Final Report_Verbal Autopsy_MaMoni_Habiganj_2010 2010

Evaluation of the MAMONI, Bangladesh Program

Final Report of verbal Autopsy, Habiganj 2010

Report prepared by:

Child Health Unit of Public Health Sciences Division ICDDR,B

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Acknowledgements

We would like to acknowledge the large number of individuals and organizations whose contribution help us successfully complete the verbal autopsy survey in the “MaMoni” areas of Habiganj. To begin with, we express our profound appreciation to the women and household members who took time out of their busy daily routines to respond to the survey questions. We thank them for their patience and openness.

We express our deep gratitude to the members of the two local NGOs engaged in the implementation of the MaMoni project (Shimantik and FIVDB) for their support.

We extend our appreciation and gratitude to the members of Save the Children USA and USAID mission in Dhaka for their great collaboration and support to implement the verbal autopsy survey.

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Contents

Page # List of tables ...... 4 List of figures ...... 5 Executive Summary ...... 6

Chapter-1: Background ...... 9

1.1 MaMoni project in Habiganj ...... 9 1.2 Causes of neonatal deaths...... 9 1.3 Chapter References ...... 12

Chapter-2: Methodology of the survey...... 13

2.1 Are and population ...... 13 2.2 Objective of verbal autopsy ...... 14 2.3 Implementation of verbal autopsy ...... 14 2.4 Sample design...... 14 2.5 Data collection tool ...... 15 2.6 Training of data collectors ...... 15 2.7 Data collection ...... 15 2.8 Data entry and Analysis ...... 16 2.9 Reference ...... 16

Chapter-3: Interview results & characteristic of respondents ...... 17

3.1 Interview result ...... 17 3.2 Relationship of respondents to the deceased ...... 18 3.3 Age and education level of the respondent ...... 18

Chapter – 4: Maternal & delivery care and conditions ...... 20

4.1 Tetanus Toxoid vaccination of mother ...... 20 4.2 Delivery conditions ...... 23

Chapter -5: Causes of neonatal deaths...... 25

5.1 Causes of neonatal death in the MaMoni area ...... 26 5.2 Key maternal characteristics of and intervention coverage...... 29 5.3 Age at death of neonatal deaths ...... 33 5.4 Chapter references ...... 35

Chapter- 6 Health care seeking prior to neonatal death ...... 39

6.1 Perception and care seeking ...... 39 6.2 Reasons of not seeking care ...... 45 6.3 Place of death ...... 47

Chapter -7: Discussions ...... 49

Chapter -8: Annexure 51 A Hierarchy of different order to assign cause of death ...... 51 B Graphs ...... 52 C Questionnaire...... 54

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List of Tables

Page # Chapter-2: Methodology of the survey ...... 13 Table 2.1.1 Population by upazila ...... 13 Table 2.2.1 Distribution of role and responsibility of verbal autopsy interview ...... 14 Table 2.3.1 Distribution of samples of neonatal deaths & still-births by upazila ...... 14

Chapter-3: Interview results & characteristic of respondents ...... 17 Percent Distribution of sampled neonatal deaths and still-births by interview results and by Table 3.1.1 17 upazila...... Percent Distribution of neonatal deaths and still-births by relationship of the respondent to Table 3.2.1 18 the deceased by upazila ...... Percent Distribution of neonatal deaths and still-births by age category & level of education Table 3.3.1 19 of the respondent by upazila......

Chapter-4: Maternal & delivery care and conditions ...... 20 Percent Distribution of neonatal deaths and still-births by TT immunization status of the Table 4.1.1 21 mother of the deceased for index pregnancy and lifetime by upazila ...... Percent Distribution of lifetime TT immunization status of women those did not receive TT Table 4.1.2 22 during index pregnancy by upazila...... Percent distribution of women (part) received valid doses of TT (from card and history) Table 4.1.3 22 during their lifetime by upazila ...... Percentage of children born protected from neonatal tetanus among live-births in the last Table 4.1.4 23 pregnancies by upazila ...... Percent Distribution of neonatal deaths and still-births by duration of pregnancy, timing of Table 4.2.1 24 rupture of membrane and by duration of labour pain during delivery by upazila ......

Chapter-5: Causes of neonatal death...... 25 Table 5.1.1 Proportion of cases with overlap between causes of death ...... 28 Table 5.1.2 Percent distribution of neonatal deaths by cause and still-births by type by upazila ...... 29 Proportion of neonates died from neonatal tetanus and other causes by status of TT Table 5.2.1 29 immunization of the mother of the deceased ...... Percent distribution of cause specific neonatal deaths and still-births by maternal age & Table 5.2.2 education, place of delivery, type of birth attendant, mode of delivery, size of the newborn at 30 birth, timing of neonatal death and whether multiple/single birth ...... Percent distribution of cause of neonatal deaths and still births by maternal and delivery Table 5.2.3 32 complications ...... Table 5.3.1 Percent distribution of cause of neonatal deaths by age at death ...... 34 Table 5.3.2 Percent distribution of age at death by sex and by cause of death ...... 35

Chapter-6: Health care seeking prior to neonatal death ...... 39 Distribution of cause of neonatal deaths by perception of parents about the severity of illness Table 6.1.1 39 by age at death ...... Distribution of cause of neonatal deaths by care seeking from type of provider and by age at Table 6.1.2 40 death ...... Distribution of cause of neonatal deaths among those who sought care by place of care and Table 6.1.3 42 by type of provider (by order of visit) ...... Table 6.1.4 Distribution of place of care and by type of provider (by order) for neonatal illness ..... 44 Table 6.2.1 Distribution of cause of neonatal deaths by reasons for not seeking care ...... 46 Table 6.2.2 Reasons for not seeking care among newborns those did not seek care by upazila ...... 46 Table 6.3.1 Distribution of cause of neonatal deaths by place of death ...... 47 Table 6.3.2 Distribution of place of death by upazila ...... 48

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List of figures

Page # Chapter-1 Background ...... 9 Fig 1.1 Causes of neonatal deaths (global), WHO report 2001 ...... 10 Fig 1.2 Causes of neonatal deaths, BDHS report 2004 ...... 10 Fig 1.3 Causes of neonatal deaths, Projahnmo-Sylhet, baseline 2002 ...... 11 Fig 1.4 Causes of neonatal deaths, ACCESS-Sylhet, baseline 2007 ...... 11

Chapter-2 Methodology ...... 13 Fig 2.1 Map of Habiganj district ...... 13

Chapter-5 Causes of neonatal deaths ...... 25 Fig 5.1 Cause of neonatal death by algorithm and hierarchy used to assign primary cause of death 27 Fig 5.2 Causes of Neonatal deaths (in percentage) in the MaMoni area, Habiganj ...... 28 Fig 5.3 Neonatal deaths by age at death in days (overall MaMoni area) ...... 34 Fig 5.4 Percent distribution of age at death by cause of neonatal death ...... 34

Chapter-6 Health care seeking prior to neonatal death ...... 39 Fig 6.1 Care seeking for the first time before death of the neonate by upazila ...... 45

Abbreviation and acronyms

MaMoni MaMoni to clinical and community maternal, neonatal and women’s health services ARI Acute Respiratory Infections BDHS Bangladesh Demographic and Health Survey BFS Bangladesh Fertility Survey BMMS Bangladesh Maternal Health Services and Maternal Mortality Survey FWV Family Welfare Visitor FWA Family Welfare Assistant AC ACCESS Counselor SACMO Sub-Assistant Community Medical Officer CHW Community Health Wotker ICDDR,B International Center for Diarrheal Disease Research, Bangladesh LBW Low Birth Weight MIS Management Information System PROJAHNMO Project for Advancing the Health of Newborns and Mothers RDW Recently Delivered Women SC-USA Save the Children-USA TT Tetanus Toxoid UHC Upazila Health Complex TBA Traditional Birth Attendant WHO World Health Organization ND Neonatal death SB Still-birth

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Executive Summary:

Back ground: Currently more than 50 percent deaths in children younger than 5 years are occurring in the first 28 days of life in Bangladesh (Bangladesh Demographic and Health Survey, 2007 report). Thus, to improve overall under 5 child mortality, it will be necessary to reduce the deaths in this age group. Early deaths are often associated with unsafe delivery practices and specific care practices need to be introduced and adopted. “MaMoni” is a USAID-funded programme in eight upazilas of Habiganj district of Bangladesh aimed at improving the health of mothers and newborns and reducing maternal and neonatal deaths through community interventions. “MaMoni” programme in Habiganj is being implemented by GoB field staff with the active support from Save the Children-USA in Bangladesh through two local NGOs (Shimantik & FIVDB). ICDDR,B was contracted by Save the Children-USA to assist the “MaMoni” programme in determining causes of neonatal deaths, and factors influencing neonatal deaths and care seeking prior to death.

Methods: All neonatal deaths and still-births were identified by interviewing around 18,000 sampled recently delivered women (pregnancy outcome period was May 2009–July 2010) in the eight upazilas of Habiganj. All neonatal deaths and still-births were investigated by interviewing mother of deceased children through a set of verbal autopsy questionnaire. It is very much pertaining to mention that the tool used in this verbal autopsy interview is the same as used in Sylhet during the ACCESS baseline survey in 2007-2008. Mothers or/and adult family members were interviewed using standard verbal autopsy (VA) questionnaires. All still-births and neonatal deaths over a 15 month period (May 2009-Jul 2010) were listed. A total of 360 still-births and 425 neonatal deaths were identified. All families with neonatal deaths and still-births were interviewed. Interviews were conducted during Sep–Dec 2010.

A semi-structured questionnaire was used for the verbal autopsy interview. This questionnaire has been adapted from WHO standard VA tool for use in Bangladesh and had been used in Projahnmo-Sylhet and ACCESS baseline in Sylhet, 2008. In 2005, an expert committee [WHO/JHU/AKU/SNL revised December 8, 2005] revised the WHO tool to improve the assignment of the cause of death of the neonates. The questionnaire was designed to be administered by trained lay data collectors, and collected information on events and symptoms and signs during the illness prior to death.

Findings: Interview results and characteristic of respondent: Families of a total of 425 neonatal deaths and 360 still-births were visited by the data collectors and interview completion rate was more than 99 percent. Mothers of the dead newborns were the usual respondent (99.5 percent) and in the remained 0.5 percent of cases other adult family members (father, aunt) provided the information. Around 56 percent of the respondents (neonatal deaths) were between 20-29 years old while it was 58 percent among respondents had still-births. 23 percent of the respondents of neonatal deaths were 30-39 years old while it was 26 percent among respondents had still-births. A little more than one-third of the respondents had no education while only 3-4 percent respondents had secondary or higher level of education in the both category.

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About half of the mothers did not receive any TT dose during their index pregnancy and 6-8 percent during their lifetime. A little less than one-fifth had received at least two doses of TT during index pregnancy and 87 percent during their lifetime among mothers whose newborns were died while it was 91 percent among mothers who had still-births. Around 60 percent mothers of Azmeriganj, Baniachong, Lakhai and Nabiganj did not receive any TT during their index pregnancy while it was less in the other four upazilas. Mothers received at least two doses of TT during their lifetime was highest in Sadar upazila (100 percent) and lowest in Bahubol (78 Percent).

Causes of neonatal deaths and geographical variation: More than one third of all neonatal deaths were due to birth asphyxia (37.4 percent), about one-fourths (27.1 percent) due to preterm, one-sixths (16.5 percent) due to sepsis or pneumonia, 2.6 percent due to neonatal tetanus, 6.4 percent due to congenital abnormality, 1.2 percent due to birth injury and cause of death of remaining 9 percent could not be determined. Neonatal deaths due to birth asphyxia were more prevalent (42-45 percent) in Sadar and Lakhai upazilas compared to 20 percent in Azmeriganj. Neonatal deaths due to preterm cause were high (36-42 percent) in Lakhai and Nabiganj upazilas compared to zero percent in Azmeriganj and 20 percent in Bahubol. Neonatal deaths due to sepsis/pneumonia was high (24 percent) in Bahubol compared to zero percent in Azmeriganj and 11 percent in Sadar. Neonatal deaths due to neonatal tetanus was very high (40 percent) in Azmeriganj compared to zero percent in Baniachong, Chunarughat and Lakhai. Similarly deaths due to congenital abnormality was high (40 percent) in Azmeriganj, 15 percent in Madhabpur and 9 percent in Sadar compared to 3-4 percent in other upazilas.

Risk factors of neonatal deaths by cause: While, overall 37 percent of the mothers of the dead neonates or still-births had no education, but this was more than half among mothers of newborns who died of sepsis/pneumonia and 40 percent who died of preterm. More than one-third of mothers (around 40 percent) of newborns dying due to congenital abnormality, birth asphyxia and birth-injury had education of class 5-9. Deliveries at home were more common (96 percent) in case of deaths due to sepsis/ pneumonia and around 80 percent in case of deaths due to congenital abnormality, preterm and birth asphyxia. Facility delivery was more common among deaths due to neonatal tetanus (one-third), birth injury (one-fifth) and birth asphyxia (one-sixth) as well as among still-births (22 percent). Among deaths due to birth asphyxia, about a fourth of the deliveries were attended by skilled birth attendant (SBA) while it was more than 50 percent among deaths due to neonatal tetanus. The rate of SBA attendance was only 15-20 percent for deaths due to all other causes except sepsis where it was only 4 percent. Instrumental delivery was high (4-7 percent) among deaths due to congenital abnormality and birth asphyxia, and caesarian section was highest among deaths due to neonatal tetanus (18 percent).

Overlapping causes of neonatal deaths: There was considerable overlap among the different causes of neonatal deaths. Eleven of the 11 deaths due to neonatal tetanus overlapped with sepsis and half of them also overlapped with birth asphyxia or birth injury. Around 73 percent of preterm deaths overlapped with birth asphyxia and 47 percent with sepsis. Birth asphyxia deaths overlapped with sepsis (45 percent) and preterm birth (34 percent), and neonatal deaths with sepsis overlapped with birth asphyxia (55 percent) and preterm birth (27 percent).

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Pregnancy and delivery complication of the mother: About a sixth of the mothers whose newborns had died reported no complications during pregnancy and delivery. Among deaths due to birth asphyxia, more than one third of the mothers had edema in hand and face, one third had breech presentation or child delivered by feet first and more than one fourth had prolonged labour. Among deaths due to preterm delivery, around one fourth had edema in hand/face and breech presentation, one fifth had bleeding during pregnancy or delivery and around 15 percent women had prolonged labour or stopped or less fetal movement. Among deaths due to sepsis/pneumonia, more than one third had edema in hands and face, and around one fourth reported had breech presentation and 17 percent had severe headache.

Timing of neonatal deaths: Neonatal deaths within 24 hours of birth were mostly from birth asphyxia, preterm and congenital abnormality. Around half of the birth asphyxia deaths occurred within 24 hours of birth and 79% within 72 hours. About half of preterm deaths were within 24 hours of birth and 64% within 72 hours. In contrast, only 1.4% of neonatal deaths due to sepsis/pneumonia were within 24 hours of birth. Around 60 percent of neonatal deaths due to sepsis happened between 7-28 days of birth.

Sex differentials in neonatal deaths: The overall male:female neonatal death ratio was 1.24:1. However, this was 1.33:1 for deaths due to preterm deliveries and 1.20:1 for birth asphyxia deaths. The male:female ratio among dead newborns was (1:1.01) among early neonatal deaths (within 7 days of birth), and it was reversed (1.04:1) among neonatal deaths occurring 7-28 days after birth.

Newborn health care seeking: 28 percent parents had considered that the illness was very serious among deaths happened within 24 hours of birth, this being somewhat higher (around 50 percent) among newborns who died on day 1-2 and 40 percent among newborn died within 3-28 days of birth. One third of all neonatal deaths were in day of birth and among them 38% died immediately, 39% did not seek care and the remaining 23% sought care. Eight percent sought care at home, mostly from village doctors. Of those who sought care from outside home (16%), around 6 percent went to the UHC/hospital/clinic and half to other places. Overall in the MaMoni area, 71 percent of all neonatal deaths occurred at home and 29 percent outside home. Almost all deaths occurring outside home were in various hospitals and clinics and a few on way to a health facility. Of all causes of neonatal deaths, deaths at home were least common for neonatal tetanus (27 percent), birth asphyxia (69 percent) and sepsis/pneumonia (69 percent).

Conclusion: The study has important findings for both research and health program planning. The burden of still-birth in the “MaMoni” area was relatively high, but better data collection methods are essential to more precisely define the burden of still-births, to track changes in still-birth and cause-specific neonatal deaths over time, and to evaluate the effect of health programs. Finally, more than half of all deaths occur by day-3 and four-fifths by day-7, which suggests that greater coverage of ante-partum including TT immunization, intra-partum and early postnatal interventions, in combination with promotion of care seeking behavior and links between communities and health facilities to ensure prompt treatment is important. A combination of community outreach and family-community care to promote essential neonatal care practices and health system strengthening should help to reduce neonatal mortality.

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Chapter-1: Background ------

1.1 MaMoni project in Habiganj, Bangladesh

Under the USAID’s global flagship programme MCHIP (Maternal, Child Health Integrated Program), MaMoni is a USAID associate award to partnership of several organizations including JHPIEGO Corporations and Save the Children, USA. MaMoni is a continuation of ACCESS project in Sylhet and is being implemented by Save the Children-USA in Bangladesh through two local NGOs in seven upazilas of Sylhet and all eight upazilas of Habiganj districts, aimed at improving the health of mothers and newborns. The MaMoni / Bangladesh program’s Strategic Objective is to increase the practice of healthy maternal and neonatal behaviours in a sustainable and potentially scalable manner. This Strategic Objective includes intermediate results - to increase knowledge, skills and practices of healthy maternal and neonatal behaviours in the home, to increase appropriate and timely utilization of home and facility- based essential maternal and neonatal health services, to improve key systems for effective service delivery, community mobilization and advocacy, to mobilize community action, support and demand for the practice of healthy maternal and neonatal behaviours, and to increase key stakeholder leadership, commitment and action for these maternal and neonatal health approaches including family planning. The implementation of the MaMoni intervention in Habiganj began in 2011. The primary components include services and counselling by GoB health workers (FWA and female HA) and MaMoni health workers where GoB position is vacant. Formation of community action groups through local initiative is currently under process.

Neonatal Mortality Rate (NMR) in the MaMoni area of Habiganj:

The baseline survey in MaMoni areas of Habiganj,2010 revealed that the early neonatal mortality rate was 22.7 deaths per thousand live births, late neonatal mortality rate was 5.7 deaths per thousand live births and neonatal mortality rate among newborns (0-28 days) was 28.4 per thousand live births.

1.2 Causes of neonatal deaths: The specific causes of neonatal mortality are usually difficult to determine as the majority of births occur at home and are unattended by health workers, and sick neonates often present with non-specific signs.4 The majority of neonatal deaths can be attributed to infectious diseases such as sepsis, pneumonia and tetanus; pregnancy-related complications such as prematurity; and delivery-related complications including intra-partum asphyxia and birth trauma.4 Risk factors for causes of neonatal mortality include low birth weight (LBW); poor status of maternal health and nutrition; malaria and untreated maternal infections; failure to fully immunize adolescent girls and pregnant women; inability to recognize severe illness in an infant; poor care-seeking behavior; and inadequate good quality medical care.2,5 Widespread poverty, illiteracy, and gender discrimination underlie these indirect and direct causes of morality.2 The high proportion of neonatal deaths attributed to infections (Figure 1.1) highlight the potential that antenatal care, safe delivery practices, postpartum care, early neonatal health interventions and case management can have to markedly improve neonatal survival.

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Data from Bangladesh on causes of Figure 1.1: Causes of neonatal deaths (global) neonatal deaths are limited. Two Source: World Health Organization, April 2005 nationwide verbal autopsy studies7,8 during Other N.Tetanus 1997-98 and 2001 provide data on the 7% 7% Congenital causes of mortality in children under five. abnormality However, because of the difficulty of 8% assigning a cause of death during the very Severe early neonatal period (0-2 days), these infection studies categorized all deaths 25% that occurred in the first 3 days of life as `early neonatal or pregnancy and delivery Preterm birth related’ deaths. Results indicate that an 27% estimated 50% of the neonatal deaths Diarrheal occurred in the first 3 days of life.7,8 The disease main known causes of mortality were 3% neonatal tetanus (17%), and acute lower Birth asphyxia respiratory infections (ALRIs) and 23% diarrhoea (which together account for about 19% of the deaths).7,8 Data thus suggest that about 36% of all neonatal deaths or about 72% of deaths in babies between 3-28 days old were due to infections. Deaths in the first three days of life where a cause of death could not be assigned could also be due to infections although birth asphyxia, birth injury, birth defects, low birth weight, and prematurity are likely important causes of these deaths. These estimates are not far from the global estimates by Stoll, which indicate that 30-40 percent of neonatal deaths are associated with infections.9 The most recent publication of the Bulletin of WHO15 (February 2009) shows the causes of neonatal mortality in the urban population of Karachi, Pakistan; preterm and low birth weight, birth asphyxia and infection contributed to three-fourths of total neonatal deaths and each of them had almost equal share.

According to the BDHS 2004 report,⁶ (Figure 1.2) the main causes of neonatal death in Bangladesh were possible severe infection (34%), birth asphyxia (21%), low birth weight and preterm (11%), acute respiratory infection (10%) and neonatal tetanus (4%).This was a nationwide survey and data were collected for the 5 years preceding the survey (mid-year was 2001). The neonatal mortality rate was 41 per 1000 live births.

Figure:1.2 Causes of Neonatal Deaths (source: BDHS 2004)

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Verbal autopsy interviews were part Diarrhea N.Tetanus 1% 4% Congenital abnormality of the baseline survey in three Undtermined 5% upazilas (Zakiganj, Beanibazar and 12% Preterm Kanaighat) of Sylhet district 9% (Projahnmo-1) during the year 2002 (Figure 1.3). A total of 350 neonatal deaths were analyzed to determine the primary causes of neonatal deaths Birth asphyxia and the parents/family were 19% interviewed. Almost half of all deaths were due to severe infection Sepsis/Pneumonia 46% (sepsis/pneumonia), one-fifth of them Birth injury were due to birth asphyxia, one-tenth 4% due to preterm births and 4.3% due to Figure 1.3: Causes of neonatal deaths neonatal tetanus. The overall neonatal (source: Baseline projahnmo-Sylhet 2002) mortality rate in this area in 2002 was 48 per 1000 live births.

