Caesarean section (C-section) is a major obstetric intervention for saving lives of women and their newborns from pregnancy and childbirth related complications. Un-necessary C-sections may have adverse impact upon maternal and neonatal outcomes. In Bangladesh there is paucity of data on clinical indication of C-section at population level. We conducted a retrospective study in icddr,b Health and Demographic Surveillance System (HDSS) area of Matlab to look into the indications and determinants of C-sections. All resident women in HDSS service area who gave birth in 2013 with a known birth outcome, were included in the study. Women who underwent C-section were identified from birth and pregnancy files of HDSS and their indication for C-section were collected reviewing health facility records where the procedure took place, supplemented by face-to-face interview of mothers where data were missing. Indications of C-section were presented as frequency distribution and further divided into different groups following 3 distinct classification systems. Socio-demographic predictors were explored following statistical method of binary logistic regression. During 2013, facility delivery rate was 84% and population based C-section rate was 35% of all deliveries in icddr,b service area. Of all C-sections, only 1.4% was conducted for Absolute Maternal Indications (AMIs). Major indications of C-sections included: repeat C-section (24%), foetal distress (21%), prolonged labour (16%), oligohydramnios (14%) and post-maturity (13%). More than 80% C-sections were performed in for-profit private facilities. Probability of C-section delivery increased with improved socio-economic status, higher education, lower birth order, higher age, and with more number of Antenatal Care use and presence of bad obstetric history. Eight maternal deaths occurred, of which five were delivered by C-section. C-section rate in this area was much higher than national average as well as global recommendations. Very few of C-sections were undertaken for AMIs. Routine monitoring of clinical indication of C-section in public and private facilities is needed to ensure rational use of the procedure.

Coastal areas in South Asian countries are particularly vulnerable to elevated water salinity. Drinking water salinity has been found to be associated with cardiovascular diseases (CVD), diarrhea, and abdominal pain. Our study aimed to find if excess drinking water salinity was associated with increased hospital visits with an array of health effects in coastal sub-districts of Bangladesh. A cross-sectional study was conducted with 157 participants from three coastal sub-districts. A face-to-face interview was conducted to collect salinity exposure and hospital visit data. Water samples were collected from both drinking and other household water sources for the measurement of salinity and total dissolved solids (TDS). CVD, diarrhea, and abdominal pain related hospital visits were found to be significantly associated with high water salinity and TDS. Households exposed to high salinity demonstrated a higher frequency of hospital visits than the low salinity-exposed households. People exposed to high salinity seemed to lack awareness regarding salinity-inducing health effects. Water salinity is a public health concern that will continue to rise due to climate change. Therefore, raising awareness about the health risks of water salinity is essential for the government to frame policies and mitigation strategies to control this emerging threat.

Background Arsenic exposure via drinking water increases the risk of chronic respiratory disease in adults. However, information on pulmonary health effects in children after early life exposure is limited. Methods This population-based cohort study set in rural Matlab, Bangladesh, assessed lung function and respiratory symptoms of 650 children aged 7–17 years. Children with in utero and early life arsenic exposure were compared with children exposed to less than 10 µg/l in utero and throughout childhood. Because most children drank the same water as their mother had drunk during pregnancy, we could not assess only in utero or only childhood exposure. Results Children exposed in utero to more than 500 µg/l of arsenic were more than eight times more likely to report wheezing when not having a cold [odds ratio (OR) = 8.41, 95% confidence interval (CI): 1.66–42.6, P < 0.01] and more than three times more likely to report shortness of breath when walking on level ground (OR = 3.86, 95% CI: 1.09–13.7, P = 0.02) and when walking fast or climbing (OR = 3.19, 95% CI: 1.22–8.32, P < 0.01]. However, there was little evidence of reduced lung function in either exposure category. Conclusions Children with high in utero and early life arsenic exposure had marked increases in several chronic respiratory symptoms, which could be due to in utero exposure or to early life exposure, or to both. Our findings suggest that arsenic in water has early pulmonary effects and that respiratory symptoms are a better marker of early life arsenic toxicity than changes in lung function measured by spirometry.

