Survival analysis of the association between antenatal care attendance and neonatal mortality in 57 low- and middle-income countries

The nexus between maternal antenatal care attendance, newborn postnatal care and neonatal mortality in India: a matched case-control study

INTRODUCTION

Our study examines the relationship between newborn postnatal care and neonatal mortality stratified by maternal antenatal care attendance under a matched case-control framework.

METHODS

Data from the fifth round of the National Family Health Survey was used. A total of 172,079 recent births to eligible women (15-49 years) in five years preceding the survey were included in the study. We used the conditional logistic regression model, a commonly used regression model to fit matched case-control data to examine the effects of newborn postnatal care on neonatal mortality. The mother's age at birth of the newborn, previous birth intervals, birth order of the newborn, and birthsize of the newborn were included as the matching variables.

RESULTS

Newborns receiving postnatal care within two days or more than two days of birth are less likely to die during the neonatal period. Preferences for newborn postnatal care were also observed to increase with more maternal antenatal care visits. Our study also found a lower risk of neonatal mortality among those newborns whose umbilical cord was examined within two days of birth, regardless of the number of maternal antenatal care visits. Similarly, the risk of newborn deaths was lower among babies whose body temperature was measured within two days of birth. The tendency to breastfeed their newborns within an hour after delivery was considerably higher among those births that occurred to mothers who had a higher number of maternal antenatal care visits. The risk of newborn deaths was also observed to be lower among those born in public or private healthcare facilities.

CONCLUSION

Considering the cohesive nature of the relationship between neonatal mortality and maternal and child healthcare utilisation, strategic planning and management of the existing policies and programmes related to accessibility, availability, and affordability of maternal and child healthcare services is needed to achieve goal 3.2 of the Sustainable Development Goals. Promoting cost-effective measures such as continuous monitoring of the baby's body temperature and umbilical cord care could also effectively help reduce neonatal mortality.

Trends in the quality of antenatal care in India: Patterns of change across 36 states and union territories, 1999-2021

Background

Antenatal care (ANC) quality is important to maternal and neonatal mortality. However, trends in the quality of ANC received by pregnant women in India have been understudied. This paper seeks to fill this gap by examining the long-term patterns nationwide and the state-specific prevalence of inadequate ANC quality received by pregnant women in India.

Methods

We utilised data from four National Family Health Surveys (NFHS) conducted in 1999 (NFHS-2), 2006 (NFHS-3), 2016 (NFHS-4), and 2021 (NFHS-5) across India's 36 states/union territories (UTs). The sample includes mothers who had given birth within three years (NFHS-2) and five years (NFHS-3, NHFS-4, and NFHS-5) before each survey. We define inadequate ANC quality as not completing seven essential ANC services (weight measurement, blood pressure measurement, urine sampling, blood sampling, provision of iron supplements, provision of tetanus vaccination, and ultrasound scans) during pregnancy. We calculated the standardised absolute change to quantify the change in the share of women receiving inadequate quality ANC nationally and by each state/UT. Additionally, we estimated the population headcount of mothers who received inadequate-quality ANC in 2021 and identified the socioeconomic correlates associated with inadequate ANC quality.

Results

The prevalence of inadequate ANC quality substantially declined between 1999-2021, from 84.8% (95% confidence interval (CI) = 84.1-85.5) to 28.8% (95% CI = 28.5-29.2). However, between-state inequality in ANC quality has increased over this time. We identified a weak correlation between prevalence and population headcounts in 2021. Socioeconomically disadvantaged groups exhibited a higher prevalence of inadequate quality of ANC than less disadvantaged groups.

Conclusions

The proportion of pregnant women receiving inadequate ANC quality has decreased over time throughout India. However, multi-faceted efforts at national and state levels are necessary to enhance the effectiveness of existing policies. Additionally, innovative and targeted approaches are required to ensure the timely and equitable provision of high-quality ANC.

Predictors of antenatal care services utilization by pregnant women in Afghanistan: Evidence from the Afghanistan Health Survey 2018

BACKGROUND

Poor utilization of maternal healthcare services remains a public health concern in most low and middle-income countries (LMICs), including Afghanistan. Late, inadequate, or no utilization of antenatal care (ANC) services pose a great concern.

OBJECTIVES

This study assessed the predictors of ANC service utilization among Afghan pregnant women, using secondary data from the Afghanistan Health Survey 2018 (AHS2018).

METHODS

In this study, we used data from 10,855 ever-married women, aged 13-49 years, who gave birth in the two years prior to the survey or those women who were currently pregnant. The outcome variable was defined as a binary variable on ANC utilization (≥1 ANC visit equals 1, and zero otherwise). We fitted a binary logistic regression model and examined the associations between ANC utilization and explanatory variables, providing findings based on univariate and multivariate analysis. STATA version 17 was employed for the data analysis.

RESULTS

Overall, 63.2%, 22.0%, and 3.1% of women had at least one ANC visit, ≥4 ANC visits, and ≥8 ANC visits during their last pregnancy, respectively. Higher odds of ANC utilization were observed in women who could read and write (AOR = 1.55, 95%CI: 1.36-1.77), whose husbands could read and write (AOR = 1.42, 95%CI: 1.29-1.56), who knew 1 sign (AOR = 1.93, 95%CI: 1.74-2.14), 2 signs (AOR = 2.43, 95%CI: 2.17-2.71) and ≥ 3 signs (AOR = 1.55, 95%CI: 1.36-1.77) of complicated pregnancy, and those with almost daily access to radio (AOR = 1.19, 95%CI: 1.08-1.327) and TV (AOR = 1.92, 95%CI: 1.73-2.13). We also found that women with one (AOR = 0.64, 95%CI: 0.49-0.84) and more than one (AOR = 0.60, 95%CI: 0.47-0.76) parity status, those for whom in-laws and others decided for their birthplace [(AOR = 0.85, 95%CI: 0.74-0.97) and (AOR = 0.63, 95%CI: 0.55-0.72), respectively], and those that resided in rural areas (AOR = 0.89, 95%CI: 0.79-1.00) had reduced odds of ANC utilization.

CONCLUSION

ANC service utilization is unacceptably low by pregnant women in Afghanistan. The predictors of ANC utilization identified by the study should be considered in the design of future interventions to enhance antenatal care utilization in Afghanistan.

Birth outcomes and survival by sex among newborns and children under 2 in the Birhan Cohort: a prospective cohort study in the Amhara Region of Ethiopia

INTRODUCTION

Despite the progress in reducing child mortality, the rate remains high, particularly in sub-Saharan African countries. Limited data exist on child survival and other birth outcomes by sex. This study compared survival rates and birth outcomes by sex among neonates and children under 2 in Ethiopia.

METHODS

Women who gave birth after 28 weeks of gestation and their newborns were included in the analysis. Survival probabilities were estimated for males and females in the neonatal period as well as the 2-year period following birth using Kaplan-Meier curves. HRs and 95% CIs were compared between males and females under 2. Descriptive statistics and χ2 tests were used to determine the sex-disaggregated variation in the birth outcomes of preterm birth, low birth weight (LBW), stillbirth, small for gestational age (SGA) and large for gestational age (LGA).

RESULTS

The study included a total of 3904 women and child pairs. The neonatal mortality rate for males (3.4%, 95% CI 2.6% to 4.2%) was higher compared with females (1.7%, 95% CI 1.1% to 2.3%). The hazard of death during the first 28 days of life was approximately two times higher for males compared with females (HR 1.99, 95% CI 1.30 to 3.06) but was not significantly different after this period. While there was a non-significant difference between males and females in the proportion of preterm, LBW and LGA births, we found a significantly higher proportion of stillbirth (2.7% vs 1.3%, p=0.003) and SGA (20.5% vs 15.6%, p<0.001) for males compared with females.

CONCLUSIONS

This study identified a significant sex difference in mortality and birth outcomes. We recommend focusing future research on the mechanisms of these sex differences in order to better design intervention programmes to reduce disparities and improve outcomes for neonates.

Predictors of neonatal mortality among neonates admitted to NICU at Dubti General hospital, Northeast Ethiopia

Background

In Ethiopia, despite various strategies and interventions being implemented, the rate of neonatal mortality remains high. Despite numerous published articles in Ethiopia, there is a lack of sufficient data regarding the time to death and its predictors in neonatal mortality, especially in pastoral communities like the Afar region. Therefore, this study aims to evaluate neonatal mortality and its predictors among neonates admitted to the neonatal intensive care unit at Dubti General Hospital, Northeast Ethiopia.

Method

We conducted a facility-based retrospective follow-up study, involving a sample of 479 neonates admitted to the neonatal intensive care unit at Dubti General Hospital. Data entry was performed using Epi-Data version 4.6, and subsequent analysis was carried out using STATA version 14.1. To identify predictors of neonatal mortality, we applied the Cox-proportional hazard model.

Results

Out of the total, 87 neonates (18.16 %) passed away. The overall incidence of neonatal mortality was 27.2 deaths per 1000 neonate-days spent in the neonatal intensive care unit, with a 95 % confidence interval of [21.8, 34.2]. Appearance, pulse, grimace, activity, and respiration score less than or equal to 5 [AHR = 0.33, 95%CI: 0.07, 0.62], respiratory distress syndrome [AHR = 3.22, 95%CI: 1.71, 6.07], Neonatal hypothermia [AHR = 3.12, 95%CI: 1.31, 7.42]. No initiation of breastfeeding [AHR = 3.68, 95%CI: 1.44, 9.36], no antenatal care visits [AHR = 0.25, 95%CI: 0.13, 0.48] and maternal birth related complication [AHR = 2.71, 95%CI: 2.43, 11.14] are predictors.

Conclusion

The mortality rate was notably high, with several factors identified as independent predictors of newborn death, including Appearance, pulse, grimace, activity, and respiration, respiratory distress syndrome, hypothermia, initiation of breastfeeding, antenatal care visits, and maternal birth-related complications. There is a pressing need for intensified programming efforts aimed at improving child survival within healthcare facilities, particularly addressing neonatal complications. Enhancing prenatal care during pregnancy and early detection and treatment of intrapartum disorders are recommended strategies for enhancing newborn health outcomes.

