Abstract
Globally 40 % of deaths to children under-five occur in the very first month of life with three-quarters of these deaths occurring during the first week of life. The promotion of delivery with a skilled birth attendant (SBA) is being promoted as a strategy to reduce neonatal mortality. This study explored whether SBAs had a protective effect against neonatal mortality in three different regions of the world. The analysis pooled data from nine diverse countries for which recent Demographic and Health Survey data were available. Multilevel logistic regression was used to understand the influence of skilled delivery on two outcomes—neonatal mortality during the first week of life and during the first day of life. Control variables included age, parity, education, wealth, residence (urban/rural), geographic region (Africa, Asia and Latin America/Caribbean), antenatal care and tetanus immunization. The direction of the effect of skilled delivery on neonatal mortality was dependent on geographic region. While having a SBA at delivery was protective against neonatal mortality in Latin America/Caribbean, in Asia there was only a protective effect for births in the first week of life. In Africa SBAs were associated with higher neonatal mortality for both outcomes, and the same was true for deaths on the first day of life in Asia. Many women in Africa and Asia deliver at home unless a complication occurs, and thus skilled birth attendants may be seeing more women with complications than their unskilled counterparts. In addition there are issues with the definition of a SBA with many attendants in both Africa and Asia not actually having the needed training and equipment to prevent neonatal mortality. Considerable investment is needed in terms of training and health infrastructure to enable these providers to save the youngest lives.
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Liu, L., Johnson, H. L., Cousens, S., et al. (2012). Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. Lancet, 379(9832), 2151–2161.
United Nations Development Program (UNDP). (2010). The path to achieving the millennium development goals: A synthesis of MDG evidence from around the world. New York: UNDP.
UNICEF. (2012). Committing to child survival: A promised renewed. New York: UNICEF.
Lawn, J. E., Kerber, K., Enweronu-Laryea, C., et al. (2009). Newborn survival in low resource settings-are we delivering? BJOG-An International Journal of Obstetrics and Gynaecology, 116, 49–59. doi:10.1111/j.1471-0528.2009.02328.x.
Saving Newborn Lives. (2001). The state of the world’s newborns: A report from saving newborn lives. Washington, DC: Save the Children.
Edmond, K. M., Quigley, M. A., Zandoh, C., et al. (2008). Aetiology of stillbirths and neonatal deaths in rural Ghana: Implications for health programming in developing countries. Paediatric and Perinatal Epidemiology, 22(5), 430–437. doi:10.1111/j.1365-3016.2008.00961.x.
Lawn, J. E., Tinker, A., & Munjanja, S. P. (2006). Where is maternal and child health now? Lancet, 368(9546), 1474–1477. doi:10.1016/S0140-6736(06)69387-2.
Lawn, J. E., Cousens, S., Zupan, J., & Lancet Neonatal Survival Steering Committee. (2005). 4 Million neonatal deaths: When? Where? Why? Lancet, 365, 891–900.
Bryce, J., Daelmans, B., Dwivedi, A., et al. (2008). Countdown to 2015 for maternal, newborn, and child survival: The 2008 report on tracking coverage of interventions. Lancet, 371(9620), 1247–1258.
Rohde, J., Cousens, S., Chopra, M., et al. (2008). Alma-Ata: Rebirth and revision 4–30years after alma-ata: Has primary health care worked in countries? Lancet, 372(9642), 950–961.
Nair, N., Tripathy, P., Prost, A., et al. (2010) Improving newborn survival in low-income countries: Community-based approaches and lessons from South Asia. Plos Medicine, 7(4). doi:10.1371/journal.pmed.1000246.
Darmstadt, G. L., Bhutta, Z. A., Cousens, S., et al. (2005). Evidence-based, cost-effective interventions: How many newborn babies can we save? Lancet, 365(9463), 977–988.
WHO (2013) Births attended by skilled health personnel (percentage). http://www.who.int/healthinfo/statistics/indbirthswithskilledhealthpersonnel/en/. Accessed 22 Feb 2013.
Harvey, S., Blandon, Y., McCaw-Binn, A., et al. (2007). Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward. Bulletin of the World Health Organization, 85, 783–790.
Mbaruku, G., van Roosmalen, J., Kimondo, I., et al. (2009). Perinatal audit using the 3-delays model in western Tanzania. International Journal of Gynecology Obstetrics, 106(1), 85–88. doi:10.1016/j.ijgo.2009.04.008.
Chalumeau, M., Bouvier-Colle, M. H., & Breart, G. (2002). Can clinical risk factors for late stillbirth in West Africa be detected during antenatal care or only during labour? International Journal of Epidemiology, 31(3), 661–668.
Taha, T. E., Gray, R. H., Abdelwahab, M. M., et al. (1994). Levels and determinants of perinatal-mortality in central Sudan. International Journal of Gynecology Obstetrics, 45(2), 109–115.
Weiner, R., Ronsmans, C., Dorman, E., et al. (2003). Labour complications remain the most important risk factors for perinatal mortality in rural Kenya. Bulletin of the World Health Organisation, 81(8), 561–566.
Ariff, S., Soofi, S., Sadik, K., et al. (2010) Evaluation of health workforce competence in maternal and neonatal issues in public health sector of Pakistan: An Assessment of their training. BMC Health Services Research, 10 (319).