Pneumonia is the leading cause of death for children under 5 years of age globally, making research on modifiable risk factors for childhood pneumonia important for reducing this disease burden. Millions of children globally are exposed to elevated levels of arsenic in drinking water. However, there is limited data on the association between arsenic exposure and respiratory infections, particularly among pediatric populations. This case control study of 153 pneumonia cases and 296 controls 28 days to 59 months of age in rural Bangladesh is the first to assess whether arsenic exposure is a risk factor for pneumonia in a pediatric population. Cases had physician diagnosed World Health Organization defined severe or very severe pneumonia. Urine collected during hospitalization (hospital admission time point) and 30 days later (convalescent time point) from cases and a single specimen from community controls was tested for urinary arsenic by graphite furnace atomic absorption. The odds for pneumonia was nearly double for children with urinary arsenic concentrations higher than the first quartile (≥6 μg/L) at the hospital admission time point (Odd Ratio (OR):1.88 (95 % Confidence Interval (CI): 1.01, 3.53)), after adjustment for urinary creatinine, weight for height, breastfeeding, paternal education, age, and number of people in the household. This was consistent with findings at the convalescent time point where the adjusted OR for children with urinary arsenic concentrations greater than the first quartile (≥6 μg/L) was 2.32 (95 % CI: 1.33, 4.02). We observed a nearly two times higher odds of pneumonia for children with creatinine adjusted urinary arsenic concentrations greater than the first quartile (≥6 μg/L) at the hospital admission time point. This novel finding suggests that low to moderate arsenic exposure may be a risk factor for pneumonia in children under 5 years of age.

Accelerating progress in reducing child deaths is needed in order to achieve the Sustainable Development Goal child mortality target. This will require a focus on vulnerable children–including young children, those who are undernourished or with acute illnesses requiring hospitalization. Improving adherence to inpatient guidelines may be an important strategy to reduce child mortality, including among the most vulnerable. The aim of our assessment of nine sub-Saharan African and South Asian hospitals was to determine adherence to pediatric inpatient care recommendations, in addition to capacity for and barriers to implementation of guideline-adherent care prior to commencing the Childhood Acute Illness and Nutrition (CHAIN) Cohort study. The CHAIN Cohort study aims to identify modifiable risk factors for poor inpatient and post discharge outcomes above and beyond implementation of guidelines. Hospital infrastructure, staffing, durable equipment, and consumable supplies such as medicines and laboratory reagents, were evaluated through observation and key informant interviews. Inpatient medical records of 2–23 month old children were assessed for adherence to national and international guidelines. The records of children with severe acute malnutrition (SAM) were oversampled to reflect the CHAIN study population. Seven core adherence indicators were examined: oximetry and oxygen therapy, fluids, anemia diagnosis and transfusion, antibiotics, malaria testing and antimalarials, nutritional assessment and management, and HIV testing. All sites had facilities and equipment necessary to implement care consistent with World Health Organization and national guidelines. However, stockouts of essential medicines and laboratory reagents were reported to be common at some sites, even though they were mostly present during the assessment visits. Doctor and nurse to patient ratios varied widely. We reviewed the notes of 261 children with admission diagnoses of sepsis (17), malaria (47), pneumonia (70), diarrhea (106), and SAM (119); 115 had multiple diagnoses. Adherence to oxygen therapy, antimalarial, and malnutrition refeeding guidelines was >75%. Appropriate antimicrobials were prescribed for 75% of antibiotic-indicative conditions. However, 20/23 (87%) diarrhea and 20/27 (74%) malaria cases without a documented indication were prescribed antibiotics. Only 23/122 (19%) with hemoglobin levels meeting anemia criteria had recorded anemia diagnoses. HIV test results were infrequently documented even at hospitals with universal screening policies (66/173, 38%). Informants at all sites attributed inconsistent guideline implementation to inadequate staffing. Assessed hospitals had the infrastructure and equipment to implement guideline-consistent care. While fluids, appropriate antimalarials and antibiotics, and malnutrition refeeding adherence was comparable to published estimates from low- and high-resource settings, there were inconsistencies in implementation of some other recommendations. Stockouts of essential therapeutics and laboratory reagents were a noted barrier, but facility staff perceived inadequate human resources as the primary constraint to consistent guideline implementation.