Associations between Antenatal Care Visit Attendance and Infant Mortality and Growth

This study examines the association between antenatal care (ANC) attendance and infant mortality and growth outcomes. The study used data from the Nouveux-nés et Azithromycine: une Innovation dans le Traitement des Enfants (NAITRE) trial conducted in Burkina Faso. This analysis included 21,795 neonates aged 8 to 27 days who were enrolled in the trial and had ANC data available. Infants were followed until 6 months of age. The analysis adjusted for potential confounders including infant's sex, maternal age, education, urbanicity, geographic region, season (dry versus rainy), pregnancy type (singleton versus multiple), number of previous pregnancies, if the infant was breastfed, and if the facility had an onsite physician to account for level of care. We used logistic and linear regression models to evaluate the association between ANC visits and all-cause infant mortality and infant growth measurements at 6 months. There was no significant association between ANC visits and 6-month mortality. Higher ANC attendance was associated with improved growth outcomes in infants at 6 months of age. After adjusting for potential confounders, each additional ANC visit was associated with a 0.03 kg increase in mean weight, 0.07 cm increase in mean length, 0.04 SD increase in mean mid-upper-arm circumference, 0.04 SD increase in mean height-for-age, 0.04 SD mean weight-for-age, and 0.02 SD mean weight-for-length Z-scores. These mean differences were statistically significant (except for weight-for-length Z-scores) but may not be clinically meaningful. Further research is warranted to explore the relationship between ANC attendance and longer-term health outcomes among infants.

Risk factors associated with neonatal mortality among neonates admitted to neonatal intensive care unit of the University Teaching Hospital in Lusaka

Globally, several children die shortly after birth and many more of them within the first 28 days of life. Sub-Sharan Africa accounts for almost half (43%) of the global neonatal death with slow progress in reduction. These neonatal deaths are associated with lack of quality care at or immediately after birth and in the first 28 days of life. This study aimed to determine the trends and risk factors of facility-based neonatal mortality in a major referral hospital in Lusaka, Zambia. We conducted retrospective analysis involving all neonates admitted in the University Teaching Hospital Neonatal Intensive Care Unit (UTH-NICU) in Lusaka from January 2018 to December 2019 (N = 2340). We determined the trends and assessed the factors associated with facility-based neonatal mortality using Generalized Linear Models (GLM) with a Poisson distribution and log link function. Overall, the facility-based neonatal mortality was 40.2% (95% CI 38.0-42.0) per 1000 live births for the 2-year period with a slight decline in mortality rate from 42.9% (95% CI 40.0-46.0) in 2018 to 37.3% (95% CI 35.0-40.0) in 2019. In a final multivariable model, home delivery (ARR: 1.70, 95% CI 1.46-1.96), preterm birth (ARR: 1.59, 95% CI 1.36-1.85), congenital anomalies (ARR: 1.59, 95% CI 1.34-1.88), low birthweight (ARR: 1.57, 95% CI 1.37-1.79), and health centre delivery (ARR: 1.48, 95% CI 1.25-1.75) were independently associated with increase in facility-based neonatal mortality. Conversely, hypothermia (ARR: 0.36, 95% CI 0.22-0.60), antenatal attendance (ARR: 0.76, 95% CI 0.68-0.85), and 1-day increase in neonatal age (ARR: 0.96, 95% CI 0.95-0.97) were independently associated with reduction in facility-based neonatal mortality. In this hospital-based study, neonatal mortality was high compared to the national and global targets. The improvement in neonatal survival observed in this study may be due to interventions including Kangaroo mother care already being implemented. Early identification and interventions to reduce the impact of risks factors of neonatal mortality in Zambia are important.

Association between adequacy of antenatal care and neonatal outcomes in Rwanda: a cross-sectional study design using the Rwanda demographic and health surveys

BACKGROUND

Maternal and neonatal health services are life-saving interventions for neonatal health outcomes. As Rwanda endeavors to accomplish sustainable development goals, adequate ANC is essential to lessen of neonatal mortality. The utilization of ANC continues to be inadequate and high neonatal mortality rate persevere in Rwanda. Understanding the direct and indirect factors that affect newborn health outcomes is necessary for well-targeted interventions. However, few studies had been conducted in Rwanda to evaluate the importance of ANC in improving neonatal health. This study therefore assessed the association between ANC and neonatal outcomes.

METHODS

The Demographic and Health Surveys (DHS) are household surveys that are cross-sectional, nationally representative, and used to collect data on population, health, and nutrition. Data from the 2010,2015 and 2020 Rwanda Demographic and Health Surveys (RDHS) were used. The study involved 17,747 women between the ages of 15 and 49 who had a single live birth and at least one ANC visit in five years prior to each survey. Bivariate and multivariable logistic regression, a survey adjusted for clusters at multiple level, and the estimation of adjusted odds ratios (aOR) and 95% confidence intervals were used to evaluate the relationship between the outcome and independent variables.

RESULTS

Out of 17,747 women ;7638(42.91%) of the mothers had adequate ANC visits and low birth weight (LBW) was found among 833(4.63%) neonates. The birth of a LBW baby (aOR:4.64;95%CI:3.19,6.74) was directly related to increased odds of neonatal death. Mothers aged 20-34 years (aOR:0.40; 95%CI:0.20,0.81), a preceding birth interval of 24months or greater (aOR:0.41:95%CI:0.28,0.60), baby being female (aOR:0.72; 95%CI:0.54,0.96), having adequate ANC visits (aOR:0.64;95% CI:0.46,0.89) and the birth order of the newborn being ranked second or third (aOR:0.60; 95%CI:0.38,0.95) were negatively associated with neonatal death.

CONCLUSION

Health education programs targeting teen and primigravida mothers should be encouraged. Among the newborn survival interventions, addressing short birth intervals and the effective management of LBW cases should be explored. The findings confirm the fundamental importance of adequate ANC in the neonatal survival.

Antenatal Care Reduces Neonatal Mortality in Ethiopia: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Neonatal deaths remain a serious public health concern in Ethiopia; being one of the top five countries contributing to half of the neonatal deaths worldwide. Although antenatal care (ANC) is assumed as one of the viable options that contribute to neonatal survival, findings from original studies indicated disparities in the effect of ANC on neonatal mortality. Thus, this review aimed to determine the pooled effect of ANC on neonatal mortality in Ethiopia.

METHODS

Databases such as PubMed, EMBASE, CINAHL, HINARI, and Cochrane Central Library were searched for articles using keywords. Selection of eligible articles and data extraction were conducted by an independent author. The risk of a bias assessment tool for non-randomized studies was used to assess the quality of the articles. Comprehensive meta-analysis version 2 software was used for meta-analysis. Heterogeneity and publication bias of included studies were assessed using I2 test statistic and Egger test, respectively. The random-effect model was employed; an outcome is reported using a risk ratio with a 95% confidence interval.

RESULTS

Of 28 included studies, 20 showed receiving at least one ANC visit had a significant association with neonatal mortality. Accordingly, the estimated pooled risk ratio for neonatal mortality was 0.59 (95% CI 0.45, 0.77) among infants born to women who had at least one ANC visit compared to infants born to women who had no ANC visits.

CONCLUSION

This finding indicated that neonatal mortality was decreased among infants born to women who had at least one ANC visit compared to infants born to women who had no ANC visit. Therefore, promoting and strengthening ANC service utilization during pregnancy would accelerate the reduction of neonatal mortality in Ethiopia.

Antenatal care coverage in a low-resource setting: Estimations from the Birhan Cohort

Antenatal care (ANC) coverage estimates commonly rely on self-reported data, which may carry biases. Leveraging prospectively collected longitudinal data from the Birhan field site and its pregnancy and birth cohort, the Birhan Cohort, this study aimed to estimate the coverage of ANC, minimizing assumptions and biases due to self-reported information and describing retention patterns in ANC in rural Amhara, Ethiopia. The study population were women enrolled and followed during pregnancy between December 2018 and April 2020. ANC visits were measured by prospective facility chart abstraction and self-report at enrollment. The primary study outcomes were the total number of ANC visits attended during pregnancy and the coverage of at least one, four, or eight ANC visits. Additionally, we estimated ANC retention patterns. We included 2069 women, of which 150 (7.2%) women enrolled <13 weeks of gestation with complete prospective facility reporting. Among these 150 women, ANC coverage of at least one visit was 97.3%, whereas coverage of four visits or more was 34.0%. Among all women, coverage of one ANC visit was 92.3%, while coverage of four or more visits was 28.8%. No women were found to have attended eight or more ANC visits. On retention in care, 70.3% of participants who had an ANC visit between weeks 28 and <36 of gestation did not return for a subsequent visit. Despite the high proportion of pregnant women who accessed ANC at least once in our study area, the coverage of four visits remains low. Further efforts are needed to enhance access to more ANC visits, retain women in care, and adhere to the most recent Ethiopian National ANC guideline of at least eight ANC visits. It is essential to identify the factors that lead a large proportion of women to discontinue ANC follow-up.

Antenatal corticosteroid therapy, delivery intervals and perinatal mortality in low-resource settings

BACKGROUND

Uncertainty exists regarding the ideal interval between the administration of antenatal corticosteroids (ACS) and delivery. The study's objective was to assess the risks of perinatal mortality and respiratory distress syndrome (RDS) among preterm neonates whose mothers gave birth within 48 h of the administration of ACS and those whose mothers gave birth between 48 h and 7 days.

METHODS

The study design was a secondary analysis of data from an observational prospective chart review study that was carried out in Tanzania in 2020. Preterm infants born to mothers who got at least one dose of ACS between 28 and 34 weeks of pregnancy were included.

RESULTS

A total of 346 preterm neonates (294 singletons and 52 twins) were exposed to ACS. Compared to infants born 48 h following the first dose of ACS, those exposed to the drug between 48 h and 7 days had significantly decreased rates of perinatal mortality and RDS. Multivariable analysis revealed that infants exposed ACS between 48 h and 7 days prior to delivery had lower risk of perinatal mortality (aRR 0.30, 95% CI 0.14-0.66) and RDS (aRR 0.27, 95% CI 0.14-0.52).

CONCLUSION

The first dose of ACS given between 48 h and 7 days before delivery was associated with a lower risk of perinatal mortality and RDS than when the first dose was given <48 h before delivery. To improve neonatal outcomes, healthcare providers should consider administering ACS to mothers at the appropriate time.

Two Pregnancy Care Models in Poland-A Descriptive-Comparative Study

Care for a pregnant woman can take various organizational forms. The World Health Organization (WHO) recommends leaders increase research into health systems. The aim of this is to manage the healthcare system in such a way as to provide beneficiaries with access to high-quality services with limited financial resources. The study presented in this paper was conducted using a diagnostic survey on a group of 1697 Polish women in the traditional model of care (TM) and 3216 women in the Coordinated Care for Pregnant Women Program (CCP). Two research tools were used in this study. The first is a survey prepared by the National Health Fund, the second is an author's survey. The results indicate that most women (85%) receiving care under the CCP received effective pain management, compared to 67% under the traditional care model (p < 0.001). In the CCP, women were significantly more likely to receive midwife assistance in infant care (90%) than women in the traditional care model (60%) (p < 0.001). Significantly more CCP patients want to return to the same hospital for their subsequent childbirth (74%) than women in the traditional model of care (43%) (p < 0.001). In patients' opinion, the new CCP model is superior in meeting their needs and providing higher-quality services. However, educating women that an obstetrician-gynecologist and a midwife can manage their pregnancy is still necessary. In addition to the CCP program, special attention should be paid to available pain management during childbirth since the use of analgesia is still insufficient in Polish hospitals.

