Determinants of neonatal mortality in rural Northern Ethiopia: A population based nested case control study

PLoS ONE, Volume 12, No. 4, Year 2017

Interprétation

Introduction: In low income and middle income countries, neonatal mortality remains high despite the gradual reduction in under five mortality. Newborn death contributes for about 38% of all under five deaths. This study has identified the magnitude and independent predictors of neonatal mortality in rural Ethiopia. Methods: This population based nested case control study was conducted in rural West Gojam zone, Northern Ethiopia, among a cohort of pregnant women who gave birth between March 2011 and Feb 2012. The cohort was established by Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) project in 2010 by recruiting mothers in their third trimester, as identified by trained community volunteers. Once identified, women stayed in the cohort throughout their pregnancy period receiving Community Maternal and Newborn Health (CMNH) training by health extension workers and community volunteers till the end of the first 48 hours postpartum. Cases were 75 mothers who lost their newborns to neonatal death and controls were 150 randomly selected mothers with neonates who survived the neonatal period. Data to identify cause of death were collected using the WHO standard verbal autopsy questionnaire after the culturally appropriate 40 days of bereavement period. Binomial logistic regression model was used to identify independent contributors to neonatal mortality. Result: The neonatal mortality rate was AOR(95%CI) = 18.6 (14.8, 23.2) per 1000 live births. Neonatal mortality declined with an increase in family size, neonates who were born among a family of more than two had lesser odds of death in the neonatal period than those who were born in a family of two AOR (95% CI) = 0.13 (0.02, 0.71). Mothers who gave birth to 2-4 AOR(95%CI) = 0.15 (0.05, 0.48) and 5+ children AOR(95%CI) = 0.08 (0.02, 0.26) had lesser odds of losing their newborns to neonatal mortality. Previous history of losing a newborn to neonatal death also increased the odds of neonatal mortality during the last birth AOR (95%CI) = 0.25 (0.11, 0.53). Conclusion: The neonatal mortality rate in our study was three times lower than the regional neonatal mortality rate estimate, indicating community based interventions could significantly decrease neonatal mortality. The identified determinants, which are amenable for change, emphasize the need to improve quality of care during pregnancy, labour and delivery to improve pregnancy outcome.This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. We conducted a population-based nested case control study among a cohort of pregnant women in three districts of West Gojam zone (North Achefer, South Achefer and Mecha). The zone is located 500 kms away north of the capital city Addis Ababa. Twenty-four kebles (i.e. the smallest administrative unit) were selected from the three districts (7 from North and South Achefer districts each and 10 from Mecha district). The selected three districts were among the highly populous districts of the zone with a total population count of 292,250 in Mecha, 155,863, in South Achefer and 173,211 in North Achefer districts [9]. Each kebele has one health post, providing disease prevention and health promotion services to 2500–5000 population. Each health post is staffed with two health extension workers (HEWs) and reports to the next level called health centers [10]. The cohort was first established in 2010 by Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) project. The project was led by Emory University in collaboration with the Ethiopian Federal Ministry of Health and Addis Ababa University [11]. The intervention implemented Community Maternal and Newborn Health (CMNH) care package through the existing Health Extension Program (HEP) in six woredas (districts) of Amhara and Oromia regions (three from each region) [11,12]. The project was aimed at improving the capability and performance of HEWs to provide targeted maternal and newborn health (MNH) services; increasing demand for targeted MNH services and improve self-care behavior and quality of MNH services in lead woredas. A lead woreda is the one that has the commitment and capacity to continuously improve MNH service delivery to meet the needs of mothers and children [12]. The project used three basic approaches to achieve its objectives: 1) Behavioral change communication on issues of maternal and newborn health, 2) Maternal and newborn health training for health extension workers, women in reproductive age and potential care givers among family members and 3) Continuous collaborative quality improvement interventions [11]. Pregnant women, in their third trimester, were enrolled into the cohort as identified by community volunteers who had CMNH training by MaNHEP. Once in the cohort, mothers received continuous training on care during pregnancy, labour and delivery by the volunteers. This study focused on data collected from mothers in Amhara Region who gave birth between March 2011 and February 2012. All pregnant women in their third trimester living in the selected kebeles were recruited into the cohort. The cases were mothers who lost their babies for neonatal death at the end of the follow up period and the controls were mothers with a live neonate at the end of the fourth week after birth. The controls were randomly selected from a sampling frame containing list of mothers, in the respective gotes (i.e. a structure smaller than kebele) of the cases, whose pregnancy outcome was confirmed (Fig 1). Age of the mother, maternal and paternal education were among the socio-demographic variables involved in the analysis (Table 1). Three high school graduate females trained for five days on the data collection tool and interview techniques collected the data. Mothers who lost their newborns were interviewed earliest at forty days after death of the newborn to minimize recall bias. Data were cleaned and entered using EpiData version 3.1 statistical software. Further cleaning and analysis was done using SPSS version 20 statistical software. Frequency and proportion were calculated for all variables which were included in the analysis. Neonatal mortality rate was calculated per 1000 live births. Bivariate analysis was conducted to measure the association between the dependent and individual independent variables. To control the effect of confounding variables multiple binary logistic regression models were used. Crude and adjusted OR with 95% CI (Confidence interval) was used to interpret findings of the bivariate and multivariate analysis respectively. Ethical clearance was obtained from School of Public Health, College of Health Sciences, Addis Ababa University, Research and Ethical Committee (REC). After the purpose of the study was explained, participants provided a written consent before the interview. Mothers who lost their newborns were interviewed after forty days of culturally acceptable bereavement period.

