gramme to Perinatal Mortality in Bangladesh. PhD thesis, Londo

353 Pages·2017·4 MB·English

LSHTM Research Online
Roy, S; (2015) The Contribution of the Matlab Safe Motherhood Programme to Perinatal Mor-
tality in Bangladesh. PhD thesis, London School of Hygiene & Tropical Medicine. DOI:
https://doi.org/10.17037/PUBS.02267959
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honline.lshtm.ac.ukhttps://researc
The Contribution of the
Matlab Safe Motherhood Programme
to Perinatal Mortality in Bangladesh

Suchismita Roy

Thesis submitted in accordance with the requirements
for the degree of Doctor of Philosophy
University of London
2015

Department of Infectious Disease Epidemiology
Faculty of Epidemiology and Population Health
LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE

Funding by: Aga Khan Foundation International Scholarship Programme
Research group affiliation: Department of Infectious Disease Epidemiology,
Faculty of Epidemiology and Population Health
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Declaration by Candidate
I have read and understood the School’s definition of plagiarism and cheating given in the
Research Degrees Handbook. I declare that this thesis is my own work, and that I have
acknowledged all results and quotations from the published or unpublished work of other
people. Where information has been derived from other sources, I confirm that this has been
indicated in the thesis. I have read and understood the School’s definition and policy on the
use of third parties (either paid or unpaid) who have contributed to the preparation of this
thesis by providing copy editing and, or, proof reading services. I declare that no changes to
the intellectual content or substance of this thesis were made as a result of this advice, and,
that I have fully acknowledged all such contributions.

Signed: ....................................................................... Date: ...............................
Name: SUCHISMITA ROY
Student Identification Number: lsh 240715

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For
my parents

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Abstract
Abstract
Current knowledge on mortality rates for stillbirths, early and late neonatal deaths and
perinatal deaths in South Asia is dependent on statistically modelled estimates. There is very
little information on the contribution of intrapartum complications and preterm births to
stillbirths and mortality in the first month of life in rural Bangladesh.

First, I systematically reviewed studies and performed a meta-analysis to obtain reliable
estimates for the above mentioned mortality rates in South Asia. Second, I examined the
association between the presence of a programme increasing professional birth attendance,
facility delivery and emergency care access and reductions in mortality levels in a
retrospective cohort in Matlab, Bangladesh. Third, I examined the determinants of preterm
birth and whether this programme was associated with preterm prevalence reduction. Fourth,
I explored the contributions of intrapartum complications and preterm births to perinatal
deaths in this cohort.
The systematic review found that perinatal mortality levels were high in Afghanistan,
Bangladesh, India, Nepal and Pakistan and low in Sri Lanka and Maldives. Stillbirths were
underreported. The cohort study found that the presence of the Matlab Safe Motherhood
Programme was strongly associated with greatly reduced stillbirths and very early (Day 0-2)
neonatal deaths. This programme did not contribute to the neonatal mortality decline after
Day 3 or to preterm birth trends. Preterm birth accounted for a third of stillbirths and deaths
in the neonatal period. Against expectations, only two intrapartum complications
(haemorrhage and multiple pregnancy) was associated with increased odds of perinatal
mortality. Dystocia and hypertensive diseases of pregnancy showed no effect.
Stillbirth and very early neonatal death reduction in Bangladesh can be achieved by improving
access to facilities and emergency care. Focused antenatal care for women might possibly
reduce preterm births but further research is needed to understand how the prevalence of
preterm birth can be reduced.
(300 words)
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Acknowledgements
Acknowledgements
I would like to thank my supervisor, Professor Carine Ronsmans, for her active guidance,
support, constructive comments and patience during the course of my PhD.

I am very grateful to staff at the school who helped me throughout the long and demanding
PhD process: Lisa Hurt, on my advisory committee, for her help and support; Ruth Farmer and
Cono Ariti, my current and previous statistical supervisors for their support; Prof. Oona
Campbell and Dr. Veronique Filippi for their encouragement through the demanding process of
the PhD and special thanks to Jenny Fleming, my research degree administrator for always
being available for me.

Very big thanks to my PhD field supervisor, Dr. Anisur Rahman for his unending patience and
mentorship during and after the fieldwork in Matlab, Bangladesh. The PhD would not have
been possible without the toil and energy of the community health workers, nurse-midwives
and doctors of ICDDR,B. Special thanks to my ICDDR, B colleagues and friends Dr. Huda and Dr.
Pervin for their unflagging support. Thanks also to Dr. Riechenbach, Dr. Koblinsky, Dr.
Chowdhury and Dr. Moran for their support in facilitating data access and to Mr Dasgupta for
his help in obtaining and managing the Matlab data files. Thanks to Dr. Alam and Mr. Saha for
their help with the Health and Demographic Surveillance System data.

