Improving neonatal mortality in sub-Saharan Africa: any cause for optimism?

Association between birth attendant and early newborn care in Senegal

OBJECTIVE

To examine the association between type of birth attendant and early newborn care in Senegal.

DESIGN

This was a secondary analysis of cross-sectional data from the 2017 Continuous Demographic and Health Survey.

PARTICIPANTS

The study included data on 6328 women with live births in the three years preceding the survey.

MEASUREMENTS

The main exposure was the type of birth attendant (doctor, nurse/midwife, auxiliary midwife/matrone, traditional birth attendant, or "others (friend, relative, or no one)). We assessed three outcomes: 1) early initiation of breastfeeding, 2) breastfeeding support, and 3) cord examination. We used multivariable logistic regression to estimate the odds ratios and 95% confidence intervals of early newborn care after adjusting for potential confounders.

FINDINGS

The coverage of all three newborn care indicators of interest was low. In the adjusted regression models, women whose births were assisted by a nurse/midwife were nearly twice as likely to initiate breastfeeding early compared to those assisted by doctors (odds ratio: 1.87, 95% confidence interval: 1.00-3.45). Women assisted at birth by doctors were significantly more likely to report breastfeeding support and newborn cord examination than those assisted by other types of birth attendants.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Although most recent births were facility-based and assisted by skilled birth attendants, the prevalence of early newborn care was suboptimal. This presents a missed opportunity to improve neonatal outcomes. Training and supporting skilled birth attendants may bridge the gap between opportunity and practice, and lead to improved coverage and quality of newborn care in Senegal.

Parents' experiences of caring for preterm infants after discharge with grandmothers as their main support

AIMS AND OBJECTIVES

To explore parents of preterm infants' experiences of caring for their preterm infants with the grandmother as their primary support after discharge.

BACKGROUND

Preterm delivery is the major cause of high neonatal mortality in sub-Saharan Africa. There is poor neonatal health outcome in the Ghanaian community with some illnesses culturally classified as not-for-hospital. In the community, grandmothers or older women provide support for new parents and decide treatment options for sick infants. However, there is paucity of research on how parents of preterm infants experience this support in the Ghanaian community.

METHOD

Qualitative narrative inquiry methodology was used. Face-to-face interviews using semi-structured interview guide were used to collect data from 21 mothers and nine fathers. Participant observation and field notes were used to complement interview data. Thematic content analysis of data within the three-dimensional narrative space was employed. Analysis focussed on the relationship of time, place, person and cultural practices affecting the care of preterm infants in the community.

RESULTS

Three themes emerged from the data, namely (i) Grandmother's prescriptions, (ii) Fighting for the well-being of the infant and (iii) Being in a confused state. Cultural practices mainly initiated by grandmothers resulted in adverse health problems for preterm infants and disruption in parents' mental health.

CONCLUSION

As grandmothers perform their traditional role of supporting new parents to care for preterm infants after discharge, they give both positive and negative advice which can adversely affect the health of vulnerable preterm infants in the community.

RELEVANCE TO CLINICAL PRACTICE

Grandmothers are the main support providers of parents of preterm infants after neonatal unit discharge. Nurses should identify and include grandmothers in predischarge education in order to equip them to render appropriate support to parents and preterm infants.

Neonatal care - what do mothers in a rural Nigerian community know and practice?

BACKGROUND

Nigeria ranks among developing countries with poor neonatal health indices. This underscores the need for households and healthcare providers to understand the concept of newborn care and react appropriately and timely too.

OBJECTIVE

To determine the knowledge and practices of mothers in the Elele community regarding neonatal care.

MATERIALS AND METHODS

This was a community-based descriptive cross sectional study of 380 mothers who had a neonate. Mothers were selected using a multistage sampling technique. Data were collected by interview using a semi-structured questionnaire (with closed and open ended questions) and analyzed using a statistical package for social sciences version 22.0. Chi-square test was used to identify statistically significant associations among antenatal care clinic (ANC) attendance cum place of delivery and neonatal care practices.

RESULTS

Ninety one (23.9%) of respondents were aware of at least four out of nine danger signs, while all reported wrapping their babies within 10 minutes after birth. Duration less than six hours from birth to first bath, feeding with or discarding of colostrum and timing of first breastfeeding within the first hour of birth were significantly associated with ANC attendance (p = 0.000, p = 0.002 and p = 0.000 respectively). Duration less than six hours to first bath, umbilical cord care and feeding with or discarding of colostrum were significantly associated with health facility delivery (p = 0.043, p = 0.026 and p = 0.003 respectively).

