Individual and community determinants of neonatal mortality in Ghana: a multilevel analysis

Quality of neonatal health care in comprehensive specialized hospitals, Amhara Region, Ethiopia: a retrospective study with neonatal death audit

BACKGROUND

Neonatal health is one of the targets for the sustainable development goals (SDGs) that aim to reduce neonatal mortality to at least as low as 12 per 1 000 live births in 2030. However, the world is not on track to achieve this target. The problem has worsened in many low-income countries, including Ethiopia, due to a fragile health system, as well as health crises such as the COVID-19 pandemic, conflict, food insecurity and climate change. According to the Mini Ethiopian Demographic Health Survey, neonatal mortality is unacceptably high in Ethiopia in general, and in Amhara region in particular. Despite these facts, there is a paucity of information on the quality of neonatal health service provision in comprehensive specialized hospitals in Amhara region. Therefore, this study is aimed at assessing the quality of neonatal health services in terms of outcome (neonatal mortality) and its causes in comprehensive specialized hospitals in Amhara region.

METHODS

A multi-center retrospective study was conducted (from September 1-30/2022) on 315 neonates in four comprehensive hospitals with chart review. Data were collected through death audit with standardized neonatal death audit tool. Data were entered into Epi-data 3.1 and exported to SPSS 20 for analysis. Descriptive analysis was used to describe and summarize the data in an informative manner.

RESULTS

From 315 neonatal deaths, about two-thirds, 205 (65.1%), were from rural areas. Nearly half, 151 (48%), of the mothers had complications and delivered outside a health facility. About 36 (11.4%), 45 (14.3%), and 21 (6.7%) neonates' mothers had 1st, 2nd, and 3rd delays, respectively. About 59 (19%) of mothers had membrane rupture before the onset of labor and 23 (7.3%) had meconium-stained liquor. Almost three-fourths, 226 (71.7%), of the deaths were low birth weight (< 2500 gram). About 25 (8%) of neonates had congenital anomalies, 65% of them had fast breathing and 54.6% were preterm.

CONCLUSION

Higher proportions of neonatal deaths were observed among neonates with rural residence, low birth weight, mothers' complications and neonates admitted for fast breathing. Histories of abortion, complications, congenital anomalies, and the 3 delays contributed to neonatal deaths.

Early neonatal mortality and determinants in Ethiopia: multilevel analysis of Ethiopian demographic and health survey, 2019

INTRODUCTION

Despite remarkable achievements in improving maternal and child health, early neonatal deaths still persist, with a sluggish decline in Ethiopia. As a pressing public health issue, it requires frequent and current studies to make appropriate interventions. Therefore, by using the most recent Ethiopian Mini Demographic Health Survey Data of 2019, we aimed to assess the magnitude and factors associated with early neonatal mortality in Ethiopia.

METHODS

Secondary data analysis was conducted based on the demographic and health survey data conducted in Ethiopia in 2019. A total weighted sample of 5,753 live births was included for this study. A multilevel logistic regression model was used to identify the determinants of early neonatal mortality. The adjusted odds ratio at 95% Cl was computed to assess the strength and significance of the association between explanatory and outcome variables. Factors with a p-value of < 0.05 are declared statistically significant.

RESULTS

The prevalence of early neonatal mortality in Ethiopia was 26.5 (95% Cl; 22.5-31.08) per 1000 live births. Maternal age 20-35 (AOR, 0.38; 95% Cl, 0.38-0.69), richer wealth index (AOR, 0.47; 95% Cl, 0.23-0.96), having no antenatal care visit (AOR, 1.86; 95% Cl, 1.05-3.30), first birth order (AOR, 3.41; 95% Cl, 1.54-7.56), multiple pregnancy (AOR, 18.5; 95% Cl 8.8-38.9), presence of less than two number of under-five children (AOR, 5.83; 95% Cl, 1.71-19.79) and Somali region (AOR, 3.49; 95% Cl, 1.70-12.52) were significantly associated with early neonatal mortality.

CONCLUSION

This study showed that, in comparison to other developing nations, the nation had a higher rate of early newborn mortality. Thus, programmers and policymakers should adjust their designs and policies in accordance with the needs of newborns and children's health. The Somali region, extreme maternal age, and ANC utilization among expectant moms should all be given special consideration.

Mortality of neonates born to mothers of extreme reproductive age in Ethiopia; multilevel mixed effect analysis of Ethiopian demographic and health survey data of 2016

Introduction

Neonatal mortality is still a major public health problem in middle- and low-income countries like Ethiopia. Despite strategies and efforts made to reduce neonatal death, the mortality rate declines at a slower pace in the country. Though there are studies conducted on neonatal mortality and its determinants, our searches of the literature have found no study on the extent of mortality of neonates born to mothers of extreme reproductive age in the study area. Therefore, this study aimed to assess the magnitude and factors associated with the mortality of neonates born to mothers of extreme reproductive age in Ethiopia.

Methods

Secondary data analysis was conducted using 2016 Ethiopian Demographic and Health Survey data. The final study contained an overall weighted sample of 2,269 live births. To determine the significant factors in newborn deaths, a multilevel binary logistic regression was fitted. For measuring the clustering impact, the intra-cluster correlation coefficient, median odds ratio, proportional change in variance, and deviation were employed for model comparison. The adjusted odds ratio with a 95% confidence interval was presented in the multivariable multilevel logistic regression analysis to identify statistically significant factors in neonatal mortality. A P-value of less than 0.05 was declared statistically significant.

Results

The neonatal mortality rate of babies born to extreme aged reproductive women in Ethiopia was 34 (95% Cl, 22.2%-42.23%) per 1,000 live birth. Being twin pregnancy (AOR = 10; 95% Cl: 8.61-20.21), being from pastoralist region (AOR = 3.9; 95% Cl: 1.71-8.09), having larger baby size (AOR = 2.93; 95% Cl: 1.4-9.12) increase the odds of neonatal mortality. On the other hand, individual level media exposure (AOR = 0.3; 95% Cl: 0.09-0.91) and community level media exposure (AOR = 0.24; 95% Cl: 0.07-0.83), being term gestation (AOR = 0.14; 95% Cl: 0.01-0.81) decreases the odds of neonatal mortality born to mothers of extreme reproductive age.

Conclusion

Ethiopia had a greater rate of neonatal death among babies born at the extremes of reproductive age than overall reproductive life. Multiple pregnancies, larger baby sizes, emerging regions, term gestation, and media exposure were found to be significant factors associated with the mortality of neonates born to mothers of extreme reproductive age. Therefore, the concerned bodies should give emphasis to mothers giving birth before the age of 20 and above 35, access to media, healthy pregnancy, and special attention to pastoralists to reduce the burden of neonatal mortality.

Assessment of Neonatal Mortality and Associated Hospital-Related Factors in Healthcare Facilities Within Sunyani and Sunyani West Municipal Assemblies in Bono Region, Ghana

Objectives

Ghana's quest to reduce neonatal mortality, in hospital facilities and communities, continues to be a nightmare. The pursuit of achieving healthy lives and well-being for neonates as enshrined in Sustainable Development Goal three lingered in challenging hospital facilities and communities. Notwithstanding that, there have been increasing efforts in that direction. This study examines the contributing factors that hinder the fight against neonatal mortality in all hospital facilities in the Sunyani and Sunyani West Municipal Assemblies in Bono Region, Ghana.

Methods

The study utilized neonatal mortality data consisting of neonatal deaths, structural facility related variables, medical human resources, types of hospital facilities and natal care. The data was collected longitudinally from 2014 to 2019. These variables were analysed using the negative binomial hurdle regression (NBH) model to determine factors that contribute to this menace at the facility level. Cause-specific deaths were obtained to determine the leading causes of neonatal deaths within health facilities in the two municipal assemblies.

Results

The study established that the leading causes of neonatal mortality in these districts are birth asphyxia (46%), premature birth (33%), neonatal sepsis (11%) and neonatal jaundice (7%). The NBH showed that neonatal mortality in hospital facilities depend on the number of incubators, monitoring equipment, hand washing facilities, CPAPb machines, radiant warmers, physiotherapy machines, midwives, paediatric doctors and paediatric nurses in the hospital facility.

Conclusions

Early management of neonatal sepsis, birth asphyxia, premature birth and neonatal infections is required to reduce neonatal deaths. The government and all stakeholders in the health sector should provide all hospital facilities with the essential equipment and the medical human resources necessary to eradicate the menace. This will make the realization of Sustainable Development Goal three, which calls for healthy lives and well-being for all, a reality.

Predictors of neonatal mortality in the Eastern Regional Hospital in Ghana: A retrospective cohort study

Neonatal mortality accounts for nearly half of under-5 mortality in Ghana. The aim of this study was to identify the predictors of neonatal mortality in the Eastern Regional Hospital, Ghana. This was a retrospective cohort study conducted using secondary data from electronic medical records from the Eastern Regional Hospital between 1st January 2022 and 31st December 2022. The Kaplan-Meier estimator and adjusted Cox regression model were used to estimate survival probability and to assess the predictors of neonatal mortality. Data on 1684 neonates were analyzed and we found that 11.82% deaths occurred with a neonatal mortality rate (NMR) of 13.98 (95% CI: 12.05, 15.91) per 1000 person-days. Most neonatal deaths occurred within the first 24hrs of life (9.9%). The predictors of neonatal mortality were found to be low birthweight [Adjusted hazard rate (aHR): 1.63, 95% CI: 1.04, 2.54], hypothermia (aHR: 1.82, 95% CI: 1.16, 2.85), hyperthermia (aHR: 1.85, 95% CI: 1.01, 3.39), birth asphyxia (aHR: 3.69, 95% CI: 1.68, 8.11), and multiparty (aHR: 1.66, 95% CI: 1.02, 2.70). However, neonates aged 8-28 days (aHR: 0.41, 95% CI: 0.21, 0.81), born in the Eastern Regional Hospital (aHR: 0.39, 95% CI: 0.28, 0.55), walk-in neonates (aHR: 0.54, 95% CI: 0.32, 0.90), and neonates whose mothers had 8 or more antenatal contacts (aHR: 0.54, 95% CI: 0.32, 0.92) had lower neonatal mortality. There was high NMR in the Eastern Regional Hospital in Ghana. Averting complications such as low birthweight, hypothermia, hyperthermia, birth asphyxia, including the provision of obstetric and early neonatal care within the first 24 hours of life is critical to reducing neonatal mortality. Adherence to the World Health Organization's recommendation of 8 or more antenatal contacts among pregnant women is also essential in reducing neonatal mortality.

Investigating the Causes of Neonatal Mortality: An Umbrella Review

Background

Neonatal mortality remains a critical global challenge, with preventable instances prevailing. The initial stride in mitigating neonatal mortality involves elucidating its underlying causes.

Methods

This study utilized an umbrella review approach to discern factors associated with neonatal mortality. Five international databases, namely Pub Med, Web of Science, Scopus, CINAHL, and EMBASE, were meticulously searched to achieve this.

Results

The initial search yielded 12,631 articles using a search strategy centered on keywords related to factors contributing to neonatal mortality. Ultimately, 95 articles met the criteria incorporated into this study.

Conclusion

This study endeavors to identify the primary risk factors contributing to neonatal mortality. The discerned risk factors have been systematically categorized into four groups: maternal factors, neonatal factors, aspects linked to healthcare systems, and socio-economic factors. As such, it is imperative for policymakers to take heed of these identified risk factors and formulate comprehensive strategies encompassing both long-term and short-term initiatives. Effective interventions spanning various sectors are crucial for the prevention of neonatal mortality.

