Neonatal and pediatric healthcare worldwide: A report from UNICEF

Neonatal mortality rate and determinants among births of mothers at extreme ages of reproductive life in low and middle income countries

Neonatal mortality, which refers to the death of neonates during the first 28 completed days of life, is a critical global public health concern. The neonatal period is widely recognized as one of the most precarious phases in human life. Research has indicated that maternal extreme ages during reproductive years significantly impact neonatal survival, particularly in low- and middle-income countries. Consequently, this study aims to evaluate the neonatal mortality rate and determinants among neonates born to mothers at extreme reproductive ages within these countries. A secondary analysis of demographic and health surveys conducted between 2015 and 2022 in 43 low- and middle-income countries was performed. The study included a total sample of 151,685 live births. Researchers utilized a multilevel mixed-effects model to identify determinants of neonatal mortality. The measures of association were evaluated using the adjusted odds ratio within a 95% confidence interval. The neonatal mortality rate among neonates born to mothers at extreme ages of reproductive life in low- and middle-income countries was 28.96 neonatal deaths per 1000 live births (95% CI 28.13-29.82). Factors associated with higher rates of neonatal mortality include male gender, low and high birth weight, maternal education (no or low), home deliveries, multiple births, short preceding birth intervals, lack of postnatal checkups, and countries with high fertility and low literacy rates. This study sheds light on the neonatal mortality rates among neonates born to mothers at extreme ages of reproductive life in low- and middle-income countries. Notably, we found that neonatal mortality was significantly higher in this group compared to neonatal mortality rates reported regardless of maternal ages. Male babies, low and high birth-weighted babies, those born to mothers with no or low education, delivered at home, singletons, babies born with a small preceding birth interval, and those without postnatal checkups faced elevated risks of neonatal mortality. Additionally, neonates born in countries with high fertility and low literacy rates were also vulnerable. These findings underscore the urgent need for targeted interventions tailored to mothers at extreme ages. Policymakers and healthcare providers should prioritize strategies that address specific risk factors prevalent in these vulnerable populations. By doing so, we can improve neonatal outcomes and ensure the survival of these newborns during the critical neonatal period.

mHealth interventions to reduce maternal and child mortality in Sub-Saharan Africa and Southern Asia: A systematic literature review

Background

Reducing maternal mortality, neonatal mortality and under 5-year mortality are important targets addressed by the United Nations' Sustainable Development Goals. Despite studies reported an improvement in maternal and child health indicators, the progress achieved is not uniform across regions. Due to the increasing availability of mobile phones in low and middle-income countries, mHealth could impact considerably on reducing maternal and child mortality and maximizing women's access to quality care, from the antenatal stage to the post-natal period.

Methods

A systematic literature review of mHealth interventions aimed at reducing maternal and child mortality in Sub-Saharan Africa and Southern Asia. Primary outcomes were maternal mortality, neonatal mortality, and under-five mortality. Secondary outcomes were skilled birth attendance, antenatal care (ANC) and post-natal care (PNC) attendance, and vaccination/immunization coverage. We searched for articles published from January 2010 to December 2020 in Embase, Medline and Web of Science. Quantitative comparative studies were included. The protocol was developed according to the PRISMA Checklist and published in PROSPERO [CRD42019109434]. The Quality Assessment Tool for Quantitative Studies was used to assess the quality of the eligible studies.

Results

23 studies were included in the review, 16 undertaken in Sub-Saharan Africa and 7 in Southern Asia. Most studies used SMS or voice message reminders for education purposes. Only two studies reported outcomes on neonatal mortality, with positive results. None of the studies reported results on maternal mortality or under-five mortality. Outcomes on skilled birth attendance, ANC attendance, PNC attendance, and vaccination coverage were reported in six, six, five, and eleven studies, respectively. Most of these studies showed a positive impact of mHealth interventions on the secondary outcomes.

Conclusion

Simple mHealth educational interventions based on SMS and voice message reminders are effective at supporting behavior change of pregnant women and training of health workers, thus improving ANC and PNC attendance, vaccination coverage and skilled birth attendance. Higher quality studies addressing the role of mHealth in reducing maternal and child mortality in resource-limited settings are needed, especially in Southern Asia.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019109434, identifier CRD42019109434.

