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Dey R, Kundu S, Ajayi KV, Kabir H, Banna MHA. Trends and inequalities in neonatal mortality rate in Bangladesh: Evidence from cross-sectional surveys. Health Sci Rep 2024; 7:e2298. [PMID: 39131597 PMCID: PMC11310099 DOI: 10.1002/hsr2.2298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 07/25/2024] [Accepted: 07/27/2024] [Indexed: 08/13/2024] Open
Abstract
Background and Aims Given the significance of addressing neonatal mortality in pursuing the 2030 Sustainable Development Goal on child health, research focus on this area is crucial. Despite the persistent high rates of neonatal mortality rate (NMR) in Bangladesh, there remains a notable lack of robust evidence addressing inequalities in NMR in the country. Therefore, this study aims to fill the knowledge gap by comprehensively investigating inequalities in NMR in Bangladesh. Methods The Bangladesh Demographic and Health Survey (BDHS) data from 2000 to 2017 were analyzed. The equity stratifiers used to measure the inequalities were wealth status, mother's education, place of residence, and subnational region. Difference (D) and population attributable fraction (PAF) were absolute measures, whereas population attributable risk (PAR) and ratio (R) were relative measures of inequality. Statistical significance was considered by estimating 95% confidence intervals (CIs) for each estimate. Results A declining trend in NMR was found in Bangladesh, from 50.2 in 2000 to 31.9 deaths per 1000 live births in 2017. This study detected significant wealth-driven (PAF: -20.6, 95% CI: -24.9, -16.3; PAR: -6.6, 95% CI: -7.9, -5.2), education-related (PAF: -11.6, 95% CI: -13.4, -9.7; PAR: -3.7, 95% CI: -4.3, -3.1), and regional (PAF: -20.6, 95% CI: -27.0, -14.3; PAR: -6.6, 95% CI: -8.6, -4.6) disparities in NMR in all survey points. We also found a significant urban-rural inequality from 2000 to 2014, except in 2017. Both absolute and relative inequalities in NMR were observed; however, these inequalities decreased over time. Conclusion Significant variations in NMR across subgroups in Bangladesh highlight the need for comprehensive, and targeted interventions. Empowering women through improved access to economic resources and education may help address disparities in NMR in Bangladesh. Future research and policies should focus on developing strategies to address these disparities and promote equitable health outcomes for all newborns.
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Affiliation(s)
- Rakhi Dey
- Statistics DisciplineKhulna UniversityKhulnaBangladesh
| | - Satyajit Kundu
- School of Medicine and DentistryGriffith UniversityGold CoastQLDAustralia
| | - Kobi V. Ajayi
- Department of Health Behavior, School of Public HealthTexas A&M University College StationCollege StationTexasUSA
| | - Humayun Kabir
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
| | - Md. Hasan Al Banna
- Faculty of Nutrition and Food SciencePatuakhali Science and Technology UniversityPatuakhaliBangladesh
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Ali IA, Inchon P, Suwannaporn S, Achalapong J. Neonatal mortality and associated factors among newborns in Mogadishu, Somalia: a multicenter hospital-based cross-sectional study. BMC Public Health 2024; 24:1635. [PMID: 38898456 PMCID: PMC11186222 DOI: 10.1186/s12889-024-19149-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 06/14/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION Neonatal mortality is a significant public health problem in Sub-Saharan Africa, particularly in Somalia, where limited data exists about this. Mogadishu, the densely populated capital, faces a high rate of neonatal mortality, but this has not been widely studied on a national level. Healthcare providers and policymakers are working to reduce newborn deaths, but a comprehensive understanding of the contributing factors is crucial for effective strategies. Therefore, this study aims to determine the magnitude of neonatal death and identify factors associated with it in Mogadishu, Somalia. METHOD A multicenter hospital-based cross-sectional study was conducted to collect data from participants at 5 purposively selected hospitals in Mogadishu, Somalia. A well-structured, reliable, self-developed, validated questionnaire containing socio-demographic, maternal, and neonatal characteristics was used as a research tool. Descriptive statistics were used for categorical and continuous variables presented. Chi-square and logistic regression were used to identify factors associated with neonatal mortality at a significant level of α = 0.05. RESULTS A total of 513 participants were recruited