Proximate and distant determinants of maternal and neonatal mortality in the postnatal period: A scoping review of data from low- and middle-income countries

Global maternal and neonatal mortality rates remain unacceptably high. The postnatal period, encompassing the first hour of life until 42 days, is critical for mother-baby dyads, yet postnatal care (PNC) coverage is low. Identifying mother-baby dyads at increased risk for adverse outcomes is critical. Yet few efforts have synthesized research on proximate and distant factors associated with maternal and neonatal mortality during the postnatal period. This scoping review identified proximate and distant factors associated with maternal and neonatal mortality during the postnatal period within low- and middle-income countries (LMICs). A rigorous, systematic search of four electronic databases was undertaken to identify studies published within the last 11 years containing data on risk factors among nationally representative samples. Results were synthesized narratively. Seventy-nine studies were included. Five papers examined maternal mortality, one focused on maternal and neonatal mortality, and the rest focused on neonatal mortality. Regarding proximate factors, maternal age, parity, birth interval, birth order/rank, neonate sex, birth weight, multiple-gestation, previous history of child death, and lack of or inadequate antenatal care visits were associated with increased neonatal mortality risk. Distant factors for neonatal mortality included low levels of parental education, parental employment, rural residence, low household income, solid fuel use, and lack of clean water. This review identified risk factors that could be applied to identify mother-baby dyads with increased mortality risk for targeted PNC. Given risks inherent in pregnancy and childbirth, adverse outcomes can occur among dyads without obvious risk factors; providing timely PNC to all is critical. Efforts to reduce the prevalence of risk factors could improve maternal and newborn outcomes. Few studies exploring maternal mortality risk factors were available; investments in population-based studies to identify factors associated with maternal mortality are needed. Harmonizing categorization of factors (e.g., age, education) is a gap for future research.

Health-system drivers influencing the continuum of care linkages for low-birth-weight infants at the different care levels in Ghana

BACKGROUND

Low birth weight (LBW) is associated with short and long-term consequences including neonatal mortality and disability. Effective linkages in the continuum of care (CoC) for newborns at the health facility, community (primary care) and home care levels have a high tendency of minimizing adverse events associated with LBW. But it is unclear how these linkages work and what factors influence the CoC process in Ghana as literature is scarce on the views of health professionals and families of LBW infants regarding the CoC. Therefore, this study elicited the drivers influencing the CoC for LBW infants in Ghana and how linkages in the CoC could be strengthened to optimize quality of care.

METHODS

A constructivist grounded theory study design was used. Data was collected between September 2020 to February 2021. A total of 25 interviews were conducted with 11 family members of LBW infants born in a secondary referral hospital in Ghana, 9 healthcare professionals and 7 healthcare managers. Audio recordings were transcribed verbatim, analyzed using initial and focused coding. Constant comparative techniques, theoretical memos, and diagramming were employed until theoretical saturation was determined.

RESULTS

Emerging from the analysis was a theoretical model describing ten major themes along the care continuum for LBW infants, broadly categorized into health systems and family-systems drivers. In this paper, we focused on the former. Discharge, review, and referral systems were neither well-structured nor properly coordinated. Efficient dissemination and implementation of guidelines and supportive supervision contributed to higher staff motivation while insufficient investments and coordination of care activities limited training opportunities and human resource. A smooth transition between care levels is hampered by procedural, administrative, logistics, infrastructural and socio-economic barriers.

CONCLUSION

A coordinated care process established on effective communication across different care levels, referral planning, staff supervision, decreased staff shuffling, routine in-service training, staff motivation and institutional commitment are necessary to achieve an effective care continuum for LBW infants and their families.

Geographic disparities in the time to under-five mortality in Ghana

Globally, there has been tremendous advancement in medicine and child healthcare with increased life expectancy. That notwithstanding, the risk of under-five mortality ─ children dying before their fifth birthday remains relatively high in countries in Sub-Saharan Africa such as Ghana. In Ghana, under-five mortality remains a major public health problem that requires significant policy interventions. Using data from the 2017 Maternal Health Survey (n = 4785), we examined the geographic disparities in the time to under-five mortality in Ghana. The Kaplan Meier estimator showed significant (Log-rank: p< 0.001) rural-urban differences in the time to under-five mortality in Ghana. A disaggregated cox proportional hazards analysis showed that despite wide consensus that children in urban areas have a high survival rate, children in urban areas in northern regions of Ghana, especially the Upper West (HR = 4.40, p < 0.05) and Upper East (HR = 5.37, p < 0.01) Regions were significantly at increased risk of dying before the age of five compared to children in urban areas in the Greater Accra Region. A rural-urban comparison showed that children born in rural areas in all the other regions of Ghana were at a higher risk of dying before the age of five when compared to their counterparts in the rural areas of Greater Accra Region. Other factors such as sex of child, mothers' age and use of the internet, number of household members, ethnicity and household wealth were significantly associated with the timing of under-five mortality in Ghana. Healthcare policies and programs such as immunizations and affordable child healthcare services should be prioritized especially in rural areas of regions with a high risk of child mortality. Also, there is a need to improve healthcare delivery in urban areas, particularly in northern Ghana, where deplorable healthcare service infrastructure and delivery coupled with high poverty rates put children at risk of dying before their fifth birthday.

Predictors of neonatal mortality in Ghana: evidence from 2017 Ghana maternal health survey

BACKGROUND

Neonatal mortality contributes about 47% of child mortality globally and over 50% of under-5 deaths in Ghana. There is limited population level analysis done in Ghana on predictors of neonatal mortality.

OBJECTIVES

The objective of the study was to examine the predictors of neonatal mortality in Ghana.

METHOD

This study utilizes secondary data from the 2017 Ghana Maternal Health Survey (GMHS). The GMHS survey focuses on population and household characteristics, health, nutrition, and lifestyle with particular emphasis on topics that affect the lives of newborns and women, including mortality levels, fertility preferences and family planning methods. A total of 10,624 respondents were included in the study after data cleaning. Descriptive statistical techniques were used to describe important background characteristics of the women and Pearson's Chi-squares (χ2) test used to assess association between the outcome (neonatal death) and independent variables. Multivariate logistic regression analysis was done to estimate odd ratios and potential confounders controlled. Confidence level was held at 95%, and a p < 0.05 was considered statistically significant. Data analysis was done using STATA 15.

RESULTS

The prevalence of neonatal mortality was 18 per 1000 live births. ANC attendance, sex of baby, and skin-to-skin contact immediately after birth were predictors of neonatal mortality. Women with at least one ANC visit were less likely to experience neonatal mortality as compared to women with no ANC visit prior to delivery (AOR = 0.11; CI = 0.02-0.56, p = 0.01). Girls were less likely (AOR = 0.68; CI = 0.47-0.98; p = 0.03) to die during the neonatal period as compared to boys. Neonates who were not put skin-to-skin contact immediately after birth were 2.6 times more likely to die within the neonatal period than those who were put skin-to-skin contact immediately after birth (AOR = 2.59; CI = 1.75-3.83, p = 0.00).

CONCLUSION

Neonatal mortality remains a public health concern in Ghana, with an estimated rate of 18 deaths per 1,000 live births. Maternal and neonatal factors such as the sex of the newborn, the number of antenatal care visits, and skin-to-skin contact between the newborn and mother immediately after birth are the predictors of neonatal mortality in Ghana.

Multilevel modelling of neonatal mortality in Ghana: Does household and community levels matter?

Background

Neonatal mortality accounts for an increasing share of under-five deaths, and they are declining at a slower rate than postnatal deaths. Apparently, neonatal mortality is increasingly becoming a major public health problem in Ghana and the world over. The current study sought to analyze neonatal mortality as a function of predictor variables and to estimate and understand unobserved household and community-level residual effects on neonatal mortality to provide data driven evidence to shape informed policies and interventions aimed at reducing the neonatal mortality burden.

Methods

The current study extracted three-level complex data on 5884 children born in the five years preceding the 2014 Ghana Demographic and Health Survey. A two-level and three-level multilevel logistic models were applied to estimate unobserved household and community-level variations in neonatal mortality in the presence of set of predictor variables. Sampling weights were incorporated in both the descriptive and inferential analysis since the data used emanated from a complex survey. Model fit statistics such as AIC scores for a weighted two-level and three-level random intercept logistic models were compared. The model with the lowest AIC score was considered the most preferred model.

Results

The household-level random intercept model suggested that the odds of neonatal mortality was higher among multiple births [OR = 3.15 (95% CI: 1.17, 8.50)], babies born to mothers who received prenatal care from non-skilled worker [OR = 5.88 (95% CI: 2.90, 11.91)], babies delivered through caesarian section [OR = 2.47 (95% CI: 1.06, 5.79)], a household with 1-4 members [OR = 10.23 (95% CI: 4.17, 25.50)], a short preceding birth interval (<24 months) [OR = 3.05 (95% CI: 1.18, 7.88)], and preceding birth interval between 24 and 47 months [OR = 2.88 (95% CI: 1.41, 5.91)]. Substantial unobserved household-level residual variations in neonatal mortality were observed.

Conclusion

The findings of the current study provide an actionable information to be used by government and other stakeholders in the health sector to renew commitment to reduce neonatal mortality to an acceptable level. There is the need to intensify maternal health education by health providers to encourage pregnant women to visit antenatal clinics at least four times so they could benefit substantially from ANC services.

Effects of short birth interval on different forms of child mortality in Bangladesh: Application of propensity score matching technique with inverse probability of treatment weighting

BACKGROUND

The prevalence of Short Birth Interval (SBI) is higher in Low- and Middle-Income countries (LMICs), including Bangladesh. Previous studies in LMICs have estimated the effects of SBI on child mortality by comparing two unequal groups of mothers based on their socio-economic status. This approach may lead to overestimation or underestimation of the true effect of birth interval on child mortality, particularly when sample sizes are relatively small.

OBJECTIVE

We determined the effects of SBI on several forms of child mortality in Bangladesh by comparing two equal groups created by applying the propensity score matching technique.

METHODS

This study analyzed data from 5,941 mothers and 1,594 health facilities extracted from the 2017/18 Bangladesh Demographic and Health Survey and the 2017 Bangladesh Health Facility Survey. The exposure variable was SBI (defined as the interval between two subsequent births <33 months: yes, no), while the outcome variables were neonatal mortality (defined as mortality within 28 days of birth: yes, no), infant mortality (defined as mortality within 1 year of birth: yes, no), and under-five mortality (defined as mortality within 5 years of birth: yes, no). Multilevel Poisson regression based on inverse probability treatment weights was used to determine the association between exposure and outcome variables.

RESULTS

The prevalence rates of neonatal, infant, and under-five mortality were 48.8, 30.8, and 23.1 per 1000 live births, respectively. Newborns of SBI mothers were found to have a 63% higher likelihood of neonatal mortality (aPR, 1.63; 95% CI, 1.08-2.46) compared to newborns of non-SBI mothers. Furthermore, the prevalence of infant mortality and under-five mortality was 1.45 times higher (aPR, 1.45; 95% CI, 1.01-2.08) and 2.82 times higher (aPR, 2.82; 95% CI, 2.16-3.70), respectively, among babies born in a short interval of their immediately preceding sibling as compared to babies born in a normal interval of their immediately preceding sibling.

CONCLUSIONS

Findings of this study indicate that SBI is an important predictor of child mortality. Consequently, around 1 million children born in a short interval every year in Bangladesh are at risk of dying before reaching their fifth birthday. This indicates a challenge for Bangladesh to achieve the SDG 3 target to reduce neonatal and under-five mortality to 12 and 25 deaths per 1000 live births, respectively. Hence, awareness-building programs about the adverse effects of SBI and strengthening existing healthcare facilities are important.

Determining factors of neonatal mortality in Ethiopia: An investigation from the 2019 Ethiopia Mini Demographic and Health Survey

BACKGROUND

Neonatal mortality is the probability of dying during the first 28 days of life. Of approximately 5 million children who die in the first year of life in the world, about 3 million are within their first 28 days of birth. In Ethiopia, the neonatal mortality rate is high about 37 per 1000 live births, and the factors are not well documented. Then, this study aimed to determine the key factors that have a significant influence on neonatal mortality.

METHODS

A total of 5753 neonatal mortality-related data were obtained from Ethiopia Mini Demographic and Health Survey (2019) data. A frequency distribution to summarize the overall data and Binary Logistic Regression to identify the subset of significant risk factors for neonatal mortality were applied to analyze the data.

RESULTS

An estimated 36 per 1000 live children had died before the first 28 days, with the highest in the Benishangul Gumuz region (15.9%) and the lowest in Addis Ababa (2.4%). From the Binary logistic regression analysis, the odds ratio and 95% CI of age 25-34 (OR = 0.263, 95% CI: 0.106-0.653), Afar (OR = 0.384, 95% CI: 0.167-0.884), SNNPR (OR = 0.265, 95% CI: 0.098-0.720), Addis Ababa (OR = 5.741, 95% CI: 1.115-29.566), Urban (OR = 0.253, 95% CI: 0.090, 0.709), toilet facility (OR = 0.603, 95% CI: 0.404-0.900), single birth (OR = 0.261, 95% CI: 0.138-0.495), poorest (OR = 10.573, 95% CI: 2.166-51.615), poorer (OR = 19.573, 95% CI: 4.171-91.848), never breastfed (OR = 35.939, 95% CI: 25.193-51.268), public health delivery (OR = 0.302, 95% CI: 0.106-0.859), private health facility (OR = 0.269, 95% CI: 0.095-0.760).