Résumé de l’IA

Study Justification:

– Neonatal mortality remains high in low income and middle income countries, despite a reduction in under five mortality.
– Newborn death contributes to a significant proportion of under five deaths.
– This study aimed to identify the magnitude and independent predictors of neonatal mortality in rural Ethiopia.

Study Highlights:

– Conducted a population-based nested case control study among a cohort of pregnant women in rural West Gojam zone, Northern Ethiopia.
– Cases included 75 mothers who lost their newborns to neonatal death, and controls included 150 mothers with neonates who survived the neonatal period.
– Identified determinants of neonatal mortality, including family size and previous history of losing a newborn to neonatal death.
– Neonatal mortality rate in the study was three times lower than the regional estimate, indicating the potential impact of community-based interventions.
– Emphasized the need to improve quality of care during pregnancy, labor, and delivery to improve pregnancy outcomes.

Recommendations for Lay Reader and Policy Maker:

– Implement community-based interventions to decrease neonatal mortality.
– Improve quality of care during pregnancy, labor, and delivery to improve pregnancy outcomes.
– Increase awareness and education on maternal and newborn health issues.
– Strengthen the capacity and performance of health extension workers to provide targeted maternal and newborn health services.
– Promote behavioral change communication on issues of maternal and newborn health.

Key Role Players Needed to Address Recommendations:

– Health extension workers
– Community volunteers
– Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) project
– Ethiopian Federal Ministry of Health
– Addis Ababa University
– Emory University

Cost Items to Include in Planning Recommendations:

– Training programs for health extension workers and community volunteers
– Behavioral change communication campaigns
– Quality improvement interventions
– Maternal and newborn health services
– Awareness and education programs on maternal and newborn health

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, but there are some areas for improvement. The study design, a population-based nested case control study, provides a good level of evidence. The sample size of 75 cases and 150 controls is adequate for this type of study. The use of binomial logistic regression to identify independent contributors to neonatal mortality is appropriate. The study also provides specific results, such as the neonatal mortality rate and odds ratios for various factors. However, there are a few areas where the evidence could be strengthened. First, the abstract does not mention how the cases and controls were selected or matched, which could affect the validity of the results. Second, the abstract does not provide information on the representativeness of the study population or the generalizability of the findings. Third, the abstract does not mention any limitations of the study, such as potential biases or confounding factors. To improve the evidence, the authors could provide more details on the selection and matching of cases and controls, describe the characteristics of the study population, and discuss any limitations of the study.