Prevalence and associated factors of neonatal mortality in Ethiopia

Neonatal mortality is the death of a live-born baby within the first 28 days of birth. For the selected households, neonatal mortality was collected from children aged 0–28 days and women aged 15–49. The neonatal period is a significant 4-week period in human life because it carries a greater mortality risk. To identify the determinant factors of neonatal mortality in Ethiopia based on EDHS 2016 data with the application of count regression models. In this study, all neonates in Ethiopia were born within the 5 years preceding EDHS 2016 of the source population in the selected EAs from September to December 2015. Count regression models were used to analyze the data. A total of 10,641 live-born neonates within the previous 5 years of EDHS 2016 had neonatal mortality of women aged 15–49, which was considered in the study to be 7193. The data were found to have excess zeros (96.6%), and the variance (0.052) was higher than its mean (0.04). The count regression model (ZINB) was best fitted to the data with maximum likelihood parameter estimation methods. The average neonatal mortality difference in multiple births was increased by IRR = 8.53 times compared with a single birth. The average number of neonatal deaths experienced during breastfeeding was lower (IRR = 0.38) than that experienced by mothers who did not experience breastfeeding their child. The average neonatal mortality difference in rural residences was increased by IRR = 3.99 times compared to urban mothers' residences. In this study, the prevalence of Neonatal mortality in Ethiopia was higher. For selected ZINB count regression models of explanatory variables, such as multiple birth types, having rural residence factors of neonatal mortality increased the risk of death. However, having early breastfeeding, a female household head, and antenatal visits (1–4) and (5–10) during pregnancy decrease the risk of neonatal death.

Determinants of neonatal mortality among preterm births in Black Lion Specialized Hospital, Addis Ababa, Ethiopia: a case-cohort study

BACKGROUND

Preterm neonatal death is a global burden in both developed and developing countries. In Ethiopia, it is the first and fourth cause of newborn and under-5 deaths, respectively. From 2015 to present, the government of Ethiopia showed its effort to improve the survival of neonates, mainly preterm births, through the inclusion of high-impact life-saving neonatal interventions. Despite these efforts, the cause of preterm neonatal death is still not reduced as expected. Therefore, this study aimed to identify determinants of preterm neonatal mortality.

METHODS

An institution-based retrospective case-cohort study was conducted among a cohort of preterm neonates who were born between March 2013 and February 2018. A total of 170 cases were considered when the neonates died during the retrospective follow-up period, which was confirmed by reviewing a medical death certificate. Controls were 404 randomly selected charts of neonates who survived the neonatal period. Data were collected from patient charts using a data extraction tool, entered using EpiData V.3.1 and analysed using STATA V.14. Finally, a multivariate logistic regression analysis was performed, and goodness of fit of the final model was tested using the likelihood ratio test. Statistical significance was declared at a p value of ≤0.05.

RESULTS

In this study, the overall incidence rate of mortality was 39.1 (95% CI: 33.6 to 45.4) per 1000 neonate-days. Maternal diabetes mellitus (adjusted OR (AOR): 2.3 (95% CI: 1.4 to 3.6)), neonatal sepsis (AOR: 1.6 (95% CI: 1.1 to 2.4)), respiratory distress (AOR: 1.5 (95% CI: 1.1 to 2.3)), extreme prematurity (AOR: 2.9 (95% CI: 1.61 to 5.11)), low Apgar score (AOR: 3.1 (95% CI: 1.79 to 5.05)) and premature rupture of membranes (AOR: 2.3 (95% CI: 1.8 to 3.5)) were found to be predictors.

CONCLUSION

In this study, the overall incidence was found to be high. Premature rupture of membranes, maternal diabetes mellitus, sepsis, respiratory distress, extreme prematurity and low Apgar score were found to be predictors of neonatal mortality. Therefore, it should be better to give special attention to patients with significantly associated factors.

Maternal hypertension, preeclampsia, and risk of neonatal respiratory disorders in a large-prospective cohort study

BACKGROUND

Possible impact of maternal hypertension and preeclampsia on neonatal respiratory disorders was unknown. We investigated the association of maternal hypertension and preeclampsia with neonatal respiratory disorders in preterm and full-term newborns.

METHOD

In this study, we used a large Chinese population-based study which includes 185,687 singleton livebirths with gestational weeks between 28 and 42 weeks. The "exposure" was maternal hypertension and preeclampsia. The outcome was neonatal respiratory disorders including neonatal respiratory distress syndrome (NRDS), pneumonia and low Apgar scores. Logistic regression was used to examine the association between the maternal hypertensive disorders and the risk for neonatal respiratory disorders. We further evaluated the association in preterm and full-term infants.