Causes of neonatal deaths in Sylhet (ACCESS baseline 2007):

Neonatal mortality rate in the ACCESS-Sylhet area was 23.1 per thousand live-births, estimated in the baseline survey, 2007.

Causes of neonatal deaths (ACCESS Baseline, Sylhet 2007)

Congenital abnormality Undetermined 6% 5% Sepsis / Pneumonia 17% Birth injury 2%

N.Tetanus 3%

Preterm birth / LBW 30%

Birth Asphyxia Fig:1.4 Causes of neonatal deaths (Source: ACCESS baseline in Sylhet, 2007) 37%

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1.3 Chapter References:

1. IOM, Improving Birth Outcomes: Meeting the Challenge in the Developing World, ed. J. Bale, B. Stoll, and A. Lucas. 2004, Washington, D.C.: The National Academies Press. 2. Child Health Research Project. Reducing Perinatal and Neonatal Mortality. in Report of a Meeting. Baltimore, MD May 10-12, 1999: Johns Hopkins University. 3. Moss, W., et al., Research priorities for the reduction of perinatal and neonatal morbidity and mortality in developing country communities. J Perinatol, 2002. 22(6): p. 484-95. 4. WHO, Perinatal mortality: A listing of available information, in World Health Organization. 1996: Geneva, Switzerland. 5. Moss, W., et al., Research priorities for the reduction of perinatal and neonatal morbidity and mortality in developing country communities. J Perinatol, 2002. 22(6): p. 484-95. 6. NIPORT, MA, and MACRO, Bangladesh Demographic and Health Survey 2004, National Institute of Population Research and Training, Mitra and Associates, and ORC Macro: Dhaka, Bangladesh and Calverton, Maryland (USA). 7. Baqui, A., et al., Causes of Childhood Deaths in Bangladesh: Results of a Nationwide Verbal Autopsy Study. Bull World Health Organ, 1998. 76(2): p. 161-171. 8. Baqui, A., et al., Causes of Childhood Deaths in Bangladesh: an Update. Acta Paediatr, 2001 Jun;90 (6) :682-90 9. Stoll, B., The global impact of neonatal infection. Clin Perinatol, 1997. 1(24): p. 1-21. 10. Reingold, A.L. and C. Phares, Infectious Diseases. in Interational Public Health: Diseases, Programs, Systems and Policies, 2001. Editors: Merson MH, Black RE, Mills AJ. 11. Santosham, M., et al., Newborn Thermal Care Practices in Rural India: A community-based program to prevent and improve recognition and management of hypothermia. USAID Project Proposal, 2003. 12. Bergstrom, S., Perinatal health, in Health and disease in developing countries, S.B.P.H.M.M.P. Kari S. Lankinen, Editor. 1994, London, England, Macmillan Press. p. 287-296. 13. James V. Freeman Evaluation of neonatal verbal autopsy using physician review versus algorithm- based cause-of-death assignment in rural Nepal; 2005 Blackwell publishing Ltd. Paediatric and Perinatal epidemiology, 19, 323-331 14. Baqui A et.al Rates,timing and causes of neonatal deaths in rural India: implications for neonatal health programs; Bulletin of the World Health Organization, September 2006, 84 (9) 15. Jehan I et.al. Neonatal mortality, risk factors and causes : a prospective population-based cohort study in urban Pakistan. Bull World Health Organization. 2009 Feb;87(2): 130-8.

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Chapter-2 Methodology and Training of Verbal Autopsy Interview:

2.1: Area and Population:

MaMoni intervention area comprises all the eight upazilas (sub-district) of Habiganj district of the north eastern region of Bangladesh. The upazilas are Ajmiriganj, Bahubol, Baniachung, Lakhai, Nabiganj, Madhabpur, Chunarughat and Habiganj Sadar. The approximate population of Habiganj MaMoni area in 2010 was 1.9 million as projected from 2001 national census data (BBS).

Fig; 2.1 Map of Habiganj district

Table 2.1.1: Population by upazila, Habiganj (MaMoni)

Upaazila Population 2001 Growth rate (BBS census Projected Population of 2010 (source:National census,BBS) 2001) Ajmiriganj 99,294 1.35 110,538 Bahubal 167,265 1.99 195,824 Baniachung 268,606 1.31 298,081 Chunarughat 267,056 1.34 297,064 Sadar 275,074 2.01 322,546 Lakhai 120,677 0.9. 129,644 Madhabpur 272,578 0.87 292,137 Nabiganj 287,030 1.52 323,874 Total: 1,757,580 1,969,682

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2.2 Objectives of verbal autopsy

• To determine the cause of neonatal deaths and still-births • To examine care seeking patterns related to neonatal deaths and still-births

2.3 Implementation of verbal autopsy:

The responsibilities to implement the survey were shared between the MaMoni project of Save the Children- USA and ICDDR,B. ICDDR,B was mainly involved in designing the survey, data entry, analysis and reporting and the sample, planning, training, collection of data by ACPR.

Table 2.3.1: Distribution of role and responsibility of verbal autopsy interview in Habiganj (implementation period: Sep-Dec. 2010)

SERIAL # ACTIVITY ORGANIZATION 01 Design and sampling ICDDR,B 02 Development of verbal autopsy tools ICDDR,B 03 Listing of neonatal deaths & still-births ACPR 04 Organization of the training ACPR 05 Facilitation of staff training & micro-plan ICDDR,B 06 Data collection & supervision ACPR 07 Data editing and checking ACPR 08 Data entry, analysis and reporting ICDDR,B

2.4 Sample design: Mothers with still-births and neonatal deaths in all eight MaMoni upazilas of Habiganj district were identified by Data collectors of main survey team who were engaged to interview recently delivered women in those areas and recorded information of neonatal deaths and still-birth. All still-births and neonatal deaths over a 15 month period were listed. For the period May 2009–July 2010, there were 360 still-births and 425 neonatal deaths recorded by the ACPR data collectors. All families with neonatal deaths and still-births were interviewed by a separate cadre of team. Table 2.3.1 shows the distribution of the selected sample (425+360=785) by upazila, Habiganj.

Table 2.4.1: Distribution of samples of neonatal deaths and still-births by upazila, Habiganj

ACCESS Upazila Neonatal death Still-birth Total Identified by Verbal Identified by Verbal interviewed household interview Autopsy household interview Autopsy Ajmiriganj 5 5 7 7 12 Bahubal 41 41 32 31 72 Baniachong 79 79 59 59 138 Chunarughat 77 77 59 58 135 Habiganj 53 53 56 56 109 Lakhai 24 24 16 16 40 Madhabpur 68 68 53 53 121 Nabiganj 78 78 78 77 155 Total 425 425 360 357 782

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2.5 Data collection tools:

A semi-structured questionnaire was used for the verbal autopsy interviews in MaMoni, Habiganj. This verbal autopsy questionnaire was developed by an expert panel of WHO based on a three country verbal autopsy validation study.¹ The instrument was further adapted to the local context and was used in Bangladesh in the “Projahnmo-1” study in Sylhet in 2002. In 2003, an expert committee chaired by Dr. Gary L Darmstadt further revised the WHO tool to make it more sensitive to assigning causes of deaths among neonates. The tool used in the MaMoni verbal autopsy interview was adapted from this revised version (2003). The questionnaire (attached in Appendix-3) started with open-ended questions to elicit a narrative about the neonate’s death, followed by close-ended questions on specific signs and symptoms and care seeking during the illness that preceded the neonate’s death. To identify fresh still-births, respondents were asked to describe whether the baby’s flesh appeared normal. The questionnaire was translated from English into Bangla, and local terms for specific illness were used when appropriate. This tool was also used in the ACCESS baseline survey-2007 in Sylhet.

2.6 Training of Data Collectors:

All data collectors received a week long training (August 19-25, 2010) organized by ACPR in Dhaka, that included classroom lectures, role plays and field practice sessions. Three trainers from ICDDR,B facilitated the sessions and the field practice. A total of 16 data collectors, 4 Field supervisors, 2 MIS officers and 2 reviewers (1 from ICDDRB and 1 from ACPR) received training. During the first four days of training, all ten sections of the verbal autopsy questionnaire were discussed thoroughly and reviewed. On the fourth day, the total questionnaire was reviewed again and feedback from participants was noted. During the second half of the 4th day, role plays on interviews (one for still- birth and one for neonatal death) were conducted to orient the team on interview techniques and appropriate methods of filling-out the questionnaire. All participants and facilitators went to Savar area for field practice and interviewed mother of deceased (2 still-births and 3 neonatal deaths) on the fifth day. They made small groups of four and conducted interview. On sixth day, participants reviewed their completed questionnaires and discussed.

2.7 Data collection:

The verbal autopsy interviews were conducted from 23 September to 30 December, 2010.

2.7.1: Plan of data collection of verbal autopsy interviews. As soon as the data collector of main team identified any ND or SB, reported to her immediate supervisor for confirmation. Then the list went to the team leader to hand over to the VA team. This phenomenon was done within a week, so that VA team can seek help to the main team for the identification of the house/household. Interview of deceased mother or family member was completed almost subsequent to the main survey. A eighteen digit unique identification number was assigned for each neonatal death and still-birth for the purpose of verbal autopsy interview and these were derived from the MaMoni questionnaire; a two digit upazila code, Three digit union, four digit cluster code, four digit village code, three digit house code and two digit household code. Supervisors assigned the selected samples to the data collectors and completed the identification part of section-1 and date of birth and death of the child in section 4.11a and 4.11b of the questionnaire (attached in Appendix-3) from the respective face sheet of the main questionnaire. Priority was given and efforts 15 | P a g e

Final Report_Verbal Autopsy_MaMoni_Habiganj_2010 2010 were made to interview the mother. If the mother was found absent or unable to respond, an adult relative was chosen as the primary respondent who had the closest contact with the newborn during the terminal illness. Data collectors conducted the interviews in Bangla. The interviews lasted about an hour. All questionnaires and data forms were reviewed and edited by a medical officer of ICDDRB and one senior supervisor from ACPR for accuracy, consistency and completeness, and if necessary, the data collectors made additional field visits to verify data. All the edited questionnaires were then sent to the data entry unit of Child Health Unit, ICDDR,B Dhaka.

2.8 Data entry and analysis:

Data entry was done using Visual Basic 6.0 for data entry by the designated data management section of the Child Health Unit of ICDDR,B and stored in the SQL server 2005.

Still-births were defined as births after 28 weeks’ gestation that resulted in a baby that failed to cry, move, or breathe. All live births that resulted in deaths on days 0-28 after the birth were judged to be neonatal deaths. For each cause of death, definitions were selected from the WHO verbal autopsy validation study.¹ The cause of death ascertainment was done by using a computerized algorithm created with STATA (version 10). A variable was created for each factor and symptom used in the causal definitions, and the algorithm was applied uniformly for each death in a hierarchical manner as shown in Figure-5.1 of Chapter-5.

2.8 Reference:

1. AH Baqui, GL Darmstadt, EK Williams, V Kumar et al. Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes. Bulletin of the World Health Organization: September 2006; 84 (9)

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Chapter-3 Interview results and characteristics of respondents:

3.1 Interview result

A total of 425 neonatal deaths and 360 still-births were visited from 23 September to 30 December, 2010. Table 3.1.1 shows the result of interviews by upazila. Interview completion rate was 100 percent among neonatal deaths and 99 percent among still-births. In still-births, less than a percent of interviews did not take place due to absence of the entire household.

Table-3.1.1: Percent distribution of neonatal deaths and still-births by interview results and by upazila of Habiganj.

Visit status

Ajmiriganj Bahubal Baniachong Chunarughat Habiganj Lakhai Madhabpur Nabiganj Total Neonatal Death (N) 5 41 79 77 53 24 68 78 425 Completed interview 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No competent respondent was at 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 home Entire household absent 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Postponed 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Refused 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Dwelling vacant/destroyed /not 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 found Incorrect sample 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Still birth (N) 7 31 59 58 56 16 53 77 357 Completed interview 100.0 96.9 100.0 98.3 100.0 100.0 100.0 98.7 99.17 No competent respondent was at 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 home Entire household absent 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Postponed 0.0 3.1 0.0 1.7 0.0 0.0 0.0 1.3 0.8 Refused 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Dwelling vacant/destroyed /not 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 found Incorrect sample 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Others 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

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3.2 Relationship of the respondents to the deceased:

Table 3.2.1 shows the distribution of neonatal deaths and still-births by relationship of the respondent to the deceased. Almost all of the respondents for neonatal deaths and still-births were the mother of the deceased. In Baniachong, for neonatal death, ninety-eight percent of the respondents were mother of the descendant; this figure was slightly higher for Chunarughat comprises with ninety-nine percent of the respondent’s as mother of the descendants; while for other upazilla all the respondents were the mother in both the cases of neonatal death and still birth.

Table-3.2.1: Percent distribution of neonatal deaths and still-births by relationship of the respondent to the deceased and by upazila of Habiganj

Visit status

hunarughat

Ajmiriganj Bahubal Baniachong C Habiganj Lakhai Madhabpur Nabiganj Total Neonatal Death (N) 5 41 79 77 53 24 68 78 425 Mother 100.0 100.0 97.5 98.7 100.0 100.0 100.0 100.0 99.3 Father 0.0 0.0 1.3 0.0 0.0 0.0 0.0 0.0 0.2 Grandmother/father 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Aunt 0.0 0.0 1.3 1.3 0.0 0.0 0.0 0.0 0.5 Birth attendant: Trained 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Birth Attendant: Not Trained 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other male/female 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Still birth (N) 7 31 59 58 56 16 53 77 357 Mother 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Father 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Grandmother/father 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Aunt 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Birth attendant: Trained 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Birth Attendant: Not Trained 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other male/female 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

3.3 Age and level of education of the respondents:

Table 3.3.1 shows the distribution of neonatal deaths and still-births with regard to age and level of education of the respondents. Almost 57 percent of the respondents were in the age group of 20-29 years among neonatal deaths as well as still-births. The rate was high in Bahubol and Baniachong upazilas. Respondents of neonatal deaths aged less than 20 years were one-fifths of respondents for neonatal deaths while it was 13 percent among respondents of still-births. The ratio was high (more than 25 percent) in Chunarughat and Sadar upazilas for neonatal deaths and Lakhai upazila for still-births. Around one-fourth of all respondents of neonatal deaths and still-births were in the age group of 30-39 years while it was only 1-3 percent in the age group of 40+ years in the both category. A little more than one third of the total respondents in both the types had no education, one-fifths had primary level education and 38-39 percent of respondents had education level of class 5-9. Around three percent respondents of both the category had secondary or higher level of education. In Azmeriganj 18 | P a g e

Final Report_Verbal Autopsy_MaMoni_Habiganj_2010 2010 upazila around one-fifths respondent of neonatal deaths had no education while it was more than half (57 percent) among respondents of still-births. 44 percent of respondents of neonatal deaths in Baniachong upazila had no education while it was 54 percent among respondents of still-births. Ratio of respondents for neonatal deaths had secondary or more level of education was high (around 10 percent) in Madhabpur upazila and 7 percent respondents for still-births had secondary or higher level of education in Sadar upazila.

Table-3.3.1: Percent distribution of neonatal deaths and still-births by age and education of the respondent and by upazila of Habiganj.

Visit status

Ajmiriganj Bahubal Baniachong Chunarughat Habiganj Lakhai Madhabpur Nabiganj Total Neonatal deaths (N) 5 41 79 77 53 24 68 78 425 Age category <20 20.0 12.2 8.9 27.3 28.3 8.3 25.0 16.7 19.1 20-29 40.0 68.3 60.8 52.0 50.9 54.2 54.4 56.4 56.2 30-39 40.0 19.5 27.9 18.2 20.8 37.5 20.6 21.8 22.8 40+ 0.0 0.0 0.0 1.3 0.0 0.0 0.0 5.1 1.2 Unknown 0.0 0.0 2.5 1.3 0.0 0.0 0.0 0.0 0.7 Level of education No education 20.0 39.0 44.3 42.9 34.0 37.5 33.8 30.8 37.4 Primary 40.0 14.6 27.9 18.2 17.0 20.8 16.2 21.8 20.2 Class 5-9 40.0 46.3 22.8 32.5 45.3 41.7 39.7 46.2 37.9 Class 10+ 0.0 0.0 2.5 3.9 3.8 0.0 10.3 1.3 3.5 Unknown 0.0 0.0 2.5 2.6 0.0 0.0 0.0 0.0 0.9

Still birth (N) 7 31 59 58 56 16 53 77 357 Age category <20 14.3 12.9 11.9 19.0 8.9 25.0 20.8 5.2 13.2 20-29 28.6 58.1 49.2 60.3 57.1 50.0 60.4 64.9 57.7 30-39 42.9 25.8 33.9 20.7 33.9 25.0 13.2 27.3 26.3 40+ 14.3 3.2 5.1 0.0 0.0 0.0 5.7 2.6 2.8 Level of education No education 57.1 38.7 54.2 34.5 23.2 37.5 28.3 35.1 36.1 Primary 14.3 29.0 17.0 19.0 19.6 12.5 35.9 18.2 21.6 Class 5-9 28.6 29.0 25.4 43.1 50.0 50.0 34.0 45.5 39.2 Class 10+ 0.0 3.2 3.4 3.5 7.1 0.0 1.9 1.3 3.1

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Chapter-4 Maternal and delivery care and conditions:

Maternal complications during pregnancy and delivery can severely impact neonatal health outcomes. It is expected that antenatal care (ANC), safe delivery practices and postpartum care of mothers – the three pillars of safe motherhood program strategies – can significantly improve neonatal and maternal health and survival.

4.1 Tetanus Toxoid (TT) vaccination of the mother:

Administration of Tetanus toxoid (TT) vaccination is an essential component of antenatal care (ANC). Table 4.1.1 shows the status of TT immunization of the mother of the deceased during their index pregnancy and lifetime coverage.

Neonatal death:

Around half of the mothers of the deceased did not receive any TT dose during their index pregnancy and around eight percent did not receive any TT during their lifetime. Therefore, at least 8 percent of the mothers were totally unimmunized and their newborns were not protected from neonatal tetanus. Similarly, 18 percent of mothers had received at least two doses of TT during the index pregnancy and their newborns were assumed to be protected from neonatal tetanus. Around 17 percent mothers from Bahubol upazila reported not received any TT vaccination during lifetime while cent percent mothers reported received at least one dose of TT during lifetime in Azmeriganj and Sadar. Around 60 percent mothers reported not received any TT vaccination during index pregnancy in Azmeriganj, Baniachong, Lakhai and Nabiganj while the rate was 40 percent in Bahubal and Chunarughat. On the other hand, 58 percent of mothers received five or more doses of TT vaccination during their lifetime and the rate were high in Sadar (76 percent) and Chunarughat (71 percent) while it was low in Baniachong (35 percent) and Azmeriganj (40 percent).

Still-birth:

Among stillbirths, around half of the mothers reported not receiving any TT dose during their index pregnancy and the rate was more than 70 percent in Azmeriganj. On the other hand 61 percent of mothers received five or more doses of TT and only 6 percent did not receive any TT during lifetime. Percentage of mothers received 5 or more doses of TT during lifetime were high in Madhabpur (77 percent), Bahubol (68 percent) and Chunarughat (66 percent) while the rate were low in Azmeriganj (29 percent) and Lakhai (31 percent).

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Table-4.1.1: Percent distribution of neonatal deaths and still-births by TT immunization status of the mother of the deceased (index pregnancy and lifetime) by upazila of Habiganj.

Visit status

Ajmiriganj Bahubal Baniachong Chunarughat Habiganj Lakhai Madhabpur Nabiganj Total Neonatal deaths (N) 5 41 79 77 53 24 68 78 425 During index pregnancy No TT dose received 60.0 41.5 58.2 40.3 49.1 58.3 51.5 59.0 51.3 1 dose received 40.0 29.3 29.1 31.2 35.9 25.0 30.9 32.1 31.1 2 doses received 0.0 29.3 12.7 28.6 15.1 16.7 17.7 9.0 17.7 During lifetime No TT dose received 0.0 17.1 12.7 3.9 0.0 8.3 8.8 6.4 7.8 1 dose received 20.0 4.9 10.1 3.9 0.0 4.2 0.0 6.4 4.7 2 doses received 40.0 7.3 15.2 6.5 5.7 16.7 10.3 11.5 10.6 3 doses received 0.0 4.9 13.9 3.9 9.4 12.5 10.3 2.6 7.8 4 doses received 0.0 12.2 12.7 10.4 9.4 12.5 11.8 12.8 11.5 5 or more doses received 40.0 53.7 35.4 71.4 75.5 45.8 58.8 60.3 57.7

Still birth (N) 7 31 59 58 56 16 53 77 357 During index pregnancy No TT dose received 71.4 48.4 55.9 36.2 55.4 43.8 54.7 54.6 51.3 1 dose received 14.3 35.5 33.9 37.9 25.0 31.3 18.9 32.5 30.3 2 doses received 14.3 16.1 10.2 25.9 19.6 25.0 26.4 13.0 18.5 During life time No TT dose received 0.0 3.2 13.6 3.5 5.4 6.3 3.8 6.5 6.2 1 dose received 0.0 9.7 5.1 1.7 1.8 12.5 0.0 0.0 2.8 2 doses received 0.0 12.9 3.4 8.6 1.8 18.8 1.9 3.9 5.3 3 doses received 42.9 6.5 23.7 6.9 12.5 12.5 11.3 13.0 13.5 4 doses received 28.6 0.0 6.8 13.8 17.9 18.8 5.7 15.6 11.8 5 or more doses received 28.6 67.7 47.5 65.5 60.7 31.3 77.4 61.0 60.5

Table 4.1.2 shows the percentage of women who received TT vaccination by number of doses during their lifetime among those did not receive any TT during their index pregnancy. It shows that in the case of neonatal deaths, 218 (around 51 percent) mothers did not receive TT during index pregnancy but of these mothers 176 (80 percent) received two doses or more and 120 (55 percent) received 5 doses or more during their lifetime period (before index pregnancy). We can conclude that, 42 (10 percent) mothers out of 425 received only one dose or no doses of TT during their lifetime and can be considered unimmunized; thus their newborns were not protected from neonatal tetanus. The percentage of non- immunized mothers was high in Bahubol (41 percent) and in Azmeriganj (33 percent) while low in Sadar (0 percent) and Chunarughat (13 percent).