Abstrait

We conducted a population-based nested case control study among a cohort of pregnant women in three districts of West Gojam zone (North Achefer, South Achefer and Mecha). The zone is located 500 kms away north of the capital city Addis Ababa. Twenty-four kebles (i.e. the smallest administrative unit) were selected from the three districts (7 from North and South Achefer districts each and 10 from Mecha district). The selected three districts were among the highly populous districts of the zone with a total population count of 292,250 in Mecha, 155,863, in South Achefer and 173,211 in North Achefer districts [9]. Each kebele has one health post, providing disease prevention and health promotion services to 2500–5000 population. Each health post is staffed with two health extension workers (HEWs) and reports to the next level called health centers [10]. The cohort was first established in 2010 by Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) project. The project was led by Emory University in collaboration with the Ethiopian Federal Ministry of Health and Addis Ababa University [11]. The intervention implemented Community Maternal and Newborn Health (CMNH) care package through the existing Health Extension Program (HEP) in six woredas (districts) of Amhara and Oromia regions (three from each region) [11,12]. The project was aimed at improving the capability and performance of HEWs to provide targeted maternal and newborn health (MNH) services; increasing demand for targeted MNH services and improve self-care behavior and quality of MNH services in lead woredas. A lead woreda is the one that has the commitment and capacity to continuously improve MNH service delivery to meet the needs of mothers and children [12]. The project used three basic approaches to achieve its objectives: 1) Behavioral change communication on issues of maternal and newborn health, 2) Maternal and newborn health training for health extension workers, women in reproductive age and potential care givers among family members and 3) Continuous collaborative quality improvement interventions [11]. Pregnant women, in their third trimester, were enrolled into the cohort as identified by community volunteers who had CMNH training by MaNHEP. Once in the cohort, mothers received continuous training on care during pregnancy, labour and delivery by the volunteers. This study focused on data collected from mothers in Amhara Region who gave birth between March 2011 and February 2012. All pregnant women in their third trimester living in the selected kebeles were recruited into the cohort. The cases were mothers who lost their babies for neonatal death at the end of the follow up period and the controls were mothers with a live neonate at the end of the fourth week after birth. The controls were randomly selected from a sampling frame containing list of mothers, in the respective gotes (i.e. a structure smaller than kebele) of the cases, whose pregnancy outcome was confirmed (Fig 1). Age of the mother, maternal and paternal education were among the socio-demographic variables involved in the analysis (Table 1). Three high school graduate females trained for five days on the data collection tool and interview techniques collected the data. Mothers who lost their newborns were interviewed earliest at forty days after death of the newborn to minimize recall bias. Data were cleaned and entered using EpiData version 3.1 statistical software. Further cleaning and analysis was done using SPSS version 20 statistical software. Frequency and proportion were calculated for all variables which were included in the analysis. Neonatal mortality rate was calculated per 1000 live births. Bivariate analysis was conducted to measure the association between the dependent and individual independent variables. To control the effect of confounding variables multiple binary logistic regression models were used. Crude and adjusted OR with 95% CI (Confidence interval) was used to interpret findings of the bivariate and multivariate analysis respectively. Ethical clearance was obtained from School of Public Health, College of Health Sciences, Addis Ababa University, Research and Ethical Committee (REC). After the purpose of the study was explained, participants provided a written consent before the interview. Mothers who lost their newborns were interviewed after forty days of culturally acceptable bereavement period.

Matériaux

https://efashare.b-cdn.net/materials/2d24e1c072f154a8d4076332219ddd7691311310131ada58c1f503e92b85bb3a/pone.0172875.s001.doc

Innovations

Based on the information provided, it is difficult to determine specific innovations for improving access to maternal health. However, some potential recommendations based on the study could include:

1. Strengthening community-based interventions: The study found that community-based interventions could significantly decrease neonatal mortality. Therefore, investing in and expanding community-based programs that provide maternal and newborn health services could improve access to care.

2. Improving quality of care during pregnancy, labor, and delivery: The study emphasized the need to improve the quality of care during these critical periods to improve pregnancy outcomes. Implementing quality improvement initiatives and ensuring that healthcare providers are trained and equipped to provide high-quality care could help reduce maternal and neonatal mortality.

3. Increasing family size: The study found that neonatal mortality declined with an increase in family size. Encouraging and supporting families to have more children could potentially reduce neonatal mortality rates.

4. Addressing previous history of neonatal death: The study found that previous history of losing a newborn to neonatal death increased the odds of neonatal mortality during subsequent births. Providing targeted support and interventions for mothers who have experienced neonatal death in the past could help improve outcomes in subsequent pregnancies.

It is important to note that these recommendations are based on the specific findings of the study and may not be applicable in all contexts. It is recommended to consult with healthcare professionals and experts in the field of maternal health for tailored and context-specific recommendations.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health and reduce neonatal mortality rates in rural Ethiopia is to implement community-based interventions that focus on improving the quality of care during pregnancy, labor, and delivery. This recommendation is based on the findings of the population-based nested case control study, which identified several determinants of neonatal mortality that are amenable to change.