CONCLUSION

All regional states of Ethiopia, specially Benishangul Gumuz, and the Somali region must take remedial actions on public health policy, design strategies to improve facilities, and improve the capacities of stakeholders living in their region toward those major factors affecting neonatal mortality in the country.

Subnational variations in electricity access and infant mortality: Evidence from Ghana

Objectives

The study investigated the relationship between electricity access and infant mortality at the subnational level in Ghana, controlling for correlates such as birth interval, children living with both parents, women's education, and income distribution.

Methods

The study employed a pooled cross-section regression approach using data from the Ghana Demographic and Health Survey (GDHS) for 10 administrative regions from 1993 to 2014. The GDHS is a detailed data set that provides comprehensive information on households and their socio-economic and demographic characteristics in Ghana.

Results

The results show that in regions with low incidence of infant mortality, a 10% improvement in electricity access reduces infant death by 11.8 per 1,000 live births, whereas in high mortality regions, improvement in electricity access has no impact on infant death. Birth interval reduces the risk of infant death in low mortality regions but not in high mortality regions. Children living with both parents have a high probability of survivorship in high mortality regions. Women's median years of education lowers the likelihood of infant death in high mortality regions but increases the likelihood in low mortality regions. Wealth distribution is inconsequential for infant death in low mortality regions, but in high mortality regions, both the wealthiest and the poorest experienced significant decline in infant death.

Conclusions

The findings underscore the fruitfulness of investigating the effects of electricity access and other correlates on infant mortality at the subnational level. The study recommends that the provision of reliable access to electricity is needed to improve infant mortality rates. However, policies that seek to improve access to reliable electricity should be implemented together with health infrastructure development policies, especially in the regions with high infant mortality rates, for electricity access to have the desired effect.

The effects of completion of continuum of care in maternal health services on adverse birth outcomes in Northwestern Ethiopia: a prospective follow-up study

Background

Globally, around 4 million babies die within the first month of birth annually with more than 3 million stillbirths. Of them, 99% of newborn deaths and 98% of stillbirths occur in developing countries. Despite giving priority to maternal health services, adverse birth outcomes are still major public health problems in the study area. Hence, a continuum of care (CoC) is a core key strategy to overcome those challenges. The study conducted on the effectiveness of continuum of care in maternal health services was scarce in developing countries and not done in the study area. We aimed to assess the effectiveness of continuum of care and determinants of adverse birth outcomes.

Methods

Community and health facility-linked prospective follow-up study designs were employed from March 2020 to January 2021 in Northwestern Ethiopia. A multistage clustered sampling technique was used to recruit 2198 pregnant women. Data were collected by using a semi-structured and pretested questionnaire. Collected data were coded, entered, cleaned, and analyzed by STATA 14. Multilevel logistic regression model was used to identify community and individual-level factors. Finally, propensity score matching was applied to determine the effectiveness of continuum of care.

Results

The magnitude of adverse birth outcomes was 12.4% (95% CI 12.2–12.7): stillbirth (2.8%; 95% CI 2.7–3.0), neonatal mortality (3.1%; 95% CI 2.9–3.2), and neonatal morbidity (6.8%; 95% CI 6.6–7.0). Risk factors were poor household wealth (AOR = 3.3; 95% CI 1.07–10.23), pregnant-related maternal complications during pregnancy (AOR = 3.29; 95% CI 1.68–6.46), childbirth (AOR = 6.08; 95% CI 2.36–15.48), after childbirth (AOR = 5.24; 95% CI 2.23–12.33), an offensive odor of amniotic fluid (AOR = 3.04; 95% CI 1.37–6.75) and history of stillbirth (AOR = 4.2; 95% CI 1.78–9.93). Whereas, receiving iron-folic acid (AOR = 0.44; 95% CI 0.14–0.98), initiating breastfeeding within 1 h (AOR = 0.22; 95% CI 0.10–0.50) and immunizing newborn (AOR = 0.33; 95% CI 0.12–0.93) were protective factors. As treatment effect, completion of continuum of care via time dimension (β = − 0.03; 95% CI − 0.05, − 0.01) and space dimension (β = − 0.03; 95% CI − 0.04, − 0.01) were significantly reduce perinatal death.

Conclusions

Adverse birth outcomes were high as compared with national targets. Completion of continuum of care is an effective intervention for reducing perinatal death. Efforts should be made to strengthen the continuum of care in maternal health services, iron supplementation, immunizing and early initiation of breastfeeding.

Adverse birth outcomes are a major public health problem and a big challenge in Ethiopia, particularly in the study area. They encompass stillbirth, neonatal death, and neonatal illness within 28 days after birth. Globally, about 4 million babies die within the first month of birth annually with more than 3 million stillbirths. Of these, about 99% of newborn deaths and 98% of stillbirths occur in developing countries. As a solution to overcome those problems, a continuum of care in maternal health services is a core strategy. Therefore, this study was planned to determine how effective continuum of care in maternal health service is in reducing perinatal death and factors contributing to the adverse birth outcomes. In this study, 2198 pregnant women were recruited and followed for 11 months. The health condition of women was frequently assessed and recorded during pregnancy, childbirth and the period until 42 days after childbirth, as well as the health condition of the babies until 28 days after the birth, the package of maternal health services received, and adverse birth outcomes. Among the 2198 pregnant women enrolled in the study, 248 women encountered adverse birth outcomes (52 had stillbirths, 58 had neonatal death and 138 had neonatal illness). Risk factors of adverse birth outcomes were a poor household wealth index quintile, pregnancy-related maternal complications, offensive odor amniotic fluid, and history of stillbirth. On the other hand, protective interventions against adverse birth outcomes were receiving iron supplementation during pregnancy, initiating breastfeeding within 1 h, and immunizing the newborn. Moreover, completions of continuum of care in maternal health services via time and space dimensions reduced perinatal death. In conclusion, neonatal and perinatal deaths were high in the study areas. Completions of continuum of care in maternal health services via time and space dimensions reduced perinatal death, neonatal death, and stillbirth. The results of this study can inform national health policymakers, maternal and child programmers, and other stakeholders to prioritize and strengthen protective intervention and continuum of care in maternal health services.

Individual and community-level determinants of cervical cancer screening in Zimbabwe: a multi-level analyses of a nationwide survey

BACKGROUND

Despite the benefits of cervical cancer (CC) screening to reduce the disease burden, uptake remains limited in developing countries. This study aims to assess the individual and community-level determinants of cervical cancer screening among women of reproductive age in Zimbabwe.

METHODS

We analyzed data collected from 400 communities from the 2015 Zimbabwe Demographic and Health Survey with a sample size of 9955 women aged 15-49 years. The descriptive statistics and multi-level regression models adjusted for potential covariates were performed to examine the association between individual, household and community-level factors and the uptake of cervical cancer screening in women.

RESULTS

The mean (SD) age of women in Zimbabwe using cervical cancer screening was 27.9 (9.9) years. A relatively small proportion of women, i.e., only 13.4% had ever screened for cervical cancer, with higher screening rates observed in the following sub-groups: middle aged women 31-49 years (odds ratio (OR) = 2.01; 95% confidence intervals (CI) 1.72-2.34), and currently working (OR = 1.35; 95% CI 1.17-1.55), those with health insurance (OR = 1.95; 95% CI 1.63-2.34), used modern contraceptives (OR = 1.51; 95% CI 1.22-1.86), exposed to multiple media (OR = 1.27; 95% CI 1.03-1.58), those living in communities that had a high predominance of women with favorable attitude towards Intimate Partner Violence (IPV) against women (OR = 1.21; 95% CI 1.04-1.41) and a non-poor wealth index (OR = 1.54; 95% CI 1.14-2.05).

CONCLUSIONS

Our data shows a significantly low prevalence of cervical cancer screening among reproductive age women in Zimbabwe. To increase the uptake of cervical cancer screening, there is an urgent need both to implement behavioral interventions targeted at women from low socio-economic groups and to advocate for universal health coverage that includes financial risk protection to help all women realize their right to health.

Causes of perinatal mortality and associated maternal factors in a tertiary referral hospital of Gandaki province of Nepal: a cross-sectional study from a hospital-based surveillance

BACKGROUND

Perinatal and neonatal death rates have decreased recently but it still poses a major challenge to the health system of Nepal. The study was conducted to explore the pattern and causes of perinatal deaths.

METHODS

This was a descriptive cross-sectional study conducted from September 2020 to June 2021 using the data of perinatal mortality of three years from June 15, 2017, to June 14, 2020. The demographic parameters of the mother consisted of maternal age, place of residence, ethnicity, antenatal care, the number of antenatal visits, gravida, gestational weeks, and the mode of delivery. The causes of death were categorized into fetal and early neonatal deaths. Fetal deaths were further classified as macerated stillbirth and fresh stillbirth. The attribution of the causes of deaths to fetal/neonatal and maternal conditions was done as per the guidelines of the WHO application of ICD-10 to deaths during the perinatal period.

RESULTS

There were a total of 145 perinatal deaths from 144 mothers among which 92 (63.5%) were males. Ten mothers (6.9%) had not sought even single antenatal care, whereas 32 (22.9%) had visited for antenatal care one to three times. At least one cause of death was identified in 114 (78.6%) and remained unknown in 31(21.4%) cases. Among the 28 cases of macerated stillbirths, the cause of death was not identified in 14 (50%), whereas preterm labor was attributed to the cause of death in four (14.3%). In 53 of the fresh stillbirths, intrapartum hypoxia was identified as the cause of death in 20 (37.7%) cases, preterm labor in nine (17%), and was left unknown in 15 (28.3%) cases. Among the 64 early neonatal deaths, prematurity was attributed as the cause of death in 32 (50%) cases, birth asphyxia, and infections each in 11 (17.2%).

CONCLUSIONS

The perinatal mortality surveillance system identified the causes of death in most of the cases in our observation. Prematurity was identified as the commonest cause of early neonatal deaths and preterm labor was the commonest cause responsible for perinatal deaths overall. The perinatal deaths should be investigated to establish exact causes of deaths which can be useful to develop prevention strategies.

Survival analysis of neonatal mortality in Ghana using three population-based surveys

Background

Neonatal mortality in many low-and middle-income countries (LMICs) remains high despite global efforts at addressing this challenge. Tackling neonatal death in LMICs is further complicated by lack of reliable data from individual countries in the region to inform effective context specific interventions. This study investigates the probability of neonatal survival and socio-demographic risk factors of neonatal mortality in Ghana.

Methods

Pooled data from three population-based surveys (N = 12,148) were analysed using multivariable Cox Proportional Hazards regression models.

Results

The risk of dying within the first 28 days of life was highest in the first week of life (early neonatal period), it then decreases sharply around the middle of the second week of life and remains low over the late neonatal period. Adjusted hazard ratios (HRs) showed that: rural residency (HR = 1.80, 95% CI: 1.15-2.75); birth order 2-3 (HR = 1.63, 95% CI: 1.10-2.42); birth order ≥7 (HR = 1.89, 95% CI: 1.07-3.33) increased the risk of neonatal death. Additionally, children born to women who were obese had higher risk of neonatal death (HR = 1.69, CI: 1.12-2.56) compared with those of women with optimal weight. Disparities in the risk of neonatal death by geographical regions were also found.

Conclusion

The risk of neonatal mortality is highest during the first week of life and it is socio-demographically patterned. The findings emphasise the need to tackle socio-demographic risk factors of neonatal mortality in order to achieve the Sustainable Development Goal 3, which is aimed at reducing neonatal mortality to 12 per 1000 live births by the year 2030.

Are maternal and child health initiatives helping to reduce under-five mortality in Ghana? Results of a quasi-experimental study using coarsened exact matching

BACKGROUND

Despite a 53 % decline in under-five mortality (U5M) worldwide during the period of the Millennium Development Goals (MDGs), U5M remains a challenge. Under-five mortality decline in Ghana is slow and not parallel with the level of coverage of child health interventions. The interventions promoted to improve child survival include early initiation of breastfeeding, clean postnatal care, and skilled delivery. This study sought to assess the effectiveness of these interventions on U5M in Ghana.