for the study. The prevalence of neonatal mortality was 26.5% [95%CI = 22.6-30.2]. In a multivariable model, 9 variables were found: female newborns (AOR = 1.98, 95%CI = 1.22-3.19), those their mothers who did not attend ANC visits (AOR = 2.59, 95%CI = 1.05-6.45), those their mothers who did not take tetanus toxoid vaccination (AOR = 1.82, 95%CI = 1.01-3.28), those their mothers who delivered in instrumental assistant mode (AOR = 3.01, 95%CI = 1.38-6.56), those who had neonatal sepsis (AOR = 2.24, (95%CI = 1.26-3.98), neonatal tetanus (AOR = 16.03, 95%CI = 3.69-69.49), and pneumonia (AOR = 4.06, 95%CI = 1.60-10.31) diseases during hospitalization, premature (AOR = 1.99, 95%CI = 1.00-3.94) and postmature (AOR = 4.82, 95%CI = 1.64-14.16) neonates, those with a birth weight of less than 2500 gr (AOR = 4.82, 95%CI = 2.34-9.95), those who needed resuscitation after delivery (AOR = 2.78, 95%CI = 1.51-5.13), and those who did not initiate early breastfeeding (AOR = 2.28, 95%CI = 1.12-4.66), were significantly associated with neonatal mortality compared to their counterparts. CONCLUSION In this study, neonatal mortality was high prevalence. Therefore, the intervention efforts should focus on strategies to reduce maternal and neonatal factors related to neonatal mortality. Healthcare workers and health institutions should provide appropriate antenatal, postnatal, and newborn care.
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Affiliation(s)
- Ikran Abdulkadir Ali
- Department of Public Health, School of Health Science, Mae Fah Luang University, Chiang Rai Province, Thailand
- Department of Neonatal Intensive Care Unit, Yardimeli Hospital, Mogadishu, Somalia
| | - Pamornsri Inchon
- Department of Public Health, School of Health Science, Mae Fah Luang University, Chiang Rai Province, Thailand.
| | - Sirinan Suwannaporn
- Department of Public Health, School of Health Science, Mae Fah Luang University, Chiang Rai Province, Thailand
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Hedley KE, Cuskelly A, Callister RJ, Horvat JC, Hodgson DM, Tadros MA. The medulla oblongata shows a sex-specific inflammatory response to systemic neonatal lipopolysaccharide. J Neuroimmunol 2024; 389:578316. [PMID: 38394966 DOI: 10.1016/j.jneuroim.2024.578316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Abstract
Early life inflammation has been linked to long-term modulation of behavioural outcomes due to the central nervous system, but it is now becoming apparent it is also linked to dysfunction of visceral physiology. The medulla oblongata contains a number of nuclei critical for homeostasis, therefore we utilised the well-established model of neonatal lipopolysaccharide (LPS) exposure to examine the immediate and long-term impacts of systemic inflammation on the medulla oblongata. Wistar rats were injected with LPS or saline on postnatal days 3 and 5, with tissues collected on postnatal days 7 or 90 in order to assess expression of inflammatory mediators and microglial morphology in autonomic regions of the medulla oblongata. We observed a distinct sex-specific response of all measured inflammatory mediators at both ages, as well as significant neonatal sex differences in inflammatory mediators within saline groups. At both ages, microglial morphology had significant changes in branch length and soma size in a sex-specific manner in response to LPS exposure. This data not only highlights the strong sex-specific response of neonates to LPS administration, but also the significant life-long impact on the medulla oblongata and the potential altered control of visceral organs.
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Affiliation(s)
- Kateleen E Hedley
- School of Biomedical Sciences & Pharmacy, University of Newcastle, NSW, Australia; Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Annalisa Cuskelly
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; School of Psychological Sciences, University of Newcastle, NSW, Australia; School of Education, University of Newcastle, NSW, Australia
| | - Robert J Callister
- School of Biomedical Sciences & Pharmacy, University of Newcastle, NSW, Australia; Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Jay C Horvat
- School of Biomedical Sciences & Pharmacy, University of Newcastle, NSW, Australia; Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Deborah M Hodgson
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; School of Psychological Sciences, University of Newcastle, NSW, Australia
| | - Melissa A Tadros
- School of Biomedical Sciences & Pharmacy, University of Newcastle, NSW, Australia; Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.