RESULTS

As a result, the incidence of neonatal RDS, pneumonia, and low Apgar score in hypertensive group was higher than that in normotensive group. Preeclampsia was associated with RDS [(adjusted relative risk (aRR): 1.85, 95% confidence interval (CI): 1.22-3.05)]. Both maternal hypertension and preeclampsia increased risks for neonatal pneumonia (aRR: 1.79, 95%CI: 1.48-2.17; aRR: 1.81, 95%CI: 1.36-2.40, respectively), for low Apgar score at 1 min (aRR: 1.20, 95%CI: 1.13-1.27; aRR: 1.53, 95%CI: 1.41-1.67, respectively), and for low Apgar score at 5 min (aRR: 1.30, 95%CI: 1.17-1.45; aRR: 1.70, 95%CI: 1.46-1.99, respectively). The risk for neonatal respiratory disorders increased with severity of maternal hypertension. The observed associations were present in both full-term and preterm birth.

CONCLUSION

Maternal hypertension and preeclampsia are risk factors for neonatal respiratory disorders in full-term and preterm newborns.

Determinants of Under-Five Pneumonia at Gondar University Hospital, Northwest Ethiopia: An Unmatched Case-Control Study

Background

Pneumonia causes about two million under-five deaths each year, accounting for nearly one in five child deaths globally. Knowing the determinants of under-five pneumonia is useful for prevention and intervention programs that are aimed to control the disease. Thus, the main aim of this study was to assess the determinants of under-five pneumonia at Gondar University Hospital, Ethiopia.

Methods

An institution-based unmatched case-control study was carried out from April 1 to April 30, 2015, taking a sample size of 435 study participants (145 cases and 290 controls). The researchers used a systematic random sampling technique for selecting cases and controls. Data were entered and cleaned using Epi Info version 7 and exported to SPSS version 20 for analysis. Bivariable analysis was performed, and variables with a p value less than 0.2 were entered into multivariable logistic regression. Determinant factors were identified based on p value less than 0.05 and adjusted odds ratio with 95% confidence interval (AOR with 95% CI).

Results

An increased odds of pneumonia was associated with children who had diarrhea in the past fifteen days of data collection (AOR = 6.183; 95% CI: 3.482, 10.977), children's mothers who did not hear about how to handle domestic smoking (AOR = 5.814; 95% CI: 2.757, 12.261), and children of mothers who did not follow proper handwashing practice (AOR = 3.469; 95% CI: 1.753, 6.863).

Conclusions

Being infected with diarrhea, not knowing how to handle domestic smoking, and poor compliance with proper handwashing practice were identified as determinants of pneumonia. Dedicated, coordinated, and integrated intervention needs to be taken to enhance proper handwashing practice by mothers/caregivers, improve the indoor air quality, and prevent diarrheal diseases at the community level.

The impact of maternal health care utilisation on routine immunisation coverage of children in Nigeria: a cross-sectional study

OBJECTIVE

To examine the impact of maternal healthcare (MHC) utilisation on routine immunisation coverage of children in Nigeria.

DESIGN

Individual level cross-sectional study using bivariate and multivariable logistic regression analyses to examine the association between MHC utilisation and routine immunisation coverage of children.

SETTING

Nigeria Demographic and Health Survey 2013.

PARTICIPANTS

5506 women aged 15-49 years with children aged 12-23 months born in the 5 years preceding the survey.

PRIMARY OUTCOME MEASURES

Fully immunised children and not fully immunised children.

RESULTS

The percentage of children fully immunised with basic routine childhood vaccines by the age of 12 months was 25.8%. Antenatal care (ANC) attendance irrespective of the number of visits (adjusted OR (AOR)_{1-3 visits} 2.4, 95% CI 1.79 to 3.27; AOR_{4-7 visits} 3.2, 95% CI 2.52 to 4.13; AOR_{≥ 8 visits} 3.5, 95% CI 2.64 to 4.50), skilled birth attendance (SBA) (AOR 1.9, 95% CI 1.65 to 2.35); and maternal postnatal care (PNC) (AOR 1.7, 95% CI 1.46 to 2.06) had positive effects on the child being fully immunised after adjusting for covariates (except for each other, ie, ANC, SBA and PNC). Further analyses (adjusting stepwise for each MHC service) showed a mediation effect that led to the effect of PNC not being significant.