My grateful thanks to the Aga Khan Foundation International Scholarship Programme for
providing the funding for my PhD. I would also like to thank the Allan and Nesta Ferguson
Foundation and the Charles Wallace Trust Bangladesh for their bursaries that helped with
miscellaneous costs. I thank Dr. Julia Mortimer for her professional proof reading. I
acknowledge that consent was taken from all the people who are pictured in the images in the
thesis. The copyrights of any images not taken by me belong to the accredited sources.

I would also like to thank Mr. Tim Satchwell and Mr. Michael Massey (LSHTM IT department),
my physiotherapist Dr. Mark Rainford and student counsellor Dr. Emma Nabavian for their
help in helping me manage the repetitive strain injury (RSI) that I developed.

Thank you to my LSHTM friends for their company and active support throughout the tough
times. Linda, Lori, Pippa, Nick and Susie were my PhD cheerleaders. Yemi, Ronnie and Jenny
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Acknowledgements
provided the physical and virtual high-fives. I specially thank Chris, Clara and Francesca for
reading and commenting on various chapters, warts and all, and cheering me on throughout
the journey.

Thank you to Mani, my life partner who weathered all the difficult times with me in this
journey and gave me fresh hope and energy to battle another day. Lastly, thank you to my
parents for their love and support during my PhD. Without their encouragement and belief in
me, this PhD would not have been undertaken.
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Table of Contents
Table of contents
Abstract ......................................................................................................................................... 5
Acknowledgements ....................................................................................................................... 6
Table of contents .......................................................................................................................... 8
List of tables ................................................................................................................................ 13
List of figures ............................................................................................................................... 17
List of Abbreviations and Acronyms .......................................................................................... 21
Chapter 1. Preface ................................................................................................................ 24
1.1 Structure of the thesis ................................................................................................ 24
1.2 Summary of the thesis objectives ............................................................................... 25
1.3 Study type ................................................................................................................... 28
1.4 Student’s role in the study and background ............................................................... 28
1.5 Timeline of the PhD..................................................................................................... 29
Chapter 2. Background ......................................................................................................... 30
2.1 Definitions ................................................................................................................... 30
2.2 Burden ......................................................................................................................... 31
2.3 Global initiatives and programmes for newborn health: ........................................... 34
2.4 Difficulty in estimating perinatal deaths in developing countries .............................. 35
2.4.1 Issues of definition .............................................................................................. 35
2.4.2 Issues of ascertainment ...................................................................................... 36
2.4.3 Issues of non-recording ....................................................................................... 36
2.5 Risk factors for perinatal deaths and preterm births ................................................. 37
2.5.1 Risk factors for perinatal deaths ......................................................................... 39
2.5.2 Risk factors for preterm births ............................................................................ 40
2.5.3 Intrapartum complications ................................................................................. 43
2.5.4 Intrapartum care ................................................................................................. 43
2.6 Interventions suggested for the reduction of perinatal mortality and preterm births
47
2.6.1 Interventions in the preconception and antenatal period ................................. 47
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Table of Contents
2.6.2 Interventions during labour and delivery ........................................................... 47
2.6.3 Interventions for immediate newborn care and postnatal care for small and ill
newborn babies .................................................................................................................. 47
2.7 Reaching mothers and neonates in greatest need ..................................................... 47
2.8 Contribution of the private health sector to delivery care provision ......................... 48
2.9 Timing of perinatal deaths .......................................................................................... 49
2.10 Rationale for the thesis ............................................................................................... 51
Chapter 3. Systematic review of the rates of stillbirths, early neonatal deaths, late neonatal
deaths and perinatal deaths in community-based studies in South Asia ................................... 52
3.1 Introduction ................................................................................................................ 52
3.2 Objectives: .................................................................................................................. 54
Overall Objective: ................................................................................................................ 54
Specific Objectives: ............................................................................................................. 54
3.3 Methods ...................................................................................................................... 54
3.3.1 Search Strategy ................................................................................................... 54
3.3.2 Study Selection .................................................................................................... 55
3.3.3 Eligibility criteria .................................................................................................. 55
3.3.4 Data Extraction and Review Terminology ........................................................... 57
3.3.5 Quality Assessment of Studies ............................................................................ 59
3.3.6 Data Analysis ....................................................................................................... 63
3.4 Results ......................................................................................................................... 66
3.4.1 Search strategy results ........................................................................................ 66
1.1 Screening ..................................................................................................................... 67
1.2 Included....................................................................................................................... 67
1.3 Eligibility ...................................................................................................................... 67
1.4 Identification ............................................................................................................... 67
3.4.2 Description of studies ......................................................................................... 68
3.4.3 Summary of results of study quality assessment: .............................................. 95
3.4.4 Mortality rates of the systematic review by outcome type: .............................. 97
3.4.5 Mortality Rates by Study Quality ...................................................................... 107
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