Background: Breastfeeding practice is still not optimum in Bangladesh. Understanding barriers to breastfeeding is needed to prevent harmful practices. This study aimed to understand barriers to breastfeeding among infants and young children in Bangladesh.Methods: This qualitative study was conducted in five rural sub-districts and one urban slum in Bangladesh. We conceptualized that barriers to breastfeeding can be broadly grouped into individual, society, and system level barriers. We conducted in-depth interviews with 33 breastfeeding mothers and 13 grandmothers of breastfed children (totaln = 46 interviews). We observed 23 of these infants and young children being breastfed. These data were supplemented by 3 focus group discussions held with the children’s fathers. We managed the data using Atlas.ti software and analyzed the data thematically using an inductive approach.Results: Important individual-level barriers perceived to influence breastfeeding included misconceptions about the adverse effects of breastfeeding on maternal health, nutrition and physical appearance, and lack of awareness of the value of breastfeeding among family members. Perceived society-level barriers included sociocultural norms, beliefs, and practices such as mother obliged to give more attention on household chores than breastfeeding to become a good housewife and feeding formula milk perceived as a symbol of parents’ financial solvency in the society. System-level barriers included attractive advertisements of breastmilk substitutes, and inadequate facilities and support processes in mothers’ work environments.Conclusion: A range of barriers at individual, society and system level have important implications for infant and young children’s breastfeeding practices in Bangladesh. Development of interventions that address the range of barriers that many mothers face is essential to support breastfeeding practices. Potential interventions include strengthening information-giving during interaction between mothers and health workers on breastfeeding techniques, and engaging fathers and other “significant others” in counseling on breastfeeding.

Background: Post-hospital discharge mortality risk is high among young children in many low and middle-income countries (LMICs). The available literature suggests that child, caregiver and health care provider gender all play important roles in post-discharge adherence to medical advice, treatment-seeking and recovery for ill children in LMICs, including those with undernutrition. Methods: A qualitative study was embedded within a larger multi-country multi-disciplinary observational cohort study involving children aged less than 2 years conducted by the Childhood Acute Illness and Nutrition (CHAIN) Network. Primary data were collected from family members of 22 purposively selected cohort children. Family members were interviewed several times in their homes over the 6 months following hospital discharge (total n = 78 visits to homes). These in-depth interviews were complemented by semi-structured individual interviews with 6 community representatives, 11 community health workers and 12 facility-based health workers, and three group discussions with a total of 24 community representatives. Data were analysed using NVivo11 software, using both narrative and thematic approaches. Results: We identified gender-related influences at health service/system and household/community levels. These influences interplayed to family members’ adherence to medical advice and treatment-seeking after hospital discharge, with potentially important implications for children’s recovery. Health service/system level influences included: fewer female medical practitioners in healthcare facilities, which influenced mothers’ interest and ability to consult them promptly for their child’s illnesses; gender-related challenges for community health workers in supporting mothers with counselling and advice; and male caregivers’ being largely absent from the paediatric wards where information sessions to support post-discharge care are offered. Gendered household/community level influences included: women’s role as primary caretakers for children and available levels of support; male family members having a dominant role in decision-making related to food and treatment-seeking behaviour; and greater reluctance among parents to invest money and time in the treatment of female children, as compared to male children. Conclusions: A complex web of gender related influences at health systems/services and household/community levels have important implications for young children’s recovery post-discharge. Immediate interventions with potential for positive impact include awareness-raising among all stakeholders – including male family members - on how gender influences child health and recovery, and how to reduce adverse consequences of gender-based discrimination. Specific interventions could include communication interventions in facilities and homes, and changes in routine practices such as who is present in facility interactions. To maximise and sustain the impact of immediate actions and interventions, the structural drivers of women’s position in society and gender inequity must also be tackled. This requires interventions to ensure equal equitable opportunities for men and women in all aspects of life, including access to education and income generation activities. Given patriarchal norms locally and globally, men will likely need special targeting and support in achieving these objectives.

Child mortality remains remarkably high in many low- and middle-income countries (LMICs), including Bangladesh. This study aimed to identify the sociodemographic and maternal health-related factors associated with under three (U3) child mortality in Bangladesh. We extracted data of 5299 U3 children from Bangladesh Demographic and Health Survey (BDHS) 2017-18. We used descriptive statistics to summarize the data. The chi-square (χ2) test, simple and multiple Firth logistic regression were performed to test the associations between priori-defined factors and U3 mortality. In Bangladesh, the U3 child mortality rate was 35 deaths per 1,000 live births, with a median age at death of less than one month. The adjusted model revealed that the odds of U3 child mortality were higher among children born to mothers aged between 30 and 39 years [adjusted odds ratio (AOR) = 2.01, 95% confidence interval (CI): 1.30–3.11; p-value (p) = 0.002], those who did not use any contraceptive [AOR = 2.57, 95% CI: 1.90–3.47; p < 0.001], with first pregnancy [AOR = 14.91, CI: 4.60–48.30; p < 0.001], had birth interval less than 24 months [AOR = 2.10, CI: 1.23–3.60; p = 0.007], children born to mothers who delivered vaginally [AOR = 3.18, 95% CI: 2.07–4.87; p < 0.001]. However, lower odds of mortality were observed among children of mothers with higher education levels [AOR = 0.50, 95% CI: 0.28–0.90; p = 0.021] and families with more than five members [AOR = 0.61, 95% CI: 0.45–0.83; p < 0.01]. In addition, religion, birth attendant during delivery, and the child’s birth order were significantly associated with U3 child mortality, whereas mortality did not vary significantly across the divisions. Higher odds of U3 child mortality were associated with mothers who did not use contraceptives, delivered vaginally, and were aged 30–39 years in Bangladesh. Conversely, higher maternal education and larger family size were associated with lower odds of U3 child mortality. The findings suggest that community-based family planning awareness programs focused on contraceptive use, as it prevents childbirth and is also a marker of health service usage.