CONCLUSIONS

The percentage of fully immunised children in Nigeria was very low. ANC attendance, SBA and maternal PNC attendance had positive impact on the child being fully immunised. The findings suggest that strategies aimed at maximising MHC utilisation in Nigeria could be effective in achieving the national coverage target of at least 80% for routine immunisation of children.

Prolonged Exclusive Breastfeeding Through Peer Support: A Cohort Study From a Community Outreach Project in Swaziland

Swaziland faces great public health challenges, including suboptimal breastfeeding practices and the world's highest prevalence of HIV. The objective of this study was to estimate neonatal and infant mortality rate and rate of exclusive breastfeeding for clients enrolled in a community-based peer support project in peri-urban areas of Swaziland. The intervention builds on the so called "Philani-model" with Mentor Mothers in the community under high level of supervision. Cohort data was collected from journals kept by the Mentor Mothers. Kaplan-Meier and Cox regression were used to analyse data. Neonatal and infant mortality were estimated to 15 respectively 57 per 1000 live births. High level of social vulnerability was associated with risk of neonatal mortality (HR 1.12, CI 95 % 1.01-1.24) while the mother's positive HIV status was associated with infant mortality (HR 2.05, CI 95 % 1.15-3.65). More visits by a Mentor Mother could not be shown to result in lower mortality. The chance to practice exclusive breastfeeding for 6 months was estimated to 50 %. The risk of discontinuing exclusive breastfeeding before 6 months was lower for mothers being unemployed (HR 0.55, CI 95 % 0.44-0.69) or socially vulnerable (HR 0.95, CI 95 % 0.92-0.99) and higher for mothers being HIV positive (HR 1.22, CI 95 % 1.01-1.48). Receiving at least four visits by a Mentor Mother during pregnancy decreased the risk of discontinuing exclusive breastfeeding prematurely (HR 0.82, CI 95 % 0.67-0.99). Peer support with Mentor Mothers thus had a positive impact on exclusive breastfeeding rates in this disadvantaged population.

Viral Lower Respiratory Tract Infections

Lower respiratory tract infections in children are often viral in origin. Unfortunately in this time of significant antimicrobial resistance of infectious organisms, especially bacteria, there is still a tendency for clinicians to manage a child who coughs with antibiotics. In addition, the World Health Organization (WHO) has defined “pneumonia” as a condition that only occurs in children who have “fast breathing or chest wall indrawing”. That would delineate upper respiratory tract infections from those in the lower airway. However, in addition to pneumonia another important entity exists in the lower respiratory tract that is almost always viral in origin. This condition is acute viral bronchiolitis. The concept of “acute lower respiratory tract infection” (ALRTI) has emerged and it is becoming increasing evident from a number of studies that the infectious base of both acute pneumonia (AP) and acute bronchiolitis in children has a mixed etiology of microorganisms. Therefore, whilst certain clinical phenotypes do not require antibiotics the actual microbial etiology is much less distinct.

Neonatal pneumonia in sub-Saharan Africa

Neonatal pneumonia is a devastating condition. Most deaths in sub-Saharan Africa can be attributed to preventable diseases, including pneumonia, diarrhoea and malaria, which together killed an estimated 2.2 million children under the age of 5 years in 2012, accounting for a third of all under-five deaths in this region. Some countries are making progress in reducing mortality through community-based health schemes; however, most countries in this region are far from achieving the World Health Organization Sustainable Development Goals for reducing childhood morbidity and mortality. The microorganisms causing neonatal pneumonia are well known. Both bacteria and viruses are commonly responsible, while fungal organisms occur in the context of nosocomial disease, and parasites occur in HIV-infected children. The common bacterial pathogens are group B streptococci (and other streptococcal species) and Gram-negative organisms, most notably Escherichia coli and Klebsiella spp. The viruses that predominate are the common respiratory pathogens, namely respiratory syncytial virus, human rhinovirus, and influenza virus. Viral disease is often nosocomial and transmitted to infected neonates in the neonatal intensive care unit or other neonatal facilities by infected parents and staff. Neonatal pneumonia often presents with non-specific respiratory distress in newborns. In the premature infant it is often indistinguishable from surfactant deficiency-associated respiratory distress syndrome. Therefore, diagnostic testing that is cheap and reliable is urgently sought in this region. All neonates with pneumonia must receive broad-spectrum antibiotic cover. This usually entails the combination of penicillin and an aminoglycoside. A lack of appropriate drugs and neonatal intensive care unit facilities are hampering progress in managing neonatal pneumonia.