivors (PE/E) in a tertiary hospital, where they received care after initiating PE/E services in different parts of the country. In four districts, we conducted one male and one female focus group discussion (FGD) to unearth care-seeking pathways and explore normative perspectives and the range of internal and external influences. Careful thematic analysis using Atlas-ti was applied. Results Prevailing views of women and communities across settings in Bangladesh indicate varied pathways to care throughout their pregnancy, during childbirth, and in the postnatal period influenced by internal and external factors at the individual, familial, social, and health systems levels. Internal influences draw on women’s own awareness of hypertension complications and options, and their ability to decide to seek care. External factors include social influences like family and community norms, culturally-accepted alternatives, and community perceptions of the health system’s capacity to provide quality care. The interaction of these factors often delay care seeking and can lead to complex pathways to care. Conclusion Women’s individual pathways to care were diverse, despite the homogenous community perceptions of the influences on women’s care-seeking behaviors. This finding supports the need for improving quality of care in primary healthcare facilities and strengthening gender equity and community-based promotion activities through targeted policy and programming.

Background Pharmacy workers in Bangladesh play an important role in managing pregnancy complications by dispensing, counselling and selling drugs to pregnant women and their families. This study examined pharmacy workers’ drug knowledge and practice for pre-eclampsia and eclampsia (PE/E) management, including antihypertensives and anticonvulsants, and determine factors associated with their knowledge. Methods A cross-sectional survey with 382 pharmacy workers in public facilities (government) and private pharmacies and drug stores assessed their knowledge of antihypertensive and anticonvulsant drugs. ‘Pharmacy workers’ include personnel who work at pharmacies, pharmacists, family welfare visitors (FWVs), sub-assistant community medical officers (SACMOs), drug storekeepers. Exploratory and multivariate logistic models were used to describe association between knowledge of medicines used in pregnancy and demographic characteristics of pharmacy workers. Results Overall, 53% pharmacy workers interviewed were drug store owners in private pharmacies while 27% FWVs/SACMOs, who are government service providers also work as drug prescribers and/or dispensers in public facility pharmacies. Majority of pharmacy workers had poor knowledge compared to correct knowledge on both antihypertensive (77.8% vs 22.3%; p < 0.001) and anticonvulsant drugs (MgSO4) (82.2% vs 17.8%; p < 0.001). Multivariate analysis showed SACMOs and FWVs were greater than 4 times more likely to have correct knowledge on anti-hypertensives (AOR = 4.2, 95% CI:1.3–12.3, P < 0.01) and anticonvulsant drugs (AOR = 4.9, 95% CI:1.3–18.1, P < 0.01) compared to pharmacists. Pharmacy workers who had received training were more likely to have correct knowledge on antihypertensive and anticonvulsant drugs than those who had no training. Conclusions Pharmacy workers’ knowledge and understanding of antihypertensive and anticonvulsant drugs, particularly for prevention and management of PE/E is limited in Bangladesh. Most pharmacies surveyed are private and staffed with unskilled workers with no formal training on drugs. Expansion of maternal and newborn health programs should consider providing additional skills training to pharmacy workers, as well as regulating these medicines at informal pharmacies to mitigate any harmful practices or adverse outcomes of unauthorized and incorrectly prescribed and used drugs. It is important that correct messaging and medicines are available as drug stores are often the first point of contact for most of the women and their families.

This analysis examines whether salinity in drinking water is associated with preeclampsia and eclampsia (PE/E), a leading cause of maternal morbidity and mortality. Bangladesh's national health information system data were extracted at the district level (n = 64) to assess PE/E rates, and these were overlaid with three environmental measures approximating drinking water salinity, remotely sensed low-elevation coastal zone (LECZ), monthly rainfall data, and electrical conductivity of groundwater (i.e., water salinity). Results from a negative binomial fixed effects model suggest PE/E rates are higher with less rainfall (dry season), lower population density, and that district level rates of PE/E increase with higher groundwater salinity and in the high risk LECZ category closest to the coast. Results suggest that drinking water salinity may be associated with PE/E and that using national health surveillance data can improve understanding of this association. This approach can potentially be leveraged in the future to inform targeted interventions to high risk regions and times.