Despite the beneficial effect of bubble continuous positive airway pressure (BCPAP) oxygen therapy for children with severe pneumonia under the supervision of physicians that has been shown in different studies, effectiveness trials in developing country settings where low-flow oxygen therapy is the standard of care are still needed. Thus, the aim of this study is to assess the effectiveness of bubble CPAP oxygen therapy compared to the WHO standard low-flow oxygen therapy among children hospitalized with severe pneumonia and hypoxemia in Ethiopia. This is a cluster randomized controlled trial where six district hospitals are randomized to BCPAP and six to standard WHO low-flow oxygen therapy. The total sample size is 620 per arm. Currently, recruitment of the patients is still ongoing where the management and follow-up of the enrolled patients are performed by general physicians and nurses under the supervision of pediatricians. The primary outcome is treatment failure and main secondary outcome is death. We anticipate to complete enrollment by September 2022 and data analysis followed by manuscript writing by December 2022. Findings will also be disseminated in December 2022. Our study will provide data on the effectiveness of BCPAP in treating childhood severe pneumonia and hypoxemia in a real-world setting.

Background: Post-hospital discharge mortality is high among undernourished children in many low and middle-income countries; often exceeding in-patient mortality rates. Although a number of studies have highlighted a range of potential socio-cultural, economic and health system factors influencing paediatric post-discharge treatment-seeking and recovery, including in Bangladesh, few studies have explored parent and provider perspectives.Methods: As part of a large, multi-country prospective cohort study - the Childhood Acute Illness and Nutrition (CHAIN) Network - we conducted a qualitative study to understand the post-discharge treatment-seeking and recovery experiences of families of undernourished children aged 2-23 months admitted in two icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh) hospitals. To gather parent perspectives, we gathered in-depth qualitative data from family members of 17 purposively selected undernourished children from a rural and urban hospital. These data were supplemented by observations in hospitals and homes and from health worker interviews. We interviewed family members on discharge and again in their homes after discharge over several visits. Results: 13 of the 17 purposively selected children were reported by family members to have fully recovered by the time we completed our interviews; four had died. Important perceived drivers of treatment-seeking and recovery included advice provided while in hospital, media campaigns on hygiene practice, positive social and financial support from family members, relatives and neighbours, and the availability of free treatment. Key challenges included low household incomes, mothers having to juggle multiple responsibilities in addition to caring for the child, lack of support - and in some cases violence - from the child’s father, and family members’ preference for relatively accessible drug shops, physicians or healers over (re)admission to hospital. For most families, a range of challenges interplayed to contribute to early discharge from hospital against medical advice and to non-adherence to follow-up advice. Providers were primarily concerned about an inappropriately high use of antibiotics among families.Conclusion: Development of interventions that address the range of vulnerabilities that many families face is essential to support post-discharge adherence to medical advice and ensure recovery. These data suggest that potential interventions could include strengthening information giving during hospitalization on what post-discharge care is needed and why, reducing direct and indirect costs associated with hospital visits, engaging fathers and other ‘significant others’ in post-discharge advice, and building mobile phone-based support for follow-up care.

Introduction: Childhood illness and hospitalisation result in both direct and indirect costs to families before, during and after admission. We aimed to estimate the catastrophic expenditure during hospitalisation for children with acute illness. Methods: This was a prespecified cross-sectional substudy nested within two prospective studies. Participants were recruited and interviewed from three rural and three urban hospitals in Kenya and Uganda. A costing questionnaire was administered to the caregivers of 731 children hospitalised for acute illness to evaluate direct and indirect costs incurred by caregivers and families. Costs incurred were compared for families with children both with and without complicated severe malnutrition (CSM). Catastrophic out-of-pocket expenditure exceeding 10% and 25% of monthly income was assessed. Results: The median (IQR) total cost during hospitalisation per child was US$47 (US$24–US$84), with higher costs for children with CSM, especially during hospitalisation (US$56 (US$26–US$99) vs US$36 (US$20–US$65); p<0.001). During hospitalisation, bed charges followed by food were the main cost drivers. Caregivers reported losing a median of 7 (4–11) days of productive time during a child’s hospitalisation with a mean loss of income of US$10 (SD US$25.6, median US$0 (US$0–US$10)). 92% and 74% of households experienced catastrophic expenditure at thresholds of 10% and 25% of monthly income, respectively. Caregivers reported borrowing, selling property and withdrawing other children from school to cope with costs. Conclusions: Despite intentions of free healthcare services for under 5, families of acutely ill children very commonly faced catastrophic expenditure, especially for children with CSM. Interventions aimed at supporting financial protection, reducing additional healthcare costs, and lowering health service charges may help prevent catastrophic expenditures.