METHODS

A quasi-experimental study was conducted using secondary data of the 2008 and 2014 Ghana Demographic and Health Surveys. Coarsened Exact Matching and logistic regression were done. The interventions assessed were iron intake, early initiation of breastfeeding, clean postnatal care, hygienic disposal of stool, antenatal care visits, skilled delivery, intermittent preventive treatment of malaria in pregnancy, and tetanus toxoid vaccine.

RESULTS

There were 2,045 children under-five years and 40 (1.9 %) deaths in 2008. In 2014, the total number of children under-five years was 4,053, while deaths were 53(1.2 %). In 2014, children less than one month old formed 1.6 % of all children under-five years, but 47.8 % of those who died. Mothers who attended four or more antenatal care visits were 78.2 % in 2008 and 87.0 % in 2014. Coverage levels of improved sanitation and water connection in the home were among the lowest, with 11.6 % for improved sanitation and 7.3 % for water connection in the home in 2014. Fifty-eight (58), 1.4 %, of children received all the eight (8) interventions in 2014, and none of those who received all these interventions died. After controlling for potential confounders, clean postnatal care was associated with a 66% reduction in the average odds of death (aOR = 0.34, 95 %CI:0.14-0.82), while early initiation of breastfeeding was associated with a 62 % reduction in the average odds of death (aOR = 0.38, 95 % CI: 0.21-0.69).

CONCLUSIONS

Two (clean postnatal care and early initiation of breastfeeding) out of eight interventions were associated with a reduction in the average odds of death. Thus, a further decline in under-five mortality in Ghana will require an increase in the coverage levels of these two high-impact interventions.

Neonatal mortality rates, characteristics, and risk factors for neonatal deaths in Ghana: analyses of data from two health and demographic surveillance systems

Background

Reducing neonatal mortality rates (NMR) in developing countries is a key global health goal, but weak registration systems in the region stifle public health efforts.

Objective

To calculate NMRs, investigate modifiable risk factors, and explore neonatal deaths by place of birth and death, and cause of death in two administrative areas in Ghana.

Methods

Data on livebirths were extracted from the health and demographic surveillance systems in Navrongo (2004–2012) and Kintampo (2005–2010). Cause of death was determined from neonatal verbal autopsy forms. Univariable and multivariable logistic regression were used to analyse factors associated with neonatal death. Multiple imputations were used to address missing data.

Results

The overall NMR was 18.8 in Navrongo (17,016 live births, 320 deaths) and 12.5 in Kintampo (11,207 live births, 140 deaths). The annual NMR declined in both areas. 54.7% of the births occurred in health facilities. 70.9% of deaths occurred in the first week. The main causes of death were infection (NMR 4.3), asphyxia (NMR 3.7) and prematurity (NMR 2.2). The risk of death was higher among hospital births than home births: Navrongo (adjusted OR 1.14, 95% CI: 1.03–1.25, p = 0.01); Kintampo (adjusted OR 1.76, 95% CI: 1.55–2.00, p < 0.01). However, a majority of deaths occurred at home (Navrongo 61.3%; Kintampo 50.7%). Among hospital births dying in hospital, the leading cause of death was asphyxia; among hospital and home births dying at home, it was infection.

Conclusion

The NMR in these two areas of Ghana reduced over time. Preventing deaths by asphyxia and infection should be prioritised, centred respectively on improving post-delivery care in health facilities and subsequent post-natal care at home.

Neonatal mortality clustering in the central districts of Ghana

INTRODUCTION

Identifying high risk geographical clusters for neonatal mortality is important for guiding policy and targeted interventions. However, limited studies have been conducted in Ghana to identify such clusters.

OBJECTIVE

This study aimed to identify high-risk clusters for all-cause and cause-specific neonatal mortality in the Kintampo Districts.

MATERIALS AND METHODS

Secondary data, comprising of 30,132 singleton neonates between January 2005 and December 2014, from the Kintampo Health and Demographic Surveillance System (KHDSS) database were used. Verbal autopsies were used to determine probable causes of neonatal deaths. Purely spatial analysis was ran to scan for high-risk clusters using Poisson and Bernoulli models for all-cause and cause-specific neonatal mortality in the Kintampo Districts respectively with village as the unit of analysis.

RESULTS

The study revealed significantly high risk of village-clusters for neonatal deaths due to asphyxia (RR = 1.98, p = 0.012) and prematurity (RR = 5.47, p = 0.025) in the southern part of Kintampo Districts. Clusters (emerging clusters) which have the potential to be significant in future, for all-cause neonatal mortality was also identified in the south-western part of the Kintampo Districts.

CONCLUSIONS

Study findings showed cause-specific neonatal mortality clustering in the southern part of the Kintampo Districts. Emerging cluster was also identified for all-cause neonatal mortality. More attention is needed on prematurity and asphyxia in the identified cause-specific neonatal mortality clusters. The emerging cluster for all-cause neonatal mortality also needs more attention to forestall any formation of significant mortality cluster in the future. Further research is also required to understand the high concentration of prematurity and asphyxiated deaths in the identified clusters.

Evaluation of a package of continuum of care interventions for improved maternal, newborn, and child health outcomes and service coverage in Ghana: A cluster-randomized trial

BACKGROUND

In low- and middle-income countries (LMICs), the continuum of care (CoC) for maternal, newborn, and child health (MNCH) is not always complete. This study aimed to evaluate the effectiveness of an integrated package of CoC interventions on the CoC completion, morbidity, and mortality outcomes of woman-child pairs in Ghana.

METHODS AND FINDINGS

This cluster-randomized controlled trial (ISRCTN: 90618993) was conducted at 3 Health and Demographic Surveillance System (HDSS) sites in Ghana. The primary outcome was CoC completion by a woman-child pair, defined as receiving antenatal care (ANC) 4 times or more, delivery assistance from a skilled birth attendant (SBA), and postnatal care (PNC) 3 times or more. Other outcomes were the morbidity and mortality of women and children. Women received a package of interventions and routine services at health facilities (October 2014 to December 2015). The package comprised providing a CoC card for women, CoC orientation for health workers, and offering women with 24-hour stay at a health facility or a home visit within 48 hours after delivery. In the control arm, women received routine services only. Eligibility criteria were as follows: women who gave birth or had a stillbirth from September 1, 2012 to September 30, 2014 (before the trial period), from October 1, 2014 to December 31, 2015 (during the trial period), or from January 1, 2016 to December 31, 2016 (after the trial period). Health service and morbidity outcomes were assessed before and during the trial periods through face-to-face interviews. Mortality was assessed using demographic surveillance data for the 3 periods above. Mixed-effects logistic regression models were used to evaluate the effectiveness as difference in differences (DiD). For health service and morbidity outcomes, 2,970 woman-child pairs were assessed: 1,480 from the baseline survey and 1,490 from the follow-up survey. Additionally, 33,819 cases were assessed for perinatal mortality, 33,322 for neonatal mortality, and 39,205 for maternal mortality. The intervention arm had higher proportions of completed CoC (410/870 [47.1%]) than the control arm (246/620 [39.7%]; adjusted odds ratio [AOR] for DiD = 1.77; 95% confidence interval [CI]: 1.08 to 2.92; p = 0.024). Maternal complications that required hospitalization during pregnancy were lower in the intervention (95/870 [10.9%]) than in the control arm (83/620 [13.4%]) (AOR for DiD = 0.49; 95% CI: 0.29 to 0.83; p = 0.008). Maternal mortality was 8/6,163 live births (intervention arm) and 4/4,068 live births during the trial period (AOR for DiD = 1.60; 95% CI: 0.40 to 6.34; p = 0.507) and 1/4,626 (intervention arm) and 9/3,937 (control arm) after the trial period (AOR for DiD = 0.11; 95% CI: 0.11 to 1.00; p = 0.050). Perinatal and neonatal mortality was not significantly reduced. As this study was conducted in a real-world setting, possible limitations included differences in the type and scale of health facilities and the size of subdistricts, contamination for intervention effectiveness due to the geographic proximity of the arms, and insufficient number of cases for the mortality assessment.

CONCLUSIONS

This study found that an integrated package of CoC interventions increased CoC completion and decreased maternal complications requiring hospitalization during pregnancy and maternal mortality after the trial period. It did not find evidence of reduced perinatal and neonatal mortality.

TRIAL REGISTRATION

The study protocol was registered in the International Standard Randomised Controlled Trial Number Registry (90618993).

A Decision-Tree Approach to Assist in Forecasting the Outcomes of the Neonatal Brain Injury

Neonatal brain injury or neonatal encephalopathy (NE) is a significant morbidity and mortality factor in preterm and full-term newborns. NE has an incidence in the range of 2.5 to 3.5 per 1000 live births carrying a considerable burden for neurological outcomes such as epilepsy, cerebral palsy, cognitive impairments, and hydrocephaly. Many scoring systems based on different risk factor combinations in regression models have been proposed to predict abnormal outcomes. Birthweight, gestational age, Apgar scores, pH, ultrasound and MRI biomarkers, seizures onset, EEG pattern, and seizure duration were the most referred predictors in the literature. Our study proposes a decision-tree approach based on clinical risk factors for abnormal outcomes in newborns with the neurological syndrome to assist in neonatal encephalopathy prognosis as a complementary tool to the acknowledged scoring systems. We retrospectively studied 188 newborns with associated encephalopathy and seizures in the perinatal period. Etiology and abnormal outcomes were assessed through correlations with the risk factors. We computed mean, median, odds ratios values for birth weight, gestational age, 1-min Apgar Score, 5-min Apgar score, seizures onset, and seizures duration monitoring, applying standard statistical methods first. Subsequently, CART (classification and regression trees) and cluster analysis were employed, further adjusting the medians. Out of 188 cases, 84 were associated to abnormal outcomes. The hierarchy on etiology frequencies was dominated by cerebrovascular impairments, metabolic anomalies, and infections. Both preterms and full-terms at risk were bundled in specific categories defined as high-risk 75-100%, intermediate risk 52.9%, and low risk 0-25% after CART algorithm implementation. Cluster analysis illustrated the median values, profiling at a glance the preterm model in high-risk groups and a full-term model in the inter-mediate-risk category. Our study illustrates that, in addition to standard statistics methodologies, decision-tree approaches could provide a first-step tool for the prognosis of the abnormal outcome in newborns with encephalopathy.

Neonatal mortality in the central districts of Ghana: analysis of community and composition factors

BACKGROUND

Communities and their composition have an impact on neonatal mortality. However, considering the smallest health administrative units as communities and investigating the impact of these communities and their composition on neonatal mortality in Ghana have not been studied. Therefore, this study aimed to investigate the effect of community-, household- and individual-level factors on the risk of neonatal mortality in two districts in Ghana.

METHODS

This was a longitudinal study that used the Kintampo Health and Demographic Surveillance System as a platform to select 30,132 neonatal singletons with 634 deaths. Multilevel cox frailty model was used to examine the effect of community-, household- and individual-level factors on the risk of neonatal mortality.

RESULTS

Regarding individual-level factors, neonates born to mothers with previous adverse pregnancy (aHR = 1.38, 95% CI: 1.05-1.83), neonates whose mothers did not receive tetanus toxoid vaccine (aHR = 1.32, 95% CI: 1.08-1.60) and neonates of mothers with Middle, Junior High School or Junior Secondary School education (aHR = 1.30, 95% CI: 1.02-1.65) compared to mothers without formal education, had a higher risk of neonatal mortality. However, female neonates (aHR = 0.61, 95% CI: 0.51-0.73) and neonates whose mother had secondary education or higher (aHR = 0.37, 95% CI: 0.18-0.75) compared to those with no formal education had a lower risk of mortality. Neonates with longer gestation period (aHR = 0.95, 95% CI: 0.94-0.97) and those who were delivered at home (aHR = 0.56, 95% CI: 0.45-0.70), private maternity home (aHR = 0.45, 95% CI: 0.30-0.68) or health centre/clinic (aHR = 0.40, 95% CI: 0.26-0.60) compared to hospital delivery had lower risk of mortality. Regarding the household-level, neonates belonging to third quintile of the household wealth (aHR = 0.70, 95% CI: 0.52-0.94) and neonates belonging to households with crowded sleeping rooms (aHR = 0.91, 95% CI: 0.85-0.97) had lower risk of mortality.

CONCLUSION

The findings of the study suggest the risk of neonatal mortality at the individual- and household-levels in the Kintampo Districts. Interventions and strategies should be tailored towards the high-risk groups identified in the study.