Accessibility and utilization of antenatal care services in sub-Saharan Africa during the COVID-19 pandemic: A rapid review

Control measures for the COVID-19 pandemic brought unprecedented challenges to health care delivery. Some countries in sub-Saharan Africa (SSA) stopped the provision of essential health care except for those services that were deemed emergencies or life-threatening. A rapid review was conducted on March 18, 2022, on the accessibility and utilization of antenatal care services in sub-Saharan Africa during the COVID-19 pandemic. PubMed, Google Scholar, SCOPUS, and the World Health Organization library databases were searched for relevant studies. A modified Population, Intervention, Control, and Outcomes (PICO) framework informed the development of the search strategy. The review included studies conducted within Africa that described the availability, access, and utilization of antenatal services during the COVID-19 pandemic. Eighteen studies met the inclusion criteria. This review revealed a reduction in access to ANC services, an increase in the number of home deliveries, and a reduction in the number of women attending ANC visits during the COVID-19 pandemic. A decrease in ANC service utilization was reported in some studies in the review. Barriers to ANC access and utilization during the COVID-19 pandemic included movement restrictions, limited transport access, fear of contracting COVID-19 at the health facilities, and facility barriers. The use of telemedicine needs to be improved in African countries to allow for the continued provision of health services during pandemics. In addition, there should strengthening of community involvement in the provision of maternal health services post-COVID-19 so that services may be able to better withstand future public health emergencies.

Preceding birth interval, timing and number of antenatal contacts in Africa, 2010-2020

BACKGROUND

Utilization of adequate and quality prenatal healthcare services confers critical benefits to women and their unborn children. However, utilization rates remain low in many countries in Africa. Several studies have attempted to understand the primary drivers behind these low statistics. This article contributes to this discourse by examining the associations between birth interval and timing and number/frequency of antenatal care visits in Africa.

METHODS

We pooled data from the publicly available Demographic and Health Surveys conducted in the last decade (2010-2020) for 32 African countries. Data were analysed using descriptive proportions and mixed effect binary logistic regression.

RESULTS

The results illustrate moderate significant associations between spacing on the most recent birth by ≥36 months and early (first trimester) first antenatal care contact in both our bivariate (odds ratio [OR] 1.18, p<0.001) and multivariate (OR 1.106, p<0.001) analyses. The benefits on optimal antenatal contacts predicted on spacing are also noticed with birth intervals of 24-35 months (OR 1.08, p<0.001) and ≥36 months (OR 1.48, p<0.001).

CONCLUSIONS

Optimal birth spacing is beneficial for ANC utilization in terms of timing and total number of contacts. Post-partum family planning/contraceptive use can be an effective pathway to prolonging birth intervals. We argue that maternal and child health programmes strengthen prioritizing contraceptive use between births.

Prevalence and correlates of low birth weight in India: findings from national family health survey 5

BACKGROUND

Childhood mortality and morbidity has become a major public health issue in low-middle-income countries. However, evidence suggested that Low birth weight(LBW) is one of the most important risk factors for childhood deaths and disability.This study is designed to estimate the prevalence of low birth weight (LBW) in India and to identify maternal correlates associated with LBW.

METHODS

Data has been taken from National Family Health Survey 5 (2019-2021) for analysis. 149,279 women belonging to reproductive age group (15-49) year who had last recent most delivery preceding the NFHS-5 survey.

RESULTS

Mother's age, female child, birth interval of less than 24 months, their low educational level, low wealth index, rural residence, lack of insurance coverage, women with low BMI, anaemia, and no ANC visits during pregnancy are predictors that contribute to LBW in India. After adjusting for covariates, smoking and alcohol consupmtion is strongly correlated with LBW.

CONCLUSION

Mother's age, educational attainment and socioeconomic status of living has a highly significant with LBW in India. However, consumption of tobacco and cigarrettes are also associated with LBW.

How does women's empowerment relate to antenatal care attendance? A cross-sectional analysis among rural women in Bangladesh

BACKGROUND

In South Asia, roughly half of women attend at least four antenatal care visits with skilled health personnel, the minimum number recommended by the World Health Organization for optimal birth outcomes. A much greater proportion of women attend at least one antenatal care visit, suggesting that a key challenge is ensuring that women initiate antenatal care early in pregnancy and continue to attend after their first visit. One critical barrier to antenatal care attendance may be that women do not have sufficient power in their relationships, households, or communities to attend antenatal care when they want to. The main goals of this paper were to 1) understand the potential effects of intervening on direct measures of women's empowerment-including household decision making, freedom of movement, and control over assets-on antenatal care attendance in a rural population of women in Bangladesh, and 2) examine whether differential associations exist across strata of socioeconomic status.

METHODS

We analyzed data on 1609 mothers with children under 24 months old in rural Bangladesh and employed targeted maximum likelihood estimation with ensemble machine learning to estimate population average treatment effects.

RESULTS

Greater women's empowerment was associated with an increased number of antenatal care visits. Specifically, among women who attended at least one antenatal care visit, having high empowerment was associated with a greater probability of ≥ 4 antenatal care visits, both in comparison to low empowerment (15.2 pp, 95% CI: 6.0, 24.4) and medium empowerment (9.1 pp, 95% CI: 2.5, 15.7). The subscales of women's empowerment driving the associations were women's decision-making power and control over assets. We found that greater women's empowerment is associated with more antenatal care visits regardless of socioeconomic status.

CONCLUSIONS

Empowerment-based interventions, particularly those targeting women's involvement in household decisions and/or facilitating greater control over assets, may be a valuable strategy for increasing antenatal care attendance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04111016, Date First Registered: 01/10/2019.

Determinants of timing, adequacy and quality of antenatal care in Rwanda: a cross-sectional study using demographic and health surveys data

BACKGROUND

Antenatal care (ANC) is a recommended intervention to lessen maternal and neonatal mortality. The increased rate in ANC coverage in most Sub-Saharan African countries is not considerably reducing the maternal and neonatal mortality. This disconnection has raised concerns to study further the trend and determinants of the ANC timing and quality. We aimed to assess the determinants and trend of the timing, the adequacy and the quality of antenatal care in Rwanda.

METHOD

A population-based cross-sectional study design. We used data from the 2010,2015 and 2020 Rwanda demographic and health surveys (RDHS). The study included 18,034 women aged 15-49 years. High quality ANC is when a woman had her first ANC visit within 3 months of pregnancy, had 4 or more ANC visits, received services components of ANC during the visits by a skilled provider. Bivariate analysis and multivariable logistic regression were used to assess the ANC (timing and adequacy), the quality of the content of ANC services and the associated factors.

RESULTS

The uptake of antenatal services increased in the last 15 years. For instance, the uptake of adequate ANC was 2219(36.16%), 2607(44.37%) and 2925(48.58%) respectively for 2010;2015 and 2020 RDHS. The uptake of high quality ANC from 205(3.48%) in 2010 through 510(9.47%) in 2015 to 779(14.99%) in 2020. Women with unwanted pregnancies were less likely to have timely first ANC (aOR:0.76;95%CI:0.68,0.85) compared to planned pregnancies, they were also less likely to achieve a high-quality ANC (aOR: 0.65;95%CI:0.51,0.82) compared to the planned pregnancies. Mothers with a secondary and higher education were 1.5 more likely to achieve a high-quality ANC (aOR:1.50;95%CI:1.15,1.96) compared to uneducated mothers. Increasing maternal age is associated with reduced odds of update of ANC component services (aOR:0.44;95%CI:0.25,0.77) for 40 years and above when referred to teen mothers).

CONCLUSION

Low-educated mothers, advanced maternal age, and unintended pregnancies are the vulnerable groups that need to be targeted in order to improve ANC-related indicators. One of the credible measures to close the gap is to strengthen health education, promote family planning, and promote service utilization.

The HIV paradox: Perinatal mortality is lower in HIV-positive mothers-A field case-control study in Ethiopia

OBJECTIVE

Sub-Saharan African countries have the highest perinatal mortality rates. Although HIV is a risk factor for perinatal death, antioretroviral therapy (ART) programs have been associated with better outcomes. We aimed to investigate how maternal HIV affects perinatal mortality.

METHODS

The authors performed a nested case-control study at Saint Luke Hospital, Wolisso, Ethiopia. Data on sociodemographic characteristics, current maternal conditions, obstetric history, and antenatal care (ANC) services utilization were collected. The association between perinatal mortality and HIV was assessed with logistic regression adjusting for potential confounders.

RESULTS

A total of 3525 birthing women were enrolled, including 1175 cases and 2350 controls. Perinatal mortality was lower among HIV-positive women (18.3% vs. 33.6%, P = 0.007). Crude analysis showed a protective effect of HIV (odds ratio, 0.442 [95% confidence interval, 0.241-0.810]), which remained after adjustment (adjusted odds ratio, 0.483 [95% confidence interval, 0.246-0.947]). Among HIV-negative women, access to ANC for women from rural areas was almost half (18.8% vs. 36.2%; P < 0.001), whereas in HIV-positive women, no differences were noted (P = 0.795).

CONCLUSION

Among HIV-positive mothers, perinatal mortality was halved and differences in access to ANC services by area were eliminated. These data highlight the benefits of integrating ANC and HIV services in promoting access to the health care system, reducing inequalities and improving neonatal mortality.

Relationship between low birth weight and infant mortality: evidence from National Family Health Survey 2019-21, India

BACKGROUND

Low birth weight (LBW) predisposes physical and mental growth failure and premature death among infants. Studies report that LBW predominately explains infant mortality. However, existing studies rarely demonstrate the phenomenon of both observed and unobserved factors, which may influence the likelihood of birth and mortality outcomes simultaneously. In this study, we identified the spatial clustering of the prevalence of LBW along with its determinants. Further, the relationship between of LBW and infant mortality, considering the unobserved factors, has been explored in the study.

METHODS

Data for this study have been extracted from the National Family Health Survey (NFHS) round 5, 2019-21. We used the directed acyclic graph model to identify the potential predictors of LBW and infant mortality. Moran's I statistics have been used to identify the high-risk areas of LBW. We applied conditional mixed process modelling in Stata software to account for the simultaneous nature of occurrences of the outcomes. The final model has been performed after imputing the missing data of LBW.