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Table 4.1.2: Percent distribution of women with their lifetime TT immunization status among those who did not receive any TT dose during the index pregnancy.

Visit status

Ajmiriganj Bahubal Baniachong Chunarughat Habiganj Lakhai Madhabpur Nabiganj Total Neonatal deaths (N) 3 17 46 31 26 14 35 46 218 No TT dose received 0.0 41.2 21.7 9.7 0.0 14.3 17.1 10.9 15.1 1 dose received 33.3 0.0 8.7 3.2 0.0 7.1 0.0 4.4 4.1 2 doses received 0.0 5.9 13.0 12.9 7.7 7.1 2.9 15.2 10.1 3 doses received 0.0 0.0 8.7 0.0 11.5 21.4 14.3 4.4 7.8 4 doses received 0.0 5.9 8.7 6.5 0.0 14.3 11.4 8.7 7.8 5 or more doses received 66.7 47.1 39.1 67.7 80.8 35.7 54.3 56.5 55.1

We have analyzed data TT vaccination coverage of 54 women (mothers) including validation of TT doses and protection status of the newborn from neonatal tetanus and detail information were pulled from the main data file of KPC questionnaire. Table 4.1.3 shows that 87 percent mothers received two doses, 82 percent received three doses, 63 percent four doses and 43 percent five valid doses of TT vaccination during lifetime. Result has shown that there was 15 percent point less coverage of five doses of valid TT vaccination compare to any five or more doses of TT vaccination among mothers of deceased children (neonatal deaths).

Table 4.1.3: Percent distribution of women received valid doses of TT (from card and history) during their lifetime by upazila, Habiganj

Schedule of validity: Dose Minimum dose interval TT-1 - TT-2 4 weeks from TT-1 TT-3 6 months from TT-2 TT-4 1 year from TT-3 TT-5 1 year from TT-4

Upazila TT-2 TT-3 TT-4 TT-5 N= Card + history Card + history Card + history Card + history

Azmeriganj 1 100.0 100.0 100.0 100.0 Bahubol 6 50.0 33.3 16.7 16.7 Baniachang 15 93.3 80.0 66.7 46.7 Chunarughat 11 90.9 90.9 72.7 45.5 Sadar 2 100.0 100.0 100.0 100.0 Lakhai 3 66.7 66.7 33.3 33.3 Madhabpur 6 100.0 100.0 66.7 0.0 Nabiganj 10 90.0 90.0 70.0 60.0 Total 54 87.0 81.5 63.0 42.6

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Table 4.1.4 shows the percentage of neonates who were protected from neonatal tetanus. We could able to pull data of 54 women out of 425 from the main data file, which shows that overall eighty three percent of neonates were found to be protected in the MaMoni area of Habiganj, with the highest percentage being in Azmeriganj, Sadar and Madhabpur (100 percent); around 90 percent in Chunarughat and Nabiganj and the lowest in Bahubol (33 percent).

Table 4.1.4: Percentage of children born protected from neonatal tetanus among live-births during last pregnancies by upazila, Habiganj.

Protection schedule: Valid Dose Protection level TT-1 No protection TT-2 3 years TT-3 5 years TT-4 10 years TT-5 life long If Mother received only 2 doses of TT and received TT-2 within 3 years before last delivery then the newborn is considered as protected. If the Mother received 3 doses of TT and received TT-3 within 5 years before the last delivery then the child is considered protected and so on.

Newborn was protected from tetanus (calculated Live-births Upazila from date of birth of newborn) N= % Azmeriganj 1 100.0 Bahubol 6 33.3 Baniachang 15 86.7 Chunarughat 11 90.9 Sadar 2 100.0 Lakhai 3 66.7 Madhabpur 6 100.0 Nabiganj 10 90.0 Total: 54 83.3

4.2 Delivery condition: Table 4.2.1 shows three-fourths of women with both neonatal deaths and still birth had a normal duration of pregnancy. Preterm delivery was similar among neonatal deaths and among still-births and around one fourth of thw women from each category reported such. Preterm deliveries were most frequent in Nabiganj (37 percent) and there was no preterm birth in Ajmeriganj among neonatal deaths, while among still birth pre-term delivery was most common in Chunarughat (38 percent) and least in Lakhai (6 percent) Two thirds women who had a neonatal death reported rupture of the membrane before delivery, one- fifths reported rupture before labour pain started and in the 15 percent of cases the water never broke. Among still-births, 58 percent of women reported rupture of the membrane before delivery, 17 percent before labour pain started and around one-fourths reported that their water never broke. Apart from the low neonatal death reported in Ajmeriganj, there were no significant differences in timing of the rupture membrane across upazillas.

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One-sixths women who had a neonatal death reported had labour pain for more than 12 hours, four-fifths had labour pain for 7-12 hours and 5 percent had less than an hour of pains. Amongst women who had a still birth, one fifth had labour pains for more than 12 hours, around three-fourths had labour pains for 7- 12 hours and 6 percent had less than an hour. In case of neonatal deaths, around one-fifth of the women reported prolonged labour (more than 12 hours) from each of Sadar, Bahubol and Madhabpur. Amongst women who had still-births, a little more than one third of women in Lakhai and 30 percent in Madhabpur reported prolonged labour (more than 12 hours).

Table-4.2.1: Percent distribution of neonatal deaths and still-births by duration of pregnancy, timing of rupture of membrane and duration of labour pain and by upazila of Habiganj.

Visit status

Ajmiriganj Bahubal Baniachong Chunarughat Habiganj Lakhai Madhabpur Nabiganj Total Neonatal deaths (N) 5 41 79 77 53 24 68 78 425 Duration of pregnancy: <7 months 0.0 0.0 0.0 0.0 0.0 0.0 2.9 0.0 0.5 7 -8 months 0.0 17.1 19.0 23.4 24.5 33.3 23.5 37.2 24.9 9-10 months 100.0 82.9 81.0 76.6 75.5 66.7 73.5 62.8 74.6 Timing of rupture of membrane: Before labour pain 60.0 14.6 12.7 7.8 26.4 12.5 23.5 30.8 19.3 Before delivery 0.0 75.6 63.3 84.4 56.6 54.2 63.2 61.5 65.9 Water did not break 40.0 9.8 24.1 7.8 17.0 33.3 11.8 7.7 14.6 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 1.5 0.0 0.2 Duration of labour pain: Less then 1 hour 0.0 7.3 3.8 2.6 7.6 4.2 7.4 1.3 4.5 1 to 6 hours 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 7 to 12 hours 100.0 70.7 87.3 90.9 73.6 75.0 72.1 80.8 80.5 More than 12 hours 0.0 22.0 8.9 6.5 18.9 16.7 20.6 16.7 14.6 Missing 0.0 0.0 0.0 0.0 0.0 4.2 0.0 1.3 0.5

Still birth (N) 7 31 59 58 56 16 53 77 357 Duration of pregnancy: <7 months 0.0 0.0 0.0 1.7 0.0 0.0 0.0 0.0 0.3 7 -8 months 14.3 29.0 22.0 36.2 17.9 6.3 22.6 26.0 24.4 9-10 months 85.7 71.0 78.0 62.1 82.1 93.8 75.5 72.7 74.8 Missing 0.0 0.0 0.0 0.0 0.0 0.0 1.9 1.3 0.6 Timing of rupture of membrane: Before labour pain 14.3 9.7 13.6 15.5 21.4 6.3 26.4 18.2 17.4 Before delivery 57.1 77.4 64.4 67.2 46.4 62.5 52.8 50.7 58.3 Water did not break 28.6 12.9 22.0 17.2 32.1 31.3 20.8 27.3 23.5 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3.9 0.8 Duration of labour pain: Less then 1 hour 0.0 3.2 8.5 3.5 10.7 6.3 7.6 3.9 6.2 1 to 6 hours 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 7 to 12 hours 100.0 71.0 81.4 70.7 76.8 56.3 60.4 75.3 72.8 More than 12 hours 0.0 22.6 10.2 22.4 10.7 37.5 30.2 20.8 19.6 Missing 0.0 3.2 0.0 3.5 1.8 0.0 1.9 0.0 1.4

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Chapter-5 Causes of neonatal deaths: ------

Three direct causes of death; infections i.e. pneumonia/sepsis, diarrhea, and tetanus (36 percent), preterm birth (27 percent), and asphyxia (23 percent) account for the majority of neonatal deaths globally for the year 2000, based on vital registration data for 45 countries and modeled estimates for 147 countries.1 Causes of death vary between the early and late neonatal periods, with deaths caused by preterm birth, asphyxia, and congenital defects occurring predominantly during the first week of life and infection being the major cause of neonatal deaths thereafter. Neonatal tetanus accounts for a smaller proportion of deaths (7%), but is easily preventable. Low birth weight is an important indirect cause of death.1 Variation in causes of neonatal death is seen between and within countries, closely associated with the NMR level. Where the NMR is high (more than 45 per 1,000 live births), more than half of neonatal deaths are due to infections; where the NMR is low, prematurity and congenital abnormalities are the major causes of death.1 Hence, information regarding the local epidemiology is important in prioritizing interventions. An estimated 20 million low birth-weight (LBW) infants (that is, weighing less than 2,500 grams), are born each year—25 percent of them in South Asia.53 Although globally only 16 percent of newborns have LBW, 60 to 80 percent of neonatal deaths occur in LBW infants.7 LBW is due to short gestation (preterm birth), intrauterine growth restriction (IUGR), or both. Globally, almost one-third of neonatal deaths are directly attributable to preterm birth. Prematurity and full-term IUGR are also indirect causes or risk factors for neonatal deaths, particularly deaths resulting from infection. The relative risk among preterm infants is much higher than for full-term IUGR infants.54 Complex technology is not necessary to avoid most deaths in moderately preterm newborns. Extra attention to warmth and feeding and to prevention or early treatment of infections is crucial.55Maternal health and health care are important determinants of neonatal survival. In general, intra-partum risk factors are associated with greater increases in risk of neonatal death than factors identified during pregnancy, which are in turn associated with greater increases in risk than pre-pregnancy factors.1 Delays in access to care for severely ill young infants are common. In a study in Uganda, find that almost 80 percent of the caregivers of severely ill young infants did not comply with recommended referrals to a health facility.56The reason given in 90 percent of the cases was lack of money, underscoring the need for pro-poor financing mechanisms and promotion of community demand for care. This recalls the "three delays" model for maternal deaths, which outlines delays in recognition of illness and in access to care and provision of care once at a health facility.57 Poverty is the root cause of many maternal and neonatal deaths, either because it increases the prevalence of risk factors such as maternal infections or because it reduces access to care. Deliberate programmatic focus is required to ensure that care reaches poor families.

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5.1 Causes of neonatal death in the “MaMoni” area of Habiganj:

Verbal autopsy is considered the only practicable method for assignment of causes of neonatal deaths in settings such as Bangladesh; however the method has its limitations.8,20,22 For example, there are inherent problems in certain case definitions. For each cause of death, used the definitions selected from the WHO verbal autopsy validation study.22 A single cause of death was assigned by application of definitions in a hierarchical manner as shown in Fig:5.1. This cause of death ascertainment was done with use of a computer algorithm created with Stata software (version-10). A variable was created for each factor and symptom used in the causal definitions, and the algorithm applied the cause of death definitions uniformly for each death. Birth asphyxia and birth injury were initially reported separately, but later they were grouped because of their common underlying causes and because they had been in previous studies.23-25 Symptoms of respiratory illness are thought to be difficult to elicit from verbal autopsy interview 20,25,26 and the definition of sepsis or pneumonia used here could include both viral and bacterial infections of various etiologies. Likewise, the definition used for preterm birth (“baby very small or smaller than usual”) is subjective, but is the only validated, feasible definition currently available in this setting, given that neonates are seldom weighed after birth and most women do not have access antenatal care. This definition may also include low-birth weight (LBW) neonates,22 but preterm birth is generally attributed as a direct cause of death, while LBW is considered a risk factor or underlying condition. No standard definition of birth asphyxia exists, particularly at community level although the definition used here is “age at death ≤7 days and not able to cry after birth or not able to breathe after birth or not able to suckle after birth” and this definition was found to have more than 70 percent sensitivity and specificity in Bangladesh.22,25 The proportion of deaths assigned to some causes, particularly sepsis/pneumonia or prematurity, is highly dependent upon their placement within the hierarchy. When multiple causes of death are examined, substantial overlap is observed. Since birth asphyxia usually occurs in term infants weighing >2000g,28 the overlap between birth asphyxia and preterm birth is probably the result of misclassification. (Table 5.1.1)

Figure 5.1 shows the hierarchy used to assign primary cause of death. Two- thirds of neonatal deaths were due to preterm birth (27.1 percent) and birth asphyxia (37.4 percent). Seventeen percent of deaths were due to sepsis/pneumonia/multiple signs and 6.4 percent due to congenital abnormality, 1.2 percent due to birth injury and 2.6 percent due to neonatal tetanus. Causes of neonatal deaths for 9 percent cases remained undetermined.

If the order of hierarchy is changed, (Annexure-1), shows increased percentage of deaths due to birth asphyxia (37 to 57 percent) and Sepsis/pneumonia (17 to 21 percent) while deaths due to preterm has reduced from 27 percent to 3 percent.

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Figure: 5.1 Cause of neonatal death in the “MaMoni” area of Habiganj by algorithm and hierarchy used to assign primary cause of death

425 Neonatal deaths

Tetanus: Age at death 3-27 days AND EITHER local word for Congenital abnormality: tetanus OR convulsion / spasm and able to suck or Physical malformation or gross cry normally after birth and stop sucking or crying malformation present at birth 11 (2.6%) deaths 27 (6.4%) deaths

N = 387

Preterm: Pregnancy ended early or baby very small 115 (27.1%) deaths

N = 272

Birth asphyxia: Age at death ≤ 7 days AND (not able to cry or breathe after birth or not able to suckle normally after birth) 159 (37.4%) deaths

N = 113

Birth injury: Age at death ≤ 7 days AND signs of injury at birth 5 (1.2%) deaths

N = 108

Sepsis or pneumonia: At least two of the following signs- • Stopped suckling • Fever or cold to touch • Unresponsive or unconscious or lethargic • Bulging fontanelle • Convulsion • Vomiting • Redness or drainage from the umbilical cord • Skin bumps containing puss or blisters or single large area of pus with swelling • Chest in drawing • Fast breathing or local term for pneumonia 70 (16.5%) deaths

N = 38

Diarrhoea: Local term for diarrhea or frequent/ watery/ loose stool 0 (0.0%) death

27 | P a g e Cause not identified: 38 (8.9%) deaths Final Report_Verbal Autopsy_MaMoni_Habiganj_2010 2010

Figure 5.2: Causes of Neonatal deaths in the MaMoni Habiganj (in percentage); N=425

Overlapping causes of neonatal deaths: There was much overlapping of different causes of neonatal deaths if hierarchy is ignored and multiple causes are allowed (Table 5.1.1). No deaths among a total of 11 deaths due to only neonatal tetanus, all the deaths overlapped with sepsis and half of them also overlapped with birth asphyxia or injury. Only one out of eleven is overlapped with other causes apart from preterm birth, Birth asphyxia, sepsis or Pneumonia. In case of preterm birth, only 11 percent of a total of 128 had no overlapping and around 73 percent of total preterm deaths markedly overlapped with each of birth asphyxia/injury. Slightly less than half of the preterm birth cases were overlapped with sepsis or pneumonia. Among 273 cases with Birth asphyxia, one in three had no overlapping with other causes of death but significantly overlapped with sepsis (45 percent) and preterm birth (34 percent). Among all neonatal deaths, 52 percent were matched with sepsis as per the algorithm used and 31 percent had no overlapping with other causes but markedly overlapped with birth asphyxia (55 percent) and preterm birth (27 percent). Moreover around 5 percent of the cases were overlapped with neonatal Tetanus.

Table 5.1.1: Proportion of cases with overlap between causes of death if multiple causes are assigned, ignoring hierarchy.

Cause of death All deaths Overlap with other cause No overlap N=425 Tetanus Preterm Birth asphyxia Sepsis or Other with cause (%) birth (%) / injury (%) pneumonia (%) cause* (%) (%) Tetanus 11 - 0 6 11 1 0 (2.6) (0.0) (54.6) (100.0) (9.1) (0.0) Preterm birth 128 0 - 93 60 13 14 (30.1) (0.0) (72.7) (46.9) (10.2) (10.9) Birth asphyxia/ 273 6 93 - 123 23 88 injury (64.2) (2.2) (34.1) (45.1) (8.1) (32.2) Sepsis or 222 11 60 123 - 13 70 Pneumonia (52.2) (5.0) (27.0) (55.4) (5.9) (31.5) *Other cause includes Congenital abnormality or diarrhoea

Table 5.1.2 shows the distribution of causes of neonatal deaths by upazila. Overall, around 3 percent of all neonatal deaths were due to neonatal tetanus and 6 percent due to congenital abnormalities. There was no death due to neonatal tetanus and congenital abnormality in Lakhai upazila. Around one-fourth of all neonatal deaths were due to preterm and it was high in Lakhai (42 percent) and Nabiganj (32 percent) while there was no death due to preterm cause in Azmeriganj. Around one percent neonatal death due to birth injuries. Birth asphyxia was the predominant cause of neonatal deaths and more than one third of

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Final Report_Verbal Autopsy_MaMoni_Habiganj_2010 2010 total deaths were due to birth asphyxia and the distribution of rate of birth asphyxia was almost similar across the upazilas except Azmeriganj (20 percent). Seventeen percent of neonatal deaths were due to sepsis/pneumonia, while it was highest in Bahubal (24 percent) and lowest in Sadar(11 percent) apart from the fact that very low neonatal death was observed in Ajmiriganj. There was no death from diarrhea and 9 percenmt of deaths remained undetermined.

Table-5.1.2: Percent distribution of neonatal deaths by cause and still-births by type in the MAMONI

upazilas of Habiganj

Visit status

Ajmiriganj Bahubal Baniachong Chunarughat Habiganj Lakhai Madhabpur Nabiganj Total Neonatal deaths (N) 5 41 79 77 53 24 68 78 425 Cause of death: Neonatal Tetanus 40.0 4.9 0.0 0.0 3.8 0.0 4.4 2.6 2.6 Congenital abnormality 40.0 2.4 3.8 3.9 9.4 0.0 14.7 3.9 6.4 Preterm 0.0 19.5 26.6 23.4 26.4 41.7 23.5 35.9 27.1 Birth Asphyxia 20.0 34.2 35.4 39.0 45.3 41.7 36.8 34.6 37.4 Birth injury 0.0 2.4 2.5 1.3 0.0 0.0 1.5 0.0 1.2 Sepsis / Pneumonia 0.0 24.4 19.0 16.9 11.3 12.5 16.2 15.4 16.5 Diarrhea 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Undetermined 0.0 12.2 12.7 15.6 3.8 4.2 2.9 7.7 8.9

Still birth (N) 7 31 59 58 56 16 53 77 357 Macerated* 14.3 45.2 11.9 46.6 21.4 68.8 39.6 42.9 35.3 Fresh** 85.7 54.8 86.4 53.5 76.8 31.3 60.4 55.8 63.9 Don’t know 0.0 0.0 1.7 0.0 1.8 0.0 0.0 1.3 0.8

5.2 Key maternal characteristics and intervention coverage:

There were total 11 deaths due to neonatal tetanus in the MaMoni area of Habiganj. There was no death due to neonatal tetanus in Baniachong, Chunarughat and Lakhai upazilas but 3 deaths from Azmeriganj and 2 deaths from each of other four upazilas. Table 5.2.1 shows the proportions of deaths from neonatal tetanus for the overall Habiganj district. Since we do not have data for all 11 women, so it would be difficult to conclude what percentage of newborn actually had protection from neonatal tetanus and therefore problematic to explain the neonatal deaths in relation to the TT immunization status of the mother. Although we have got detail TT vaccination report of the mother and newborn protection in case of two neonatal deaths which were due to neonatal tetanus (by hierarchy) and found protected from neonatal tetanus. Table 5.2.1: Proportion of neonates died from neonatal tetanus and other causes by status of TT immunization of the mother of the deceased.

A. Overall MAMONI area Lifetime TT vaccination status TT (0-1 dose) TT (2+ doses) Total Death due to Neonatal tetanus 1 10 11 Death due to other causes 52 362 414 Total 53 (12.5%) 372 (87.4%) 425

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Table-5.2.2: Percent distribution of cause-specific neonatal deaths and still-births by maternal age and education, place of delivery, type of birth attendant, mode of delivery, size of the newborn at birth, timing of neonatal death and whether multiple/single birth.