The study found that neonatal mortality rates were lower among neonates born into larger families (more than two children) compared to those born into smaller families (two children). Additionally, mothers who had previously lost a newborn to neonatal death were more likely to experience neonatal mortality in subsequent births. These findings highlight the importance of providing support and care to mothers during pregnancy and childbirth, particularly for those with a history of neonatal mortality.

To implement this recommendation, community-based interventions can be designed to provide targeted maternal and newborn health (MNH) services. This can be done through existing health extension programs, such as the Health Extension Program (HEP) in Ethiopia. The interventions should focus on improving the capability and performance of health extension workers (HEWs) to provide quality MNH services. This can be achieved through training programs that equip HEWs with the necessary knowledge and skills to provide comprehensive care during pregnancy, labor, and delivery.

In addition to training HEWs, behavioral change communication can be used to raise awareness and promote positive health-seeking behaviors among pregnant women and their families. This can include educating women and their families about the importance of antenatal care, skilled attendance at birth, and postnatal care. It can also involve addressing cultural beliefs and practices that may hinder access to maternal health services.

Continuous collaborative quality improvement interventions should also be implemented to ensure that the quality of care provided by health facilities and health workers is continuously monitored and improved. This can involve regular supervision and mentoring of health workers, as well as the establishment of quality improvement teams at health facilities.

Overall, the recommendation is to implement community-based interventions that focus on improving the quality of care during pregnancy, labor, and delivery. This can be achieved through training programs for health extension workers, behavioral change communication, and continuous collaborative quality improvement interventions. By addressing the identified determinants of neonatal mortality, these interventions have the potential to significantly decrease neonatal mortality rates and improve access to maternal health in rural Ethiopia.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthen Community Maternal and Newborn Health (CMNH) programs: Expand and enhance the existing CMNH programs to reach more pregnant women in rural areas. This can be done by increasing the number of trained community volunteers and health extension workers, and providing them with ongoing training and support.

2. Improve quality of care during pregnancy, labor, and delivery: Focus on improving the quality of care provided to pregnant women during all stages of pregnancy, labor, and delivery. This can include training healthcare providers on evidence-based practices, ensuring availability of essential equipment and supplies, and promoting respectful and compassionate care.

3. Increase awareness and demand for maternal health services: Implement targeted behavioral change communication campaigns to increase awareness about the importance of maternal health and encourage pregnant women to seek timely and appropriate care. This can involve community outreach activities, media campaigns, and engagement with local leaders and influencers.

4. Address socio-economic determinants of maternal health: Recognize and address the socio-economic factors that contribute to poor maternal health outcomes, such as poverty, lack of education, and limited access to resources. This can involve implementing interventions that address these determinants, such as providing economic support to pregnant women, improving access to education, and promoting gender equality.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations on improving access to maternal health. These indicators can include metrics such as the number of pregnant women receiving CMNH services, the percentage of pregnant women receiving quality care during pregnancy, labor, and delivery, and the change in neonatal mortality rate.

2. Collect baseline data: Gather baseline data on the selected indicators before implementing the recommendations. This can involve conducting surveys, interviews, and data analysis to assess the current state of access to maternal health services and outcomes.

3. Implement the recommendations: Roll out the recommended interventions and initiatives to improve access to maternal health. This can involve training healthcare providers, mobilizing community volunteers, implementing awareness campaigns, and addressing socio-economic determinants.

4. Monitor and evaluate: Continuously monitor and evaluate the implementation of the recommendations. Collect data on the selected indicators at regular intervals to assess the progress and impact of the interventions. This can involve conducting surveys, interviews, and data analysis to measure changes in access to maternal health services and outcomes.

5. Analyze and interpret the data: Analyze the collected data to assess the impact of the recommendations on improving access to maternal health. This can involve statistical analysis, comparing the baseline data with the post-intervention data, and identifying trends and patterns.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the recommendations in improving access to maternal health. Identify strengths, weaknesses, and areas for improvement. Make recommendations for further interventions or adjustments to existing strategies based on the findings.

7. Communicate the results: Share the findings of the impact assessment with relevant stakeholders, including policymakers, healthcare providers, and community members. Use the results to advocate for continued investment in improving access to maternal health and to inform future decision-making processes.

Auteurs et co-auteurs

Statistics:

Citations: 17

Authors: 3

Identifiers:

DOI: 10.1371/journal.pone.0172875

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female

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