RESULTS

Overall, in India, 53% of the mothers reported their babies' birth weight by seeing health card, 36% reported by recall, and about 10% of the LBW information was observed as missing. The state/union territory of Punjab and Delhi were observed to have the highest levels of LBW (about 22%) which is much higher than the national level (18%). The effect of LBW was more than four times larger compared to the effect in the analysis which does not account for the simultaneous occurrence of LBW and infant mortality (marginal effect; from 12 to 53%). Also, in a separate analysis, the imputation technique has been used to address the missing data. Covariates' effects showed that female children, higher order births, births that occur in Muslim and non-poor families and literate mothers were negatively associated with infant mortality. However, a significant difference was observed in the impact of LBW before and after imputing the missing values.

CONCLUSIONS

The current findings showed the significant association of LBW with infant deaths, highlighting the importance of prioritising policies that help improve the birth weight of new-born children that may significantly reduce the infant mortality in India.

Dependency Theory: An Evaluation of the Period-Based Changes in the Utilization of Maternal Health Care and Neonatal Mortality in Tanzania Between 1991 and 2016

While efforts have been made to increase maternal health care (MHC) utilization and decrease neonatal mortality in Tanzania, much remains to be known about the effect of dependency (particularly on reproductive policy changes) on the use of MHC and neonatal health over time among varying socioeconomic groups. This study applied dependency theory to cross-sectional secondary data (collected by the Tanzania Demographic Health Surveys between 1991 and 2016) to investigate period-based changes in MHC and neonatal mortalities in Tanzania. Results from the data analysis found that while neonatal mortalities were decreasing in Tanzania (from 1991 to 2016), the odds of neonatal mortality were still greater in 2016. Also, a decline in the recommended skilled delivery assistance and 4 + antenatal care visits occurred in the data period. A significant increase in socioeconomic inequality around MHC use and neonatal mortality occurred during the study period as well. Policy recommendations to reduce these inequalities and move toward meeting Sustainability Development Goals for maternal and neonatal health in Tanzania are discussed.

Factors that affect the utilisation of maternal healthcare in the Mchinji District of Malawi

BACKGROUND

It is widely accepted that maternal healthcare is vital for improving maternal and neonatal mortality rates. Furthermore, the continuum of care-the integrated delivery of antenatal, delivery and postnatal care-has been shown to be particularly important. Sub-Saharan Africa has the highest neonatal and maternal mortality rates in the world; significant improvements in the provision and utilisation of the continuum are urgently needed, therefore the barriers preventing access need to be better understood. This study aimed to identify key factors associated with the utilisation of maternal healthcare, in the Mchinji District of Malawi.

METHODS

4,244 pregnant women from the Mchinji District of Malawi were interviewed between March and December 2013. The overall utilisation of maternal healthcare was calculated by combining the use of antenatal, delivery and postnatal care into one variable-continuum of care. Univariate and multivariate logistic regressions were performed to determine the factors associated with utilisation of maternal healthcare.

RESULTS

Utilisation of maternal healthcare in the Mchinji District was inadequate; only 24% of women received the recommended package. Being further from a healthcare facility (OR = 0.2, 95%CI = 0.04-0.96), having at least one live child (OR = 0.87, 95%CI = 0.84-0.99), previous experience of miscarriage (OR = 0.64, 95%CI = 0.50-0.82) or abuse (OR = 0.81, 95%CI = 0.69-0.95) reduced utilisation, whereas being in the richest 20% (OR = 1.33 95%CI = 1.08-1.65), having a planned pregnancy (OR = 1.3, 95%CI = 1.11-1.51) or more control over decisions (OR = 1.09, 95%CI = 0.80-1.49) increased utilisation.

CONCLUSION

Seven groups of women were identified as having an increased risk of low utilisation of maternal healthcare; women living >5km from a healthcare facility, within the poorest socio-economic group, experiencing an unplanned pregnancy, with at least one live child, experience of a previous miscarriage, no control over their healthcare decisions or experience of abuse. Policy makers should pay extra attention to these high-risk groups when designing and delivering strategies to improve maternal healthcare utilisation.

Challenges in antenatal care utilization in Kandahar, Afghanistan: A cross-sectional analytical study

BACKGROUND

Quality antenatal care (ANC) is one of the four pillars of safe motherhood initiatives and improves the survival and health of mother and neonate. The main objective of this study was to assess the barriers in the utilization of ANC services in Kandahar, Afghanistan.

METHODS

This was a cross-sectional analytical study conducted over one year from December 2018-November 2019. Data were analyzed by descriptive statistics, Chi squared, and binary logistic regression.

RESULTS

A total of 1524 women were recruited in this study with mean age of 30.3 years. Of these women, 848 (55.6%) were rural dwellers, 1450/1510 (96.0%) were illiterate, 438/608 (72.0%) belonged to low-income families, 1112/1508 (73.7%) lived in joint families, 1420/1484 (95.7%) lived in a house of >10 inhabitants, while 388/1494 (26.0%) had attended had at least one ANC visit during their last pregnancy. On univariate analysis, the main barriers in the utilization of ANC services were living in rural areas, being illiterate, having lower socio-economic status, remoteness of the health facility from home, bad behavior of clinic personnel, and unplanned pregnancy. Only lower socio-economic status and bad behavior of clinic personnel were independent explanatory variables in the regression model.

CONCLUSIONS

Utilization of ANC services is inadequate in Kandahar province. Improving clinic staff professional behavior and status of women by expanding educational opportunities, and enhancing community awareness of the value of ANC are recommended.

Does provision of antenatal care in Southern Asia improve neonatal survival? A systematic review and meta-analysis

BACKGROUND

Southern Asia has one of the highest burdens of neonatal mortality worldwide (26/1000 live births). Ensuring that women receive antenatal care from a skilled provider may play an important role in reducing this burden.

OBJECTIVE

This study aimed to determine whether antenatal care received from a skilled provider could reduce neonatal mortality in Southern Asia by systematically reviewing existing evidence.

STUDY DESIGN

Seven databases were searched (MEDLINE, Embase, Cochrane Library, CINAHL, PubMed, PsycINFO, and International Bibliography of the Social Sciences [IBSS]). The key words included: "neonatal mortality," "antenatal care," and "Southern Asia." Nonrandomized comparative studies conducted in Southern Asia reporting on neonatal mortality in women who received antenatal care compared with those who did not were included. Two authors carried out the screening and data extraction. The Risk of Bias Assessment tool for Non-randomized Studies (RoBANS) was used to assess quality of studies. Results were reported using a random-effects model based on odds ratios with 95% confidence intervals.

RESULTS

Four studies were included in a meta-analysis of adjusted results. The pooled odds ratio was 0.46 (95% confidence interval, 0.24 to 0.86) for neonatal deaths among women having at least 1 antenatal care visit during pregnancy compared with women having none. In the final meta-analysis, 16 studies could not be included because of lack of adjustment for confounders, highlighting the need for further higher-quality studies to evaluate the true impact.

CONCLUSION

This review suggests that in Southern Asia, neonates born to women who received antenatal care have a lower risk of death in the neonatal period compared with neonates born to women who did not receive antenatal care. This should encourage health policy to strengthen antenatal care programs in Southern Asia.

Use of antenatal and delivery care services and their association with maternal and infant mortality in rural India

Optimum use of antenatal care (ANC) and delivery care services could reduce morbidity and mortality among prospective mothers and their children. However, the role of ANC and delivery services in prevention of both maternal and child mortality is poorly understood, primarily because of dearth of prospective cohort data. Using a ten-years population-based prospective cohort data, this study examined the use of ANC and delivery services and their association with maternal and infant mortality in rural India. Descriptive statistics were estimated, and multivariable logistic regression modelling was used to attain the study objective. Findings revealed that consumption of ≥ 100 iron-and-folic acid (IFA) tablet/equivalent syrup during pregnancy had a protective association with maternal and infant mortality. Lack of maternal blood group checks during pregnancy was associated with increased odds of the death of infants. Caesarean/forceps delivery and delivery conducted by untrained personnel were associated with increased odds of maternal mortality. Findings from this study reemphasizes on increasing coverage and consumption of IFA tablets/equivalent syrup. Improved ANC and delivery services and increased uptake of all types of ANC and delivery care services are equally important for improvement in maternal and child survival in rural India.

High Prevalence of Anemia and Poor Compliance with Preventive Strategies among Pregnant Women in Mwanza City, Northwest Tanzania: A Hospital-Based Cross-Sectional Study

Anemia in pregnancy is prevalent in Tanzania despite the implementation of existing prevention strategies. This study aims to determine the level of compliance with anemia preventive strategies among pregnant women and the factors associated with poor compliance. A cross sectional study was conducted among 768 pregnant women who attended the Bugando Medical Center, Sekou-Toure Regional Hospital, Nyamagana District Hospital, and Buzuruga Health Center in Mwanza, Northwest Tanzania. The prevalence of anemia at term was 68.8% (95% CI, 65.5-72.0%). The average hemoglobin level at term was 10.0 g/dL (95% CI, 9.8-10.1). Only 10.9% of pregnant women complied fully with anemia-preventive strategies. A decrease in mean hemoglobin level was observed across levels of compliance, with women who were non-compliant displaying a significantly lower mean hemoglobin level (8.3 g/dL) compared to women who were fully compliant (11.0 g/dL). Poor compliance was associated with no formal or primary education and initiating antenatal care in the 2nd or 3rd trimester. Anemia in pregnancy was commonly associated with lack of compliance with preventive strategies among participants. There is a need for community-based health education on the importance of complying with anemia-preventive strategies in order to reduce the burden during pregnancy and the consequences of anemia to the unborn baby.

Association between timing and type of postnatal care provided with neonatal mortality: A large scale study from India

OBJECTIVES

This study examines the association between quality Postnatal Care (PNC) considering timing and providers' type on neonatal mortality. The aim extends to account for regional disparities in service delivery and mortality including high and non-high focus states.

METHODS

Ever-married women aged 15-49 years (1,87,702) who had delivered at least one child in five years preceding the survey date surveyed in National Family Health Survey (2015-16) were included in the study. Neonatal deaths between day two and seven and neonatal deaths between day two and twenty-eight were considered dependent variables. Descriptive statistics and multivariate regression analysis were conducted.

RESULTS

Chances of early neonatal mortality were 29% (OR = 0.71; 95%CI: 0.59-0.84) among newborns receiving PNC within a day compared to ones devoid of it while 40% (OR: 0.60; 95%CI: 0.51-0.71) likelihood for the same was noted if PNC was delivered within a week. Likelihood of neonatal mortality decreased by 24% (OR: 0.76; 95%CI: 0.65-0.88) when skilled PNC was delivered within 24 hours. Receiving quality PNC by skilled providers within a day in a non-high focus state decreased the chances of neonatal mortality by 26% (OR: 0.74; 95%CI: 0.59-0.92) compared to ones who did not receive any PNC.

