Background: Digital health interventions (DHIs) can alleviate several barriers to achieving better maternal and child health. The World Health Organization’s guideline recommendations for DHIs emphasize the need to integrate multiple DHIs for maximizing impact. The complex health system of Bangladesh provides a unique setting for evaluating and understanding the role of an electronic registry (eRegistry) for antenatal care, with multiple integrated DHIs for strengthening the health system as well as improving the quality and utilization of the public health care system. Objective: The aim of this study is to assess the effect of an eRegistry with DHIs compared with a simple digital data entry tool without DHIs in the community and frontline health facilities. Methods: The eRegMat is a cluster-randomized controlled trial conducted in the Matlab North and Matlab South subdistricts in the Chandpur district, Bangladesh, where health facilities are currently using the eRegistry for digital tracking of the health status of pregnant women longitudinally. The intervention arm received 3 superimposed data-driven DHIs: health worker clinical decision support, health worker feedback dashboards with action items, and targeted client communication to pregnant women. The primary outcomes are appropriate screening as well as management of hypertension during pregnancy and timely antenatal care attendance. The secondary outcomes include morbidity and mortality in the perinatal period as well as timely first antenatal care visit; successful referrals for anemia, diabetes, or hypertension during pregnancy; and facility delivery. Results: The eRegistry and DHIs were co-designed with end users between 2016 and 2018. The eRegistry was implemented in the study area in July 2018. Recruitment for the trial started in October 2018 and ended in June 2020, followed by an 8-month follow-up period to capture outcome data until February 2021. Trial results will be available for publication in June 2021. Conclusions: This trial allows the simultaneous assessment of multiple integrated DHIs for strengthening the health system and aims to provide evidence for its implementation. The study design and outcomes are geared toward informing the living review process of the guidelines for implementing DHIs. Trial Registration: ISRCTN Registry ISRCTN69491836; https://www.isrctn.com/ISRCTN69491836 International Registered Report Identifier (IRRID): DERR1-10.2196/26918

BACKGROUND Digital health interventions (DHIs) can alleviate several barriers to achieving better maternal and child health. The World Health Organization’s guideline recommendations for DHIs emphasize the need to integrate multiple DHIs for maximizing impact. The complex health system of Bangladesh provides a unique setting for evaluating and understanding the role of an electronic registry (eRegistry) for antenatal care, with multiple integrated DHIs for strengthening the health system as well as improving the quality and utilization of the public health care system. OBJECTIVE The aim of this study is to assess the effect of an eRegistry with DHIs compared with a simple digital data entry tool without DHIs in the community and frontline health facilities. METHODS The eRegMat is a cluster-randomized controlled trial conducted in the Matlab North and Matlab South subdistricts in the Chandpur district, Bangladesh, where health facilities are currently using the eRegistry for digital tracking of the health status of pregnant women longitudinally. The intervention arm received 3 superimposed data-driven DHIs: health worker clinical decision support, health worker feedback dashboards with action items, and targeted client communication to pregnant women. The primary outcomes are appropriate screening as well as management of hypertension during pregnancy and timely antenatal care attendance. The secondary outcomes include morbidity and mortality in the perinatal period as well as timely first antenatal care visit; successful referrals for anemia, diabetes, or hypertension during pregnancy; and facility delivery. RESULTS The eRegistry and DHIs were co-designed with end users between 2016 and 2018. The eRegistry was implemented in the study area in July 2018. Recruitment for the trial started in October 2018 and ended in June 2020, followed by an 8-month follow-up period to capture outcome data until February 2021. Trial results will be available for publication in June 2021. CONCLUSIONS This trial allows the simultaneous assessment of multiple integrated DHIs for strengthening the health system and aims to provide evidence for its implementation. The study design and outcomes are geared toward informing the living review process of the guidelines for implementing DHIs. CLINICALTRIAL ISRCTN Registry ISRCTN69491836; https://www.isrctn.com/ISRCTN69491836 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/26918