CONCLUSIONS

Inadequate knowledge of newborn care among mothers was found, while non-ANC attendance and non-health facility delivery were associated with inappropriate neonatal care practices. We recommend comprehensive behavior change interventions, to promote proper neonatal care practices.

Self-reported practices among traditional birth attendants surveyed in western Kenya: a descriptive study

Background

The high rate of home deliveries conducted by unskilled birth attendants in resource-limited settings is an important global health issue because it is believed to be a significant contributing factor to maternal and newborn mortality. Given the large number of deliveries that are managed by unskilled or traditional birth attendants outside of health facilities, and the fact that there is on-going discussion regarding the role of traditional birth attendants in the maternal newborn health (MNH) service continuum, we sought to ascertain the practices of traditional birth attendants in our catchment area. The findings of this descriptive study might help inform conversations regarding the roles that traditional birth attendants can play in maternal-newborn health care.

Methods

A structured questionnaire was used in a survey that included one hundred unskilled birth attendants in western Kenya. Descriptive statistics were employed.

Results

Inappropriate or outdated practices were reported in relation to some obstetric complications and newborn care. Encouraging results were reported with regard to positive relationships that traditional birth attendants have with their local health facilities. Furthermore, high rates of referral to health facilities was reported for many common obstetric emergencies and similar rates for reporting of pregnancy outcomes to village elders and chiefs.

Conclusions

Potentially harmful or outdated practices with regard to maternal and newborn care among traditional birth attendants in western Kenya were revealed by this study. There were high rates of traditional birth attendant referrals of pregnant mothers with obstetric complications to health facilities. Policy makers may consider re-educating and re-defining the roles and responsibilities of traditional birth attendants in maternal and neonatal health care based on the findings of this survey.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1007-8) contains supplementary material, which is available to authorized users.

Transformative Innovations in Reproductive, Maternal, Newborn, and Child Health over the Next 20 Years

As part of the "Grand Convergence: Aligning Technologies and Realities in Global Health" Collection, Cyril Engmann and colleagues discuss promising innovations that have the potential to move the RMNCH agenda forward.

A systematic review of risk factors for neonatal mortality in adolescent mother's in Sub Saharan Africa

Background

Worldwide, approximately 14 million mothers aged 15 – 19 years give birth annually. The number of teenage births in Sub Saharan Africa (SSA) is particularly high with an estimated 50% of mothers under the age of 20. Adolescent mothers have a significantly higher risk of neonatal mortality in comparison to adults. The objective of this review was to compare perinatal/neonatal mortality in Sub Saharan Africa and it’s associated risk factors between adolescents and adults.

Results

We systematically searched six databases to determine risk factors for perinatal/neonatal mortality, and pregnancy outcomes, between adolescent and adults in SSA. Article’s quality was assessed and synthesized as a narrative. Being single and having a single parent household is more prevalent amongst adolescents than adults. Nearly all the adolescent mothers (97%) were raised in single parent households. These single life factors could be interconnected and catalyze other risky behaviors. Accordingly, having co-morbidities such as Sexually Transmitted Infections, or not going to school was more prevalent in younger mothers.

Conclusions

Inter-generational support for single mothers in SSA communities appears essential in preventing both early pregnancies and ensuring healthy outcomes when they occur during adolescence. Future studies should test related hypothesis and seek to unpack the processes that underpin the relationships between being single and other risk indicators for neonatal mortality in young mothers. Current policy initiatives should account for the context of single African women’s lives, low opportunity, status and little access to supportive relationships, or practical help.

Electronic supplementary material

The online version of this article (doi:10.1186/1756-0500-7-750) contains supplementary material, which is available to authorized users.

Risk factors for mortality among human immunodeficiency virus-exposed and unexposed infants admitted to a neonatal intensive care unit in Botswana

AIM

Newborns admitted to neonatal units (NNUs) in resource-limited settings face a high risk of mortality, but the epidemiology of these deaths is poorly understood. We describe risk factors for NNU mortality in an area with high prevalence of human immunodeficiency virus (HIV).

METHODS

We performed a prospective cohort study of infants admitted to the NNU at a public referral hospital in Gaborone, Botswana. The primary outcome was neonatal death, defined as death within 28 days of a live delivery. Cox proportional hazard models were used to evaluate risk factors for mortality.