CONCLUSIONS

Neonatal deaths were significantly associated with socioeconomic and contextual characteristics including age, education, household wealth, social group and region. Timing of PNC delivered and by a skilled healthcare provider was found significant in reducing neonatal mortality.

Improving WHO's understanding of WHO guideline uptake and use in Member States: a scoping review

Background

WHO publishes public health and clinical guidelines to guide Member States in achieving better health outcomes. Furthermore, WHO’s Thirteenth General Programme of Work for 2019–2023 prioritizes strengthening its normative functional role and uptake of normative and standard-setting products, including guidelines at the country level. Therefore, understanding WHO guideline uptake by the Member States, particularly the low- and middle-income countries (LMICs), is of utmost importance for the organization and scholarship.

Methods

We conducted a scoping review using a comprehensive search strategy to include published literature in English between 2007 and 2020. The review was conducted between May and June 2021. We searched five electronic databases including CINAHL, the Cochrane Library, PubMed, Embase and Scopus. We also searched Google Scholar as a supplementary source. The review adhered to the PRISMA-ScR (PRISMA extension for scoping reviews) guidelines for reporting the searches, screening and identification of evaluation studies from the literature. A narrative synthesis of the evidence around key barriers and challenges for WHO guideline uptake in LMICs is thematically presented.

Results

The scoping review included 48 studies, and the findings were categorized into four themes: (1) lack of national legislation, regulations and policy coherence, (2) inadequate experience, expertise and training of healthcare providers for guideline uptake, (3) funding limitations for guideline uptake and use, and (4) inadequate healthcare infrastructure for guideline compliance. These challenges were situated in the Member States’ health systems. The findings suggest that governance was often weak within the existing health systems amongst most of the LMICs studied, as was the guidance provided by WHO’s guidelines on governance requirements. This challenge was further exacerbated by a lack of accountability and transparency mechanisms for uptake and implementation of guidelines. In addition, the WHO guidelines themselves were either unclear and were technically challenging for some health conditions; however, WHO guidelines were primarily used as a reference by Member States when they developed their national guidelines.

Conclusions

The challenges identified reflect the national health systems’ (in)ability to allocate, implement and monitor the guidelines. Historically this is beyond the remit of WHO, but Member States could benefit from WHO implementation guidance on requirements and needs for successful uptake and use of WHO guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00899-y.

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.

Factors Associated with Infant Deaths in Indonesia: An Analysis of the 2012 and 2017 Indonesia Demographic and Health Surveys

BACKGROUND

This exploratory study aimed to investigate factors related to infant deaths using a conceptual framework that explains the risk factors of infant deaths in developing countries.

METHODS

The study adopted a cross-sectional study design and used data from the 2012 and 2017 Indonesia Demographic and Health Surveys, with a sample of 3694 singleton live births in 2012 and 3413 in 2017.

RESULTS

Female infants had a lower chance of mortality compared to male infants [adjusted odds ratio (aOR) = 0.51; 95% confidence interval (CI) = 0.34-0.77]. Infants with a smaller birth size had a higher risk of infant death compared to those with an average size (aOR = 5.66; 95% CI = 3.66-8.77). The risk of infant death with a preceding birth interval of ≥24 months was lower than that with a preceding birth interval of <24 months (aOR = 0.48; 95% CI = 0.26-0.90). An older maternal age was a risk factor for infant death compared to younger mothers (aOR = 3.61; 95% CI = 1.42-9.23). Infants who were born in Sumatra (aOR = 0.38; 95% CI = 0.16-0.89) and Java and Bali (aOR = 0.33; 95% CI = 0.14-0.78) were less likely to die than infants who were born in Papua and Maluku.

CONCLUSIONS

A higher infant death risk was associated with male babies and a shorter birth interval (<24 months). Mothers who perceived their babies to be small and mothers who were older (35-49 years old) were high-risk factors for infant mortality. Mothers who lived in Java and Bali as well as Sumatera were less likely to experience infant mortality compared to those who lived in Papua and Maluku.

Experience of a telehealth and education program with maternal and perinatal outcomes in a low-resource region in Colombia

INTRODUCTION

Maternal morbidity and mortality rates associated with perinatal care remain a significant public health concern. Rural populations from low and middle-income countries have multiple barriers to access that contribute to a lack of adherence to prenatal care, and high rates of maternal mortality and morbidity. An intervention model based on telehealth and education was implemented between a tertiary high complex care hospital and a second-level hospital from a limited source region.

OBJECTIVES

We sought to identify an association in maternal and perinatal care quality indicators after implementing a model based on telehealth and education for patients with obstetric emergencies between two hospitals in a southwestern region of Colombia.

METHODS

We conducted an ecological study between 2017 and 2019 to compare before and after obstetric emergency care through telemedicine from a secondary care center (Hospital Francisco de Paula Santander-HFPS) to the referral center (Fundación Valle del Lili-FVL). The intervention included verification visits to determine the installed capacity of care, a concerted improvement plan, and on-site educational training modules in obstetric and perinatal care.

RESULTS

There were 102 and 148 patients treated before and after telemedicine implementation respectively. Clinical indicators after model implementation showed a reduction in perinatal mortality of 29%. In addition, a reduction in the need for transfusion of blood products due to postpartum hemorrhage was observed as well as the rate of eclampsia.

CONCLUSIONS

Implementing a model based on telehealth and education between secondary and tertiary care centers allowed the strengthening of the security of care in obstetric emergencies and had a positive effect on perinatal mortality.

Intimate partner violence and timely antenatal care visits in sub-Saharan Africa

BACKGROUND

Intimate partner violence (IPV) during pregnancy has negative physical and psychological health consequences on the pregnant women. As such, women who experience IPV during pregnancy are likely to have challenges accessing maternal healthcare services. In this study, we examined the influence of exposure to IPV on timely antenatal care (ANC) visits in sub-Saharan Africa.

METHODS

Cross-sectional data from the most recent Demographic and Health Survey of twenty-two countries in sub-Saharan Africa between 2012 and 2020 were analysed. Data were obtained from 61,282 women with birth history in the five years prior to the survey. A multilevel logistic regression was used to determine the association between IPV and timely ANC visits while controlling for significant covariates. Adjusted odds ratios (aOR) with 95% Confidence Intervals (CI) were used to present results from the multilevel logistic regression analysis.

RESULTS

The prevalence of timely ANC visit and IPV were 38.1% and 34.9% respectively. The highest and lowest prevalence of IPV were found in Sierra Leone (52.9%) and Comoros (8.1%), respectively. Timely ANC attendance among pregnant women was more prevalent in Liberia (74.9%) and lowest in DR Congo (19.0%). Women who experienced IPV during pregnancy were less likely to utilize timely ANC (aOR = 0.89, 95% CI = 0.86-0.92) compared to those who did not experience IPV. In terms of the covariates, the odds of timely ANC were higher among women aged 40-44 compared to those aged 15-19 (aOR = 1.35, 95% CI = 1.21-1.51). Higher odds of timely ANC was found among women who were cohabiting (aOR = 1.15, 95% CI = 1.10-1.20), those from the richest wealth quintile (aOR = 1.38, 95% CI = 1.28-1.48), those exposed to watching television (aOR = 1.24, 95% CI = 1.18-1.30), and those with health insurance (aOR = 1.46, 95% CI = 1.37-1.56).

CONCLUSION

Findings from the study indicate the role of IPV in timely ANC visit in sub-Saharan Africa. To enhance timely ANC visits, there is the need for policy makers to strengthen and enforce the implementation of policies that alleviate IPV during pregnancy. Education and sensitization of married and cohabiting women and men on the negative effects of IPV on timely ANC should be done using media sources such as television. Inequalities in timely ANC can be eliminated through the provision and strengthening of existing maternal health policies such as health insurance.

Late antenatal care initiation and its contributors among pregnant women at selected public health institutions in Southwest Ethiopia

Introduction

early commencement of antenatal care by pregnant women as well as regular visits has the potential to affect maternal and fetal outcomes positively. Even with antenatal care, the intervention requires fewer resources; however, most pregnant women in sub-Saharan Africa have begun late for antenatal care services. This study aimed to assess the magnitude and contributors of late antenatal care initiation among pregnant women at selected public health institutions of the Bench-Sheko Zone in southwest Ethiopia.

Methods

a cross-sectional study was conducted among 509 pregnant women attending the Antenatal Care (ANC) service at selected public health institutions. The data were collected using a structured and pre-tested questionnaire. The data were entered using Epi-data version 3.1 and analyzed using SPSS version 22. A binary logistic regression analysis was computed to determine the association using crude and adjusted odds ratios at 95% confidence intervals. Independent variables with a p-value of less than 0.05 in the multivariable logistic regression model were considered significant.

Results

of the 509 respondents interviewed, 337 (66%) reported late antenatal care initiation. The factors associated with late antenatal care initiation were mothers aged 25 years and above (AOR = 1.59, 95% CI [1.02, 2.48]), attended below secondary school (AOR =2.33, 95% CI [1.05, 5.19]), unplanned pregnancy (AOR=2.25, 95%CI [1.34, 3.77]), pregnancy recognition by missing period (AOR=0.61, 95%CI [0.39, 0.93]), perceived right time of ANC after 4 months (AOR=2.29, 95% CI [1.36, 3.85]), and did not get advice to have ANC (AOR=1.64, 95% CI [1.10, 2.45]).

Conclusion

the majority of pregnant women initiate their first antenatal care lately. We can conclude that late antenatal care initiation is a major problem in the study area. Therefore, providing continuous health education on the importance of initiating antenatal care visits early to prevent unwanted pregnancy outcomes is an important segment of intervention that can be done through health extension workers.

The Determinants of Four or More Antenatal Care Visits Among Working Women in Indonesia

This study aimed to analyze the determinants of four or more antenatal care (ANC) visits among working women in Indonesia. The researchers extracted data from the Indonesian Demographic and Health Survey 2017 and obtained a sample size of 8239 working women aged between 15 and 49 years. Women’s residence, age, marital status, education level, parity, economic status, and health insurance were selected as the independent variables. Binary logistic regression was used for the analysis. Older working women, married working women, educated working women, those in higher economic status, and those with health insurance were more likely to complete four or more of their ANC visits. The more children the working women had, the less likely they would complete their ANC visits. In conclusion, age, marital status, education, parity, economic status, and health insurance are the determinants for completing ANC visits among working women in Indonesia. At the same time, place of residence does not affect the frequency of ANC visits.

Prenatal consultation and survival of children under five in Togo

INTRODUCTION

Child survival is low in Togo, often linked to socio-economic and other exogenous factors such as lack of antenatal consultation and Bacille Calmette-Guérin (BCG) vaccination. These different variables impacting the chances of survival of children underneath five have not been completely examined. The objective of this study is to analyse the socio-economic variables that influence the survival risk of children beneath five in Togo.