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Boerner KE, Keogh E, Inkster AM, Nahman-Averbuch H, Oberlander TF. A developmental framework for understanding the influence of sex and gender on health: Pediatric pain as an exemplar. Neurosci Biobehav Rev 2024; 158:105546. [PMID: 38272336 DOI: 10.1016/j.neubiorev.2024.105546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 07/07/2023] [Accepted: 11/06/2023] [Indexed: 01/27/2024]
Abstract
Sex differences are a robust finding in many areas of adult health, including cardiovascular disease, psychiatric disorders, and chronic pain. However, many sex differences are not consistently observed until after the onset of puberty. This has led to the hypothesis that hormones are primary contributors to sex differences in health outcomes, largely ignoring the relative contributions of early developmental influences, emerging psychosocial factors, gender, and the interaction between these variables. In this paper, we argue that a comprehensive understanding of sex and gender contributions to health outcomes should start as early as conception and take an iterative biopsychosocial-developmental perspective that considers intersecting social positions. We present a conceptual framework, informed by a review of the literature in basic, clinical, and social science that captures how critical developmental stages for both sex and gender can affect children's health and longer-term outcomes. The literature on pediatric chronic pain is used as a worked example of how the framework can be applied to understanding different chronic conditions.
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Affiliation(s)
- Katelynn E Boerner
- Department of Pediatrics, University of British Columbia, and BC Children's Hospital Research Institute, Vancouver, BC, Canada.
| | - Edmund Keogh
- Department of Psychology & Centre for Pain Research, University of Bath, Bath, United Kingdom
| | - Amy M Inkster
- Department of Medical Genetics, University of British Columbia, and BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Hadas Nahman-Averbuch
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Tim F Oberlander
- Department of Pediatrics, University of British Columbia, and BC Children's Hospital Research Institute, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, and BC Children's Hospital Research Institute, Vancouver, BC, Canada
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González FAI. Income, stress, and sex ratios over 1895-2010. BIODEMOGRAPHY AND SOCIAL BIOLOGY 2024; 69:4-18. [PMID: 38437066 DOI: 10.1080/19485565.2024.2325348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
The medical literature has shown that populations under high stress have a lower sex ratio at birth (i.e. number of males for every 100 females). In this paper, I examine the relationship between income, as a source of economic stress, and the sex ratio at a subnational level for the 1895-2010 period. For this, I use census microdata from Argentina -a developing country that experienced rapid growth at the end of the 19th century and stagnated in recent decades- and I estimate from a two-way fixed effects model that exploits the wide temporal and geographic variability in income. The results show that as per capita income increases, the sex ratio at birth also increases. In particular, for every US$ 1,000 increase in per capita income, the sex ratio increases between 0.3 and 0.6 points. These findings make it possible to quantify the lost boys (i.e. those boys who were not born due to high economic stress on their parents) and constitute a call for attention in favor of the implementation of prenatal care policies -especially in periods of stagnation or income decline- to maintain a more balanced sex ratio.