Postnatal care utilisation among women in rural Ghana: analysis of 2014 Ghana demographic and health survey

Background

Maternal mortality is high in Ghana, averaging 310 maternal deaths per 100,000 live births in 2017. This is partly due to inadequate postnatal care especially among rural communities. Ghana can avert the high maternal deaths if women meet the World Health Organisation’s recommended early postnatal care check-up. Despite the association between geographical location and postnatal care utilisation, no study has been done on determinants of postnatal care among rural residents in Ghana. Therefore, this study determined the prevalence and correlates of postnatal care utilization among women in rural Ghana.

Methods

The study utilised women’s file of the 2014 Ghana Demographic and Health Survey (GDHS). Following descriptive computation of the prevalence, binary logistic regression was fitted to assess correlates of postnatal care at 95% confidence interval. The results were presented in adjusted odds ratio (AOR). Any AOR less than 1 was interpreted as reduced likelihood of PNC attendance whilst AOR above 1 depicted otherwise. All analyses were done using Stata version 14.0.

Results

The study revealed that 74% of the rural women had postnatal care. At the inferential level, women residing in Savanna zone had higher odds of postnatal care compared to those in the Coastal zone [AOR = 1.80, CI = 1.023–3.159], just as among the Guan women as compared to the Akan [AOR = 7.15, CI = 1.602–31.935]. Women who were working were more probable to utilise postnatal care compared to those not working [AOR = 1.45, CI = 1.015–2.060]. Those who considered distance as unproblematic were more likely to utilise postnatal care compared to those who considered distance as problematic [AOR = 1.63, CI = 1.239–2.145].

Conclusions

The study showed that ethnicity, ecological zone, occupation and distance to health facility predict postnatal care utilisation among rural residents of Ghana. The study points to the need for government to increase maternal healthcare facilities in rural settings in order to reduce the distance covered by women in seeking postnatal care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03497-4.

Individual-and community-level determinants of neonatal mortality in the emerging regions of Ethiopia: a multilevel mixed-effect analysis

BACKGROUND

Unlike infant and child mortality, neonatal mortality has declined steadily in Ethiopia. Despite the large-scale investment made by Ethiopia to improve the health of newborns and infants, it is among the regions with the highest burden of neonatal mortality. Although there are studies done on neonatal mortality in different areas of Ethiopia, as to our search of pieces of literature there is no study in Emerging regions of the country. Therefore, this study aimed to investigate the individual and community-level determinants of neonatal mortality in the Emerging regions of Ethiopia.

METHODS

Using the 2016 Ethiopian Demographic and Health Survey (EDHS) data, secondary data analysis was done. A total weighted sample of 4238 live births in Emerging regions were included for the final analysis. A multilevel binary logistic regression was fitted to identify the significant determinants of neonatal mortality. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), Proportional Change in Variance (PCV) were used for assessing the clustering effect, and deviance for model comparison. Variables with a p-value < 0.2 in the bi-variable analysis were considered in the multivariable analysis. In the multivariable multilevel binary logistic regression analysis, Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare statistically significant determinants of neonatal mortality.

RESULTS

The neonatal mortality rate in Emerging regions of Ethiopia was 34.9 per 1000 live births (95% CI: 29.8, 40.9). Being born to a mother who had no formal education (AOR = 1.79, 95% CI: 1.12, 2.88), being born to a mother who did not participate in making health care decisions (AOR = 1.25, 95% CI: 1.14, 1.79), and being twin birth (AOR = 6.85, 95% CI: 3.69, 12.70) were significantly associated with higher odds of neonatal mortality. On the other hand, being female (AOR = 0.67, 95% CI: 0.47, 0.95), having 1-3 Antenatal Care (ANC) visits (AOR = 0.34, 95% CI: 0.15, 0.74), high community media exposure (AOR = 0.64, 95% CI: 0.41, 0.98), and preceding birth interval of two to 4 years (AOR = 0.38, 95% CI: 0.24, 0.58) were significantly associated with lower odds of neonatal mortality.

CONCLUSION

Neonatal mortality in Emerging regions of Ethiopia was unacceptably high. Maternal education, women's autonomy in making decisions for health care, sex of a child, type of birth, preceding birth interval, ANC visit, and community media exposure were found significant determinants of neonatal mortality. Therefore, empowering women in making health care decisions and increasing access to mass media play a major role in reducing the incidence of neonatal mortality in Emerging regions of Ethiopia.

Examining the Effect of Geographic Region of Residence on Childhood Malnutrition in Uganda

OBJECTIVES

In our study, we examine how geographic region of residence may predict childhood malnutrition, expressed as stunting, wasting and underweight, among children under the age of 5 years in Uganda.

METHODS

Using data from the 2016 Uganda Demographic and Health Survey, we performed an incremental multivariate multilevel mixed-effect modelling to examine the effect of a child, parental and household factors on the association between region of residence and each indicator of childhood malnutrition.

RESULTS

Approximately 28%, 3% and 9% of children under age 5 suffered from stunting, wasting and underweight, respectively. The bivariate result shows that the proportion of children suffering from stunting and underweight was relatively lower in the Kampala region compared with the other regions. With the exception of the Northern region (6.44%), wasting was higher (4.12%) among children in the Kampala region. Children in the other regions were more likely to experience stunting and underweight. When controlling for child, parent and household factors, children in the other regions were less likely to suffer from underweight and stunting, compared with those in Kampala region. Children in the other regions, except the Northern region, were less likely to be wasted compared with those in Kampala region.

CONCLUSION

Our finding suggests that child, parental and household characteristics have effects on the association between region of residence and childhood malnutrition. Addressing individual and household socioeconomic disparities may be vital in tackling regional differences in childhood malnutrition.

Stigma toward small babies and their mothers in Ghana: A study of the experiences of postpartum women living with HIV

Infants born to HIV-infected mothers are more likely to be low birthweight (LBW) than other infants, a condition that is stigmatized in many settings worldwide, including sub-Saharan Africa. Few studies have characterized the social-cultural context and response to LBW stigma among mothers in sub-Saharan Africa or explored the views of women living with HIV (WLHIV) on the causes of LBW. We purposively sampled thirty postpartum WLHIV, who had given birth to either LBW or normal birthweight infants, from two tertiary hospitals in Accra, Ghana. Using semi-structured interviews, we explored women's understanding of the etiology of LBW, and their experiences of caring for a LBW infant. Interviews were analyzed using interpretive phenomenology. Mothers assessed their babies' smallness based on the baby's size, not hospital-recorded birthweight. Several participants explained that severe depression and a loss of appetite, linked to stigma following an HIV diagnosis during pregnancy, contributed to infants being born LBW. Women with small babies also experienced stigma due to the newborns' "undesirable" physical features and other people's unfamiliarity with their size. Consequently, mothers experienced blame, reluctance showing the baby to others, and social gossip. As a result of this stigma, women reported self-isolation and depressive symptoms. These experiences were layered on the burden of healthcare and infant feeding costs for LBW infants. LBW stigma appeared to attenuate with increased infant weight gain. A few of the women also did not breastfeed because they thought their baby's small size indicated pediatric HIV infection. Among WLHIV in urban areas in Ghana, mother and LBW infants may experience LBW-related stigma. A multi-component intervention that includes reducing LBW incidence, treating antenatal depression, providing psychosocial support after a LBW birth, and increasing LBW infants' weight gain are critically needed.

Incidence of neonatal mortality and its predictors among live births in Ethiopia: Gompertz gamma shared frailty model

Background

Neonatal mortality remains a serious public health concern in developing countries including Ethiopia. Ethiopia is one of the countries with the highest neonatal mortality in Africa. However, there is limited evidence on the incidence and predictors of neonatal mortality at the national level. Therefore, this study aimed to investigate the incidence of neonatal mortality and its predictors among live births in Ethiopia. Investigating the incidence and predictors of neonatal mortality is essential to design targeted public health interventions to reduce neonatal mortality.

Methods

A secondary data analysis was conducted based on the 2016 Ethiopian Demographic and Health Survey (EDHS) data. A total weighted sample of 11,022 live births was included in the analysis. The shared frailty model was applied since the EDHS data has hierarchical nature, and neonates are nested within-cluster, and this could violate the independent and equal variance assumption. For checking the proportional hazard assumption, Schoenfeld residual test was applied. Akakie Information Criteria (AIC), Cox-Snell residual test, and deviance were used for checking model adequacy and for model comparison. Gompertz gamma shared frailty model was the best-fitted model for this data since it had the lowest deviance, AIC value, and the Cox-Snell residual graph closet to the bisector. Variables with a p-value of less than 0.2 were considered for the multivariable Gompertz gamma shared frailty model. In the multivariable Gompertez gamma shared frailty model, the Adjusted Hazard Ratio (AHR) with a 95% confidence interval (CI) was reported to identify significant predictors of neonatal mortality.

Results

Overall, the neonatal mortality rate in Ethiopia was 29.1 (95% CI: 26.1, 32.4) per 1000 live births. In the multivariable Gompertz gamma shared frailty model; male sex (AHR = 1.92, 95% CI: 1.52, 2.43), twin birth (AHR = 5.22, 95% CI: 3.62, 7.53), preceding birth interval less than 18 months (AHR = 2.07, 95% CI: 1.51, 2.85), small size at birth (AHR = 1.64, 95% CI: 1.24, 2.16), large size at birth (AHR = 1.53, 95% CI: 1.16, 2.01) and did not have Antenatal Care (ANC) visit (AHR = 2.10, 95% CI: 1.44, 3.06) were the significant predictors of neonatal mortality.

Conclusion

Our study found that neonatal mortality remains a public health problem in Ethiopia. Shorter birth interval, small and large size at birth, ANC visits, male sex, and twin births were significant predictors of neonatal mortality. These results suggest that public health programs that increase antenatal care service utilization should be designed to reduce neonatal mortality and special attention should be given for twin births, large and low birth weight babies. Besides, providing family planning services for mothers to increase birth intervals and improving accessibility and utilization of maternal health care services such as ANC is crucial to improve neonatal survival.

Factors associated with HPV vaccination uptake in Uganda: a multi-level analysis

BACKGROUND

The cervical cancer burden in Uganda is high amidst low uptake of HPV vaccination. Identification of individual and community factors associated with HPV vaccination are imperative for directed interventions. Conversely, in most Low and Middle Income Countries (LMICs) including Uganda this problem has not been sufficiently studied as the influence of individual and contextual determinants remains undetermined in spite of their substantial effect on HPV vaccine uptake. The aim of the study was to identify individual (school attendance status, age of girls, ethnicity, and amount of media exposure) and community (socioeconomic disadvantages) factors associated with HPV vaccination.

METHODS

Based on a modified conceptual framework for health care utilization, hierarchical modelling was used to study 6093 girls, aged 10-14 years (level 1), nested within 686 communities (level 2) in Uganda by analyzing data from the 2016 Uganda Demographic and Health Survey.

RESULTS

Majority (78%) of the girls had not been vaccinated. A number of both individual and community factors were significantly associated with HPV vaccination. The Odds of HPV vaccination were higher among girls age; 11, 13, and 14 compared to girls age 10 years, attending school compared to girls not attending school, who were; foreigners, Iteso, Karamajong, Banyoro, Basoga, and other tribe compared to Baganda, living in families with 1-8 members compared to those living in families with 9 or more members and middle social economic status compared to poor wealth quintile.

CONCLUSIONS

Both individual and community factors show a noticeable effect on HPV vaccination. If higher vaccination rates are to be achieved in Uganda, these factors should be addressed. Strategies aimed at reaching younger girls, street children, out of school girls, and girls with lower SES should be embraced in order to achieve high vaccination uptake.

Factors associated with HPV vaccination uptake in Uganda: a multi-level analysis

BACKGROUND

The cervical cancer burden in Uganda is high amidst low uptake of HPV vaccination. Identification of individual and community factors associated with HPV vaccination are imperative for directed interventions. Conversely, in most Low and Middle Income Countries (LMICs) including Uganda this problem has not been sufficiently studied as the influence of individual and contextual determinants remains undetermined in spite of their substantial effect on HPV vaccine uptake. The aim of the study was to identify individual (school attendance status, age of girls, ethnicity, and amount of media exposure) and community (socioeconomic disadvantages) factors associated with HPV vaccination.