METHODS

These different variables influencing the chances of survival of the data used is from the 2017 MICS6 Overview. It speaks to an arrangement of broadly agent tests of families, children matured 0-5 years, women matured 15-49 years and men matured 15-59 years. Information on pre-birth meetings and the inoculation status of children at (BCG) were collected from this overview. The Cox corresponding risks backslide illustrate is used to evaluate the connection between pre-birth visits and child survival.

RESULTS

The risk of survival in children beneath 5 years is high as the age of the mother increases. This risk is 0.48 for the age between 19 and 24 years (AHR = 2.485, 95% CI 1.49-4.13). A child born to a woman with no education is at high risk of child survival (AHR = 2.96, 95% CI 092-9.36). Furthermore, the results show that women with twins have a high risk of 0.44 of the death of these children (AHR = 1.44, 95% CI 1.25-1.67). In addition, (BCG) vaccination has been related with an expanded recurrence in children, where it was found that 70.37% of vaccinated children were born to women who had experienced pre-birth meetings.

CONCLUSION

Basic risk variables for child survival can offer assistance in defining policy suggestions for children's wellbeing. The results recommend they have to empower policies to improve women's proficiency, the presence of a wellbeing insurance framework is suggested to decrease the burden of care, implement a procedure for access to antenatal meetings.

Towards stronger antenatal care: Understanding predictors of late presentation to antenatal services and implications for obstetric risk management in Rwanda

Background

Early antenatal care (ANC) reduces maternal and neonatal morbidity and mortality through identification of pregnancy-related complications, yet 44% of Rwandan women present to ANC after 16 weeks gestational age (GA). The objective of this study was to identify factors associated with delayed initiation of ANC and describe differences in the obstetric risks identified at the first ANC visit (ANC-1) between women presenting early and late to care.

Methods

This secondary data analysis included 10,231 women presenting for ANC-1 across 18 health centers in Rwanda (May 2017-December 2018). Multivariable logistic regression models were constructed using backwards elimination to identify predictors of presentation to ANC at ≥16 and ≥24 weeks GA. Logistic regression was used to examine differences in obstetric risk factors identified at ANC-1 between women presenting before and after 16- and 24-weeks GA.

Results

Sixty-one percent of women presented to ANC at ≥16 weeks and 24.7% at ≥24 weeks GA, with a mean (SD) GA at presentation of 18.9 (6.9) weeks. Younger age (16 weeks: OR = 1.36, 95% CI: 1.06, 1.75; 24 weeks: OR = 1.33, 95% CI: 0.95, 1.85), higher parity (16 weeks: 1–4 births, OR = 1.55, 95% CI: 1.39, 1.72; five or more births, OR = 2.57, 95% CI: 2.17, 3.04; 24 weeks: 1–4 births, OR = 1.93, 95% CI: 1.78, 2.09; five or more births, OR = 3.20, 95% CI: 2.66, 3.85), lower educational attainment (16 weeks: primary, OR = 0.75, 95% CI: 0.65, 0.86; secondary, OR = 0.60, 95% CI: 0.47,0.76; university, OR = 0.48, 95% CI: 0.33, 0.70; 24 weeks: primary, OR = 0.64, 95% CI: 0.53, 0.77; secondary, OR = 0.43, 95% CI: 0.29, 0.63; university, OR = 0.12, 95% CI: 0.04, 0.32) and contributing to household income (16 weeks: OR = 1.78, 95% CI: 1.40, 2.25; 24 weeks: OR = 1.91, 95% CI: 1.42, 2.55) were associated with delayed ANC-1 (≥16 and ≥24 weeks GA). History of a spontaneous abortion (16 weeks: OR = 0.74, 95% CI: 0.66, 0.84; 24 weeks: OR = 0.70, 95% CI: 0.58, 0.84), pregnancy testing (16 weeks: OR = 0.48, 95% CI: 0.33, 0.71; 24 weeks: OR = 0.41, 95% CI: 0.27, 0.61; 24 weeks) and residing in the same district (16 weeks: OR = 1.55, 95% CI: 1.08, 2.22; 24 weeks: OR = 1.73, 95% CI: 1.04, 2.87) or catchment area (16 weeks: OR = 1.53, 95% CI: 1.05, 2.23; 24 weeks: OR = 1.84, 95% CI: 1.28, 2.66; 24 weeks) as the health facility were protective against delayed ANC-1. Women with a prior preterm (OR, 0.71, 95% CI, 0.53, 0.95) or low birthweight delivery (OR, 0.72, 95% CI, 0.55, 0.95) were less likely to initiate ANC after 16 weeks. Women with no obstetric history were more likely to present after 16 weeks GA (OR, 1.18, 95% CI, 1.06, 1.32).

Conclusion

This study identified multiple predictors of delayed ANC-1. Focusing existing Community Health Worker outreach efforts on the populations at greatest risk of delaying care and expanding access to home pregnancy testing may improve early care attendance. While women presenting late to care were less likely to present without an identified obstetric risk factor, lower than expected rates were identified in the study population overall. Health centers may benefit from provider training and standardized screening protocols to improve identification of obstetric risk factors at ANC-1.

Verbal/social autopsy analysis of causes and determinants of under-5 mortality in Tanzania from 2010 to 2016

Background

Tanzania has decreased its child mortality rate by more than 70 percent in the last three decades and is striving to develop a nationally-representative sample registration system with verbal autopsy to help focus health policies and programs toward further reduction. As an interim measure, a verbal and social autopsy study was conducted to provide vital information on the causes and social determinants of neonatal and child deaths.

Methods

Causes of neonatal and 1-59 month-old deaths identified by the 2015-16 Tanzania Demographic and Health Survey were assessed using the expert algorithm verbal autopsy method. The social autopsy examined prevalence of key household, community and health system indicators of preventive and curative care provided along the continuum of care and Pathway to Survival models. Careseeking for neonates and 1-59 month-olds was compared, and tests of associations of age and cause of death to careseeking indicators and place of death were conducted.

Results

The most common causes of death of 228 neonates and 351 1-59 month-olds, respectively, were severe infection, intrapartum related events and preterm delivery, and pneumonia, diarrhea and malaria. Coverage of early initiation of breastfeeding (24%), hygienic cord care (29%), and full immunization of 12-59 month-olds (33%) was problematic. Most (88.8%) neonates died in the first week, including 44.3% in their birth facility before leaving. Formal care was sought for just 41.9% of newborns whose illness started at home and was delayed by 5.3 days for 1-59 month-olds who sought informal care. Care was less likely to be sought for the youngest neonates and infants and severely ill children. Although 70.3% of 233 under-5 year-olds were moderately or severely ill on discharge from their first provider, only 29.0%-31.2% were referred.

Conclusions

The study highlights needed actions to complete Tanzania’s child survival agenda. Low levels of some preventive interventions need to be addressed. The high rate of facility births and neonatal deaths requires strengthening of institutionally-based interventions targeting maternal labor and delivery complications and neonatal causes of death. Scale-up of Integrated Community Case Management should be considered to strengthen careseeking for the youngest newborns, infants and severely ill children and referral practices at first level facilities.

Association between antenatal corticosteroid use and perinatal mortality among preterm births in hospitals in Tanzania

OBJECTIVES

The primary aims of this study were to investigate if exposure to antenatal corticosteroids (ACS) was associated with lower rates of perinatal mortality (primary outcome) and other adverse perinatal outcomes (i.e., stillbirth, early neonatal mortality, APGAR score of < 7 at 5 mins, neonatal sepsis and respiratory distress syndrome) in preterm infants in hospitals in Tanzania. We also examine factors associated with administration of ACS among women at risk of preterm delivery.

METHODS

A hospital-based prospective chart review study was undertaken in four hospitals located in Nyamagana and Sengerema districts, Tanzania. The study population included all stillborn and live born preterm infants delivered between 24 to 34 weeks of gestation between July 2019 to February 2020. A total 1125 preterm infants were delivered by 1008 women (895 singletons, 230 multiple). Sociodemographic and medical data were recorded from participants' medical records.

RESULTS

Three hundred and fifty-six (35.3%) women were administered at least one dose of ACS between 24 to 34 weeks' gestation and 385 (34.2%) infants were exposed to ACS. Infants exposed to ACS had a lower rate of perinatal mortality (13.77%) compared to those who were not exposed (28.38%). Multivariate analysis indicated that infants exposed to ACS were less likely to die during perinatal period, aRR 0.34 (95%CI 0.26-0.44). Only one-third of the sample was provided with ACS. Administration of ACS was associated with maternal education, attending antenatal care more than 3 times, method used to assess gestational age, maternal infection, exposure to maternal antibiotics, delivery mode and level of health facility.

CONCLUSION

ACS significantly reduced the risk in perinatal mortality among infants born preterm in a limited resource setting. However, only about one-third of eligible women were provided with ACS, indicating low usage of ACS. Numerous factors were associated with low usage of ACS in this setting.

A 12 Years Neonatal Mortality Rate and Its Predictors in Eastern Ethiopia

Introduction. Surviving and thriving of newborn is essential to ending extreme poverty. However, the surviving and thriving of new born is depends on where neonates are born. The true feature of neonatal mortality rate and trends is not well known in the study area. Thus, we aimed to estimate a neonatal mortality incidence in each year, and determine factors associated though pregnancy observation cohort study in Eastern Ethiopia. Methods. The study was conducted in Kersa Health Demographic Surveillance System (KHDSS) among 36 kebeles. We extracted all events (38 541 live birth and 776 neonatal death) occurred between January 1, 2008 and December 30, 2019. Neonatal mortality rate was presented by neonatal death per 1000 live birth with 95% confidence interval in each years, and trends of neonatal morality was described with line regression. Cox proportional regression model was used to assess predictors and presented with an adjusted hazard ratio (AHR) and 95% CI. Results. The estimated cumulative average of neonatal mortality rate in this study was 20.3 (95% CI: 18.9-21.8) per 1000 live births. The rate was decline with regression coefficient β = -1.60. Risk of neonatal death was found to be significantly associated with neonate born to mother living in rural Kersa (AHR = 5.31; 95% CI: 3.07-9.18), born to mother not receiving antenatal care (AHR = 1.43; 95% CI: 1.15-1.78), low birthweight (AHR = 2.59; 95% CI: 2.05-3.27), and preterm newborn (AHR = 12.10; 95% CI: 9.23-15.86). Conclusion. Neonatal mortality in the study site is far from reaching the national and global target goals.