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Erchick DJ, Lama TP, Subedi S, Verhulst A, Guillot M, Khatry SK, LeClerq SC, Tielsch JM, Mullany LC, Katz J. Comparison of pregnancy and neonatal outcomes in a retrospective full pregnancy history survey versus population-based prospective records: a validation study in rural Sarlahi District, Nepal. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2023; 42:139. [PMID: 38066542 PMCID: PMC10709973 DOI: 10.1186/s41043-023-00472-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023]
Abstract
INTRODUCTION Countries without complete civil registration and vital statistics systems rely on retrospective full pregnancy history surveys (FPH) to estimate incidence of pregnancy and mortality outcomes, including stillbirth and neonatal death. Yet surveys are subject to biases that impact demographic estimates, and few studies have quantified these effects. We compare data from an FPH vs. prospective records from a population-based cohort to estimate validity for maternal recall of live births, stillbirths, and neonatal deaths in a rural population in Sarlahi District, Nepal. METHODS We used prospective data, collected through frequent visits of women from early pregnancy through the neonatal period, from a population-based randomized trial spanning 2010-2017. We randomly selected 76 trial participants from three pregnancy outcome groups: live birth (n = 26), stillbirth (n = 25), or neonatal death (n = 25). Data collectors administered the Nepal 2016 Demographic and Health Surveys (DHS)-VII pregnancy history survey between October 22, 2021, and November 18, 2021. We compared total pregnancy outcomes and numbers of pregnancy and neonatal outcomes between the two data sources. We matched pregnancy outcomes dates in the two sources within ± 30 days and calculated measures of validity for adverse outcomes. RESULTS Among 76 participants, we recorded 122 pregnancy outcomes in the prospective data and 104 outcomes in the FPH within ± 30 days of each woman's total observation period in the trial. Among 226 outcomes, we observed 65 live births that survived to 28 days, 25 stillbirths, and 32 live births followed by neonatal death in the prospective data and participants reported 63 live births that survived to 28 days, 15 stillbirths, and 26 live births followed by neonatal death in the pregnancy history survey. Sixty-two FPH outcomes were matched by date within ± 30 days to an outcome in prospective data. Stillbirth, neonatal death, higher parity, and delivery at a health facility were associated with likelihood of a non-matched pregnancy outcome. CONCLUSIONS Stillbirth and neonatal deaths were underestimated overall by the FPH, potentially underestimating the burden of mortality in this population. There is a need to develop tools to reduce or adjust for biases and errors in retrospective surveys to improve reporting of pregnancy and mortality outcomes.
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Affiliation(s)
- Daniel J Erchick
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Tsering P Lama
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Nepal Nutrition Intervention Project - Sarlahi, Kathmandu, Nepal
| | - Seema Subedi
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | | | - Michel Guillot
- University of Pennsylvania, Philadelphia, PA, USA
- French Institute for Demographic Studies (INED), Aubervilliers, France
| | - Subarna K Khatry
- Nepal Nutrition Intervention Project - Sarlahi, Kathmandu, Nepal
| | - Steven C LeClerq
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Nepal Nutrition Intervention Project - Sarlahi, Kathmandu, Nepal
| | - James M Tielsch
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Luke C Mullany
- Applied Physics Laboratory, Johns Hopkins University, Baltimore, MD, USA
| | - Joanne Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Yan T, Mullany LC, Subedi S, Hazel EA, Khatry SK, Mohan D, Zeger S, Tielsch JM, LeClerq SC, Katz J. Risk factors for neonatal mortality: an observational cohort study in Sarlahi district of rural southern Nepal. BMJ Open 2023; 13:e066931. [PMID: 37709319 PMCID: PMC10503364 DOI: 10.1136/bmjopen-2022-066931] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 08/31/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVES To assess the association between maternal characteristics, adverse birth outcomes (small-for-gestational-age (SGA) and/or preterm) and neonatal mortality in rural Nepal. DESIGN This is a secondary observational analysis to identify risk factors for neonatal mortality, using data from a randomised trial to assess the impact of newborn massage with different oils on neonatal mortality in Sarlahi district, Nepal. SETTING Rural Sarlahi district, Nepal. PARTICIPANTS 40 119 pregnant women enrolled from 9 September 2010 to 16 January 2017. MAIN OUTCOME The outcome variable is neonatal death. Cox regression was used to estimate adjusted Hazard Ratios (aHRs) to assess the association between adverse birth outcomes and neonatal mortality. RESULTS There were 32 004 live births and 998 neonatal deaths. SGA and/or preterm birth was strongly associated with increased neonatal mortality: SGA and preterm (aHR: 7.09, 95% CI: (4.44 to 11.31)), SGA and term/post-term (aHR: 2.12, 95% CI: (1.58 to 2.86)), appropriate-for-gestational-age/large-for-gestational-age and preterm (aHR: 3.23, 95% CI: (2.30 to 4.54)). Neonatal mortality was increased with a history of prior child deaths (aHR: 1.53, 95% CI: (1.24 to 1.87)), being a twin or triplet (aHR: 5.64, 95% CI: (4.25 to 7.48)), births at health posts/clinics or in hospital (aHR: 1.34, 95% CI: (1.13 to 1.58)) and on the way to facilities or outdoors (aHR: 2.26, 95% CI: (1.57 to 3.26)). Risk was lower with increasing maternal height from <145 cm to 145-150 cm (aHR: 0.78, 95% CI: (0.65 to 0.94)) to ≥150 cm (aHR: 0.57, 95% CI: (0.47 to 0.68)), four or more antenatal care (ANC) visits (aHR: 0.67, 95% CI: (0.53 to 0.86)) and education >5 years (aHR: 0.75, 95% CI: (0.62 to 0.92)). CONCLUSION SGA and/or preterm birth are strongly associated with increased neonatal mortality. To reduce neonatal mortality, interventions that prevent SGA and preterm births by promoting ANC and facility delivery, and care of high-risk infants after birth should be tested. TRIAL REGISTRATION NUMBER NCT01177111.