METHODS

Based on a modified conceptual framework for health care utilization, hierarchical modelling was used to study 6093 girls, aged 10-14 years (level 1), nested within 686 communities (level 2) in Uganda by analyzing data from the 2016 Uganda Demographic and Health Survey.

RESULTS

Majority (78%) of the girls had not been vaccinated. A number of both individual and community factors were significantly associated with HPV vaccination. The Odds of HPV vaccination were higher among girls age; 11, 13, and 14 compared to girls age 10 years, attending school compared to girls not attending school, who were; foreigners, Iteso, Karamajong, Banyoro, Basoga, and other tribe compared to Baganda, living in families with 1-8 members compared to those living in families with 9 or more members and middle social economic status compared to poor wealth quintile.

CONCLUSIONS

Both individual and community factors show a noticeable effect on HPV vaccination. If higher vaccination rates are to be achieved in Uganda, these factors should be addressed. Strategies aimed at reaching younger girls, street children, out of school girls, and girls with lower SES should be embraced in order to achieve high vaccination uptake.

Incidence and predictors of neonatal mortality among neonates admitted in Amhara regional state referral hospitals, Ethiopia: prospective follow up study

BACKGROUND

Globally, about 2.7 million neonates die annually and more than 99% of these deaths happened in developing countries. Although most neonatal deaths are preventable and attempts had been taken to tackle these deaths, an aggregate of 30 neonatal deaths per 1000 live births had been reported in Ethiopia. In this regard, identifying the predictors could be an important step. However, evidence on the incidence and predictors of neonatal mortality has been limited in Ethiopia, in the study area in particular. Even the available studies were limited in scope and were retrospective or cross section in nature. Thus, this study is aimed at assessing the incidence and predictors of neonatal mortality among neonates admitted in Amhara regional state referral hospitals, Ethiopia..

METHOD

A multi center prospective follow up study was conducted on 612 neonates admitted in Amhara region referral hospitals from July 01 to August 30, 2018. A simple random sampling technique was used to select three of all referral hospitals in the study settings and all neonates admitted in the selected hospitals were included. Data were entered into Epi info version 7.0 and exported to STATA 14.0 for analysis. Cox proportional hazard regression model was fitted to identify predictors of neonatal mortality. Crude and Adjusted hazard ratio with 95% confidence interval was computed and variables' statistical significance was declared based on its AHR with 95% CI and p-value ≤0.05.

RESULT

Overall, 144 (18.6%) neonates died with a total person-time of 4177.803 neonate-days which is equivalent to the neonatal mortality rate of 186 per 1000 admitted neonates with 95% CI (157,219). The incidence rate of neonatal mortality was 27 per 1000 admitted neonates with 95%CI (23, 33). Maternal age ≥ 35 years (AHR = 2.60; 95%CI: 1.44, 4.72), mothers unable to read and write (AHR = 1.40; 95%CI: 1.23, 2.44), multiple pregnancy (AHR = 3.96; 95%CI: 2.10, 7.43) and positive maternal HIV status (AHR = 6.57; 95%CI: 2.53, 17.06) were predictors of neonatal mortality.

CONCLUSION

In this study, the neonatal mortality rate was higher than the national figure. Its most predictors were found to be modifiable. Thus, the stakeholders would better consider the aforementioned predictors to decrease this higher burden.

Trends for Neonatal Deaths in Nepal (2001-2016) to Project Progress Towards the SDG Target in 2030, and Risk Factor Analyses to Focus Action

Introduction

Nepal has made considerable progress on improving child survival during the Millennium Development Goal period, however, further progress will require accelerated reduction in neonatal mortality. Neonatal survival is one of the priorities for Sustainable Development Goals 2030. This paper examines the trends, equity gaps and factors associated with neonatal mortality between 2001 and 2016 to assess the likelihood of Every Newborn Action Plan (ENAP) target being reached in Nepal by 2030.

Methods

This study used data from the 2001, 2006, 2011 and 2016 Nepal Demographic and Health Surveys. We examined neonatal mortality rate (NMR) across the socioeconomic strata and the annual rate of reduction (ARR) between 2001 and 2016. We assessed association of socio-demographic, maternal, obstetric and neonatal factors associated with neonatal mortality. Based on the ARR among the wealth quintile between 2001 and 2016, we made projection of NMR to achieve the ENAP target. Using the Lorenz curve, we calculated the inequity distribution among the wealth quintiles between 2001 and 2016.

Results

In NDHS of 2001, 2006, 2011 and 2016, a total of 8400, 8600, 13,485 and 13,089 women were interviewed respectively. There were significant disparities between wealth quintiles that widened over the 15 years. The ARR for NMR declined with an average of 4.0% between 2001 and 2016. Multivariate analysis of the 2016 data showed that women who had not been vaccinated against tetanus had the highest risk of neonatal mortality (adjusted odds ratio [AOR] 3.38; 95% confidence interval [CI] 1.20–9.55), followed by women who had no education (AOR 1.87; 95% CI 1.62–2.16). Further factors significantly associated with neonatal mortality were the mother giving birth before the age of 20 (AOR 1.76; CI 95% 1.17–2.59), household air pollution (AOR 1.37; CI 95% 1.59–1.62), belonging to a poorest quintile (AOR 1.37; CI 95% 1.21–1.54), residing in a rural area (AOR 1.28; CI 95% 1.13–1.44), and having no toilet at home (AOR 1.21; CI 95% 1.06–1.40). If the trend of neonatal mortality rate of 2016 continues, it is projected that the poorest family will reach the ENAP target in 2067.

Conclusions

Although neonatal mortality is declining in Nepal, if the current trend continues it will take another 50 years for families in the poorest group to attain the 2030 ENAP target. There are different factors associated with neonatal mortality, reducing the disparities for maternal and neonatal care will reduce mortality among the poorest families.

Electronic supplementary material

The online version of this article (10.1007/s10995-019-02826-0) contains supplementary material, which is available to authorized users.

Neonatal mortality in the neonatal intensive care unit of Debre Markos referral hospital, Northwest Ethiopia: a prospective cohort study

BACKGROUND

Neonatal mortality remains a serious global public health problem, but Sub-Saharan Africa (SSA), in particular, is largely affected. Current evidence on neonatal mortality is essential to inform programs and policies, yet there is a scarcity of information concerning neonatal mortality in our study area. Therefore, we conducted this prospective cohort study to determine the incidence and predictors of neonatal mortality at Debre Markos Referral Hospital, Northwest Ethiopia.

METHODS

This institutionally-based prospective cohort study was undertaken among 513 neonates admitted to the neonatal intensive care unit of Debre Markos Referral Hospital between December 1st, 2017 and May 30th, 2018. All newborns consecutively admitted to the neonatal intensive care unit during the study period were included. An interviewer administered a questionnaire with the respective mothers. Data were entered using Epi-data™ Version 3.1 and analyzed using STATA™ Version 14. The neonatal survival time was estimated using the Kaplan-Meier survival curve, and the survival time between different categorical variables were compared using the log rank test. Both bi-variable and multivariable Cox-proportional hazard regression models were fitted to identify independent predictors of neonatal mortality.

RESULTS

Among a cohort of 513 neonates at Debre Markos Referral Hospital, 109 (21.3%) died during the follow-up time. The overall neonatal mortality rate was 25.8 deaths per 1, 000 neonate-days (95% CI: 21.4, 31.1). In this study, most (83.5%) of the neonatal deaths occurred in the early phase of neonatal period (< 7 days post-partum). Using the multivariable Cox-regression analysis, being unemployed (AHR: 1.6, 95% CI: 1.01, 2.6), not attending ANC (AHR: 1.9, 95% CI: 1.01, 3.5), not initiating exclusive breastfeeding (AHR: 1.7, 95% CI: 1.02, 2.7), neonatal admission due to respiratory distress syndrome (AHR: 2.0, 95% CI: 1.3, 3.1), and first minute Apgar score classification of severe (AHR: 2.1, 95% CI: 1.1, 3.9) significantly increased the risk of neonatal mortality.

CONCLUSION

In this study, we found a high rate of early neonatal mortality. Factors significantly linked with increased risk of neonatal mortality included: unemployed mothers, not attending ANC, not initiating exclusive breastfeeding, neonates admitted due to respiratory distress syndrome, and first minute Apgar score classified as severe.

Neonatal survival and determinants of mortality in Aroresa district, Southern Ethiopia: a prospective cohort study

Background

The first 28 days of aliveness are the biggest challenge mentioned for the continuity of life for children. In Ethiopia, despite a significant reduction in under-five mortality during the last 15 years, neonatal mortality remains a public health problem accounting for 47% of under-five mortality. Understanding neonatal survival and risk factors for neonatal mortality could help devising tailored interventions. The aim of this study was to determine the neonatal survival and risk factors for neonatal mortality in Aroresa district, Southern Ethiopia.

Methods

A community based prospective follow up study was conducted among a cohort of term pregnant mothers and neonates delivered from January 1/2018 to March 30/2018. A total of 586 term pregnant mothers were selected with a multistage sampling technique and 584 neonates were followed-up for a total of 28 days, with 12 twin pairs. Data were coded, entered cleaned and analyzed using SPSS version 22. Kaplan–Meier survival curve was used to show pattern of neonatal death in 28 days. Independent and adjusted relationships of different predictors with neonates’ survival were assessed with Cox regression model. The risk of mortality was explored and presented with hazard ratio and 95% confidence interval and P-value less than 0.05 were considered as significant.

Result

The overall neonatal mortality was 41 per 1000 live births. Hazards of neonatal mortality was high for neonates with complications (AHR = 3.643; 95% CI, 1.36–9.77), male neonates (AHR = 2.71; 95% CI, 1.03–7.09), neonates that mothers perceived to be small (AHR = 3.46; 95% CI, 1.119–10.704), neonates who had initiated exclusive breast feeding (EBF) after 1 h (AHR = 3.572; 95% CI, 1.255–10.165) and mothers who had no postnatal care (AHR = 3.07; 95% CI, 1.16–8.12).

Conclusion

Neonatal mortality in the study area was 4.1% which was high and immediate action should be taken towards achieving the Sustainable Development Goals. To improve neonatal survival, high impact interventions such as promotion of maternal service utilization, essential newborn care and early initiation of exclusive breast feeding were recommended.

Prevalence and factors associated with neonatal mortality among neonates hospitalized at the National Hospital Nouakchott, Mauritania

Introduction

Neonatal mortality remains a significant public health burden worldwide, with about 4 million deaths per year. To provide evidence for the implementation of prevention measures aimed at the reduction of neonatal mortality, we performed a study on factors associated with neonatal mortality at the Referral Hospital in Nouakchott, Mauritania.

Methods

We conducted a cross-sectional study between January 2013 and December 2013 and included neonatal patients hospitalized at the National Referral Hospital (NRH). Data were collected by reviewing the medical charts and through questionnaires administered to the parents.

Results

Two hundred and thirty-two (34.7%) of the 669 neonates included in the study died; 159 (71.3%) of deaths occurred during the first six days of life. Most neonates that died were born outside the hospital and admitted to NRH after birth (71.7%; 142/198). About 1/3 were transferred from other parts of the country outside of Nouakchott. Thirty (13.4%) of deaths were neonates born from teenage mothers. In bivariate analysis teenage mothers (RR=1.54; 95% CI: 1.15-2.05; p = 0.004), illiteracy of father (1.61; 1.13-23.0; p = 0.007), birth outside NRH (1.65; 1.28-2.13; p < 0.0001), low gestational age (3.28; 2.40-5.50; p < 0.0001), and low body temperature at admission (1.42; 1.11-1.83; p < 0.004) were significantly associated with neonatal death. In logistic regression analysis, low birth weight (adjusted odds ratio = 3.91; 95% confidence interval 1.69-9.05; p = 0.001), hypothermia (2.40; 1.12-5.14; p = 0.025), and birth outside the NRH (2.13; 1.02-4.45; p = 0.044) were independently associated with neonatal deaths.

Conclusion

Neonatal mortality remains a significant burden in Mauritania. We identified different socioeconomic and clinical risk factors indicating the need for more intensified prenatal care and improved transport of high risk neonates, especially in the regions outside the capital.

A qualitative appraisal of stakeholders' perspectives of a community-based primary health care program in rural Ghana

Background

The Ghana Community-based Health Planning and Services (CHPS) initiative is a national strategy for improving access to primary health care services for underserved communities. Following a successful trial in the North Eastern part of the country, CHPS was adopted as Ghana’s flagship programme for achieving the Universal Health Coverage. Recent empirical evidence suggests, however, that scale-up of CHPS has not necessarily replicated the successes of the pilot study. This study examines the community’s perspective of the performance of CHPS and how the scale up could potentially align with the original experimental study.