Visit status

Neonatal Neonatal Tetanus Congenital abnormality Preterm Birth Asphyxia injury Birth / Sepsis Pneumonia Undetermined TOTAL Birth Still Neonatal deaths (N) 11 27 115 159 5 70 38 425 357 Maternal age (years) <20 36.4 14.8 14.8 26.4 0.0 10.0 18.4 19.1 13.2 20-29 36.4 48.2 56.5 54.1 80.0 68.6 50.0 56.2 57.7 30-39 27.3 29.6 27.8 17.6 20.0 20.0 29.0 22.8 26.3 40 + 0.0 3.7 0.9 1.3 0.0 0.0 2.6 1.2 2.8 Missing 0.0 3.7 0.0 0.6 0.0 1.4 0.0 0.7 0.0 Maternal education No education 9.1 33.3 39.1 32.1 20.0 51.4 42.1 37.4 36.1 Primary 27.3 3.7 22.6 20.1 20.0 18.6 26.3 20.2 21.6 Class 5 – 9 63.6 48.2 37.4 40.9 40.0 28.6 29.0 37.9 39.2 Class 10+ 0.0 11.1 0.9 6.3 20.0 0.0 0.0 3.5 3.1 Unknown 0.0 3.7 0.0 0.6 0.0 1.4 2.6 0.9 0.0 Place of Delivery Home 54.6 85.2 78.3 79.9 60.0 95.7 92.1 82.6 67.8 Health facility 36.4 14.8 13.9 15.7 20.0 4.3 7.9 13.2 21.6 Other places 9.1 0.0 7.8 4.4 20.0 0.0 0.0 4.2 10.6 Type of birth attendant Skilled birth attendant* 54.6 14.8 23.5 26.4 40.0 4.3 10.5 20.7 35.0 Other health professional** 0.0 0.0 0.9 0.0 0.0 0.0 0.0 0.2 0.0 TBA/TTBA 36.4 77.8 66.1 68.6 60.0 88.6 86.8 72.5 57.7 Family members/relatives 0.0 7.4 2.6 2.5 0.0 1.4 2.6 2.6 3.4 No one 0.0 0.0 7.0 1.3 0.0 4.3 0.0 3.1 3.4 Others*** 9.1 0.0 0.0 1.3 0.0 1.4 0.0 0.9 0.6 Mode of delivery Normal delivery ( without any help) 36.4 55.6 69.6 49.7 40.0 62.9 76.3 59.5 48.2 Normal delivery (with manipulation) 27.3 37.0 26.1 36.5 60.0 35.7 18.4 32.0 42.0 Instrumental (vacuum or forceps) 0.0 0.0 0.9 1.9 0.0 0.0 2.6 1.2 1.4 Failed instrumental + C-section 0.0 7.4 1.7 2.5 0.0 0.0 0.0 1.9 2.5 C-section (alone) 18.2 0.0 1.7 6.9 0.0 1.4 2.6 4.0 4.2 Others 18.2 0.0 0.0 2.5 0.0 0.0 0.0 1.4 1.7 Size of the newborn at birth Very small 0.0 33.3 47.0 0.0 0.0 0.0 0.0 14.8 8.1 Smaller than normal 18.2 11.1 28.7 10.7 40.0 18.6 15.8 17.9 11.5 Normal 54.6 51.9 23.5 66.7 60.0 72.9 73.7 55.3 61.9 Bigger than normal size 27.3 3.7 0.9 22.6 0.0 8.6 10.5 12.0 18.2 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3 Timing of neonatal deaths Early (0-6 days) 72.7 88.9 86.0 95.6 100.0 41.4 57.9 79.7 - Late (7-28 days) 27.3 11.1 14.0 4.4 0.0 58.6 42.1 20.3 - Outcome ( # babies delivered) Single 100.0 74.1 81.7 90.6 100.0 94.3 86.8 87.8 93.3 Multiple 0.0 25.9 18.3 9.4 0.0 5.7 13.2 12.2 6.7

Type of Birth attendant: *Skilled birth attendant: MBBS doctor, Nurse, Midwife, Paramedic and FWV **Other health professional: HA, FWA, AC or SACMO *** Others: Neighbor, friend, Traditional healers including quack/village doctor and others

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Table 5.2.2 shows the distribution of neonatal deaths and still-births by maternal age (by age category) and level of education, place of delivery, type of birth attendant attending the delivery, mode of delivery (normal, instrumental or caesarian section), size of the newborn at birth (mother’s perception), timing of neonatal deaths (early or late neonatal death) and number of babies delivered in the index pregnancy.

Maternal age: Around 56 percent of women had a neonatal death were aged between 20-29 years, 23 percent between 30-39 years, 19 percent were less than 20 years and only 1 percent was more than 40 years of age. In case of still-births, distribution of women by age group was almost similar as in neonatal deaths. There was no visible difference by cause of neonatal deaths and by age category of mothers. The highest death rate was among mothers in the 20-29 years age group: around 80 percent deaths due to birth injury, 69 percent due to sepsis/pneumonia and 57 percent due to preterm were in this age group. Maternal education: Around one-thirds women who’s newborns were eventually died within 28 days of birth had no education, one-fifths had primary level education, a little more than one-third of women had education level of class 5-9 and 3-4 percent had secondary completed or higher level of education. The rates were almost similar in case of women had a still-birth. Among neonatal deaths from sepsis, 51 percent of women had no education while it was zero percent among women had secondary completed or above level of education. There was also no death from neonatal tetanus among women had secondary completed or higher level of education. Around a third of deaths attributed to birth injury, preterm birth and birth asphyxia among women those had no education. The data in Table 5.2.2 revealed that a mother with lower level of education was correlated with a higher the mortality rate of the neonate. Place of delivery: Among the neonatal deaths, around 83 percent of deliveries occurred at home with more than 95% of the sepsis cases were attributed to the home deliveries. In the case of deaths due to birth asphyxia, congenital abnormality and preterm birth, around 80 percent of women had their delivery at home. The percentage of health facility delivery was also found high in cases of still-birth (21 percent) compare to neonatal deaths (13 percent). Type of birth attendant: Most commonly the birth attendant was a TBA (73 percent) across the causes of neonatal deaths and there was no significant variation by cause. Around 21 percent of all neonatal deaths occurred when the deliveries were attended by a skilled birth attendant, 0.2 percent by other health professionals, 3 percent by family members/relatives and 1 percent by others (local quacks) while it was high (9 percent) in case of neonatal tetanus. The percentage of deaths due to sepsis was very low (4 percent) when deliveries were attended by a skilled birth attendant. In case of still-births, around one-third of deliveries were attended by a skilled birth attendant, it increases to 58 percent for TBA. Mode of delivery: In case of neonatal deaths around 60 percent of deliveries were normal and without any help or manipulation, additional 32 percent were normal but needed manipulation, 1 percent was forceps or vacuum delivery and around 4 percent were caesarian sections. Normal delivery (without external help) was high (around 76 percent) in case of deaths due to undetermined cause, followed by preterm birth (70 percent) and sepsis (63 percent). Sixty percent of neonatal deaths due to birth injury needed manipulation. In cases of still-births around 90 percent of all deliveries were normal, while 48 percent needed manipulation by hand or other support, 1 percent by forceps/vacuum and 4 percent caesarean section.

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Size of the newborns at birth: In case of neonatal deaths, 55 percent newborns were reported born of normal size, 18 percent smaller than normal size. In addition, 15 percent were small in size while 12 percent were bigger than normal size. Among the deaths occurred due to sepsis, 73 percent of newborns were born normal in size, this figure for Birth Asphyxia, Birth injury and neonatal tetanus were 67, 60 and 55 percent respectively. Among deaths from preterm, 47 percent of babies were very small in size. Around two fifths newborns died from birth injury were smaller than normal in size at birth. In case of still-births, 62 percent were born of normal size, 18 percent were bigger than normal and 8 percent were with very small size. Timing of neonatal deaths by cause of death: Overall, 80 percent of the neonatal deaths occurred within the first seven days of life. A high percentage of neonatal deaths due to birth asphyxia (95 percent), birth injury (100 percent), congenital abnormality (89 percent) and preterm (86 percent) occurred during the first week of life. About two-fifths of the deaths due to sepsis were during the first week after birth. Multiple/single birth: Around 88 percent of all neonatal deaths were singleton and the distribution was similar across the causes of deaths with the exception of deaths due to congenital abnormality (74 percent). In the case of still- births, 93 percent were born as singleton and 7 percent were multiple.

Table-5.2.3: Percent distribution of cause of neonatal deaths and still-births by maternal and delivery complications.

Causes of neonatal deaths

Complication

Neonatal Neonatal Tetanus Congenital abnormality Preterm Birth Asphyxia injury Birth / Sepsis Pneumonia Undetermined TOTAL Birth Still Total: 11 27 115 159 5 70 38 425 357

Had no complication 9.1 7.4 10.4 11.3 20.0 32.9 15.8 14.8 2.2 Had complication: Convulsions 0.0 0.0 2.6 3.1 0.0 0.0 5.3 2.4 5.3 Edema in hand & face 45.5 22.2 24.4 35.9 40.0 37.1 42.1 32.9 28.6 Severe headache or blurred vision 27.3 11.1 19.1 23.3 0.0 17.1 7.9 18.8 16.7 High BP or severe anemia 9.1 18.5 4.4 4.4 0.0 5.7 2.6 5.4 8.6 Severe backache before delivery 0.0 3.7 4.4 0.6 0.0 0.0 0.0 1.7 2.2 Breech presentation or child delivered by feet 45.5 44.4 27.8 32.7 40.0 22.9 34.2 31.1 24.2 first Prolonged labour 36.4 14.8 15.7 28.3 0.0 7.1 15.8 19.3 29.4 Bleeding during last part of pregnancy or 9.1 33.3 20.0 10.7 0.0 8.6 5.3 13.7 15.3 excessive bleeding during delivery Multiple delivery 0.0 25.9 9.6 5.0 0.0 4.3 7.9 7.5 5.6 Water greenish/brown/yellow-stained or foul- 0.0 11.1 7.0 7.6 20.0 5.7 5.3 7.1 11.4 smelling Stopped or less fetal movement 0.0 25.9 15.7 20.1 20.0 8.6 15.8 16.5 79.7 Fever during labour 0.0 7.4 12.2 8.2 0.0 5.7 0.0 7.8 10.3 Waters broke > 1 day before labour 36.4 11.1 14.8 12.0 40.0 8.6 5.3 12.5 12.5 Other important signs (includes C-section) 9.1 18.5 3.5 10.1 0.0 5.7 2.6 7.3 12.8 Others 45.5 29.6 29.6 34.0 40.0 18.6 29.0 29.9 0.0 *Multiple answers were accepted

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Table 5.2.3 shows that only fifteen percent of the mothers of dead newborns had no complications during pregnancy and delivery. Among these mothers the distribution by cause of neonatal deaths were: 33 percent of total deaths from sepsis/pneumonia, 20 percent from birth injury, 11 percent from birth asphyxia, 10 percent from preterm, 9 percent from neonatal tetanus and 7 percent from congenital abnormality. The remaining 85 percent of women whose newborns died had any kind of complication during pregnancy or delivery and the overall distribution of reported complications were: 33 percent reported edema in hand and face, 31 percent reported Breech presentation or child delivered by feet first, 19 percent reported a prolonged labour (more than 12 hours), 19 percent had severe headache or blurred vision, 17 percent reported had less or no fetal movement, 14 percent reported excessive bleeding during delivery, 8 percent reported having fever during labour and 5 percent had high BP or severe anemia. (Multiple answers were accepted) The relationship between maternal complication and cause of neonatal deaths shows that amongst the neonatal death due to birth asphyxia, about one-third of their mother reported edema in hand and face as well as breech presentation. Among the neonates who died with birth injury two-fifths of them died due to mother having edema, breaking waters in one or more days prior delivery. Edema in hands and face appeared to be the most significant cause of death in case of neonatal tetanus, sepsis and birth asphyxia. In the case of still-births, 80 percent reported less or no fetal movement, 29 percent reported edema in hand and face, 29 percent reported a prolonged labour (more than 12 hours), 24 percent reported Breech presentation or child delivered by feet first, 17 percent had severe headache or blurred vision, 15 percent reported excessive bleeding during delivery,10 percent had bleeding during last part of pregnancy or during delivery, 10 percent reported having fever during labour and 5 percent had convulsion during labour. (Multiple answers were accepted)

5.3 Age at death of neonatal deaths:

Table 5.3.1 shows the distribution of cause of deaths by age at death. Around two-fifths of all neonatal deaths were within 24 hours and three-fifths within 3 days of birth. Causes of neonatal deaths are described in table 5.3.1 and figure 5.3 and figure 5.4. The primary causes of neonatal deaths within 24 hours of birth were from birth asphyxia, preterm and congenital abnormality. Birth asphyxia was the predominant cause of neonatal deaths in the MaMoni area of Habiganj (37 percent); around half of the babies died within 24 hours of birth and four-fifths within 72 hours (3 days). Preterm is the second highest cause of neonatal deaths and constitutes one-fourth of all neonatal deaths. Among deaths due to preterm, half of the death occurred within 24 hours and three-fifths were within 72 hours of birth. Sepsis/pneumonia is the third highest cause of neonatal deaths and constitutes one-seventh of all neonatal deaths. About 10 percent of all neonatal deaths due to sepsis or pneumonia occurred within first three days of birth and three-fifths after seven days of birth.

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Table-5.3.1: Percent distribution of cause of neonatal deaths by age at death in Habiganj.

Age at Death (in days)

N e o n C a o t n a g P l e r n e T i t B e t e i t a r r a l m t B n h i u a r s b A t S n s h e o p p r h i s U m y n i n a x j s d l i u e T i a r / t O t y e T y P r A n m L e i u n m e o d n i a

Neonatal Neonatal Tetanus Congenital abnormality Preterm Asphyxia Birth injury Birth / Sepsis Pneumonia Undetermined TOTAL N= 11 27 115 159 5 70 38 425 % 2.8 6.4 27.1 37.4 1.2 16.5 8.9

0 0.0 51.9 51.3 53.5 40.0 1.4 13.2 39.1 1-2 0.0 22.2 12.2 25.2 0.0 8.6 21.1 17.4 3-6 72.7 14.8 22.6 17.0 60.0 31.4 23.7 23.3 7-13 0.0 7.4 7.0 4.4 0.0 30.0 13.2 10.1 14-28 27.3 3.7 7.0 0.0 0.0 28.6 29.0 10.1

Figure 5.3: Neonatal deaths by age at death in days (n=425)

Figure 5.4: Percent distribution of age at death by cause of neonatal death

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Table 5.3.2 shows the distribution of the causes of neonatal deaths by age at death and by sex. The overall death ratio between male and female was 57:43 and the trend was similar across different causes of deaths except for deaths due to birth injury. Apart from that, a large disproportion was observed in the case of deaths due to congenital abnormality where the male to female ratio was 2:1. Among early neonatal deaths (within 7 days of birth) there were similar male and females.

Table-5.3.2: Percent distribution of age at death by sex and by cause of death in Habiganj

Causes of Neonatal death

Age at Neonatal Congenital Preterm Birth Birth injury Sepsis / Undetermined TOTAL Death Tetanus abnormality Asphyxia Pneumonia Sex M F M F M F M F M F M F M F M F N= 8 3 18 9 69 46 88 71 4 1 38 32 15 23 240 185 % 72.7 27.3 66.7 33.3 60.0 40.0 55.4 44.7 80.0 20.0 54.3 45.7 39.5 60.5 56.5 43.5

0 days 0.0 0.0 66.7 22.2 53.6 47.8 48.9 59.2 25.0 100.0 2.6 0.0 6.7 17.4 39.6 39.0 1-2 days 0.0 0.0 16.7 33.3 13.0 10.9 26.1 23.9 0.0 0.0 7.9 9.4 33.3 13.0 17.9 16.6 3-6 days 75.0 66.7 5.6 33.3 18.8 28.3 20.5 12.7 75.0 0.0 26.3 37.5 13.3 30.4 22.1 24.6 7-13 days 0.0 0.0 5.6 11.1 5.8 8.7 4.6 4.2 0.0 0.0 42.1 15.6 20.0 8.7 11.7 8.0 14+ days 25.0 33.3 5.6 0.0 8.7 4.4 0.0 0.0 0.0 0.0 21.1 37.5 26.7 30.4 8.8 11.8

5.4: References:

1. Lawn JE, Cousens S, Zupan J 4 million neonatal deaths: when? Where? Why? Lancet 2005;365:891-900.

2. Bryce J, Boschi-Pinto C, Shibuya K, Black RE. WHO estimates of the causes of death in children. Lancet 2005;365:1147-52.

3. NFHS-II. National Family Health Survey-II 1989-1999 Mumbai; international institute for Populations Sciences and ORC-Macro;2001.

4. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361:2226-34.

5. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N,de Berris L. Evidence based, cost-effective interventions; how many newborn babies can we save? Lancet 2005;365:977-88.

6. Bhutta Z, Darmstadt G, Hasan B, Haws R. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries; a review of the evidence. Pediatrics 2005;115:519-617

7. Lawn JE, Cousens SN, Wilczynska K. Estimating the causes of four million neonatal deaths in the year 2000 statistical annex—the World Health Report 2005. Geneva: World Health Organization; 2005.

8. Freeman JV, Christian P, Khatry SK, Adhikari RK, Lederq SC, Katz J, et al. Evaluation of neonatal verbal autopsy using physician review versus algorithm-based cause-of-death assignment in rural Nepal. Paediatr Perinat Epidemiol 2005;19:323-31.

9. Morris SS, Black RE, Tomaskovic L. Predicting the distribution of under-five deaths by cause in countries without adequate vital registration systems. Int J Epidemiol 2003;32:1041-51.

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10. Rudan I, Lawn J, Cousens S, Rowe AK, Boschi-Pinto C, Tomaskovic L, et al. Gaps in policy-relevant information on burden of disease in children: a systematic review. Lancet 2005;365:2031-40.

11. Gray RH, Smith G, Barss P. The use of verbal autopsy to determine selected causes of death in children. Baltimore (MD): The Johns Hopkins University School of Hygiene and Public Health; 1990.

12. Bang AT, Bang RA. Diagnosis of causes of childhood deaths in developing countries by verbal autopsy; suggested criteria. The SEARCH team. Bull World Health Organization 1992;70:499-507

13. Baqui AH, Sabir AA, Begum N, Arifeen SE, Mitra SN, Black RE. Causes of childhood deaths in Bangladesh; an update. Acta Paediatr 2001;90:682-90.

14. Bang AT, Paul VK, Reddy HM, Baitule SB. Why do neonates die in rural Gadchiroli, India? (Part I); primary causes of death assigned by neonatilogist based on prospectively observed records. J Perinatol 2005;25 suppl 1:529-34.

15. Hinderaker SG, Olsen BE, Bergsjo PB, Gasheka P, Lie RT, Havnen J, et al. Avoidable still-births and neonatal deaths in rural Tanzania. BJOG 2003;110:616-23.

16. Kappor RK, Srivastava AK, Misra PK, Sharma B, Thakur S, Srivastava KI, et al. Perinatal mortality in urbal slums of Lucknow, India Pediatr 1996;33:19-23.

17. Marsh DR, Sadruddin S, Fikree FF, Krishan C, Darmstadt GL. Validation of verbal autopsy to determine the cause of 137 neonatal deaths in Karachi, Pakistan. Paediatr Perinat Epidemiol 2003;17:132-42.

18. Chowdhury ME, Akhter HH, Chongsuvivatwong V, Geater AF. Neonatal mortality in rural Bangladesh an exploratory study. J Health Popul Nutr 2005;23:16-24.

19. Benara SK, Singh P. Validity of causes of infant death by verbal autopsy. Indian J Pediatr 1990;66:647-50.

20. Snow RW, Armstrong JR, Forster D, Winstanley MT, Marsh VM, Newton CR, et al. Childhood deaths in Africa; uses and limitations of verbal autopsies. Lancet 1992;340:351-5.

21. Awasthi S, Pande VK. Cause specific mortality in under fives in the urban slums of Lucknow, north India. J Trop Pediatr 1998;44:358-61.

22. Anker M, Black RE, Coldham C, Kalter HD, Quigley MA, Ross D, et al. A standard verbal autopsy method for investigating causes of death in infants and young children. Geneva: World Health Organization, 1999.

23. Lawn J, Shibuya K, Stein C. No cry at birth; global estimates of intrapartum still-births and intrapartum- related neonatal deaths. Bull World Health Organ 2005;83:409-17.

24. Shrivastava SP, Kumar A, Kumar Ojha A. Verbal autopsy determine causes of neonatal deaths. Indian Pediatr 2001;38:1022-5.

25. kalter HD, Hossain M, Burnham G, Khan NZ, Saha SK, Ali MA, et al. Validation of caregiver interviews to diagnose common causes of severe neonatal illness. Paediatr Perinat Epidemiol 1999;13:99-113.

26. Anker M. The effect of misclassification error on reported cause-specific mortality fractions from verbal autopsy. Int J Epidemiol 1997;26:1090-6.

27. Bang AT, Bang RA, Baitule SB, Reddy HM, Deshmukh MD. Management of birth asphyxia in home deliveries in rural Gadchiroli; the effect of two types of birth attendants and of resuscitating with mouth-to- mouth, tube-mask or bag-mask. J Perinatol 2005;25 Suppl 1:582-91. 36 | P a g e

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28. Ellis M. Birth asphyxia in developing countries; epidemiology, sequelae and prevention.In: Costello A, Manandhar D, (editors), Improving newborn infant health in developing countries, London: Imperial College Press; 2000.

29. Bale JR, Stoll BJ, Lucas AO, (editors). Improving birth outcomes: meeting the challenges in the developing world/committee on improving birth outcomes. Board of Global Health, Washington DC: National Academy of Sciences;2003.

30. Fikree FF, Azam SI, Berendes HW. Time to focus child survival programmes on the newborn; assessment of levels and causes of infant mortality in rural Pakistan. Bull World Health Organ 2002;80:271-6.

31. Singhal PK, Mathur GP, Mathur S, Singh YD. Neonatal morbidity and mortality in ICDS urban slums. Indian Pediatr 1990;27:485-8.

32. Tinker A, ten Hoope-Bender P, Azfar S, Bustreo F, Bell R. A continuum of care to save newborn lives. Lancet 2005;365:822-5.

33. Lawn JE, Darmstadt GL. Birth asphyxia: report of a meeting. Washington, DC: Saving Newborn lives, Save the Children/USA; 2003.

34. Rahmathullah L, Tielsch JM, Thulasiraj RD, Katz J, Coles C, Devi S, et al. Impact of supplementing newborn infants with vitamin A on early infant mortality: community-based randomised trial in southern India. BMJ 2003;327:254.

35. WHO Collabourative Study Team on the Role of Breastfeeding in the Prevention of infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet 2000;355:451-5.

36. Kumar V, Yadav R. Lessons from implementation of skin-to-skin care in rural India for the development of strategies for community KMC. First International Congress of Kangaroo Mother Care, Rio de Janeiro, 4 November 2004.

37. Quasem I, Sloan NL, Chowdhury A, Ahmed S, Winikoff B, Chowdhury AM. Adaptation of kangaroo mother care for community-based application. J Perinatol 2003;23:646-51.

38. Taha TE, Bigar RJ, Broadhead RL, Mtimavalye LA, Justesen AB, Liomba GN, et al. Effect of cleansing the birth canal with antiseptic solution on maternal and newborn morbidity and mortality in Malawi: clinical trial. BMJ 1997;315:216-20.

39. Tielsch JM, Darmstadt GL, Mullany LC, Khatry SK, Katz J, Leclerq SC, et al. A community-based cluster randomized trial of newborn skin cleansing. Pediatric Academic Societies Annual Meeting, Washington, DC, May 2005.