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Affiliation(s)
- Tingting Yan
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Luke C Mullany
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Seema Subedi
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth A Hazel
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Subarna K Khatry
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Nepal Nutrition Intervention Project - Sarlahi (NNIPS), Nepal Eye Hospital Complex, Tripureshwor, Kathmandu, Nepal
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Scott Zeger
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - James M Tielsch
- Department of Global Health, George Washington University School of Public Health and Health Services, Washington, DC, USA
| | - Steven C LeClerq
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Nepal Nutrition Intervention Project - Sarlahi (NNIPS), Nepal Eye Hospital Complex, Tripureshwor, Kathmandu, Nepal
| | - Joanne Katz
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Alam N, Rahman MM, Bashar MI, Ahmed A, Ali T, Haider MM. Sex differences in the care of the fetus in the mother's womb and the neonate on her lap: Evidence from demographic surveillance and survey data from Bangladesh. SSM Popul Health 2022; 19:101261. [PMID: 36238821 PMCID: PMC9550641 DOI: 10.1016/j.ssmph.2022.101261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/27/2022] [Accepted: 10/02/2022] [Indexed: 11/17/2022] Open
Abstract
Valuation of sons over daughters introduces sex-biased health, economic, and socio-demographic inequalities in many societies. This study aims to examine fetus-sex differences in maternity services and sex differences in medical care for terminally ill neonates in Bangladesh, using secondary data from the Matlab Health and Demographic Surveillance System (HDSS), maintained by icddr,b since 1966 along with data from the Bangladesh Maternal Mortality and Health Care Survey (BMMS) 2016. The HDSS follows a well-defined rural population (0.24 million in 2018) to register vital events and migrations and records the use of maternity services for the index birth and medical care-seeking during the terminal illness of each death in verbal autopsy. The BMMS 2016 recorded maternity care and maternal complications for the last live birth of mothers in the same population (weighted n = 27,133; unweighted n = 26,939). Bivariate analyses estimated the use (in %) of maternity services for the index live births and medical services for terminally ill neonates for each socio-demographic variable. Logistic regression models estimated odds ratios (AORs) adjusted for socio-demographic variables and clustering of births to the same mothers. The HDSS registered 49,827 live births and 1,049 neonatal deaths during 2009-2018. We found similar prenatal care-seeking for male and female fetuses but higher facility delivery (AOR = 1.17, 95% CI: 1.12-1.23) and C-sections (AOR = 1.20, 95% CI: 1.15-1.25) for male fetus pregnancies, differences that remain after adjusting for maternal complications. Sex differences persisted in seeking care for terminally ill neonates. Trained provider consultation (AOR = 1.46, CI: 1.00-2.12); hospital admissions (AOR = 1.43, CI: 1.01-2.03); and dying in hospital (AOR = 1.91, CI: 1.31-2.78) were all higher for male neonates. Other variables positively associated with delivery care and medical care-seeking were lower birth order of the child, higher maternal education, and higher household wealth status. Policy and decision-makers need to be aware of gender disparities in maternity care and care of sick neonates and plan remedial actions.
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