Method

Applying a qualitative research methodology, this study analysed transcripts from 20 focus group discussions (FGDs) in four functional CHPS zones in separate districts of the Northern and Volta Regions of Ghana to understand the community’s assessment of CHPS. The study employed the thematic analysis to explore the content of the CHPS service provision, delivery and how community members feel about the service. In addition, ordinary least regression model was applied in interpreting 126 scores consigned to CHPS by the study respondents.

Results

Two broad areas of consensus were observed: general favourable and general unfavourable thematic areas. Favourable themes were informed by approval, appreciation, hard work and recognition of excellent services. The unfavourable thematic area was informed by rudeness, extortion, inappropriate and unprofessional behaviour, lack of basic equipment and disappointments. The findings show that mothers of children under the age of five, adolescent girls without children, and community leaders generally expressed favourable perceptions of CHPS while fathers of children under the age of five and adolescent boys without children had unfavourable expressions about the CHPS program. A narrow focus on maternal and child health explains the demographic divide on the perception of CHPS. The study revealed wide disparities in actual CHPS deliverables and community expectations.

Conclusions

A communication gap between health care providers and community members explains the high and unrealistic expectations of CHPS. Efforts to improve program acceptability and impact should address the need for more general outreach to social networks and men rather than a sole focus on facility-based maternal and child health care.

Knowledge about Neonatal Danger Signs and Associated Factors among Mothers Attending Immunization Clinic at Arba Minch General Hospital, Southern Ethiopia: A Cross-Sectional Study

Background

The first 28 days of life (the neonatal period) constitute the most vulnerable time for a child's survival. Overall 2.7 million neonatal deaths were stated by the 2015 global report of neonatal mortality and they account for 45% of under-five deaths. Sub-Saharan Africa remains the region with the highest risk of death in the first month of life and is among the regions showing the least progress in reducing neonatal mortality in the world. Ethiopia, as part of sub-Saharan Africa, also shares the greatest risk of neonatal death. A recent report in Ethiopia showed that neonatal mortality was 29 deaths per 1,000 live births. Therefore, the signs that suggest the onset of severe illness which leads to death and their contributing factors should be identified. The aim of the study was to assess knowledge about neonatal danger signs and associated factors among mothers attending immunization clinic at Arba Minch General Hospital.

Method

Institution-based cross-sectional study design was employed from Feb to April 2018. Systematic sampling technique was used to select a total of 345 mother-child pairs. A pretested, structured, and interviewer-administered questionnaire was used to collect data. Data were entered using Epidata version 3.1 and analyzed using SPSS version 20. Bivariate and multivariable analysis were carried out using binary logistic regression to check and test the association between dependent and explanatory variables. Model fitness was checked by Hosmer-Lemeshow goodness of fit test.

Result

Nearly two-fifths (40.9%) of all mothers had good knowledge about neonatal danger signs (95% CI; 35.7, 46.4). Close to thirty-three percent of mothers identified child's body hotness (fever) as a neonatal danger sign. Maternal educational status (AOR: 5.64; 95% CI: 1.68, 18.95) and attendance of postnatal care (AOR: 2.64; 95% CI: 1.36, 5.15) were significantly associated with maternal knowledge about neonatal danger signs in multivariable analysis.

Conclusion

Even though considerable improvement has been achieved over the past decades as a result of expanded coverage of maternal and childcare services, still there are a significant number of mothers who have limited knowledge about neonatal danger signs. Therefore, interventional strategies that stress strengthening maternal education and ANC follow-up should be extended.

Estimation of a Neonatal Health Production Function for Iran: Secondary Analysis of Iran's Multiple Indicator Demographic and Health Survey 2010

BACKGROUND

Despite constant decrease in rate of neonatal mortality, the rate is still higher than that of other under-five children. One of the first steps towards reduction of neonatal mortality is to identify its determinants using health production function. The aim of the present study was to estimate neonatal health production function for Iran.

METHODS

In this cross-sectional study, Iranian Multiple Indicator Demographic and Health Survey (Ir-MIDHS) 2010 was used. Four categories of socioeconomic, mother, neonatal demographic and healthcare system factors were entered into the Binomial Logistic Regression model to estimate neonate health production function. Households' economic status was constructed using principal component analysis.

RESULTS

History of abortion/stillbirth had the highest significant positive impact on odds of neonatal mortality (odds ratio=1.98; 95 % CI=1.55-2.75), indicating that neonates of mothers with such a history had 1.98 times higher chance of death compared to other neonates. Moreover, odds ratio of neonatal death for the poorest quintiles was 1.70 (95 % CI=1.08-2.74), indicating that by moving from the poorest quintile to the richest one, the odds of being alive for neonates increased up to 70%. However, skilled birth attendant decreased the chance of death up to 58% (odds ratio=0.58; 95 % CI=0.36-0.93).

CONCLUSION

Considering the most significant inputs of neonatal health production function in Iran, improvement of economic status of households, provision of appropriate care services for mothers, and improvement of delivery care provided by trained personnel, could be priorities for health policymakers to act and reduce neonatal mortality in Iran.

Socio-demographic determinants of post-caesarean neonatal mortality in Nigeria

Neonatal mortality remains a major health concern in sub-Saharan Africa. We conducted a cross-sectional, population-based, retrospective analysis of 31,828 births between 2009 and 2013 to explore the relationship between socio-demographic variables and post-caesarean neonatal mortality in Nigeria. We calculated the caesarean section (CS) rates, the odds of having a CS and post-CS neonatal mortality within variable subgroups. The national average CS rate was 2.1%. The CS rate increased with the increasing wealth index, educational attainment, maternal age, higher among urban residents and among those from the Southern part of Nigeria. The odds of experiencing post-CS neonatal mortality was significantly higher in the Northern regions (OR 2.51-3.17) among rural residents (OR 2.63), economically poorer groups (OR 3.68), with no formal education (OR 3.01) and older maternal age groups (OR 1.76-2.0). Efforts to increase the rate and quality of peripartum services delivered to pregnant women are needed among both advantaged and disadvantaged groups.Impact statementWhat is already known on this subject? In sub-Saharan Africa, a caesarean section is a lifesaving procedure for both the women and their unborn babies. The neonatal mortalities that occur following the procedure need to be explored and quantified.What do the results of this study add? Socioeconomic differentials exist in the access to a caesarean section. However, these differentials have a limited influence on neonatal mortality post-caesarean section in Nigeria.What are the implications of these findings for clinical practice and/or further research? While socio-demographic variables influence access to health care services, timeliness and quality of care are factors to be considered in ensuring societies get the benefits of caesarean section as a lifesaving procedure.

Perinatal Mortality in Sub-Saharan Africa: A Meta-Analysis of Demographic and Health Surveys

Background:

Sub-Saharan Africa (SSA) has one of the highest levels of perinatal mortality globally. However, there are sub-regional and country-specific disparities in its distribution.

Objective:

The aim of this study was to undertake a meta-analysis of demographic and health surveys to quantify perinatal mortality rate within sub-Saharan Africa and to depict sub-regional and country-specific differences.

Methods:

This study used cross-sectional data from the most recent demographic and health surveys (2010–2016) conducted in 21 sub-Saharan African countries. The countries were grouped into four sub-regions (Eastern Africa, Western Africa, Southern Africa and Central Africa), and a meta-analysis was conducted to estimate perinatal mortality rate within each of the sub-regions. Significant heterogeneity was detected among the various surveys (I² > 50%), hence a random effect model was used. Sensitivity analysis was also performed to examine the effects of outliers. Perinatal mortality was defined as pregnancy losses occurring after seven completed months of gestation (stillbirths) and deaths to live births within the first seven days of life (early neonatal deaths).

Findings:

The pooled estimate for perinatal mortality rate per 1000 births across 21 countries in the four sub-regions of SSA was 34.7 (95% CI: 32.6, 36.8). Eastern Africa reported 34.5 (95% CI: 32.2, 36.8), with the highest rate observed in Tanzania [39.5 (95% CI: 35.8, 43.4)]. Western Africa reported 35.7 (95% CI: 32.2, 39.3), with the highest rate observed in Nigeria [40.9 (95% CI: 38.3, 43.2)]. Southern Africa reported 30.3 (95% CI: 26.5, 34.0), with the highest rate observed in Lesotho [49.6 (95% CI: 42.3, 57.8)]. Central Africa reported 30.7 (95% CI: 28.0, 33.3), with the highest rate observed in Equatorial Guinea [37.3 (95% CI: 30.5, 45.1)].

Conclusions:

To reduce mortality in the perinatal period, interventions should focus on improving access to high quality antenatal and postnatal care, as well as strengthening health care systems within countries in sub-Saharan Africa.

Understanding the determinants of infant and under-five mortality rates: a multivariate decomposition analysis of Demographic and Health Surveys in Ghana, 2003, 2008 and 2014

INTRODUCTION

Despite the decline in infant and under-five mortality rates since the last decade, Ghana did not meet the millennium development goal (MDG) 4 target. To implement effective interventions that could fast-track progress towards achieving the sustainable development goal 3 in 2030, factors contributing to the decline in child mortality throughout the MDG period and which factor(s) has/have been consistent in affecting child survival in the last decade need to be understood.

METHODS

This study used Demographic and Health Surveys (DHS) from 2003, 2008 and 2014 and data from World Bank Development Indicators (2000-2018). We employed modified Poisson with robust SE and multivariate decomposition approach to assess risk factors of child mortality using DHS data from 2003, 2008 and 2014. Penalised regression was used assess the effect of 25 country-level contextual factors on child survival.

RESULTS

The risk of infant mortality is approximately five times higher among mothers who had multiple births compared with mothers who had single birth over the last decade (adjusted relative risk 4.6, 95% CI 3.2 to 6.6, p<0.001). An increase in the annual percentage of female labour force participation (FLFP) is associated with the reduction of approximately 10 and 18 infant and under-five annual deaths per 1000 live births, respectively.

CONCLUSIONS

This study found that multiple births and shorter birth spacing are associated with increased risk of infant and under-five deaths over the last decade. Increased in FLFP, and the proportion of children sleeping under bed-net are associated with reduced risk of both infants and under-five deaths.

The effect of an mHealth clinical decision-making support system on neonatal mortality in a low resource setting: A cluster-randomized controlled trial

BACKGROUND

MHealth interventions promise to bridge gaps in clinical care but documentation of their effectiveness is limited. We evaluated the utilization and effect of an mhealth clinical decision-making support intervention that aimed to improve neonatal mortality in Ghana by providing access to emergency neonatal protocols for frontline health workers.

METHODS

In the Eastern Region of Ghana, sixteen districts were randomized into two study arms (8 intervention and 8 control clusters) in a cluster-randomized controlled trial. Institutional neonatal mortality data were extracted from the District Health Information System-2 during an 18-month intervention period. We performed an intention-to-treat analysis and estimated the effect of the intervention on institutional neonatal mortality (primary outcome measure) using grouped binomial logistic regression with a random intercept per cluster. This trial is registered at ClinicalTrials.gov (NCT02468310 ) and Pan African Clinical Trials Registry (PACTR20151200109073).

FINDINGS

There were 65,831 institutional deliveries and 348 institutional neonatal deaths during the study period. Overall, 47 ∙ 3% of deliveries and 56 ∙ 9% of neonatal deaths occurred in the intervention arm. During the intervention period, neonatal deaths increased from 4 ∙ 5 to 6 ∙ 4 deaths and, from 3 ∙ 9 to 4 ∙ 3 deaths per 1000 deliveries in the intervention arm and control arm respectively. The odds of neonatal death was 2⋅09 (95% CI (1 ∙ 00;4 ∙ 38); p = 0 ∙ 051) times higher in the intervention arm compared to the control arm (adjusted odds ratio). The correlation between the number of protocol requests and the number of deliveries per intervention cluster was 0 ∙ 71 (p = 0 ∙ 05).

INTERPRETATION

The higher risk of institutional neonatal death observed in intervention clusters may be due to problems with birth and death registration, unmeasured and unadjusted confounding, and unintended use of the intervention. The findings underpin the need for careful and rigorous evaluation of mHealth intervention implementation and effects.

FUNDING

Netherlands Foundation for Scientific Research - WOTRO, Science for Global Development; Utrecht University.