40. Darmstadt GL, Badrawi N, Law PA, Ahmed S, Bashir M, Iskander I, et al. Topically applied sunflower seed oil prevents invasive bacterial infections in preterm infants in Egypt: a randomized, controlled clinical trial. Pediatr Infect Dis J 2004;23:719-25.

41. Darmstadt GL, Saha SK, Ahmed AS, Chowdhury MA, Law PA, Ahmed S, et al. Effect of topical treatment with skin barrier-enhancing emollients on nosocomial infections in preterm infants in Bangladesh: a randomised controlled trial. Lancet 2005;365:1039-45.

42. Bang AT, Baitule SB, Reddy HM, Deshmukh MD, Bang RA. Low birth weight and preterm neonates: can they be managed at home by mother and a trained village Health worker? J Perinatol 2005;25 Suppl 1:S72-81.

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43. Kumar V, Bharti N, Awasthy S, Singh JV, Baqui AH, Winch P, et al. Community driven essential newborn care in rural India. In: Global Health Council Annual Meeting 2005. Washington, DC, 3 June, 2005.

44. Vergnano S, Sharland M, Kazembe P, Mwansambo C, Health PT. Neonatal sepsis: an international perspective. Arch Dis Child Fetal Neonatal Ed 2005; 90:F220-4.

45. Mullany LC, Darmstadt GL, Tielsch JM. Role of antimicrobial applications to the umbilical cord in neonates to prevent bacterial colonization and infection: a review of the eidence. Pediatr Infect Dis J 2003;22:996-1002.

46. Mullany LC, Darmstadt GL, Khatry SK, Katz J, Leclerq SC, Shrestha S, et al. Topical applications of chlorhexidine to the umbilical cord prevent omphalitis and neonatal mortality in southern Nepal: a community-based, cluster-randomized trial. Lancet. In press.

47. Bang AT, Bang RA, Stoll BJ, Baitule SB, Reddy HM, Deshmukh MD. Is home-based diagnosis and treatment of neonatal sepsis feasible and effective? Seven years of intervention in the Gadchiroli field trial (1996 to 2003). J Perinatol 2005;25 Suppl 1:S62-71.

48. Knippenberg R, Lawn J, Darmstadt G, Begkoyian G, Fogstad H, Walelign N, et al. Systematic scaling up of neonatal care in countries. Lancet 2005; 365:1087-98.

49. Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004;364:970-9.

50. Bang AT, Bang RA, Reddy HM, Home-based neonatal care: summary and applications of the field trial in rural Gadchiroli, India (1993 to 2003). J Perinatol 2005;25 Suppl 1:S108-22.

51. Kiran U. Reaching Scale with Essential Newborn Care Interventions. Global Health Council Annual Meeting 2005. Washington, DC, 3 June 2005.

52. Baqui AH, Darmstadt GL, Williams EK, Kumar V, Kiran TU, Panwar D, Srivastava VK, Ahuja R, Black RE, Santosham M. Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes. Bulletin of the World Health Organization; September 2006, 84 (9)

53. Blanc AK, Wardlaw T. Monitoring low birth weight: an evaluation of international estimates and an updated estimation procedure. Bull World Health Organization.

54. Yasmin S, Osrin D, Paul E, Costello A. Neonatal mortality of low birth weight infants in Bangladesh. Bull World Health Organ 2001; 79:608-14

55. Lawn JE, McCarthy B, Ross SR. The healthy newborn: a reference guide for program managers. Atlanta CDC and CARE, 2001

56. Peterson S, Nsungwa-Sabiiti, Were W, et al. Coping with paediatric referral: Ugandan Parents’ experience. Lancet 2004; 363:1955-56

57. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994; 38: 1091-110.

58. UNICEF, State of the World’s Children 2005

59. Verbal Autopsy Report of ACCESS baseline survey, 2007 in Sylhet (Bangladesh)

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Chapter-6 Health care seeking prior to neonatal death:

This chapter discusses the perceptions of the families about the illness of the newborns who died and their care-seeking practices and attitudes. It discusses the type and location of health care provider from whom care was sought and the sequence of care seeking (limiting to only the first and second visits as additional visits were rare). The chapter also discusses the reasons for not seeking care if care was not sought during the terminal illness.

6.1 Perception of families about the severity of illness of the neonates prior to their death. Table 6.1.1 shows that only one-fourth of families where neonates died within 24 hours of birth in the MaMoni areas perceived the terminal illness as “very serious”. This was around half among families where newborns died on day 1-2 and 40 percent of families perceived as “very serious” where babies died between 3-28 days. In cases of deaths due to birth asphyxia on day-0, half of babies had died immediately after birth and only one-fifth of the families perceived the illness as ‘very serious’. The perception that the baby was very seriously ill was about 55 percent among families with neonatal deaths after 24 hours of birth. In the case of preterm deaths on day-0, 27 percent died immediately and one-third of families considered the illness as ‘very serious’, while the perception of severity was about 43 percent in deaths on subsequent days. In the case of deaths due to sepsis, all the families perceived the illness as mild on day 0; however the perception was 50 percent among deaths after 24 hours of birth. Congenital abnormality and neonatal tetanus was regarded as very serious disease among those who died after day 3. Table 6.1.1: Distribution of causes of neonatal deaths by perception of mothers about the severity of illness by age at death.

Perception of mothers about the Causes of Neonatal Death

severity of neonatal illness

-

Neonatal Neonatal Tetanus Congenital abnormality Preterm Birth Asphyxia Birthinjury / Sepsis Pneumonia Un determined TOTAL Day 0 (N) 0 14 59 85 2 1 5 166 Not serious at all 0.0 28.6 10.2 4.7 0.0 0.0 20.0 9.0 Mild 0.0 7.1 27.1 21.2 100.0 100.0 40.0 24.1 Very serious 0.0 50.0 33.9 21.2 0.0 0.0 20.0 27.7 Died Immediately 0.0 14.3 27.1 51.8 0.0 0.0 20.0 38.0 Don't know about problem 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Others 0.0 0.0 1.7 0.0 0.0 0.0 0.0 0.6 Don’t know 0.0 0.0 0.0 1.2 0.0 0.0 0.0 0.6 Day 1-2 (N) 0 6 14 40 0 6 8 74 Not serious at all 0.0 16.7 7.1 12.5 0.0 0.0 12.5 10.8 Mild 0.0 50.0 50.0 32.5 0.0 50.0 25.0 37.8 Very serious 0.0 33.3 42.9 55.0 0.0 50.0 37.5 48.7 Died Immediately 0.0 0.0 0.0 0.0 0.0 0.0 12.5 1.4 Don't know about problem 0.0 0.0 0.0 0.0 0.0 0.0 12.5 1.4 Others 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Day 3-28 (N) 11 7 42 34 3 63 25 185 Not serious at all 0.0 28.6 16.7 8.8 0.0 6.4 16.0 10.8 Mild 27.3 14.3 40.5 55.9 66.7 47.6 56.0 46.5 Very serious 72.7 57.1 42.9 32.4 33.3 44.4 16.0 40.0 Died Immediately 0.0 0.0 0.0 2.9 0.0 1.6 4.0 1.6 Don't know about problem 0.0 0.0 0.0 0.0 0.0 0.0 8.0 1.1 Others 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

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Table 6.1.2: Distribution of causes of neonatal deaths by care seeking, type of provider by age at death.

Causes of Neonatal death

-

Neonatal Neonatal Tetanus Congenital abnormality Preterm Birth Asphyxia injury Birth / Sepsis Pneumonia Un determined TOTAL Day 0 (N) 0 14 59 85 2 1 5 166 Care seeking: Did not seek care 0.0 50.0 49.2 31.8 0.0 0.0 40.0 39.2 Died immediately 0.0 14.3 27.1 51.8 0.0 0.0 20.0 38.0 Sought care 0.0 35.7 23.7 16.5 100.0 100.0 40.0 22.9 At home: 0.0 7.1 8.5 5.9 0.0 100.0 20.0 7.8 MBBS doctor 0.0 0.0 1.7 1.2 0.0 100.0 0.0 1.8 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Homeopath 0.0 0.0 3.4 0.0 0.0 0.0 0.0 1.2 Village doctor 0.0 7.1 1.7 2.4 0.0 0.0 0.0 2.4 Spiritual 0.0 0.0 1.7 0.0 0.0 0.0 0.0 0.6 Others 0.0 0.0 0.0 4.7 0.0 0.0 20.0 3.0 Outside home: 0.0 28.6 15.3 10.6 100.0 0.0 20.0 15.6 Medical college hospital 0.0 0.0 0.0 1.2 0.0 0.0 0.0 0.6 FWC 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Upazila Health complex 0.0 14.3 3.4 2.4 0.0 0.0 20.0 4.2 NGO clinic/hospital 0.0 0.0 0.0 3.5 0.0 0.0 0.0 1.8 Chamber of MBBS doctor 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Quack/ Village doctor’s chamber 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Pharmacy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Others 0.0 14.3 11.9 4.7 100.0 0.0 0.0 9.0 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Day 1-2 (N) 0 6 14 40 0 6 8 74 Care seeking: Did not seek care 0.0 66.7 35.7 22.5 0.0 16.7 50.0 31.1 Died immediately 0.0 0.0 0.0 0.0 0.0 0.0 12.5 1.4 Sought care 0.0 33.3 64.3 77.5 0.0 83.3 37.5 67.6 At home: 0.0 33.3 21.4 20.0 0.0 50.0 25.0 24.3 MBBS doctor 0.0 0.0 0.0 2.5 0.0 0.0 0.0 1.4 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Homeopath 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Village doctor 0.0 0.0 7.1 15.0 0.0 50.0 12.5 14.9 Spiritual 0.0 16.7 14.3 12.5 0.0 0.0 12.5 12.2 Others 0.0 0.0 0.0 2.5 0.0 0.0 0.0 1.4 Outside home: 0.0 0.0 42.9 65.0 0.0 50.0 12.5 48.7 Medical college hospital 0.0 0.0 0.0 12.5 0.0 16.7 0.0 8.1 FWC 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Upazila Health complex 0.0 0.0 14.3 22.5 0.0 16.7 12.5 17.6 NGO clinic/hospital 0.0 0.0 0.0 10.0 0.0 0.0 0.0 5.4 Chamber of MBBS doctor 0.0 16.7 0.0 7.5 0.0 16.7 0.0 6.8 Quack/ Village doctor’s chamber 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Pharmacy 0.0 0.0 0.0 2.5 0.0 0.0 0.0 1.4 Others 0.0 0.0 42.9 27.5 0.0 33.3 0.0 25.7 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Day 3-28 (N) 11 7 42 34 3 63 25 185 Care seeking:

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Did not seek care 0.0 42.9 31.0 23.5 0.0 25.4 48.0 28.1 Died immediately 0.0 0.0 0.0 2.9 0.0 1.6 4.0 1.6 Sought care 100.0 57.1 69.1 73.5 100.0 73.0 44.0 69.7 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 4.0 0.5 At home: 18.2 0.0 26.2 26.5 66.7 28.6 16.0 24.9 MBBS doctor 18.2 0.0 4.8 0.0 0.0 1.6 4.0 3.2 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Homeopath 0.0 14.3 7.1 8.8 0.0 4.8 0.0 5.4 Village doctor 9.1 0.0 11.9 5.9 0.0 15.9 8.0 10.8 Spiritual 0.0 0.0 14.3 8.8 66.7 15.9 8.0 12.4 Others 9.1 0.0 2.4 2.9 0.0 4.8 0.0 3.2 Outside home: 100.0 57.1 57.1 55.9 33.3 58.7 36.0 56.8 Medical college hospital 9.1 0.0 4.8 2.9 0.0 4.8 12.0 5.4 FWC 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Upazila Health complex 27.3 14.3 21.4 23.5 33.3 15.9 12.0 18.9 NGO clinic/hospital 27.3 14.3 11.9 5.9 0.0 7.9 4.0 9.2 Chamber of MBBS doctor 18.2 0.0 7.1 8.8 0.0 17.5 0.0 10.3 Quack/ Village doctor’s chamber 0.0 0.0 2.4 0.0 0.0 3.2 0.0 1.6 Pharmacy 0.0 0.0 0.0 2.9 0.0 9.5 0.0 3.8 Others 54.6 28.6 14.3 26.5 33.3 15.9 4.0 18.9 Don’t know 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Multiple responses were accepted

Table 6.1.2 shows that there were 166 neonatal deaths on day-0, 38 percent of babies died immediately and their families did not get time to seek care, 39 percent of families did not seek care although they could have sought care and 23 percent sought care either at home (7.8 percent) and outside home (15.6 percent). Distribution of families (7.8 percent) who sought care at home were; 2.4 percent families sought care from village doctor, 1.8 percent from MBBS doctor, 2 percent from homeopaths and kabiraj and 3 percent from other local healers. Distribution of families (15.6 percent) who sought care from outside were; 4.2 percent from UHC, 1.8 percent from NGO clinic/hospital and 9 percent from other sources. Of neonatal deaths on day 1-2 (74), 1.4 percent died immediately. Thirty-one percent of families did not seek care and 68 percent sought care either at home (24.3 percent) or from outside (48.7 percent). Distribution of families (24.3 percent) who sought care at home were; 14.9 percent from a village doctor, 12.2 percent from spiritual healer (Kabiraj) and 1.4 percent from a MBBS doctor. Distribution of families (48.7 percent) who sought care from outside were; 17.6 percent from UHC, 8.1 percent from medical college hospital, 5.4 percent from NGO clinic/hospital, 6.8 percent from chamber of MBBS doctor, 1.4 percent from pharmacy and 25.7 percent from other sources. Care seeking practices among these groups were more positive than among families of day-0 deaths. Of neonatal deaths between days 3-28 (185), 1.6 percent died immediately. 28 percent of families did not seek care and around 70 percent sought care at home (24.9 percent) and outside (56.8 percent). Distribution of families (24.9 percent) sought care at home were; 12.4 percent from a spiritual healer, 10.8 percent from a village doctor, 5.4 percent from homeopaths and 3.2 percent from a MBBS doctor. Distribution of families (56.8 percent) who sought care from outside were; 18.9 percent from UHC, 5.4 percent from medical college hospital, 9.2 percent from NGO clinic/hospital, 10.3 percent from a chamber of MBBS doctor, 3.8 percent from pharmacy and 18.9 percent from other sources. Around four percent of the families sought care from pharmacy which is very rare in less than 3 days of age group.

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Table 6.1.3: Distribution of cause of neonatal deaths among those who sought care by place of care and by type of provider (by order of visit)

Causes of Neonatal death

-

Neonatal Neonatal Tetanus Congenital abnormality Preterm Birth Asphyxia injury Birth / Sepsis Pneumonia Un determined TOTAL Total Neonatal Deaths [N] 11 27 115 159 5 70 38 425

1st provider: Did not seek care 0.0 59.3 54.8 56.0 0.0 25.7 57.9 48.9 Sought care at home 27.3 11.1 16.5 15.7 40.0 34.3 21.0 19.8 MBBS doctor 18.2 0.0 0.9 0.6 0.0 1.4 2.6 1.4 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Homeopath 0.0 3.7 4.4 1.9 0.0 4.3 0.0 2.8 Village doctor 9.1 3.7 5.2 6.3 0.0 15.7 7.9 7.5 Spiritual 0.0 3.7 5.2 3.1 40.0 10.0 7.9 5.7 Others 0.0 0.0 0.9 3.8 0.0 2.9 2.6 2.4 Sought care outside home 72.7 29.6 28.7 28.3 60.0 40.0 21.1 31.3 Medical college hospital 0.0 0.0 0.0 1.9 0.0 0.0 7.9 1.4 FWC 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Upazila Health complex 27.3 11.1 7.8 10.7 20.0 11.4 13.2 10.8 NGO clinic/hospital 18.2 3.7 3.5 3.1 0.0 0.0 0.0 2.8 Chamber of MBBS doctor 0.0 3.7 1.7 1.9 0.0 14.3 0.0 3.8 Quack/ Village doctor’s home/chamber 0.0 0.0 0.9 0.0 0.0 2.9 0.0 0.7 Pharmacy 0.0 0.0 0.0 0.6 0.0 7.1 0.0 1.4 Others 27.3 11.1 14.8 10.1 40.0 4.3 0.0 10.4

2nd Provider: Did not seek care 54.6 96.3 84.4 84.9 80.0 58.6 92.1 80.9 Sought care at home 9.1 0.0 7.0 2.5 0.0 11.4 2.6 5.2 MBBS doctor 0.0 0.0 1.7 0.6 0.0 0.0 2.6 0.9 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Homeopath 0.0 0.0 0.9 0.0 0.0 2.9 0.0 0.7 Village doctor 0.0 0.0 1.7 0.0 0.0 2.9 0.0 0.9 Spiritual 0.0 0.0 2.6 1.9 0.0 5.7 0.0 2.4 Others 9.1 0.0 0.0 0.0 0.0 0.0 0.0 0.2 Sought care from outside home 36.4 3.7 8.7 12.6 20.0 30.0 5.3 13.9 Medical college hospital 0.0 0.0 0.9 1.9 0.0 4.3 2.6 1.9 FWC 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Upazila Health complex 0.0 0.0 3.5 1.3 0.0 5.7 0.0 2.4 NGO clinic/hospital 9.1 0.0 0.0 3.1 0.0 2.9 2.6 2.1 Chamber of MBBS doctor 0.0 0.0 0.9 1.3 0.0 4.3 0.0 1.4 Quack/ Village doctors home/chamber 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Pharmacy 0.0 0.0 0.0 0.6 0.0 1.4 0.0 0.5 Others 27.3 3.7 3.5 4.4 20.0 11.4 0.0 5.7 Multiple responses were accepted

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Table 6.1.3 shows the care-seeking pattern by order of visit and type of provider. First health care provider: Around half of families (51.1 percent) who had neonatal deaths sought care at-least once during the illness of their newborns. 19.8 percent families sought care at home and 31.3 percent from outside. Distribution of families (19.8 percent) who sought care at home were; 7.5 percent from a village doctor, 5.7 percent from a spiritual healer, 2.8 percent from a homeopath, 1.4 percent from a MBBS doctor and 2.4 percent from other health care providers. Distribution of families (31.3 percent) who sought care from outside were; 10.8 percent from UHC, 1.4 percent from medical college hospital, 2.8 percent from NGO clinic/hospital, 3.8 percent from chamber of a MBBS doctor, 1.4 percent from pharmacy and 10.4 percent from other sources. Cent percent families who had neonatal deaths due to neonatal tetanus and birth injury sought care either at home or outside. Around 40 percent families had neonatal deaths due to congenital abnormality, birth asphyxia, preterm and undetermined cause sought care from a health care provider either at home or from outside. Second health care provider: Nineteen percent newborns received care from a second health care provider before death. It was found that as high as 45 percent sick neonates received care for 2nd time in case of deaths due to neonatal tetanus and sepsis/pneumonia. While only 4 percent newborns died due to congenital abnormality, 15 percent newborns died due to birth asphyxia and 16 percent due to preterm received care at home or outside by any health care provider before death. Distribution of families (5.2 percent) sought care at home from a second provider were; 2.4 percent from spiritual healer, 0.9 percent from a MBBS doctor, 0.9 percent from a village doctor, 0.7 percent from a homeopath and 0.2 percent from others. Distribution of families (13.9 percent) sought care outside home from a second provider were; 2.4 percent from UHC, 1.9 percent from medical college hospital, 2.1 percent from NGO clinic/hospital, 1.4 percent from chamber of a MBBS doctor, 0.5 percent from pharmacy and 5.7 percent from other providers.

Table 6.1.4 describes the distribution of place of care seeking, type of provider by order of visit for neonatal illness. First health care provider: Around half of total families had neonatal deaths did not receive any care for their sick newborns before death (48.9 percent), one fifth (19.4 percent) of families received care at home and one-third (31.3 percent) received care from outside home. Distribution of families (19.4 percent) who sought care at home were; 7.5 percent from village doctor, 5.7 percent from spiritual healer, 2.8 percent from homeopath, 1.4 percent from a MBBS doctor and 2.4 percent from others. Distribution of families (31.3 percent) who sought care from outside were; 10.8 percent from UHC, 3.8 percent from chamber of MBBS doctor, 2.8 percent from NGO clinic/hospital, 1.4 percent from medical college hospital and 1.4 percent from pharmacy. Around two-third of families did not seek care for their sick neonates in Chunarughat and Lakhai, while the rate was 20-40 percent in Azmeriganj and Bahubol. As the number of neonatal deaths varies by upazila (range was 5-79), lowest 5 deaths recoded in Azmeriganj and highest 79 in Baniachong. Percentage of families had neonatal death sought care from first provider at home was high in Bahubol (34.2 percent) and low in Chunarughat (15.6 percent). Similarly percentage of families sought care from first provider for their sick newborns (before death) was high in Azmeriganj (60 percent and Sadar (47.2 percent) while it was low in Lakhai (16.7 percent ) and Chunarughat (19.5 percent).