Wall, S. N., Lee, A. C. C., Carlo, W., et al. (2010). Reducing intrapartum-related neonatal deaths in low-and middle-income countries-what works? Seminars in Perinatology, 34(6), 395–407. doi:10.1053/j.semperi.2010.09.009.
Mbonye, A. K., Sentongo, M., Mukasa, G. K., et al. (2012). Newborn survival in Uganda: A decade of change and future implications. Health Policy and Planning, 27, 104–117. doi:10.1093/heapol/czs045.
Blum, L. S., Sharmin, T., & Ronsmans, C. (2006). Attending home vs. clinic-based deliveries: Perspectives of skilled birth attendants in Matlab, Bangladesh. Reproductive Health Matters, 14(27), 51–60.
Huque, Z. A., Leppard, M., Mavalankar, D., et al. (1999). Safe motherhood programmes in Bangladesh. In M. Berer & T. K. S. Ravindra (Eds.), Safe motherhood initiatives: Critical issues (pp. 53–61). London: Blackwell Science (Reproductive Health Matters).
Geefhuysen, C. J. (1999). Safe motherhood in Indonesia: A task for the next century. In M. Berer & T. K. S. Ravindra (Eds.), Safe motherhood initatives: Critical issues (pp. 62–72). London: Blackwell Science (Reproductive Health Matters).
WHO/UNFA/UNICEF (1999). Reduction of maternal mortality. Geneva: Author.
Stanton, C., Blanc, A., Croft, T., & Choi, Y. (2007). Skilled care at birth in the developing world: Progress to date and strategies for expanding coverage. Journal of Biosocial Science, 39, 109–120.
Adam, T., Lim, S. S., Mehta, S., et al. (2005). Achieving the millennium development goals for health: Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries. British Medical Journal, 331(7525), 1107–1110.
Darmstadt, G. L., Walker, N., Lawn, J. E., et al. (2008). Saving newborn lives in Asia and Africa: Cost and impact of phased scale-up of interventions within the continuum of care. Health Policy and Planning, 23(2), 101–117. doi:10.1093/heapol/czn001.
Izugbara, C., Karbiru, C., & Zulu, E. (2009). Urban poor Kenyan women and hospital-based delivery. Public Health Reports, 124(4), 585–589.
Edmond, K. M., Quigley, M. A., Zandoh, C., Danso, S., Hurt, C., Owusu Agyei, S., et al. (2008). Aetiology of stillbirths and neonatal deaths in rural Ghana: Implications for health programming in developing countries. Paediatric Perinatal Epidemiology, 22(5), 430–437.
Afsana, K., & Rashid, S. F. (2001). The challenges of meeting rural Bangladeshi women’s needs in delivery care. Reproductive Health Matters, 9(18), 79–89.
Bazant, E. (2008) Women’s place of delivery and experience of quality in delivery car: A quantitative and qualitative study in nairobi’s informal settlements. (Doctoral dissertation, Bloomberg, MD: School of Public Health, Johns Hopkins University, 2008).
Paul, B. K., & Rumsey, D. J. (2002). Utilization of health facilities and trained birth attendants for childbirth in rural Bangladesh: An empirical study. Social Science in Medicine, 54(12), 1755–1765.
Walraven, G. E., Mkanje, R. J., van Roosmalen, J., van Dongen, P. W., Dolmans, W. M. Comparison of perintal outcomes in rural Tanzania.
Lawn, J. E., Kinney, M. V., Black, R. E., et al. (2012). Newborn survival: A multi-country analysis of a decade of change. Health Policy and Planning, 27, 6–28. doi:10.1093/heapol/czs053.
Waiswa, P., Kalter, H. D., Jakob, R., et al. (2012). Increased use of social autopsy is needed to improve maternal, neonatal and child health programmes in low-income countries. Bulletin of the World Health Organisation, 90(6), 403. doi:10.2471/Blt.12.105718.
Zimba, E., Kinney, M. V., Kachale, F., et al. (2012). Newborn survival in Malawi: A decade of change and future implications. Health Policy and Planning, 27, 88–103. doi:10.1093/heapol/czs043.
Ali, M., Ahmed, K., & Kuroiwa, C. (2008). Emergency obstetric care in Punjab, Pakistan: Improvement needed. The European Journal of Contraception and Reproductive Health Care, 13(2), 201–207.
Moran, A., Kerber, K., Pfitzer, A., et al. (2012). Benchmarks to measure readiness to integrate and scale up newborn survival interventions. Health Policy and Planning, 27, iii29–iii39.
Acknowledgments
This study was funded by the United States Agency for International Development (USAID) through a cooperative agreement (GHA-A-00-08-00003-00) with MEASURE Evaluation. The views expressed in this paper do not necessarily reflect those of USAID. This work was also supported in part by an R24 Center Grant to the Carolina Population Center at the University of North Carolina at Chapel Hill. The authors would like to thank Lily Kak, Lisa Maniscalco and Allisyn Moran for comments on earlier drafts of the paper, and Erica Haney for assistance with the literature review.
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Singh, K., Brodish, P. & Suchindran, C. A Regional Multilevel Analysis: Can Skilled Birth Attendants Uniformly Decrease Neonatal Mortality?. Matern Child Health J 18, 242–249 (2014). https://doi.org/10.1007/s10995-013-1260-7
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DOI: https://doi.org/10.1007/s10995-013-1260-7