Using Mobile Health to Support Clinical Decision-Making to Improve Maternal and Neonatal Health Outcomes in Ghana: Insights of Frontline Health Worker Information Needs

BACKGROUND

Developing and maintaining resilient health systems in low-resource settings like Ghana requires innovative approaches that adapt technology to context to improve health outcomes. One such innovation was a mobile health (mHealth) clinical decision-making support system (mCDMSS) that utilized text messaging (short message service, SMS) of standard emergency maternal and neonatal protocols via an unstructured supplementary service data (USSD) on request of the health care providers. This mCDMSS was implemented in a cluster randomized controlled trial (CRCT) in the Eastern Region of Ghana.

OBJECTIVE

This study aimed to analyze the pattern of requests made to the USSD by health workers (HWs). We assessed the relationship between requests made to the USSD and types of maternal and neonatal morbidities reported in health facilities (HFs).

METHODS

For clusters in the intervention arm of the CRCT, all requests to the USSD during the 18-month intervention period were extracted from a remote server, and maternal and neonatal health outcomes of interest were obtained from the District Health Information System of Ghana. Chi-square and Fisher exact tests were used to compare the proportion and type of requests made to the USSD by cluster, facility type, and location; whether phones accessing the intervention were shared facility phones or individual-use phones (type-of-phone); or whether protocols were accessed during the day or at night (time-of-day). Trends in requests made were analyzed over 3 6-month periods. The relationship between requests made and the number of cases reported in HFs was assessed using Spearman correlation.

RESULTS

In total, 5329 requests from 72 (97%) participating HFs were made to the intervention. The average number of requests made per cluster was 667. Requests declined from the first to the third 6-month period (44.96% [2396/5329], 39.82% [2122/5329], and 15.22% [811/5329], respectively). Maternal conditions accounted for the majority of requests made (66.35% [3536/5329]). The most frequently accessed maternal conditions were postpartum hemorrhage (25.23% [892/3536]), other conditions (17.82% [630/3536]), and hypertension (16.49% [583/3536]), whereas the most frequently accessed neonatal conditions were prematurity (20.08% [360/1793]), sepsis (15.45% [277/1793]), and resuscitation (13.78% [247/1793]). Requests made to the mCDMSS varied significantly by cluster, type of request (maternal or neonatal), facility type and its location, type-of-phone, and time-of-day at 6-month interval (P<.001 for each variable). Trends in maternal and neonatal requests showed varying significance over each 6-month interval. Only asphyxia and sepsis cases showed significant correlations with the number of requests made (r=0.44 and r=0.79; P<.001 and P=.03, respectively).

CONCLUSIONS

There were variations in the pattern of requests made to the mCDMSS over time. Detailed information regarding the use of the mCDMSS provides insight into the information needs of HWs for decision-making and an opportunity to focus support for HW training and ultimately improved maternal and neonatal health.

Decomposing the rural-urban gap in the factors of under-five mortality in sub-Saharan Africa? Evidence from 35 countries

BACKGROUND

Understanding urban-rural gap in childhood survival is essential for health care interventions and to explain disparities in the determinants of Under-5 mortality. There is dearth of information about the factors explaining differentials in urban-rural Under-5 mortality especially in sub-Saharan Africa (SSA). In this study, we sought to quantify the contributions of bio-demographic, socioeconomic and proximate factors in explaining the urban-rural gap in Under-5 mortality in SSA.

METHODS

This study utilized secondary data from Demographic and Health Survey (DHS) in 35 sub-Saharan countries conducted between 2006 and 2016. Child (aged 0 and 59 months) death was the outcome variable in this study. Oaxaca-Blinder decomposition was used to decipher urban-rural gap in the factors of Under-5 mortality.

RESULTS

Significant urban-rural differentials were observed in Under-5 mortality across bio-demographic, socioeconomic and proximate factors. In the decomposition model, about 44.27% of urban group and 74.71% of rural group had Under-5 mortality in sub-Saharan countries. Maternal age, education, use of newspaper, TV, wealth index, total children ever born, size of baby and age at first birth contributed towards explaining urban-rural gap inUnder-5 mortality.

CONCLUSION

These findings could be contributory to health care system improvement and socioeconomic developmental plans to address under-5 mortality in SSA. Strengthening maternal and child health (MCH) programmes, specifically in rural areas and improving health care services would help to ensure overall child survival.

Quality gap in maternal and newborn healthcare: a cross-sectional study in Myanmar

Introduction

Access to maternal and newborn healthcare has improved in Myanmar. However, regular contact with skilled care providers does not necessarily result in quality care. We assessed adequate contact made by women and newborns with skilled care providers, reception of high-quality care and quality-adjusted contacts during antenatal care (ANC), peripartum care (PPC) and postnatal care (PNC) in Myanmar.

Methods

This cross-sectional study was conducted in a predominantly urban township of Yangon and a predominantly rural township of Ayeyawady in March 2016. We collected data from 1500 women. We measured quality-adjusted contact, which refers to adequate contact with high-quality care, as follows: ≥4 ANC contacts and receiving 11–14 of 14 intervention items; facility-based delivery assisted by skilled care providers, receiving 7 of 7 PPC intervention items; and receiving the first PNC contact ≤24 hours postpartum and ≥2 additional contacts, and receiving 16–17 of 17 intervention items. Using multilevel logistic regression analysis with a random intercept at cluster level, we identified factors associated with adequate contact and high-quality ANC, PPC and PNC.

Results

The percentage of crude adequate contact was 60.9% for ANC, 61.3% for PPC and 11.5% for PNC. However, the percentage of quality-adjusted contact was 14.6% for ANC, 15.2% for PPC and 3.6% for PNC. Adequate contact was associated with receiving high-quality care at ANC, PPC and PNC. Being a teenager, low educational level, multiparity and low level in the household wealth index were negatively associated with adequate contact with healthcare providers for ANC and PPC. Receiving a maternal and child health handbook was positively associated with adequate contact for ANC and PPC, and with receiving high-quality ANC, PPC and PNC.

Conclusion

Women and newborns do not receive quality care during contact with skilled care providers in Myanmar. Continuity and quality of maternal and newborn care programmes must be improved.

The effect of sex of last child on short birth interval practice: the case of northern Ethiopian pregnant women

Objective

Improving short birth interval practice is a key strategy to reduce maternal mortality, neonatal mortality, adverse pregnancy outcomes, high fertility rate and undermining economic development efforts. However, there were limited evidences on short birth interval practice and its determinant factors in Ethiopia. This study aimed to determine the prevalence of short birth interval practice and associated factors among pregnant women. Institutional based cross-sectional study was conducted among 418 pregnant mothers using stratified sampling technique. Multivariable logistic regression analysis was performed at the level of significance of P-value < 0.05.

Result

Short birth interval practice was found to be 40.9%. Child death (AOR = 3.60, 95% CI 1.35, 9.59), female child (AOR = 2.03, 95% CI 1.12, 3.67), younger maternal age (AOR = 4.23, 95% CI 1.14, 12.66), contraceptive non-use (AOR = 8.15, 95% CI 4.17, 15.94), increase duration of breastfeeding (AOR = 4.72, 95 CI% 1.10, 20.60) and home delivery (AOR = 4.75, 95 CI% 2.30, 9.79) were found to be significantly associated with short birth interval practice. The prevalence of short birth interval practice is high. Multi disciplinary approach through improving maternal and child health care are recommended to prevent short birth interval practice.

The economic consequences of practice style variation in providing medical interventions: A systematic review of the literature

The practice style variation (PSV) incurs undesirable clinical and economic consequences for patients and the healthcare system. This review aims to analyze the economic consequences of PSV in medical interventions. A comprehensive electronic search was conducted through PubMed, Web of Sciences, EBSCO, EMBASE, and Cochrane databases to retrieve studies on economic consequences of PSV within 1975-2018. The studies were independently assessed by two reviewers. The quality of studies was assessed by Strengthening the Reporting of Observational Studies in Epidemiology checklist. No language restriction was applied. Only four studies met the eligibility criteria. These studies have been conducted retrospectively in developed countries. Most of the included studies used consumer demand theory to measure the economic consequences of PSV. Findings showed 12%-74% of all variations in healthcare services are related to PSV, thereby incurring up to 23 million dollars for the healthcare system. The PSV is related to the total expenditure, price elasticity, and coefficient of variation of healthcare services. PSV associated with huge inefficiency and inequity in access to healthcare services. To mitigate the consequences of PSV, policymakers should consider PSV in both developing the medical education plans as well as cost management. Using multilevel analysis to investigate the determinants of PSV would be beneficial.

Causes of death and predictors of childhood mortality in Rwanda: a matched case-control study using verbal social autopsy

Background

Rwanda has dramatically reduced child mortality, but the causes and sociodemographic drivers for mortality are poorly understood.

Methods

We conducted a matched case-control study of all children who died before 5 years of age in eastern Rwanda between 1st March 2013 and 28th February 2014 to identify causes and risk factors for death. We identified deaths at the facility level and via a community health worker reporting system. We used verbal social autopsy to interview caregivers of deceased children and controls matched by area and age. We used InterVA4 to determine probable causes of death and cause-specific mortality fractions, and utilized conditional logistic regression to identify clinical, family, and household risk factors for death.

Results

We identified 618 deaths including 174 (28.2%) in neonates and 444 (71.8%) in non-neonates. The most commonly identified causes of death were pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related death among non-neonates. Among neonates, 54 (31.0%) deaths occurred at home and for non-neonates 242 (54.5%) deaths occurred at home. Factors associated with neonatal death included home birth (aOR: 2.0; 95% CI: 1.4–2.8), multiple gestation (aOR: 2.1; 95% CI: 1.3–3.5), both parents deceased (aOR: 4.7; 95% CI: 1.5–15.3), mothers non-use of family planning (aOR: 0.8; 95% CI: 0.6–1.0), lack of accompanying person (aOR: 1.6; 95% CI: 1.1–2.1), and a caregiver who assessed the medical services they received as moderate to poor (aOR: 1.5; 95% CI: 1.2–1.9). Factors associated with non-neonatal deaths included multiple gestation (aOR: 2.8; 95% CI: 1.7–4.8), lack of adequate vaccinations (aOR: 1.7; 95% CI: 1.2–2.3), household size (aOR: 1.2; 95% CI: 1.0–1.4), maternal education levels (aOR: 1.9; 95% CI: 1.2–3.1), mothers non-use of family planning (aOR: 1.6; 95% CI: 1.4–1.8), and lack of household electricity (aOR: 1.4; 95% CI: 1.0–1.8).

Conclusion

In the context of rapidly declining childhood mortality in Rwanda and increased access to health care, we found a large proportion of remaining deaths occur at home, with home deliveries still representing a significant risk factor for neonatal death. The major causes of death at a population level remain largely avoidable communicable diseases. Household characteristics associated with death included well-established socioeconomic and care-seeking risk factors.

The coverage of continuum of care in maternal, newborn and child health: a cross-sectional study of woman-child pairs in Ghana

Introduction

The continuum of care has recently received attention in maternal, newborn and child health. It can be an effective policy framework to ensure that every woman and child receives timely and appropriate services throughout the continuum. However, a commonly used measurement does not evaluate if a pair of woman and child complies with the continuum of care. This study assessed the continuum of care based on two measurements: continuous visits to health facilities (measurement 1) and receiving key components of services (measurement 2). It also explored individual-level and area-level factors associated with the continuum of care achievement and then investigated how the continuum of care differed across areas.

Methods

In this cross-sectional study in Ghana in 2013, the continuum of care achievement and other characteristics of 1401 pairs of randomly selected women and children were collected. Multilevel logistic regression was used to estimate the factors associated with the continuum of care and its divergence across 22 areas.

Results

Throughout the pregnancy, delivery and post-delivery stages, 7.9% of women and children achieved the continuum of care through continuous visits to health facilities (measurement 1). Meanwhile, 10.3% achieved the continuum of care by receiving all key components of maternal, newborn and child health services (measurement 2). Only 1.8% of them achieved it under both measurements. Women and children from wealthier households were more likely to achieve the continuum of care under both measurements. Women’s education and complications were associated with higher continuum of care services-based achievement. Variance of a random intercept was larger in the continuum of care services-based model than the visit-based model.

Conclusions

Most women and children failed to achieve the continuum of care in maternal, newborn and child health. Those who consistently visited health facilities did not necessarily receive key components of services.