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Table 6.1.4: Distribution of place of care and type of provider (by order of visit) for neonatal illness by upazila, Habiganj

Visit status

Ajmiriganj Bahubal Baniachong Chunarughat Habiganj Lakhai Madhabpur Nabiganj Total Neonatal deaths (N) 5 41 79 77 53 24 68 78 425

1st Provider: Did not seek care 20.0 39.0 49.4 64.9 35.9 66.7 50.0 42.3 48.9 Sought care at home 20.0 34.2 17.7 15.6 17.0 16.7 22.1 19.2 19.8 MBBS doctor 20.0 0.0 0.0 2.6 0.0 0.0 2.9 1.3 1.4 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Homeopath 0.0 0.0 3.8 3.9 5.7 0.0 2.9 1.3 2.8 Village doctor 0.0 17.1 6.3 2.6 1.9 8.3 8.8 11.5 7.5 Spiritual 0.0 12.2 7.6 2.6 9.4 8.3 5.9 0.0 5.7 Others 0.0 4.9 0.0 3.9 0.0 0.0 1.5 5.1 2.4 Sought care from outside home 60.0 26.8 32.9 19.5 47.2 16.7 27.9 38.4 31.3 Medical college hospital 0.0 0.0 2.5 0.0 0.0 4.2 1.5 2.6 1.4 FWC 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Upazila Health complex 40.0 9.8 15.2 13.0 5.7 4.2 10.3 9.0 10.8 NGO clinic/hospital 20.0 2.4 2.5 0.0 1.9 0.0 8.8 1.3 2.8 Chamber of MBBS doctor 0.0 2.4 5.1 2.6 1.9 0.0 1.5 9.0 3.8 Quack/ Village doctor’s chamber 0.0 0.0 0.0 0.0 0.0 4.2 1.5 1.3 0.7 Pharmacy 0.0 0.0 1.3 1.3 5.7 0.0 0.0 1.3 1.4 Others 0.0 12.2 6.3 2.6 32.1 4.2 4.4 14.1 10.4

2nd Provider: Did not seek care 100.0 65.9 83.5 85.7 83.0 87.5 82.4 75.6 80.9 Sought care at home 0.0 14.6 1.3 3.9 0.0 8.3 8.8 5.1 5.2 MBBS doctor 0.0 2.4 0.0 1.3 0.0 0.0 2.9 0.0 0.9 Medical assistant/SACMO 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Homeopath 0.0 0.0 1.3 1.3 0.0 0.0 1.5 0.0 0.7 Village doctor 0.0 2.4 0.0 1.3 0.0 0.0 1.5 1.3 0.9 Spiritual 0.0 9.8 0.0 0.0 0.0 8.3 2.9 2.6 2.4 Others 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.3 0.2 Sought care from outside home 0.0 19.5 15.2 10.4 17.0 4.2 8.8 19.2 13.9 Medical college hospital 0.0 2.4 1.3 1.3 1.9 0.0 1.5 3.9 1.9 FWC 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Upazila Health complex 0.0 0.0 2.5 2.6 0.0 4.2 2.9 3.9 2.4 NGO clinic/hospital 0.0 4.9 1.3 0.0 3.8 0.0 0.0 5.1 2.1 Chamber of MBBS doctor 0.0 0.0 3.8 0.0 1.9 0.0 0.0 2.6 1.4 Quack/ Village doctor’s chamber 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Pharmacy 0.0 0.0 0.0 2.6 0.0 0.0 0.0 0.0 0.5 Others 0.0 12.2 6.3 3.9 9.4 0.0 4.4 3.9 5.7

Multiple responses were accepted

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Figure 6.1 shows the percentage of not seeking care, sought care at home and sought care from outside home for the first attempt during the illness of the neonates before their deaths. As depicted in graph two-third of the mother of Lakhai, and Chunarughat did not seek care, while in Baniachong and Madhobpur around half of the mother did not seek care.

Figure 6.1 Care seeking from first provider by upazila (correspond to table 6.1.4)

100% 90%

80%

70%

60%

50%

40%

30%

20%

10%

0% Ajmeriganj Bahubol Baniachong Chunarughat Sadar Lakhai Madahbpur Nabiganj

Did not seek care Sought care at home Sought care from outside

Second care provider: Around one fifths of neonates who received care for the first time, also received care for the second time and the rate of seeking care from the second provider was very similar across all the upazilas. Among the families who received care for their sick newborns from 2nd provider, 5.2 percent received care at home and 13.9 percent received care from outside home. Distribution of families (5.2 percent) who sought care at home were; 2.4 percent from spiritual healer, 0.9 percent from village doctor, 0.9 percent from MBBS doctor and 0.7 percent from homeopath. Distribution of families (13.9 percent) who sought care outside home were; 2.4 percent from UHC, 1.9 percent from medical college hospital, 2.1 percent from NGO clinic/hospital, 1.4 percent from chamber of a MBBS doctor and 5.7 percent from other sources. Highest around 35 percent families of Bahubol sought care for their newborns from a second provider and lowest in Azmeriganj (zero percent). Around 20 percent of families of Bahubol and Nabiganj received care from a second provider outside home while it was low in Azmeriganj (zero percent) and Lakhai (4.2 percent).

6.2 Reasons of not seeking care: Table 6.2.1 shows the various reasons for not seeking care during the terminal illness of neonates by cause of neonatal deaths. In the MaMoni area, among families who did not seek care, around half of them could not recognize the seriousness of the illness, one third of the families reported having had no time to transfer the patient to a health facility, one fifths reported unavailability of money for care-seeking, 15 percent did not feel the need of treatment, around one-fourths had transportation problems or health facility was too far or no one was there to accompany the baby and the mother, and one fifths of mothers reported some other causes in addition to the primary cause. Among neonates who did not receive care (141), around one-third of them died due to preterm, 31 percent due to birth asphyxia and 12 percent due to sepsis/pneumonia. The most important reasons for 45 | P a g e

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not seeking care for these newborns related to lack of understanding the seriousness of illness of the newborn and the distributions were; 36 percent among preterm death, 56 percent among deaths due to birth asphyxia and 53 percent among deaths due to sepsis. Around one third of families reported shortness of time for seeking care of sick neonates who eventually died from birth asphyxia, preterm and sepsis/pneumonia. Among families who did not seek care for their newborns due to lack of money; 19 percent died from preterm, 11 percent from birth asphyxia and 29 percent from sepsis/pneumonia.

Table- 6.2.1: Distribution of causes of neonatal deaths by reasons for not seeking care.

Causes of Neonatal death

Reasons for not seeking care following illness of

newborn

-

Neonatal Neonatal Tetanus Congenital abnormality Preterm Birth Asphyxia injury Birth / Sepsis Pneumonia Un determined TOTAL Total: (N=) 0 14 47 44 0 17 19 141 Does not need treatment 0.0 35.7 14.9 11.4 0.0 11.8 10.5 14.9 Do not have money (Poor) 0.0 28.6 19.2 11.4 0.0 29.4 10.5 17.7 Health facility is far away 0.0 14.3 6.4 18.2 0.0 11.8 5.3 11.4 Transportation is difficult 0.0 14.3 12.8 9.1 0.0 5.9 0.0 9.2 No one was there to accompany 0.0 7.1 4.3 2.3 0.0 0.0 5.3 3.6 Could not transfer to the health facility due to short of 0.0 7.1 36.2 36.4 0.0 29.4 15.8 29.8 time Baby died on way to hospital 0.0 0.0 6.4 4.6 0.0 0.0 5.3 4.3 Did not understand the seriousness of illness 0.0 21.4 36.2 56.8 0.0 52.9 42.1 44.0 Some other cause 0.0 35.7 8.5 15.9 0.0 29.4 36.8 19.9 Do not know/not sure/confused 0.0 0.0 2.1 0.0 0.0 0.0 0.0 0.7 Multiple answers were accepted

Table- 6.2.2: Reasons for not seeking care among newborns those did not seek care by upazila

Reasons for not seeking care following illness of

newborn

Ajmiriganj Bahubal Baniachong Chunarughat Habiganj Lakhai Madhabpur Nabiganj Total Neonatal deaths (N) 0 11 28 22 16 13 26 25 141 Does not need treatment 0.0 0.0 32.1 13.6 0.0 0.0 34.6 0.0 14.9 Do not have money (Poor) 0.0 0.0 42.9 4.6 6.3 23.1 11.5 20.0 17.7 Health facility is far away 0.0 0.0 32.1 4.6 0.0 7.7 3.9 16.0 11.4 Transportation is difficult 0.0 9.1 21.4 4.6 0.0 0.0 0.0 20.0 9.2 No one was there to accompany 0.0 18.2 10.7 0.0 0.0 0.0 0.0 0.0 3.6 Could not transfer to the health facility due to short of time 0.0 27.3 21.4 18.2 56.3 30.8 7.7 56.0 29.8 Baby died on way to hospital 0.0 9.1 3.6 4.6 18.8 0.0 0.0 0.0 4.3 Did not understand the seriousness of illness 0.0 36.4 25.0 68.2 25.0 61.5 50.0 44.0 44.0 Some other cause 0.0 36.4 28.6 31.8 6.3 15.4 3.9 20.0 19.9 Do not know/not sure/confused 0.0 9.1 0.0 0.0 0.0 0.0 0.0 0.0 0.7

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Table 6.2.2 shows the reasons for not seeking care by upazila. In Baniachong and Madhabpur upazilas, around one third of families did not seek care for their newborns during the illness as they perceived that treatment was not required, while it was 13.6 percent in Chunarughat and none in the rest of upazilas. Around 43 percent families in Baniachong reported lack of funds for treatment, while it was around 20 percent in Lakhai and Nabiganj and around 5-6 percent in Chunarughat and Sadar. One-fifth of families from Baniachong and Nabiganj reported a transportation problem. In Sadar and Nabiganj, around half of families reported being unable to transfer their sick newborns to the health facility due to shortness of time while it was 31 percent in Lakhai, and 27 percent in Bahubal. More than half of families reported not being aware of the seriousness of the illness in Chunarughat, Lakhai and Madhabpur while it was around 25 percent in Baniachong and Habiganj.

6.3 Place of death:

Table 6.3.1 describes the place of neonatal deaths by cause of neonatal deaths. Around 70 percent of neonatal deaths occurred at home. Apart from home, 3.5 percent died at a medical college hospital, 3.8 percent at an upazila health complex, 3.8 percent at a private clinic/hospital, 2.8 percent at MCWC, 3.5 percent died on the way to a health facility and 10.8 percent in other places. Around 90 percent of deaths due to undetermined causes died at home while it was 27 percent in case of deaths due to neonatal tetanus. Around one-third of neonatal deaths occurred outside home in case of deaths due to birth asphyxia and sepsis/pneumonia. Majority of them died in the private hospitals/clinics, UHC and MCWC.

Table-6.3.1: Distribution of cause of neonatal deaths by place of Death.

Causes of Neonatal death

Place of Death

determined

-

Neonatal Neonatal Tetanus Congenital abnormality Preterm Birth Asphyxia injury Birth / Sepsis Pneumonia Un TOTAL Total: N= 11 27 115 159 5 70 38 425 Home 27.3 85.2 72.2 68.6 40.0 68.6 89.5 71.1 Outside Home: 72.7 14.8 27.8 31.4 60.0 31.4 10.5 28.9 Medical college hospital 18.2 0.0 2.6 3.8 0.0 4.3 2.6 3.5 Family welfare center 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Upazila health complex 0.0 3.7 4.4 3.1 20.0 5.7 0.0 3.8 MCWC 0.0 0.0 2.6 4.4 0.0 1.4 2.6 2.8 NGO hospital/ clinic 0.0 0.0 0.0 1.3 0.0 0.0 0.0 0.5 Private hospital/clinic 9.1 0.0 0.9 6.9 0.0 4.3 0.0 3.8 Chamber of MBBS doctor 0.0 0.0 0.9 0.0 0.0 0.0 0.0 0.2 Chamber of Village doctor 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 On the way to hospital/ HC 9.1 3.7 3.5 3.1 0.0 4.3 2.6 3.5 Other 36.4 7.4 13.0 8.8 40.0 11.4 2.6 10.8 Don’t know/don’t remember 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

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Table 6.3.2 describes the place of neonatal deaths by upazila. In the overall area, around three-fourth of neonatal deaths took place at home and the rates were high in Chunarughat (84 percent), Lakhai (83 percent), and Madhabpur (81 percent). Among newborns who died outside home, mostly took place at UHCs, private clinics/hospitals, medical college hospital and MCWC.

Table-6.3.2: Distribution of Place of Death by upazila

Reasons for not seeking care

following illness of newborn

Ajmiriganj Bahubal Baniachong Chunarughat Habiganj Lakhai Madhabpur Nabiganj Total Neonatal deaths (N) 5 41 79 77 53 24 68 78 425 Home 40.0 73.2 65.8 84.4 56.6 83.3 80.9 61.5 71.1 Outside Home: 60.0 26.8 34.2 15.6 43.4 16.7 19.1 38.5 28.9 Medical college hospital 0.0 7.3 1.3 1.3 1.9 8.3 5.9 3.9 3.5 Family welfare center (FWC/RD) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Upazila health complex 20.0 0.0 7.6 2.6 1.9 8.3 2.9 2.6 3.8 MCWC 0.0 7.3 2.5 0.0 3.8 0.0 0.0 6.4 2.8 NGO hospital/ clinic 0.0 0.0 0.0 0.0 1.9 0.0 0.0 1.3 0.5 Private hospital/clinic 20.0 2.4 2.5 2.6 1.9 0.0 4.4 7.7 3.8 Chamber of MBBS doctor 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.3 0.2 Chamber of Village doctor 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 On the way to hospital/ HC 0.0 2.4 5.1 2.6 5.7 0.0 4.4 2.6 3.5 Other 20.0 7.3 15.2 6.5 26.4 0.0 1.5 12.8 10.8 Do not know/ remember 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

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Chapter-7 Discussion: ------

The neonatal mortality rate (NMR) in the MaMoni area of Habiganj was 28.4 per thousand live births, estimated from the baseline survey of 2010. The process of examining causes of death by number of days since birth yielded useful insights for health program planning and illustrates the need for a continuum of care. Deaths occurring on the first day were about 40 percent of total neonatal deaths. Most deaths on the first day of life were the result of birth asphyxia, congenital abnormality and complication of preterm delivery. In combination with the high rates of fresh still-births (21 per 1,000 births), these data highlight the vital need to increase coverage by skilled birth attendants, to ensure prompt referral and quality emergency obstetric care as well as neonatal care, and to equip skilled birth attendants with the capabilities to identify and manage birth asphyxia.

On day 1-2, sepsis or pneumonia deaths made up around 9 percent of total deaths from sepsis and the proportion of deaths attributed to this cause thereafter. Most of the early deaths due to infection were probably due to pathogens acquired from the mother. Later deaths from infections including tetanus can be prevented through maternal tetanus immunization and good quality practices during home delivery and care. Infections after 3 days of life were mostly acquired and early recognition of danger signs and symptoms and immediate management at the health facilities can save substantial number of neonates.

In an area with a low neonatal mortality rate (NMR), it was expected that the rate of proportional deaths due to birth asphyxia would be higher than the proportional death rate due to sepsis/pneumonia. Improved care of preterm or LBW babies can substantially improve survival.5,6 (in Chapter-5). Early postnatal vitamin A dosing;34 promotion of early and exclusive breast feeding;6,35 hypothermia prevention and management, including skin-to-skin care;36,37 topical skin cleansing with chlorhexidine;38,39 and topical emollient treatment for hospitalized newborns40,41 may also reduce mortality and morbidity in LBW or preterm neonates.5,42,43

In addition, any program should focus on routine preventive care for all newborns to prevent the substantial proportion of early deaths that occurred in the absence of distinct symptoms and signs. The study has important findings for both research and health program planning. The burden of still-birth in the MaMoni area was relatively high, but better data collection methods are essential to more precisely define the burden of still-births, to track changes in still-birth and cause-specific neonatal deaths over time, and to evaluate the effect of health programs.

Finally, half of all deaths occur by day-3, which suggests that greater coverage of ante-partum, intra- partum and early postnatal interventions, in combination with promotion of care seeking behavior and links between communities and health facilities to ensure prompt treatment is important. A combination of community outreach and family-community care to promote essential neonatal care practices and health system strengthening should help to achieve the goals.

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Major findings of verbal autopsy study:

▪ More than four-fifths of all neonatal deaths were due to birth asphyxia, preterm and sepsis. ▪ Early neonatal deaths were mostly due to birth asphyxia, preterm and congenital abnormality.

Implication of the study findings:

❖ Deaths due to birth asphyxia can be reduced by early detection of women with high risk pregnancies and promoting deliveries at a health facility or home delivery attended by HBB trained community skilled birth attendant (CSBA). ❖ Deaths due to preterm and low birth weight can be reduced by early and exclusive breast feeding, hypothermia prevention by skin to skin care, early recognition of danger signs and immediate management at the health facility. ❖ Deaths due to neonatal tetanus can be easily prevented by ensuring TT immunization to all women of 15-45 years of age including pregnant women. ❖ Treatment of maternal asymptomatic bacteriuria, urinary tract infections and reproductive tract infections are effective in reducing the incidence of neonatal infections. ❖ Clean delivery and neonatal care practices (clean cord cutting and care, skin care) may reduce early deaths from sepsis/infection. ❖ Early recognition of danger signs of sepsis/pneumonia of the newborn by the parents/family members and care seeking from a qualified provider or referral to health facility can reduce significant number of deaths. Also provision of good quality care in the community and facilities.

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Annexure:1 Type 2 algorithm and hierarchy used to assign primary cause of death in MaMoni Habiganj

425 Neonatal deaths

Tetanus: Congenital abnormality: Age at death 3-27 days AND EITHER local word Gross malformation or anencephaly or for tetanus or convulsions/ spasms and able to meningomyelocele present at birth suck or cry normally after birth and stop sucking or crying. 11 (2.6%) deaths 27 (6.4%) deaths

N = 387

Birth asphyxia: Age at death ≤ 7 days AND (not able to cry after birth or not able to breathe after birth or not able to suckle normally after birth) 240 (56.5%) deaths

N = 147

Birth injury: Age at death ≤ 7 days AND signs of injury at birth 6 (1.4%) deaths

N = 141

Sepsis or pneumonia: At least two of the following signs- • Stopped suckling • Fever or cold to touch • Unresponsive or unconscious or lethargic • Bulging fontanelle • Convulsion • Vomiting • Redness or drainage from the umbilical cord • Skin bumps containing puss or blisters or single large area of pus with swelling • Chest in drawing • Fast breathing or local term for pneumonia 90 (21.2%) deaths

N = 51

Diarrhoea: Local term for diarrhea or frequent/ watery/ loose stool 0 deaths

N = 51

Preterm: Pregnancy ended early or baby very small 13 (3.1%) deaths

Cause not identified: 38 (8.9%) deaths

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Annexure:2

Age at death by cause of neonatal deaths (in percentage).

Graph A1: Birth asphyxia (=159)

Graph A2: Preterm (N=115)

Graph A3: Neonatal Tetanus (N=11)

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Graph A4: Sepsis/Pneumonia multiple signs (N=70)

Graph A5: Congenital abnormality (N=27)

Graph A6: Undetermined cause (N=38)

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Annexure:3 Verbal Autopsy Questionnaire (VA tool)

MaMoni Survey 2010 Verbal Autopsy of Neonatal Deaths and Still-births, Habiganj

Instructions to interviewer: Introduce yourself and explain the purpose of your visit. Ask to speak to the mother or to another adult caretaker who was present during the illness that led to death. If this is not possible, arrange a time to revisit the household when the mother or caretaker will be home.

Section–1 (Identification) (Supervisor will fill-up the information in the box) Name Code

District

Upazila Union Cluster number Village name and code Name of ‘Bari’ and number Name of House-hold head and HH number Name of RDW and number

NAME OF HUSBAND OF RDW Interviewer’s Visit and Status Household 1 2 Final Visit Day ...... Date Month ...... Year ......

Interviewer’s Name INTERVIEWER’S. CODE RESULT* RESULT CODE Next Date Total Number of Visit Visit Time *RESULT CODES 01. Completed interview. 07 07. Dwelling destroyed. 02. No HH member at home OR no competent respondent at 08 08. Dwelling not found. home at time of household visit. 09 09. There is no death (still-birth or neonatal 03. Entire HH absent for extended period of time. death) during 01 May’09 to 31 July ‘10. 04. Postponed. 11 10. Others.______05. Refused. (Specify) 06. Dwelling vacant OR address is not a dwelling. Reviewed by: Supervisor Reviewed by: Physician Name/Code______Name/Code______Date / / Date / /

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Section-2

International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B)

Information sheet to obtain verbal consent from participants for the Verbal Autopsy

Title of Project: Evaluation of the ACCESS/MaMoni Bangladesh program: population based surveys in Sylhet division of Bangladesh.

Principal Investigator: Shams El Arifeen Head, Child Health Unit PHSD, ICDDR,B

Description of the project: We are working on behalf of Save the Children, USA for the health of mother and new born in a project entitled ‘ACCESS / MaMoni’ aiming to reduce morbidity and mortality of newborn babies. The project is implemented in seven upazilas of Sylhet, by two NGO’s Shimantik and FIVDB (Friends in Village Development Bangladesh), under the financial support of Save the Children USA. We are trying to understand whether the health of local children is improved through these activities. The findings/result will be utilized in a way that, it will be more effective and acceptable to you and the members of your communities. The information will also help to ascertain rates of newborn deaths and improvement of the newborn health practices in this community. In this regard, we are collecting information about the causes of death of newborn babies who died in last one and half year. This information will help us to understand clearly the specific causes of newborn death in this locality; so that we will be able to find the easy way out to reduce the neonatal death in future. We came to know that a new born baby died in this house within last one and half year. Today we will ask you some questions regarding the illness of that baby or what s/he suffered and what happened before his/her death. We know that we will ask you about very unfortunate incident of your life which may cause you emotional distress. Though there is no personal benefit by taking part in this study but we will be able to utilize the information collected from you to reduce the risk of child death. We seek your permission for your participation in this study. There is no major risk in participating in this study. If you take part in this study, the information that we will collect from you, will contribute to the development of the child health status of Bangladesh and other part of the world as well. If you agree to participate in the study we will ask you some questions. You will be interviewed once and it would take only 30-45 minutes. During the interview, we will write some information in paper so that we could remember what you said. We hope you will take part in this survey voluntarily. You have the right to withdraw yourself from taking part in the survey at any time. You can also avoid answering any question that you think sensitive. Even if you do not want to take part in the study, or if you withdraw yourself, you will still receive the same quality of services and care from health workers.

Your identity will remain confidential. Only project staff will have access to these forms.

If you think that you’ve been treated unfairly or been hurt by joining this survey or if you have questions, you may contact Dr. Shams El Arifeen, Principal Investigator, Child Health Unit, ICDDR,B, Mohakhali, Dhaka, Tel# 8802- 8860523-32, Ext 3800 and/or Mr. M. A. Salam Khan, Committee Coordination Secretariat, ICDDR,B, Mohakhali, Dhaka, Tel #9886498.

Do you have any question? Yes |___| No |___|

Do you agree to be interviewed? Yes |___| No |___|

Signature of the Interviewer: ______Date: ______

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❖ Section 3:

INFORMATION ABOUT CARETAKER / RESPONDENT:

3.1 Key Respondent:

Ask to speak to the person who was the child's main caregiver during the illness. This is usually, but not always, the child's mother. Someone else may have cared for the child if the mother was absent or sick. If the child died in the first few days of life, a grandmother, the father, or another senior female family member may be most aware of the child's illness. Ask the family to help you pick the person who cared for the child during the illness. Often you will come across situations where more than one respondent participates in the interview. Do not discourage the additional respondents even if they are not the best ones because the information given by them could be complimentary and important. If the information provided by the main respondent and additional respondent(s) are not consistent, accept the information provided by the main respondent. If the main caretaker during the illness that led to death of the child is not at home, arrange a time to revisit the household when [s/he] will be home.