Factors associated with neonatal mortality in a tertiary hospital in Phnom Penh, Cambodia

This study aimed to identify hospital neonatal mortality rate (NMR) and the causes of neonatal deaths, and to understand risk factors associated with neonatal mortality in a national tertiary hospital in Cambodia. The study included all newborn infants, aged 0-28 days old, hospitalized in the Pediatrics department of Khmer-Soviet Friendship Hospital between January 2016 and December 2017. In total, 925 infants were included in the study. The mean gestational age was 35.9 weeks (range, 24-42 weeks). Preterm infants and low birth weight accounted for 47.5% and 56.7%, respectively. With respect to payment methods, the government (53.5%) and non-governmental organizations (NGO) (13.7%) paid the fees as the families were not in a financial position to do so. The hospital NMR at the Pediatrics department was 9.3%. Respiratory distress syndrome (37.2%) was the main cause of deaths followed by hypoxic-ischemic encephalopathy (31.4%) and neonatal infection (21.0%). Factors associated with neonatal mortality were Apgar score at 5th minute <7 (adjusted odds ratio (AOR) = 3.57), payment by the government or NGO (AOR = 11.32), admission due to respiratory distress (AOR = 11.94), and hypothermia on admission (AOR = 9.41). The hospital NMR in the Pediatrics department was 9.3% (95% confidence interval 7.50-11.35) at Khmer-Soviet Friendship Hospital; prematurity and respiratory distress syndrome were the major causes of neonatal mortality. Introducing continuous positive airway pressure machine for respiratory distress syndrome and creating neonatal resuscitation guidelines and preventing hypothermia in delivery rooms are required to reduce the high NMR.

Annual trend of neonatal mortality and its underlying causes: population-based study - São Paulo State, Brazil, 2004-2013

BACKGROUND

Population-based studies analyzing neonatal deaths in middle-income countries may contribute to design interventions to achieve the Sustainable Development Goals, established by United Nations. This study goal is to analyze the annual trend of neonatal mortality in São Paulo State, Brazil, over a 10-year period and its underlying causes and to identify maternal and neonatal characteristics at birth associated with neonatal mortality.

METHOD

A population-based study of births and deaths from 0 to 27 days between 2004 and 2013 in São Paulo State, Brazil, was performed. The annual trend of neonatal mortality rate according to gestational age was analyzed by Poisson or by Negative Binomial Regression models. Basic causes of neonatal death were classified according to ICD-10. Association of maternal demographic variables (block 1), prenatal and delivery care variables (block 2), and neonatal characteristics at birth (block 3) with neonatal mortality was evaluated by Poisson regression analysis adjusted by year of birth.

RESULTS

Among 6,056,883 live births in São Paulo State during the study period, 48,309 died from 0 to 27 days (neonatal mortality rate: 8.0/1,000 live births). For the whole group and for infants with gestational age 22-27, 28-31, 32-36, 37-41 and ≥ 42 weeks, reduction of neonatal mortality rate was, respectively, 18 %, 15 %, 38 %, 53 %, 31 %, and 58 %. Median time until 50 % of deaths occurred was 3 days. Main basic causes of death were respiratory disorders (25 %), malformations (20 %), infections (17 %), and perinatal asphyxia (7 %). Variables independently associated with neonatal deaths were maternal schooling, prenatal care, parity, newborn sex, 1st minute Apgar, and malformations. Cesarean delivery, compared to vaginal, was protective against neonatal mortality for infants at 22-31 weeks, but it was a risk factor for those with 32-41 weeks.

CONCLUSIONS

Despite the significant decrease in neonatal mortality rate over the 10-year period in São Paulo State, improved access to qualified health care is needed in order to avoid preventable neonatal deaths and increase survival of infants that need more complex levels of assistance.

Association between different types of mass media and antenatal care visits in India: a cross-sectional study from the National Family Health Survey (2015-2016)

OBJECTIVE

To generate evidence for the association between different types of mass media and antenatal care (ANC) visits in India.

DESIGN

A cross-sectional study design, analysing data from India's National Family Health Survey 4 (NFHS-4), 2015-2016.

SETTING

Rural and urban India.

PARTICIPANTS

From NFHS-4, women who had given birth in the last 5 years before survey administration were included in this study. Women with missing information about their number of ANC visits and their caste were excluded, leaving 187 894 women in the final analytical sample.

PRIMARY OUTCOME MEASURES

Logistic regression analysis was conducted to determine the association of ANC utilisation with mass media exposure.

RESULTS

Overall, our study showed that high exposure to all four types of mass media was positively associated with making at least eight ANC visits. In rural India, women who had high exposure to newspaper/magazine (adjusted OR (aOR), 1.43; 95% CI, 1.31 to 1.57), radio (aOR, 1.22; 95% CI, 1.09 to 1.37), television (aOR, 2.07; 95% CI, 1.94 to 2.2) and movies (aOR, 1.33; 95% CI, 1.2 to 1.47) were more likely to make at least eight ANC visits. In urban India, women who had high exposure to newspaper/magazine (aOR, 1.12; 95% CI, 1.02 to 1.24), radio (aOR, 1.37; 95% CI, 1.13 to 1.65), television (aOR, 1.39; 95% CI, 1.24 to 1.55) and movies (aOR, 1.23; 95% CI, 1.09 to 1.38) were more likely to make at least eight ANC visits.

CONCLUSIONS

Our findings emphasise the need for increased awareness about adequate ANC visits in India, to improve maternal, neonatal and child health outcomes. Our study highlights that television penetration is broader than other forms of media and has the potential to create awareness about health in both urban and rural populations. These findings can inform ANC-related health awareness campaigns in the country to allocate resources to appropriate media sources to encourage healthy behaviours.

Attitude and practices related to coronavirus disease (COVID-19) pandemic among pregnant women attending family welfare clinic amid Phase-2 lock down

BACKGROUND

The antenatal period is an important landmark where the services provided to mothers through antenatal care (ANC) checkups also act as a way for additional interventions influencing maternal and child health. This study aimed to know about the perception and practice among the patients of ANC checkups (ANCs) regarding COVID-19 and what are the implications of it on their routine check-ups.

METHODS

We conducted this study from 15 April, 2020 to 03 May, 2020, Phase 2 {Country wide lockdown in India}, which was imposed for over 19 days. The sample size was kept open and we used convenient type of sampling and included all those pregnant women who attended the clinic for ANC checkup amid the countrywide lock down. Each patient of ANC checkup was interviewed by the treating doctor using a predesigned structured questionnaire containing questions based on demographic information and the perception and practices regarding corona virus infection.

RESULTS

The majority, 66 (79.5%) were in the age group of 26-35 years, 63 (75.9%) were in the second and third trimester of their pregnancy, 72 (86.7%) were from urban areas, 26 (31.3%) and 17 (20.5%) were having education level of bachelor's and higher, respectively. The majority 39 (47%) reported that they are worried that someone they know may have the coronavirus infection and they are unaware about it, 57 (68.7%) feel the nature of the disease as fatal, all ANCs reported that their families are taking initiatives to prevent corona virus infection and they should take extra precautions for corona virus infection, 6 (7.2%) reported that any member of their family has been quarantined during the period, 81 (97.6%) feel that primary precautions like hand washing, social distancing, wearing a face mask, and isolation and quarantine will help in the reduction of infection, 69 (83.1%) choose to report to hospital if any of their close relatives are down with symptoms of corona virus.

CONCLUSION

Our study showed that the respondents had a good attitude, perception, and were following sensible positive practices regarding COVID-19 prevention.

What caused neonatal deaths in Senegal in 2017? a secondary analysis of 2017 DHS

Introduction

in Senegal, the fight for newborn and child survival is a public health priority. The aim of this study is to analyze the factors associated with neonatal deaths in Senegal in 2017.

Methods

this article used data from the Senegal Demographic and Health Survey 2017. It covered 6073 children under the age of 5. The sample from the 2017 Continuous DHS is nationally representative. A bivariate analysis was conducted. The multivariate analysis was performed using STATA 15 software. Adjusted odds ratios had been calculated for variables with significant p values. The dependent variable was neonatal death.

Results

a total of 6,073 children had been investigated. The neonatal death rate is 2.12%. Neonatal deaths account for 50.97% of all infant and child deaths. Newborns with a low birth weight < 2500 g are 2.3 times more likely to die with an ORaj of 2.3 [1.01-5.28]. Newborns who are considered “very small” by their mother at birth are 2.5 times more likely to die in the neonatal period ORaj=2.5 [1.04-6.04]. The last risk factor identified is birth by caesarean section (ORaj=3.97 [1.68-9.39]).

Conclusion

this study concludes that low birth weight is an important risk factor for neonatal deaths in Senegal. These results suggest better management of antenatal care. However, this study showed that there was a deficit in the provision of perinatal services in Senegal. A qualitative analysis of caesarean section in the context of universal coverage could be a perspective for further reflection on improving newborn survival in Senegal.

Predictive Modeling for Perinatal Mortality in Resource-Limited Settings

IMPORTANCE

The overwhelming majority of fetal and neonatal deaths occur in low- and middle-income countries. Fetal and neonatal risk assessment tools may be useful to predict the risk of death.

OBJECTIVE

To develop risk prediction models for intrapartum stillbirth and neonatal death.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Global Network for Women's and Children's Health Research population-based vital registry, including clinical sites in South Asia (India and Pakistan), Africa (Democratic Republic of Congo, Zambia, and Kenya), and Latin America (Guatemala). A total of 502 648 pregnancies were prospectively enrolled in the registry.

EXPOSURES

Risk factors were added sequentially into the data set in 4 scenarios: (1) prenatal, (2) predelivery, (3) delivery and day 1, and (4) postdelivery through day 2.

MAIN OUTCOMES AND MEASURES

Data sets were randomly divided into 10 groups of 3 analysis data sets including training (60%), test (20%), and validation (20%). Conventional and advanced machine learning modeling techniques were applied to assess predictive abilities using area under the curve (AUC) for intrapartum stillbirth and neonatal mortality.

RESULTS

All prenatal and predelivery models had predictive accuracy for both intrapartum stillbirth and neonatal mortality with AUC values 0.71 or less. Five of 6 models for neonatal mortality based on delivery/day 1 and postdelivery/day 2 had increased predictive accuracy with AUC values greater than 0.80. Birth weight was the most important predictor for neonatal death in both postdelivery scenarios with independent predictive ability with AUC values of 0.78 and 0.76, respectively. The addition of 4 other top predictors increased AUC to 0.83 and 0.87 for the postdelivery scenarios, respectively.

CONCLUSIONS AND RELEVANCE

Models based on prenatal or predelivery data had predictive accuracy for intrapartum stillbirths and neonatal mortality of AUC values 0.71 or less. Models that incorporated delivery data had good predictive accuracy for risk of neonatal mortality. Birth weight was the most important predictor for neonatal mortality.

