A. M. Quaiyum Rahman

Anaemia affects over one-third of pregnant women in Bangladesh, leading to serious consequences including maternal death and stillbirth. Yet, only about half of pregnant women are tested for anaemia, and few receive intravenous iron – an effective treatment option. It remains unclear whether health facilities have the resources, and whether health workers are willing and able, to deliver these services. Embedded within a demonstration project, our study aimed to evaluate the organisational readiness of Bangladesh’s primary health care system to provide point-of-care anaemia testing and intravenous iron treatment for pregnant women. We employed a multi-phase, mixed-methods, parallel convergent design. Formative research included a baseline health facility readiness assessment (n=20). In the parallel process evaluation, health workers completed the Organisational Readiness for Implementing Change questionnaire (n=35), and a sample participated in qualitative interviews (n=21). Quantitative data were analysed descriptively, while qualitative data were analysed using inductive thematic analysis and mapped to the Capability, Opportunity, and Motivation model of Behaviour Change. Findings were integrated across data sources for a comprehensive evaluation. We found high psychological readiness for implementing anaemia testing and intravenous iron treatment, with health workers demonstrating strong commitment and confidence in providing these services to pregnant women. However, structural readiness was incomplete, with sustaining both interventions beyond the demonstration project requiring addressing resource constraints, including shortages of equipment, guidelines, nurses, and doctors. Government support for implementation and resource provision will be essential to ensure the continued delivery of anaemia testing and intravenous iron treatment in Bangladesh’s primary health care system.

Antenatal anaemia affects 48% of pregnant women in South Asia. In Bangladesh, the standard of care is oral iron and folic acid supplementation, but access and adherence are poor. Intravenous iron is an alternative treatment that deliver high dose of iron in a single short infusion and is commonly used in high-income countries. A demonstration project will be conducted to test the real-world feasibility and acceptability of implementing an intravenous iron intervention to treat pregnant women with moderate and severe anaemia in the primary healthcare setting of Bangladesh. This protocol paper outlines the development, implementation, and evaluation of an intravenous iron intervention. The demonstration project consists of three phases, supported by implementation science frameworks: (1) a formative phase involving a review, qualitative research, and readiness assessment; (2) the development and implementation of care pathways and strategies using a participatory research approach; and (3) a process evaluation of care pathways and strategies involving qualitative and quantitative assessment of the costs, processes and contextual factors affecting its implementation. Intravenous iron presents a novel opportunity to reduce antenatal anaemia in low-and-middle income countries. The demonstration project will ascertain whether an intravenous iron intervention can be effectively introduced into routine antenatal care and the extent to which it is considered an acceptable treatment by pregnant women, healthcare providers, and policymakers. If successful, insights into the care pathways and costs will provide guidance for integrating intravenous iron in the primary healthcare system of Bangladesh and other low-and-middle income countries.

Accurate and timely data on cause of death are critically important for guiding health programs and policies. Deaths certified by doctors are implicitly considered to be reliable and accurate, yet the quality of information provided in the international Medical Certificate of Cause of Death (MCCD) usually varies according to the personnel involved in certification, the diagnostic capacity of the hospital, and the category of hospitals. There are no published studies that have analysed how certifying doctors in Bangladesh adhere to international rules when completing the MCCD or have assessed the quality of clinical record keeping. The study took place between January 2011 and April 2014 in the Chandpur and Comilla districts of Bangladesh. We introduced the international MCCD to all study hospitals. Trained project physicians assigned an underlying cause of death, assessed the quality of the death certificate, and reported the degree of certainty of the medical records provided for a given cause. We examined the frequency of common errors in completing the MCCD, the leading causes of in-hospital deaths, and the degree of certainty in the cause of death data. The study included 4914 death certificates. 72.9% of medical records were of too poor quality to assign a cause of death, with little difference by age, hospital, and cause of death. 95.6% of death certificates did not indicate the time interval between onset and death, 31.6% required a change in sequence, 13.9% required to include a new diagnosis, 50.7% used abbreviations, 41.5% used multiple causes per line, and 33.2% used an ill-defined condition as the underlying cause of death. 99.1% of death certificates had at least one error. The leading cause of death among adults was stroke (15.8%), among children was pneumonia (31.7%), and among neonates was birth asphyxia (52.8%). Physicians in Bangladeshi hospitals had difficulties in completing the MCCD correctly. Physicians routinely made errors in death certification practices and medical record quality was poor. There is an urgent need to improve death certification practices and the quality of hospital data in Bangladesh if these data are to be useful for policy.