RESULTS

From October 2008 to April 2009, 449 neonates were admitted to the NNU. Cumulative mortality was 24.5% (110/449). Factors associated with increased risk of death included lack of enteral feeding (hazard ratio (HR) 18.8, 95% confidence interval (CI) 10.3, 34.2), gestational age <28 weeks (HR 2.0, 95% CI 1.1, 3.8) and Apgar score <7 at 10 min (HR 2.5, 95% CI 1.5, 4.2). Among 348 (78%) infants who were fed, there was no difference in mortality between infants who were breastfed compared with those who were formula fed or had mixed feeding (P = 0.76). There was no significant mortality difference by HIV exposure status; 35 (28%) of 128 HIV-exposed infants died compared with 55 (21%) of 272 HIV-unexposed infants (P = 0.19).

CONCLUSIONS

This study identified low Apgar scores, extreme prematurity and lack of enteral feeding as the most important risk factors for mortality in this NNU setting. HIV exposure and formula feeding were not significantly associated with death in neonates who were very ill.

Clean delivery practices in rural northern Ghana: a qualitative study of community and provider knowledge, attitudes, and beliefs

Background

Knowledge, attitudes and practices of community members and healthcare providers in rural northern Ghana regarding clean delivery are not well understood. This study explores hand washing/use of gloves during delivery, delivering on a clean surface, sterile cord cutting, appropriate cord tying, proper cord care following delivery, and infant bathing and cleanliness.

Methods

In-depth interviews and focus group discussions were audiotaped, transcribed, and analyzed using NVivo 9.0.

Results

253 respondents participated, including women with newborn infants, grandmothers, household and compound heads, community leaders, traditional birth attendants, and formally trained health care providers. There is widespread understanding of the need for clean delivery to reduce the risk of infection to both mothers and their babies during and shortly after delivery. Despite this understanding, the use of gloves during delivery and hand washing during and after delivery were mentioned infrequently. The need for a clean delivery surface was raised repeatedly, including explicit discussion of avoiding delivering in the dirt. Many activities to do with cord care involved non-sterile materials and practices: 1) Cord cutting was done with a variety of tools, and the most commonly used were razor blades or scissors; 2) Cord tying utilized a variety of materials, including string, rope, thread, twigs, and clamps; and 3) Cord care often involved applying traditional salves to the cord - including shea butter, ground shea nuts, local herbs, local oil, or “red earth sand.” Keeping babies and their surroundings clean was mentioned repeatedly as an important way to keep babies from falling ill.

Conclusions

This study suggests a widespread understanding in rural northern Ghana of the need for clean delivery. Nonetheless, many recommended clean delivery practices are ignored. Overarching themes emerging from this study included the increasing use of facility-based delivery, the disconnect between healthcare providers and the community, and the critical role grandmothers play in ensuring clean delivery practices. Future interventions to address clean delivery and prevention of neonatal infections include educating healthcare providers about harmful traditional practices so they are specifically addressed, strengthening facilities, and incorporating influential community members such as grandmothers to ensure success.

Birth attendants as perinatal verbal autopsy respondents in low- and middle-income countries: a viable alternative?

OBJECTIVE

To assess the feasibility of using birth attendants instead of bereaved mothers as perinatal verbal autopsy respondents.

METHODS

Verbal autopsy interviews for early neonatal deaths and stillbirths were conducted separately among mothers (reference standard) and birth attendants in 38 communities in four developing countries. Concordance between maternal and attendant responses was calculated for all questions, for categories of questions and for individual questions. The sensitivity and specificity of individual questions with the birth attendant as respondent were assessed.

FINDINGS

For early neonatal deaths, concordance across all questions was 94%. Concordance was at least 95% for more than half the questions on maternal medical history, birth attendance and neonate characteristics. Concordance on any given question was never less than 80%. Sensitivity and specificity varied across individual questions, more than 80% of which had a sensitivity of at least 80% and a specificity of at least 90%. For stillbirths, concordance across all questions was 93%. Concordance was 95% or greater more than half the time for questions on birth attendance, site of delivery and stillborn characteristics. Sensitivity and specificity varied across individual questions. Over 60% of the questions had a sensitivity of at least 80% and over 80% of them had a specificity of at least 90%. Overall, the causes of death established through verbal autopsy were similar, regardless of respondent.

CONCLUSION

Birth attendants can substitute for bereaved mothers as verbal autopsy respondents. The questions in existing harmonized verbal autopsy questionnaires need further refinement, as their sensitivity and specificity differ widely.