Gary Darmstadt
Bangladesh
Bloomberg School of Public Health, MSH/MPH program >>View Report
Deaths during the neonatal period are responsible for a significant proportion of under-5 mortality. Severe infection is responsible for an estimated 36% of all neonatal deaths. Omphalitis comprises a large portion of these infections. This project involved prospective data collection on perceptions regarding time to umbilical cord separation after birth in Sylhet, Bangladesh and was nested within the larger PROJAHNMO 3 trial. The time to cord separation is an important factor governing cord care. Chlorhexidine has been shown to prolong the cord separation time, and in southern Nepal, it was demonstrated that newborns born in clusters allocated to chlorhexidine had a longer mean time to cord separation compared to those receiving dry cord care and soap/water care. Information was needed regarding the relevance of this delayed separation time. By obtaining this data through a short structured questionnaire, we aimed to determine if a delay in cord separation following chlorhexidine application was detectable by mothers, and if this delay affected their desire to use the intervention for future births. This project began as an idea in September 2006, after I attended a presentation by Dr. Gary Darmstadt on the importance of global neonatal health. This was an inspiring discussion, where I learned that the health of newborns bridges maternal and child health. About 4 million child deaths each year occur during the neonatal period, that is, the time from birth to day 28 of life. While this statistic is daunting, the vast majority of these deaths can be prevented with low-cost, low-tech interventions. Yet, new policies to recommend such interventions need to be supported by strong evidence. This is the aim of the parent trial, PROJAHNMO 3. A previous trial in Nepal showed that the topical application of chlorhexidine is an appropriate method of decreasing the risk of newborn morbidity and mortality. Moving forward to 2007, PROJAHNMO 3 aimed to replicate these findings in Bangladesh. This trial added a new intervention arm, in order to distinguish between the benefits provided by chlorhexidine applied once, compared to daily for seven days. My study, conducted in Sylhet, Bangladesh, was nested within the larger PROJAHNMO 3 trial. I was thus able to use the pre-existing infrastructure to investigate maternal perceptions on umbilical cord separation time following the cord care intervention.
In the latter part of 2006, I began to review the literature surrounding omphalitis in the developing world. I also began to familiarize myself with the parent trial, and the setting in which I would soon find myself immersed. Numerous project proposals later, my supervisors and I decided that we would focus on maternal perceptions on cord separation time, in order to discern whether such perceptions might affect the use of the intervention. This investigation has both quantitative and qualitative components. I was very fortunate to receive the Frameworks Fellowship, which helped to offset some of my travel and living costs. In the early Summer of 2007, we began to work towards receiving IRB approval for the sub-study. This involved participating in an online Human Subjects Training module, submitting a revised amendment to the JHU Committee on Human Research (CHR), and obtaining approval from the ethics board of the host country IRB. The JHU CHR requested a revised protocol (to include my sub-study) for PROJAHNMO 3. For the host country ethics approval (from the International Centre for Diarrhoel Disease Research Bangladesh – ICDDR,B), a separate research plan with attached memo was required.
Once this was received, we began to refine the questionnaires and focus group discussion guides. With the assistance of a translator, I met with the Community Health Workers (CHWs) to discuss the project idea, and to begin training them on administering the questionnaire. We also met with a sample of mothers, to probe more deeply into their perceptions of umbilical cord separation and their allocated intervention. At the time of writing, the data collection from the questionnaires is close to completion, and will be analyzed subsequently.
I began writing a literature review on umbilical cord separation time and caregiver perceptions, once I began to encounter delays with the fieldwork portion of the study. These delays were primarily due to the time needed for IRB review, the volatile political situation, and heavy flooding in the project area. One of the most important lessons I learned was that ideal timelines are rarely followed, and that delays should be expected.
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