Introduction: Studies of gestational weight gain (GWG) and adverse pregnancy outcomes seldom focus on low-to-middle-income countries (LMICs), despite their high burden of morbidity and mortality. We examined GWG patterns and adverse pregnancy outcomes in a consortium of pregnancy cohorts from LMICs. Methods: We analysed data from five observational pregnancy cohorts in Bangladesh (two cohorts), India, Pakistan and Zambia. The study population comprised 15 286 singleton pregnancies with two or more maternal antenatal weight measurements. We estimated reference values for GWG using longitudinal models and calculated weight gain for gestational age Z-scores. We then estimated the associated risks of preterm birth, low birth weight, and small for gestational age, stratified by maternal body mass index (BMI), using marginal generalised linear models and plotted non-linear trends in the associations. Results: The median baseline maternal and gestational age were 24 years (IQR, 21–28) and 13 weeks (IQR 11–16), respectively, with 23% of participants having underweight BMI. The median GWG was 6.8 kg (4.2–9.4) and varied across cohorts from 6.1 kg (3.7–8.5; Bangladesh) to 7.0 kg (4.0–10.0; Zambia). The risk of preterm birth (13%) increased with lower GWG Z-scores among underweight (adjusted risk ratio (ARR), 1.4; 95% CI, 1.1 to 1.9 for lowest Z-score group) and normal BMI participants (ARR, 1.1; 95% CI, 1.0 to 1.2). The risk of low birth weight (25%) increased with lower GWG Z-scores in all BMI strata except obese participants (ARR, 1.7; 95% CI 1.5 to 1.9 among underweight). The risk of small for gestational age (36%) increased with lower GWG Z-scores in all BMI strata (ARR, 1.3; 95% CI 1.2 to 1.4 among underweight). In secondary analyses, alternative measures of GWG (adequacy ratio; INTERGROWTH-21^st) had associations that were consistent with those from our study-specific Z-scores, except for a less clear association between preterm birth and INTERGROWTH-21^st Z-score. Conclusion: GWG was associated with preterm birth, low birth weight and small for gestational age. Early pregnancy BMI modified the association between GWG and outcomes in the study setting.

Introduction: Although an appropriate population range for caesarean section (CS) has been debated, the WHO recommends national CS rates be between 10% and 15%. Yet rates are much higher in many low-income and middle-income countries, including Bangladesh. These studies also reveal wide disparities in CS use by geographic location and sociodemographic conditions. Nevertheless, few studies have the sample size and temporal precision necessary to model convergence and divergence trends over time. We assessed trends in CS segregated by key sociodemographic factors known to affect CS. Methods: We conducted our study using prospective pregnancy observation data from two distinct Maternal, Neonatal, and Child Health service areas: International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and the government service areas in Matlab, Bangladesh. We evaluated sociodemographic variations and trends using the multivariable logistic regression model. Findings: The proportion of CS rose from 5.9% in 2005 to 55.7% in 2019, about a ninefold increase, implying a 3.3% average annual growth rate. The CS was positively associated with residence in the icddr,b service area (vs government service area), older age, higher assets, lower parity births and, to a lesser extent, with higher levels of schooling. Among factors positively associated with CS, we observed negative time interactions for maternal age, education and place of delivery, suggesting a convergence in CS rates between high-risk and low-risk groups in these categories. However, positive time interactions for parity and asset score indicate that disparities in CS rates persist and are widening over time. Conclusions: Transition towards near-universal CS, irrespective of sociodemographic status or service area, is likely to be the inevitable future for rural Bangladesh. If such high rates of CS are considered sub-optimal for mother-and-child health, then evidence is needed to support alternatives.

Post-term birth is birth at a gestation of ≥42 weeks [1–3]. It has been associated with increased perinatal morbidity and mortality [4–7]. The estimated global prevalence of post-term births ranges from 1–10% of all deliveries [8–10]. The occurrence differs within and between countries [11], partly depending on assessments by reported last menstrual period (LMP) dates […]