3.2 What is the name of the main respondent? ______3.3 What is the relationship of main respondent to deceased child? (circle the appropriate code). Mother ...... 1 Father...... 2 Grandmother ...... 3 Grandfather ...... 4 Aunt ...... 5 Uncle ...... 6 Birth attendant: Trained ...... 7 Birth Attendant: Not Trained ...... 8 Other male (specify) ...... 9 Other female (specify)...... 10

3.4 What is the age of main respondent (in years)? |___|___| in years 3.5 How many years of school did the main respondent complete? |___|___| Write ‘00’ if no education. 3.6 Were other people present at the interview? Yes………..1 No…………2 Go to next question irrespective of answer (Yes or No)

If the answer is ‘Yes’ then mark all in the next table and fill-up the status of presence in the different events till the death of the baby. If the answer is ‘No’ then mark the main respondent only in the next table and fill-up the status of presence in the different events till the death of the baby. (NB. After filling up 3.6, 3.6.1 and 3.6.2; please cross check again and then proceed).

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3.6.1 Of those present at the interview, which were present during pregnancy/at delivery/during illness/at death during the illness that led to the child’s death? (tick all relevant boxes). Circle ‘2’ if absent

Present at Present during Present at Present during Present at Sl interview pregnancy delivery illness death Person present # Present Present Present Present Present Yes No Yes No Yes No Yes No Yes No 1 Mother ...... 1 2  1 2 1 2

2 Father ...... 1 2  1 2 1 2 1 2 1 2

3 Grandmother ...... 1 2  1 2 1 2 1 2 1 2

4 Grandfather ...... 1 2  1 2 1 2 1 2 1 2

5 Aunt ...... 1 2  1 2 1 2 1 2 1 2

6 Uncle...... 1 2  1 2 1 2 1 2 1 2

7 Birth Attendant (Trained) . 1 2  1 2 1 2 1 2 1 2

8 Birth Attendant (not trained) 1 2  1 2 1 2 1 2 1 2 9 Other male (Specify) 1 2  1 2 1 2 1 2 1 2 10 Other female (Specify) 1 2  1 2 1 2 1 2 1 2

3.6.2 Total number of person present at interview (excluding interviewer): |___|___|

3.6.2.1 (Check Ques. 3.3) Is the mother present as main respondent? Yes...... 1 → 4.0 No………………………….……...... 2

3.6.3 In case where the mother is not the main respondent and the mother is not present at the interview, then ask where is the mother? Alive ...... 1→ 4.0 Dead ...... 2

3.6.3a If the mother is dead, then ask when the mother died? At the time of delivery 1 → 4.0 After the birth of the child 2 Don’t know/Can’t remember……………………...... 9

3.6.3b If the mother is dead then ask; After how many days / month after birth, the mother died?

Days |____|____| (Write 00 if less than 1 day) Month |____|____| (write in days if less than 2 months & in months if more than 2 months) Don’t know / Can’t remember...... 9

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❖ Section 4: INFORMATION ABOUT THE CHILD

4.0 Was the child given name? Yes……………………………01 No….……..…………………..02 If yes, what is the name of the child? ______

4.1 Where did the delivery occur? (Circle the appropriate code) Home ...... 01 Out side home; Public Sector: Medical College Hospital ...... 02 Family Welfare Center (FWC)/RD ...... 03 Upajila Health Complex ...... 04 Maternal And Child Welfare Center (MCWC) ...... 05 NGO Sector: NGO Hospital/Clinic ...... 06 Private Medical Sector: Private Hospital/Clinic...... 07 Qualified Doctor’s Chamber...... 08 Traditional Doctor’s Chamber ...... 09 On the way to Hospital or Health Center...... 10 Others ______98 (Specify) Don’t know/Cant remember ...... 99

4.2 Who delivered the baby? (Identify the main person) Among the family members Mother-in-law ...... 01 Mother/Ma ...... 02 Sister ...... 03 Sister-In-Law ...... 04 Husband/ ...... 05 Father-In-Law ...... 06 Other member from in laws house ...... 07 Other member from natal house ...... 08 Other relatives ...... 09 Outside the family members Health Professional: Qualified Doctor ...... 10 Nurse/Midwife ...... 11 Paramedic ...... 12 Family Welfare Visitor ...... 13 MA/SACMO ...... 14 Health Assistant (HA) ...... 15 Family Welfare Asst (FWA) ...... 16 [If above mentioned person, code 12, 13, 14, 15, 16, came at home during delivery, record his/her name in the specified place] Other person: Birth Attendant (TTBA) ...... 17 Untrained TBA (Dai) ...... 18 Neighbour or Friend...... 19 Unqualified Doctor ...... 20 Other ...... 98 (Specify) No one ...... 77 Don’t know/Can’t remember ...... 99

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4.3 Was the delivery…? (Read the choices.) Spontaneous without any assistance ...... 1 Assisted with manipulation with hands...... 2 Instrumental (vacuum or forceps) ...... 3 Failed instrumental + C-section ...... 4 C-section (alone) ...... 5 Others (Specify) ...... 6 Don’t know/Can’t remember ...... 9

4.4 Was the delivery…? (Read the choices.) Spontaneous without medication ...... 1 Induced with medicine ...... 2 Augmented with medicine ...... 3 Used homeopath/Herbal medicine to induce delivery ...... 4 Don’t know/Can’t remember ...... 9

4.5. What was the colour of the liquor when the waters broke? Green or brown (i.e, meconium-stained) ...... 1 Clear (normal) ...... 2 Other (Specify) ...... 3 Water didn't break ...... 4 → 4.7 Don’t know/Can’t remember ...... 9

4.6 Was the liquor foul-smelling? Yes...... 1 No ...... 2 Don’t know/Can’t remember ...... 9

4.7 At the time of the delivery was the baby: (Read out choices) Very small ...... 1 Smaller than usual ...... 2 About average ...... 3 Larger than usual ...... 4 Don’t know/Can’t remember ...... 9

4.8 What was the weight of the baby? |___|___|___|___| grams (if not known write 9999)

4.9 What was the baby’s gender? Boy ...... 1 Girl ...... 2 Don’t know...... 9

4.10 Was the child born alive or dead? Alive ...... 1 Dead ...... 2 Don’t know/Can’t remember ...... 9

Ask following questions ireespective of answer in 4.10

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4.10.1 Did the baby ever cry? Yes...... 1 No ...... 2 Don’t know...... 9

4.10.2 Did the baby ever move? Yes...... 1 No ...... 2 Don’t know...... 9

4.10.3 Did the baby ever breathe? Yes...... 1 No ...... 2 Don’t know...... 9

(If “Dead” and no crying, movement or breathing, go to question 5.1 regarding stillbirths). (If “Alive”and circled (2) in 4.10.1, 4.10.2 & 4.10.3 then ask the questions again and make corrections). Similarly, if “Dead” and circled 1 in 4.10.1, 4.10.2 and 4.10.3 then ask the questions again and make necessary correction).

4.11. How old was the baby when the fatal illness started? |___|___| days (Completed days) Write ‘00’ when less than 1 day. Don’t know...... 9

4.11a What was the date of birth of the baby? |___|___|-|___|___|-|___|___| Day Month Year If don’t know then write 99-99-99

4.11b What was the date of death of the baby? |___|___|-|___|___|-|___|___| Day Month Year If don’t know then write 99-99-99

4.12. How old was the baby at the time of death? |___|___| Days (Completed days). Write ‘00’ when less than 1 day. Don’t know...... 9

Interviewer: Take your time to calculate and compare age at death and date of death of the deceased. If there is inconsistency reconcile the age at death.

4.13. Where did the baby die? (Circle the appropriate code) Home ...... 01 → Section 5 Outside Home: Public Sector: Medical College Hospital ...... 02 Family Welfare Center (FWC)/RD ...... 03 Upazila Health Complex ...... 04 Maternal and Child Welfare Center (MCWC) ...... 05 60 | P a g e

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NGO Sector: NGO Hospital/Clinic ...... 06 Private Medical Sector: Private Hospital/Clinic ...... 07 Qualified Doctor’s Chamber ...... 08 Traditional Doctor’s Chamber...... 09 On the way to hospital ...... 10 Others ...... 98 (Specify) Don’t know/Can’t remember...... 99

4.13.1 For deaths at hospital or health facility, record facility name and address: ______

Go to next section if the age at death of the baby was 28 days or less, when the age at death was 29 days or more, then stop interview.

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❖ Section 5: Open history questions

Instructions to interviewer: Allow the respondent to tell you about the pregnancy, delivery and the baby’s illness in her own words. Write down what the respondent tells you in her own words. Do not prompt except for asking whether there was anything else after the respondent finishes. Keep prompting until the respondent says there was nothing else. While recording, underline any unfamiliar terms.

5.1 For stillbirths (i.e., no cry, no breathing, no movement at birth), ask: Could you tell me about the pregnancy and delivery, and what happened after the delivery? For live births that died at less than 28 days old, ask: Could you tell me about the pregnancy and birth, and what happened after the birth, including about the baby’s illness that led to death? Prompt: “Was there anything else?”

______

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Instructions to interviewer: Take a moment to tick all items mentioned spontaneously in the open history questionnaire. Use this to guide you through the rest of the questionnaire. Note: severity scale** (Column-7) ; Mild=1; Moderate=2; Severe=3; Not applicable=8

1 2 3 4 5 6 7 8

(Write in in (Write

=2

Sl. # Complications

Was it present Wasit started/diagnosed it When during pregnancy of month Howmany days/month the persists complication name the Local complication of Severitythe complication of ** completed month if more than 1 month month 1 than more if month completed month) 1 than less if day in and complication the diagnosed Who =1 Worker Health health Not worker Complication during Pregnancy Yes..... 1 5.1.1 Multiple pregnancy Month No ..... 2 |___| Yes..... 1 Month Mon |___|___| 5.1.2 Vaginal bleeding |___| No ..... 2 |___| Day |___|___| Severe or persistent Yes..... 1 5.1.3 Month Mon |___|___| |___| abdominal or back pain No ..... 2 |___| Day |___|___| High blood pressure Yes..... 1 5.1.4 |___| 1 2 (before pregnancy) No ..... 2 5.1.14 High blood pressure Yes..... 1 Month Mon |___|___| |___| 1 2 a (during pregnancy) No ..... 2 |___| Day |___|___| Hand or facial swelling, or Yes..... 1 5.1.5 Month Mon |___|___| |___| rapid leg swelling No ..... 2 |___| Day |___|___| Blurred vision, or severe or Yes..... 1 Month Mon |___|___| 5.1.6 |___| persistent headache No ..... 2 |___| Day |___|___| Yes..... 1 5.1.7 Convulsions Month Mon |___|___| |___| No ..... 2 |___| Day |___|___| Diabetes (before Yes..... 1 5.1.8 |___| 1 2 pregnancy) No ..... 2 Diabetes (during Yes..... 1 5.1.8a Month Mon |___|___| |___| 1 2 pregnancy) No ..... 2 |___| Day |___|___| Yes..... 1 Month Mon |___|___| 5.1.9 Malaria |___| 1 2 No ..... 2 |___| Day |___|___| Yes..... 1 Month Mon |___|___| 5.1.10 Severe anaemia |___| 1 2 No ..... 2 |___| Day |___|___| Felt baby moving much less Yes..... 1 5.1.11 Month Mon |___|___| than normal No ..... 2 |___| Day |___|___| Yes..... 1 5.1.12 Baby stopped moving Month No ..... 2 |___| Yes..... 1 5.1.13 Positive syphilis test Month 1 2 No ..... 2 |___| 5.1.13 If yes, then was Syphilis Yes..... 1 Month Mon |___|___| a treated? No ..... 2 |___| Day |___|___| Yes..... 1 Month Mon |___|___| 5.1.14 Genital ulcer |___| 1 2 No ..... 2 |___| Day |___|___| Yes..... 1 5.1.15 Positive HIV test Month 1 2 No ..... 2 |___| Urinary complaints Yes..... 1 5.1.16 Month Mon |___|___| |___| 1 2 ______No ..... 2 |___| Day |___|___| Other 1 (Specify) Yes..... 1 5.1.17 Month Mon |___|___| |___| 1 2 ______No ..... 2 |___| Day |___|___| Other 2 (Specify) Yes..... 1 Month Mon |___|___| |___| 1 2 ______No ..... 2 |___| Day |___|___| Complication during delivery/Labour complication 64 | P a g e

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1 2 3 4 5 6 7 8

(if (if

(Write in in (Write

=2

Sl. # Complications

Who diagnosed Who the

Was it present Wasit started/diagnosed it When after labour started pain Howmany days/month the persists complication name the Local of complication Severitythe complication of ** complication HealthWorker =1 Notworker health less than 1 hour, 1 than less ‘ write 00’ ) 1 than more if month completed day in and month than less if 1 month) Yes..... 1 5.1.18 Multiple pregnancy Hour 1 2 No ..... 2 |___|___| Vaginal bleeding (like a Yes..... 1 Hour Mon |___|___| 5.1.19 |___| period or more) No ..... 2 |___|___| Day |___|___| Yes..... 1 5.1.20 High blood pressure Hour Mon |___|___| |___| 1 2 No ..... 2 |___|___| Day |___|___| Yes..... 1 5.1.21 Hand or facial swelling Hour Mon |___|___| |___| No ..... 2 |___|___| Day |___|___| Blurred vision, or severe or Yes..... 1 5.1.22 Hour Mon |___|___| |___| persistent headache No ..... 2 |___|___| Day |___|___| Yes..... 1 5.1.23 Convulsions Hour Mon |___|___| |___| No ..... 2 |___|___| Day |___|___| Yes..... 1 Hour Mon |___|___| 5.1.24 Malaria |___| 1 2 No ..... 2 |___|___| Day |___|___| Yes..... 1 5.1.25 Severe anaemia Hour Mon |___|___| |___| 1 2 No ..... 2 |___|___| Day |___|___| Waters broke >1 day before Yes..... 1 5.1.26 labour began No ..... 2 Yes..... 1 5.1.27 Fever during labour Mon |___|___| |___| No ..... 2 Day |___|___| Yes..... 1 5.1.28 Baby stopped moving Hour No ..... 2 |___|___| Yes..... 1 5.1.29 Obstructed labour |___| 1 2 No ..... 2 Labour longer than 12 Yes..... 1 5.1.30 1 2 hours No ..... 2 Umbilical cord delivered Yes..... 1 5.1.31 |___| 1 2 before the baby No ..... 2 Umbilical cord around the Yes..... 1 5.1.32 1 2 baby’s neck No ..... 2 5.1.33 Yes..... 1 Breech delivery 1 2 a No ..... 2 5.1.33 Yes..... 1 Babies leg coming first 1 2 b No ..... 2 Waters brown- or yellow- Yes..... 1 5.1.34 1 2 stained or foul smelling No ..... 2 5.1.34 Yes..... 1 Water was foul smelling 1 2 a No ..... 2 5.1.34 Emergency C-section was Yes..... 1 1 2 b done No ..... 2 Injection (Oxytocin) was 5.1.34 given before delivery Yes..... 1 1 2 c Injection given |__|__| hour No ..... 2 after labour pain started Other 1 (Specify) Yes..... 1 5.1.35 Hour Mon |___|___| |___| 1 2 ______No ..... 2 |___|___| Day |___|___| Other 2 (Specify) Yes..... 1 Hour Mon |___|___| |___| 1 2 ______No ..... 2 |___|___| Day |___|___|

Other 3 (Specify) Yes..... 1 Hour Mon |___|___| |___| 1 2 ______No ..... 2 |___|___| Day |___|___|

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Condition of the Neonate

1 2 3 4 5 6 7 8

(Write in in (Write

Sl. # Complications 1 than less (if

worker=2

Was it present Wasit started/diagnosed it When after delivery Howmany days/month the persists complication name the Local of complication Severitythe complication of ** diagnosed Who the complication HealthWorker =1 Not health hour, write ‘ write hour, 00’ ) 1 than more if month completed day in and month than less if 1 month) Yes..... 1 5.1.36 Born early Hour |___| 1 2 No ..... 2 |___|___| Yes..... 1 5.1.37 Very small |___| 1 2 No ..... 2 Yes..... 1 5.1.38 Bruises or signs of an injury |___| 1 2 No ..... 2 Yes..... 1 5.1.39 Macerated dead baby 1 2 No ..... 2 Yes..... 1 5.1.40 Physical malformation |___| 1 2 No ..... 2 Other (Specify) Yes..... 1 5.1.41 Hour Mon |___|___| |___| 1 2 ______No ..... 2 |___|___| Day |___|___|

If the baby is dead, no need to fillup 5.1.42 to 5.1.70. Problem of the newborn Baby

1 2 3 4 5 6 7 8

(Write in in (Write

Sl. # Complications

Was it present Wasit started/diagnosed it When after‘ birth (Write 00’ if lesshour) 1 than Howmany hours/days the persists complication name the Local of complication Severitythe complication of ** diagnosed Who the complication HealthWorker =1 Notworker health =2 hours if less than 1 day and and day 1 than less if hours ‘ 00’hour) 1 than less if Yes..... 1 Hour |___|___| 5.1.42 No cry at birth 1 2 No ..... 2 Day |___|___| Yes..... 1 5.1.43 Not breathing at birth Hour |___|___| 1 2 No ..... 2 Day |___|___| Hour Yes..... 1 5.1.44 Stopped crying |___|___| Hour |___|___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour 5.1.44 Poorly or not suck breast Yes..... 1 |___|___| Hour |___|___| 1 2 a after birth No ..... 2 Day Day |___|___| |___|___| Hour 5.1.44 Yes..... 1 |___|___| Hour |___|___| Stopped sucking breast 1 2 b No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.45 Diarrhoea |___|___| Hour |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.46 Cough |___|___| Hour |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___|

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Hour Yes..... 1 5.1.47 Fever |___|___| Hour |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Cold to the touch (low body Yes..... 1 5.1.48 |___|___| Hour |___|___| |___| 1 2 temp) No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.49 Rash |___|___| Hour |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 |___|___| 5.1.50 Injury |___| 1 2 No ..... 2 Day |___|___| Hour Yes..... 1 5.1.51 Loss of consciousness |___|___| Hour |___|___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Lethargic/decreased Yes..... 1 5.1.52 |___|___| Hour |___|___| |___| 1 2 movement No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.53 Fit/convulsion |___|___| Hour |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.54 Feeding problem |___|___| Hour |___|___| |___| No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 |___|___| Hour |___|___| 5.1.55 Vomiting |___| No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 |___|___| Hour |___|___| 5.1.56 Tetanus |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Umbilical infection Yes..... 1 5.1.57 |___|___| Hour |___|___| |___| 1 2 (redness, pus discharge) No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.58 Skin pustules |___|___| Hour |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.59 Eye redness or discharge |___|___| Hour |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 |___|___| Hour |___|___| 5.1.60 Cyanosis (body blue) |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 |___|___| Hour |___|___| 5.1.61 Bleeding ______|___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.62 Difficult breathing |___|___| Hour |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.63 Chest in-drawing |___|___| Hour |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.64 Rapid breathing |___|___| Hour |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour 5.1.65 Very thin Yes..... 1 |___| 1 2 |___|___| 67 | P a g e

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No ..... 2 Day |___|___| Hour Yes..... 1 |___|___| Hour |___|___| 5.1.66 Pneumonia |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.67 Accident |___|___| |___| No ..... 2 Day |___|___| Hour Yes..... 1 5.1.68 Malaria |___|___| Mon |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Yes..... 1 5.1.69 Jaundice |___|___| Mon |___|___| |___| 1 2 No ..... 2 Day Day |___|___| |___|___| Hour Other terms 1 (Specify) Yes..... 1 5.1.70 |___|___| Mon |___|___| |___| 1 2 ______No ..... 2 Day Day |___|___| |___|___| Hour Other terms 2 (Specify) Yes..... 1 |___|___| Mon |___|___| |___| 1 2 ______No ..... 2 Day Day |___|___| |___|___| Hour Other terms 3 (Specify) Yes..... 1 |___|___| Mon |___|___| |___| 1 2 ______No ..... 2 Day Day |___|___| |___|___| ______If child was born alive, go to live birth module (section 7b, 8, 9 & 10). If child was born dead and never cried, moved or breathed, go to stillbirth module (section 6a,7a and then section 10). ______

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STILL-BIRTH MODULE: For the child was born dead and never cried, moved or breathed Section 6A: Maternal History

Additional questions on prenatal care, labour and delivery, and obstetrical complications.