Evaluating the effect of the initiative 'Caring for the Newborn and the Mother at Home' in Mexico

Objective:

The WHO and UNICEF recommend home visits to improve health outcomes for mothers and newborns. We evaluated the effect of home visits by community volunteers during pregnancy and postpartum on breast-feeding practices, women’s knowledge about benefits, beliefs and myths of breast-feeding, obstetric and neonatal warning signs, preparation for childbirth and initial care for newborns, and diarrhoea and respiratory diseases in children.

Design:

Community quasi-experimental design. We estimated difference-in-difference models with fixed effects at the community level weighted by propensity score and investigated implementation barriers through focus groups and semi-structured interviews.

Setting:

Poor rural communities in Mexico; 48 intervention and 29 control.

Participants:

Baseline and follow-up information were reported from two independent cross-sectional samples of women with babies aged between 6 and 18 months (baseline: 292 control, 320 intervention; follow-up: 292 control, 294 intervention).

Results:

The intervention increased reports of exclusive breast-feeding in the first 6 months by 24·4 percentage points (pp) (95 % CI: 13·4, 35·4), mothers’ knowledge of obstetric warning signs by 23·4 pp (95 % CI: 9·2, 37·5) and neonatal warning signs by 26·2 pp (95 % CI: 15·2, 37·2) compared to the control group. A non-linear dose–response relation with the number of home visits was found. Diarrhoea and respiratory diseases among children decreased in the intervention v. control group but were not statistically significant.

Conclusions:

Home visits should be implemented as a complementary strategy to the provision of prenatal and postnatal care in rural communities due to their potential positive effects on the health of mothers and their children.

Preterm Neonatal Mortality and Its Determinants at a Tertiary Hospital in Western Uganda: A Prospective Cohort Study

Background

Prematurity contributes greatly to the neonatal mortality burden in sub-Saharan Africa. This study evaluated the proportion of preterm neonatal death, medical conditions at admission, and determinants of mortality of preterm neonates in the neonatal intensive care unit (NICU) of a tertiary hospital in Western Uganda.

Materials and Methods

A prospective cohort study of 351 consecutively enrolled preterm neonates was conducted from March to June 2019. Interviewer-administered questionnaires and physical assessment of neonates were used to obtain socio-demographic and clinical data for mothers and their preterm neonates. Descriptive statistics for participants’ characteristics were generated, while bivariate and multivariate logistic regression models were fitted so as to establish the determinants of mortality outcome. A p-value <0.05 was considered statistically significant.

Results

In-hospital neonatal mortality of 31.6% (95% CI: 26.9–36.7) was noted, with 65.8% of deaths occurring within 72 hours from admission. The most common medical conditions at admission were: hypothermia (67.2%), respiratory distress syndrome (43.0%), small for gestational age (15.7%), and perinatal asphyxia (14.5%). Under multivariate regression modelling, maternal age ≥35 years (AOR: 4.5; 95% CI: 1.35–15.31), no antenatal care (AOR: 4.7; 95% CI: 1.05–21.21), >4 ANC visits (AOR: 5.3; 95% CI: 1.88–15.21), neonatal resuscitation (AOR: 3.4; 95% CI: 1.66–6.82), outborn status (AOR: 2.3; 95% CI: 1.20–4.50), singleton pregnancy (AOR: 3.7; 95% CI: 1.74–7.89), <28 weeks’ gestation (AOR: 12.0; 95% CI: 2.24–64.27), and male sex (AOR: 2.0; 95% CI: 1.04–3.74), respiratory distress syndrome (AOR: 2.6; 95% CI: 1.22–5.70), apnea (AOR: 6.2; 95.5% CI: 1.09–35.38), hypothermia (AOR: 2.3; 95% CI: 1.09–4.92), and small for gestational age (AOR: 4.7; 95% CI: 2.06–10.74) were significantly associated with mortality.

Conclusion and Recommendations

In-hospital mortality of preterm neonates was high. We identified various maternal and neonatal risk factors, indicating a need for stakeholders to enhance efforts towards prevention of preterm-associated complications and optimize facility-based continuum of care.

'Mothers moving towards empowerment' intervention to reduce stigma and improve treatment adherence in pregnant women living with HIV in Botswana: study protocol for a pragmatic clinical trial

BACKGROUND

With high rates of HIV and multiple vulnerable subgroups across diverse settings, there is a need for culturally based, HIV stigma reduction interventions. Pregnant women who are living with HIV are especially in need of services to protect not only their own but also their children's lives. Uptake of HIV services worldwide is hindered by stigma towards persons living with HIV/AIDS. While cultural context plays a key role in shaping HIV stigma, these insights have not yet been fully integrated into stigma reduction strategies. By utilizing the "What Matters Most" stigma framework, we propose that an intervention to counter culturally salient aspects of HIV stigma will improve treatment adherence and other relevant outcomes. A pragmatic clinical trial in Botswana will evaluate the "Mothers Moving towards Empowerment" (MME) intervention, which seeks to address HIV stigma in Botswana and to specifically engage pregnant mothers so as to promote antiretroviral therapy (ART) adherence in the postpartum period.

METHODS

This study will test MME against treatment as usual (TAU) among pregnant mothers diagnosed with HIV and their infants. Outcomes will be assessed during pregnancy and 16 weeks postpartum. Women who meet eligibility criteria are assigned to MME or TAU. Women assigned to MME are grouped with others with similar estimated delivery dates, completing up to eight intervention group sessions scheduled before week 36 of their pregnancies. Primary outcomes among mothers include (i) reducing self-stigma, which is hypothesized to mediate improvements in (ii) psychological outcomes (quality of life, depression and social functioning), and (iii) adherence to antenatal care and ART. We will also examine a set of follow-up infant birth outcomes (APGAR score, preterm delivery, mortality (at < 16 weeks), birth weight, vaccination record, and HIV status).

DISCUSSION

Our trial will evaluate MME, a culturally based HIV stigma reduction intervention using the "What Matters Most" framework, to reduce stigma and improve treatment adherence among pregnant women and their infants. This study will help inform further refinement of MME and preparation for a future large-scale, multisite, randomized controlled trial (RCT) in Botswana.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03698981 . Registered on October 8, 2018.

Building a Global Evidence Base to Guide Policy and Implementation for Group Antenatal Care in Low- and Middle-Income Countries: Key Principles and Research Framework Recommendations from the Global Group Antenatal Care Collaborative

Evidence from high‐income countries suggests that group antenatal care, an alternative service delivery model, may be an effective strategy for improving both the provision and experience of care. Until recently, published research about group antenatal care did not represent findings from low‐ and middle‐income countries, which have health priorities, system challenges, and opportunities that are different than those in high‐income countries. Because high‐quality evidence is limited, the World Health Organization recommends group antenatal care be implemented only in the context of rigorous research. In 2016 the Global Group Antenatal Care Collaborative was formed as a platform for group antenatal care researchers working in low‐ and middle‐income countries to share experiences and shape future research to accelerate development of a robust global evidence base reflecting implementation and outcomes specific to low‐ and middle‐income countries. This article presents a brief history of the Collaborative's work to date, proposes a common definition and key principles for group antenatal care, and recommends an evaluation and reporting framework for group antenatal care research.

Using propensity scores to estimate the effectiveness of maternal and newborn interventions to reduce neonatal mortality in Nigeria

Background

Nigeria is the largest country in sub-Saharan Africa, with one of the highest neonatal mortality rates and the second highest number of neonatal deaths in the world. There is broad international consensus on which interventions can most effectively reduce neonatal mortality, however, there is little direct evidence on what interventions are effective in the Nigerian setting.

Methods

We used the 2013 Nigeria Demographic and Health Survey (NDHS) and the follow-up 2014 Verbal and Social Autopsy study of neonatal deaths to estimate the association between neonatal survival and mothers’ and neonates’ receipt of 18 resources and interventions along the continuum of care with information available in the NDHS. We formed propensity scores to predict the probability of receiving the intervention or resource and then weighted the observations by the inverse of the propensity score to estimate the association with mortality. We examined all-cause mortality as well as mortality due to infectious causes and intrapartum related events.

Results

Among 19,685 livebirths and 538 neonatal deaths, we achieved adequate balance for population characteristics and maternal and neonatal health care received for 10 of 18 resources and interventions, although inference for most antenatal interventions was not possible. Of ten resources and interventions that met our criteria for balance of potential confounders, only early breastfeeding was related to decreased all-cause neonatal mortality (relative risk 0.42, 95% CI 0.32–0.52, p <  0.001). Maternal decision making and postnatal health care reduced mortality due to infectious causes, with relative risks of 0.29 (95% CI 0.09–0.88; 0.030) and 0.46 (0.22–0.95; 0.037), respectively. Early breastfeeding and delayed bathing were related to decreased mortality due to intrapartum events, although these are not likely to be causal associations.

Conclusion

Access to immediate postnatal care and women’s autonomous decision-making have been among the most effective interventions for reducing neonatal mortality in Nigeria. As neonatal mortality increases relative to overall child mortality, accessible interventions are necessary to make further progress for neonatal survival in Nigeria and other low resource settings.

Determinants of subnational disparities in antenatal care utilisation: a spatial analysis of demographic and health survey data in Kenya

BACKGROUND

The spatial variation in antenatal care (ANC) utilisation is likely associated with disparities observed in maternal and neonatal deaths. Most maternal deaths are preventable through services offered during ANC; however, estimates of ANC coverage at lower decision-making units (sub-county) is mostly lacking. In this study, we aimed to estimate the coverage of at least four ANC (ANC4) visits at the sub-county level using the 2014 Kenya Demographic and Health Survey (KDHS 2014) and identify factors associated with ANC utilisation in Kenya.

METHODS

Data from the KDHS 2014 was used to compute sub-county estimates of ANC4 using small area estimation (SAE) techniques which relied on spatial relatedness to yield precise and reliable estimates at each of the 295 sub-counties. Hierarchical mixed-effect logistic regression was used to identify factors influencing ANC4 utilisation. Sub-county estimates of factors significantly associated with ANC utilisation were produced using SAE techniques and mapped to visualise disparities.

RESULTS

The coverage of ANC4 across sub-counties was heterogeneous, ranging from a low of 17% in Mandera West sub-county to over 77% in Nakuru Town West and Ruiru sub-counties. Thirty-one per cent of the 295 sub-counties had coverage of less than 50%. Maternal education, household wealth, place of delivery, marital status, age at first marriage, and birth order were all associated with ANC utilisation. The areas with low ANC4 utilisation rates corresponded to areas of low socioeconomic status, fewer educated women and a small number of health facility deliveries.

CONCLUSION

Suboptimal coverage of ANC4 and its heterogeneity at sub-county level calls for urgent, focused and localised approaches to improve access to antenatal care services. Policy formulation and resources allocation should rely on data-driven strategies to guide national and county governments achieve equity in access and utilisation of health interventions.