6.A.1 Was the child a singleton or multiple births? (If two or more children are born at the same time, it is counted as a multiple birth, even if one or more of the babies are born dead). Singleton ...... 1 → 6A.2 Multiple ...... 2 Don’t know ...... 9

6.A.1.1 If “Multiple”, ask: Was this the first, second, or later in the birth order? First ...... 1 Second ...... 2 Third or more ...... 3 Don’t know ...... 9

6.A.2 Was there any complication developed during last trimester or during delivery? Yes ...... 1 No ...... 2 → 6.A.3 Don’t know ...... 9 → 6.A.3

6.A.2.1 If “Yes,” ask: What complications occurred during late pregnancy, labour or delivery? (Record all responses). Yes No 1 Mother had convulsions ...... 1 2 2 Mother had oedema in hand & face...... 1 2 3 Mother had severe headache or blurred vision ...... 1 2 4 Mother had high BP, measured by any health worker ...... 1 2 5 Mother had severe anaemia, identified by HW ...... 1 2 6 Mother had severe backache before delivery ...... 1 2 7 Mother had diabetes, diagnosed by HW ...... 1 2 8 Breech presentation ...... 1 2 9 Prolonged labour ...... 1 2 10 Retained placenta ...... 1 2 11 Child delivered feet first ...... 1 2 12 Cord delivered first ...... 1 2 13 Cord was around child’s neck ...... 1 2 14 Excessive bleeding ...... 1 2 15 Bleeding during last 3 months of pregnancy ...... 1 2 16 Emergency Caesarean section ...... 1 2 17 Multiple delivery ...... 1 2 18 Waters brown- or yellow-stained or foul-smelling...... 1 2 19 Felt baby moving much less than normal ...... 1 2 20 Felt baby stopped moving ...... 1 2 21 Fever during labour ...... 1 2 22 Waters broke > 1 day before labour began ...... 1 2 23 Other (Specify) ______1 2

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6.A.3 How many months long was the pregnancy? |___|___| Months (Record 99, if the number of months is not known and go to Question 6.A.4)

6.A.3.1 Did the pregnancy end early, on time, or late? Early ...... 1 On time ...... 2 Late ...... 3 Don’t know ...... 9

6.A.4 Was the baby moving in the last few days before the birth? Yes ...... ………1 No ...... ………2 Don’t know ...... ……...9

6.A.5 When did you last feel the movement of the baby before delivery? Hour ...... 1 |___|___| hours before delivery Day ...... 2 |___|___| days before delivery Don’t know ...... 9

6.A.6 When did the water break? Before labour pain...... 1 Before the delivery ...... 2 → 6.A.7 Waters never broke ...... 3 → 6.A.7 Don’t know ...... 9 → 6.A.7

6.A 6.1 If waters broke before labour, ask: How much time before labour did the waters break? |____|____| Hour ...... 1 |____| Day ...... 2 Don’t know ...... 9

6.A.6.2 What was the colour of the water, when it was broken? Greenish/ Yellow stained or brown ...... 1 Clear ...... 2 Other ______...... 3 (specify) Don’t know ...... ……….9

6.A.6.3 Was the water foul smelling? Yes ...... 1 No ...... 2 Don’t know ...... 9

6.A.7 How much time did the labour and delivery take? (Note: labour begins when contractions are no more than 10 minutes apart.) |____|____| Hour ...... 1 Don’t know ...... 9

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6.A.8 Was anything done to try to help the baby breathe at birth? (like; slap the baby, mouth to mouth resuscitation, stimulation by rubbing the back etc.) Yes ...... 1 No ...... 2 Don’t know ...... 9

6.A.9 Did the baby’s mother receive any tetanus vaccinations (TT) since reaching adulthood before this pregnancy? Yes ...... 1 No ...... 2 → 6.A.10 Don’t know ...... 9 → 6.A.10

6.A.9.1 If “yes”, ask: “How many doses?” |____|____| dose

6.A.10 Did the baby’s mother receive any tetanus vaccinations (TT) during this pregnancy? Yes ...... 1 No ...... 2 → 7.A.1 Don’t know ...... 9 → 7.A.1

6.A.10.1 If “yes”, ask: “How many doses?” |____|____| dose

Section 7A: Stillbirth Appearance:

(Interview and fill-up section-7A for still born baby who did not cry at all, move or take breath after birth).

7. A 1 Were there any bruises or signs of injury on the baby’s body at birth? Yes ...... 1 No ...... 2 Don’t know ...... 9

7. A 2 Was the baby’s body macerated (skin and tissue was pulpy)? Yes ...... 1 No ...... 2 Don’t know ...... 9

7. A 3 Did the baby has any gross malformations at delivery? Yes ...... 1 No ...... 2 → 7.A.4 Don’t know ...... 9 → 7.A.4

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7. A.3.1 If yes ask: What were the malformations? (After the respondent finishes, prompt: Were there malformations anywhere else? (Keep using this prompt until the respondent replies that there were no more malformations.)

1. ______2. ______3. ______

7. A 4 Was the head size very small at the time of birth (Anencephaly)? (Show photo) Yes ...... 1 No ...... 2 Don’t know ...... 9

7. A 5 Was there a mass or defect on the back of the head or spine (meningomyelocele)? (Show Photo) Yes ...... 1 No ...... 2 Don’t know ...... 9

7. A 6 Was there any cleft lip or palate? (Show photo) Yes ...... 1 No ...... 2 Don’t know ...... 9

7. A 7 Were there any (other) limb defects? Yes ...... 1 No ...... 2 Don’t know ...... 9

If the answer is 'Yes', then mention where was the defect: ______

▪ End the Interview and go to Section-10

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LIVE-BIRTH MODULE

Interview with this section only for live born baby Section 7B: Maternal History:

Additional questions on prenatal care, labour and delivery, and obstetrical complications.

7.B.1 Was the child a singleton or multiple births? (If two or more children are born at the same time, it is counted as a multiple birth, even if one or more of the babies are born dead). Singleton ...... 1 →7 B.2 Multiple ...... 2 Don’t know ...... 9

7B.1.1 If “Multiple”, ask: Was this the first, second, or later in the birth order? First ...... 1 Second ...... 2 Third or more ...... 3 Don’t know ...... 9

7 B.2 Was the late part of the pregnancy (i.e. last 3 months), labour or delivery complicated? Yes ...... 1 No ...... 2 → 7.B.3 Don’t know ...... 9 → 7.B.3

7. B 2.1 If “Yes,” ask: What complications occurred during late pregnancy, labour or delivery? (Record all responses) Yes No 1 Mother had convulsions ...... 1 2 2 Mother had oedema in hand & face ...... 1 2 3 Mother had severe headache or blurred vision ...... 1 2 4 Mother had high BP, measured by any health worker ...... 1 2 5 Mother had severe anaemia, identified by HW ...... 1 2 6 Mother had severe backache before delivery ...... 1 2 7 Mother had diabetes, diagnosed by HW ...... 1 2 8 Breech presentation...... 1 2 9 Prolonged labour ...... 1 2 10 Retained placenta ...... 1 2 11 Child delivered feet first ...... 1 2 12 Cord delivered first ...... 1 2 13 Cord was around child’s neck ...... 1 2 14 Excessive bleeding ...... 1 2 15 Bleeding during last 3 months of pregnancy ...... 1 2 16 Emergency Caesarean section ...... 1 2 17 Multiple delivery...... 1 2 18 Water greenish/brown or yellow-stained or foul-smelling ...... 1 2 19 Felt baby moving much less than normal ...... 1 2 20 Felt baby stopped moving ...... 1 2 21 Fever during labour ...... 1 2 22 Waters broke > 1 day before labour began ...... 1 2 23 Other (Specify) ...... 1 2 After respondent finishes prompt: Was there anything else? (Keep using this prompt until the respondent replies that there were no other complications.) 73 | P a g e

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7. B.3 How many months long was the pregnancy? |___|___| Months (Record 99, if the number of month is not known and then go to question 7.B.4)

7.B.3.1 Did this child’s pregnancy end early, on time, or late? Early ...... 1 On time...... 2 Late ...... 3 Don’t know ...... 9

7. B 4 When did the water break? Before starting the labour pain ...... 1 Before the delivery ...... 2→7.B 5 Waters never broke ...... 3→7.B 5 Don’t know ...... 9→7.B 5

7. B 4.1 If waters broke before labour, ask: How much time before labour did the waters break? |____|____| Hour ...... 1 |____| Day ...... 2 Don’t know ...... 9

7. B 4.2 What was the color of the water, when it was broke? Greenish/Yellow stained or brown ...... 1 Clear ...... 2 Other (Specify)______...... 3 Don’t know ...... 9

7. B 4.3 Was the water foul smelling? Yes ...... 1 No ...... 2 Don’t know ...... 9

7. B.5 How much time did the labour and delivery take? (Note: labour begins when contractions are no more than 10 minutes apart.)

|____|____| Hour ...... 1 Don’t know ...... 9

7. B.6 Did the baby’s mother receive any tetanus vaccinations since reaching adulthood before this pregnancy? Yes ...... 1 No ...... 2→7.B.7 Don’t know ...... 9→7.B.7

7. B.6.1 If “yes”, ask: “How many doses?” |____|____| dose

7. B.7 Did the baby’s mother receive any tetanus vaccinations during this pregnancy? Yes ...... 1 No ...... 2→ 8.1 Don’t know ...... 9→ 8.1

7. B.7.1 If “yes”, ask: “How many doses?” |____|____| dose

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Section 8: Neonatal Death

8.1 Were there any bruises or signs of injury on ______’s body at birth? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.2 Did he/she have any gross malformations at birth? Yes ...... 1 No ...... 2→ 8.3 Don’t know ...... 9→ 8.3

8.2.1 If yes ask: What were the malformations? (After the respondent finishes, prompt: Were there malformations anywhere else? (Keep using this prompt until the respondent replies that there were no more malformations.)

1.______2.______3.______

8.3. Was the head size very small at the time of birth (Anencephaly)? Show photograph Yes ...... 1 No ...... 2 Don’t know ...... 9

8.4. Was there a mass or defect on the back of the head or spine (meningomyelocele)? (Show Photo) Yes ...... 1 No ...... 2 Don’t know ...... 9

8.5 Was there any cleft lip or palate? (Show Photo) Yes ...... 1 No ...... 2 Don’t know ...... 9

8.6 Were there any (other) limb defects? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.7 Was the baby______able to breathe immediately after birth? (Note: This does not include gasps or very brief efforts to breathe) Yes ...... 1 No ...... 2 Don’t know ...... 9

8.8 Was anything done to try to help the baby breathe at birth? Yes ...... 1 No ...... 2 Don’t know ...... 9

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8.9 Was (name)______able to cry after birth? Yes ...... 1 No ...... 2→ 8.10 Don’t know ...... 9→ 8.10

8.9.1 How long after birth did the baby first cry? Within 5 minutes ...... 1 Within 5-30 minutes ...... 2 More than 30 minutes ...... 3 Don’t know ...... 9

8.10 Did (name) stop being able to cry? Yes ...... 1 No ...... 2→8.11 Don’t know ...... 9→8.11

8.10.1 If yes ask: How long before he/she died did the baby stop crying? Less than one day ...... 1 One day or more...... 2 Don’t know ...... 9

8.11 Was the (name) able to suckle in a normal way during the first day of life? Yes ...... 1→8.12 No ...... 2 Don’t know ...... 9

8.11.1 Did the baby ever suckle in a normal way? Yes ...... 1 No ...... 2 Don’t know ...... 9→ 8.13

8.12 Did (Name) stop being able to suckle in a normal way? Yes ...... 1 No ...... 2→ 8.13 Don’t know ...... 9→ 8.13

8.12.1 If yes ask: How long before he/she died did (Name) stop suckling? Less than one day ...... 1 One day or more...... 2 Don’t know ...... 9

8.12.2. How long after birth did (Name) stop suckling? Hour ...... 1|___|___| after hours Day ...... 2|___|___| after days Don’t know ...... 9

8.13 Was the (Name) able to open the mouth when stopped breast feeding? Yes ...... 1 No ...... 2 Don’t know ...... 9 76 | P a g e

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8.14 During the illness that led to death, did (Name) have difficult breathing? Yes ...... 1 No ...... 2→8.15 Don’t know ...... 9→8.15

8.14.1 If yes ask: At what age did the difficult breathing start? Hour ...... 1|___|___| Hour Day ...... 2|___|___| Day Don’t know ...... 9

8.14.2 For how many hours/days did the difficult breathing last? Hour ...... 1|___|___| Hour Day ...... 2|___|___| Day Don’t know ...... 9

8.15 During the illness that led to death, did the child have fast breathing? Yes ...... 1 No ...... 2→ 8.16 Don’t know ...... 9→ 8.16

8.15.1 If yes ask: At what age did the fast breathing start? Hour ...... 1|___|___| Hour Day ...... 2|___|___| Day Don’t know ...... 9

8.15.2 For how many hours/days did the fast breathing last? Hour ...... 1|___|___| Hour Day ...... 2|___|___| Day Don’t know ...... 9

8.16 During the illness that led to death, did he/she have in-drawing of the chest? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.17 During the illness that led to death, did he/she have grunting? (Demonstrate) Yes ...... 1 No ...... 2 Don’t know ...... 9

8.18 During the illness that led to death, did his/her nostrils flare with breathing? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.19 During the illness that led to death, did (Name) have pneumonia? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.20 During the illness that led to death did (name) have spasms or convulsions?

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Yes ...... 1 No ...... 2 Don’t know ...... 9

8.21 During the illness that led to death, did (Name) have “tetanus” (use local word)? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.22 During the illness that led to death, did (name) have fever? Yes ...... 1 No ...... 2→8.23 Don’t know ...... 9→8.23

8.22.1 If fever, ask: At what age did the fever start? Hour ...... 1|___|___| Hour Day ...... 2|___|___| Day Don’t know ...... 9

8.22.2 How many days did the fever last? Hour ...... 1|___|___| Hour Day ...... 2|___|___| Day Don’t know ...... 9

8.23 During the illness that led to death, did (Name) become cold to touch? Yes ...... 1 No ...... 2→8.24 Don’t know ...... 9→8.24

8.23.1 If cold, ask: At what age did the (Name) start feeling cold? Hour ...... 1|___|___| Hour Day ...... 2|___|___| Day Don’t know ...... 9

8.23.2 How many days did the (name) feel cold? Hour ...... 1|___|___| Hour Day ...... 2|___|___| Day Don’t know ...... 9

8.24 During the illness that led to death, did (Name) become lethargic, after a period of normal activity? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.25 During the illness that led to death, did (name) become unresponsive or unconscious? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.26 During the illness that led to death, did (name) have a bulging fontanelle? Yes ...... 1 78 | P a g e

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No ...... 2 Don’t know ...... 9

8.27 During the illness that led to death, did (name) have redness of the umbilical cord stump? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.27a During the illness that led to death, did the redness of skin extend around the umbilicus? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.27b During the illness that led to death, was there any pus discharge from the umbilicus? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.28 During the illness that led to death, did (Name) have skin bumps containing pus, or blisters, or a single large area of pus or redness with swelling? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.28a During the illness that led to death, did he/she have swelling or redness of skin in a large area? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.28b During the illness that led to death, did the baby have any injury in the body? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.28c During the illness that led to death, did the baby had any blackening in the body? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.29 During the illness that led to death, did (Name)have redness of and drainage of pus from the eyes? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.30 During the illness that led to death, did (name) bleed from anywhere? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.30.1 If yes, ask: “From where? ______

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8.31 During the illness that led to death, did he/she have more frequent loose or liquid stools than usual? Yes ...... 1 No ...... 2 → 8.33 Don’t know ...... 9 → 8.33

8.32 During the illness that led to death, did (name) have (local terms for diarrhoea)? Yes ...... 1 No ...... 2 → 8.33 Don’t know ...... 9 → 8.33

8.32.1 If more than usual frequent or liquid stools, ask: How many stools did (Name)have on the day that the diarrhoea/loose or liquid stools was most frequent? |___|___| Times

8.33 During the illness that led to death, did (Name) vomit everything? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.34 During the illness that led to death, did (Name) have jaundice? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.34.1 During the illness that led to death, did he/she have yellow color skin anywhere in the body? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.34.2 During the illness that led to death, did he/she have yellow color in the eye? Yes ...... 1 No ...... 2 Don’t know ...... 9

8.35 Was the baby apparently healthy, but suddenly died ? Yes ...... 1 No ...... 2 Don’t know ...... 9

Go to Health Records Module (Section 9). ______

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Section 9: Health Records Module

9.0a How much time after the 1st sign of that illness (that kill the baby) appear have you noticed that the baby is very sick? After few hours from the 1st sign of the illness appear ...... 1|___|___| Hour After few days from the 1st sign of the illness appear ...... 2|___|___| Day At the same moment ...... 3 The baby died immediately after appearing the 1st sign ...... 4 →9.7 Don’t know ...... 9 →9.1

9.0b How seriously you and your family took/considered the illness of the child before the baby died? Not serious at all ...... 1 Moderately severe ...... 2 Very serious and grave...... 3 Others ...... 8 Don’t know ...... 9

9.1 Was care sought from anywhere while (Name) had this illness? Yes ...... 1 No ...... 2 → 9.1.2 Don’t know ...... 9 → 9.1.2

9.1.0 If yes ask: from where did you seek care? In home ...... 1 Out side home ...... 2 Both inside and outside the home ...... 3

9.1.1 Ask the respondent, from where and from whom (Name) sought care? A person can seek care from multiple caregivers in a single occurrence. Circle number by caregiver and sequence of service received chronologically (1,2,3 or more)

At Home: Health Personnel Qualified (MBBS) Doctor ...... AA 1 2 3 4 5 6 Nurse/Midwife...... BA 1 2 3 4 5 6 Paramedic ...... CA 1 2 3 4 5 6 Family Welfare Visitor (FWV) ...... DA 1 2 3 4 5 6 Medical Assistant / SACMO ...... EA 1 2 3 4 5 6 Health Assistant/Family Welfare Assistannt ...... FA 1 2 3 4 5 6 Other Homeopath ...... GA 1 2 3 4 5 6 Ayurved ...... HA 1 2 3 4 5 6 Trained TBA...... IA 1 2 3 4 5 6 Untrained TBA ...... JA 1 2 3 4 5 6 ACCESS Counselor/MaMoni Health Worker ...... IB 1 2 3 4 5 6 Quack...... KA 1 2 3 4 5 6 Village Doctor ...... LA 1 2 3 4 5 6 Spiritual person/Kabiraj ...... MA 1 2 3 4 5 6 Mother in law ...... NA 1 2 3 4 5 6 Mother of respondent ...... OA 1 2 3 4 5 6 Other member of the family ...... PA 1 2 3 4 5 6 Outside Home:

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Government Medical College Hospital ...... QA 1 2 3 4 5 6 Union Health & Family Welfare Centre ...... RA 1 2 3 4 5 6 Upazila Health Complex ...... SA 1 2 3 4 5 6 Satellite clinic / EPI outreach site...... TA 1 2 3 4 5 6 Maternal & Child Welfare Centre ...... UA 1 2 3 4 5 6 Health Assistant/Family Welfare Assistannt ...... VA 1 2 3 4 5 6 NGO NGO Satellite clinic ...... WA 1 2 3 4 5 6 NGO Fixed clinic ...... XA 1 2 3 4 5 6 NGO Hospital ...... YA 1 2 3 4 5 6 Private: Private hospital / clinic ...... ZA 1 2 3 4 5 6 Chamber of qualified (MBBS) doctor ...... AB 1 2 3 4 5 6 House of Nurse / Midwife ...... BB 1 2 3 4 5 6 Chamber / house of paramedic ...... CB 1 2 3 4 5 6 House of Family Welfare Visitor ...... DB 1 2 3 4 5 6 Chamber/house of Medical Assistant ...... EB 1 2 3 4 5 6 Chamber/house of SACMO ...... FB 1 2 3 4 5 6 Chamber/house of quack or village doctor ...... GB 1 2 3 4 5 6 Drug store (Pharmacy) ...... HB 1 2 3 4 5 6 Others ...... YY 1 2 3 4 5 6 Specify Don’t know/Can’t remember...... ZZ 1 2 3 4 5 6

After respondent finishes, prompt: Did you seek care anywhere else? Keep using this prompt until respondent replies that they did not seek care from anyone else. Go to 9.2 If did not seek care at all, then ask next question (9.1.2)

9.1.2 Why the sick baby wasn't taken to the doctors or health facility. (Don't read out the answers)

1 Doesn't need treatment ...... A →9.7 ...... 2 We don't treat baby usually and traditionally ...... B →9.7 3 Expensive ...... C →9.7 4 Don't have money (Poor) ...... D →9.7 5 Health facility is far away from the house ...... E →9.7 6 Transportation is difficult ...... F →9.7 7 No one was there to accompany...... G →9.7 8 Treatment is not good in the health facility ...... H →9.7 9 Family doesn't permit me to take the baby to the facility ...... I →9.7 10 It is better to treat the baby at home rather than outside ...... J →9.7 11 Didn't know how to reach/go to the health facility ...... K →9.7 12 We had a very little time, so couldn't transfer to the health facility...... L →9.7 13 Didn't know where to go? ...... M →9.7 14 Baby was died on the way of Health centre ...... N →9.7 15 Didn't understand that the illness was too serious...... O →9.7 16 Some other cause...... Y →9.7 17 Don't know/I am not sure/Confused...... Z →9.7

9.2 Do you have any health/treatment records that belonged to (Name)? Yes ...... 1 No ...... 2→9.5 Don’t know ...... 9→9.5

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Yes ...... 1 No ...... 2

If you couldn't see the health records by yourself then mention the cause below and then go to the ques no 9.5.

If the answer is 'No' then write down the cause______If respondent allows you to see the records, transcribe all the entries.in 9.3.

9.3 Medical notes: 9.3.1 Record the date of the last note |___|___|-|___|___|-|___|___| (dd/mm/yy)

9.3.2 Transcribe the note: ______9.4 Weights (most recent two)

9.4.1 Record the date of the two most recent weights.

1. |___|___|-|___|___|-|___|___| (dd/mm/yy)

2. |___|___|-|___|___|-|___|___| (dd/mm/yy)

If the date is not known, write 99-99-99.

9.4.2 Record the two most recent weights on those dates.

1. |___|___|___|___| gram

2. |___|___|___|___| gram

If weight in not known or recorded, write 9999.

9.5 Was a death certificate issued? Yes ...... 1 No ...... 2→9.7 Don’t know ...... 9→9.7

INSTRUCTIONS TO INTERVIEWER - Ask to see the death certificate and record whether you have been able to see it.

9.5.1 Can you see the death certificate? Yes ...... 1

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No ...... 2

If you couldn't see the death certificate by yourself then mention the cause below and then go to the ques no 9.7.

If the answer is 'No' then write cause______

9.6 Record the immediate cause of death from the certificate:

9.6.1 Record the first underlying cause of death from the certificate______

9.6.2 Record the second underlying cause of death from the certificate______

9.6.3 Record the third underlying cause of death from the certificate______

9.6.4 Record the contributing cause(s) of death from the certificate______

Now I would like to ask a few questions about the child’s mother: 9.7 Has the child’s (biological) mother ever been tested for “HIV”? Yes ...... 1 No ...... 2→9.8 Refuse to answer ...... 8→9.8 Don’t know ...... 9→9.8

9.7.1 (If yes ask): Was the “HIV” test ever positive? Yes ...... 1 No ...... 2 Refuse to answer ...... 8 Don’t know ...... 9

9.8 Has the ___Name’s (biological) mother ever been told she had “AIDS” by a health worker? Yes ...... 1 No ...... 2 Refuse to answer ...... 8 Don’t know ...... 9

END OF INTERVIEW THANK RESPONDENT(S) FOR THEIR COOPERATION.

Section 10: INTERVIEWER COMMENTS AND OBSERVATIONS ______

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