Survival of neonates in rural Southern Tanzania: Does place of delivery or continuum of care matter?

BMC Pregnancy and Childbirth, Volume 12, Year 2012

Interpretation

Background: The concept of continuum of care has recently been highlighted as a core principle of maternal, newborn and child health initiatives, and as a means to save lives. However, evidence has consistently revealed that access to care during and post delivery (intra and postpartum) remains a challenge in the continuum of care framework. In places where skilled delivery assistance is exclusively available in health facilities, access to health facilities is critical to the survival of the mother and her newborn. However, little is known about the association of place of delivery and survival of neonates. This paper uses longitudinal data generated in a Health and Demographic Surveillance System in rural Southern Tanzania to assess associations of neonatal mortality and place of delivery.Methods: Three cohorts of singleton births (born 2005, 2006 and 2007) were each followed up from birth to 28 days. Place of birth was classified as either “health facility” or “community”. Neonatal mortality rates were produced for each year and by place of birth. Poisson regression was used to estimate crude relative risks of neonatal death by place of birth. Adjusted ratios were derived by controlling for maternal age, birth order, maternal schooling, sex of the child and wealth status of the maternal household.Results: Neonatal mortality for health facility singleton deliveries in 2005 was 32.3 per 1000 live births while for those born in the community it was 29.7 per 1000 live births. In 2006, neonatal mortality rates were 28.9 and 26.9 per 1,000 live births for deliveries in health facilities and in the community respectively. In 2007 neonatal mortality rates were 33.2 and 27.0 per 1,000 live births for those born in health facilities and in the community respectively. Neonates born in a health facility had similar chances of dying as those born in the community in all the three years of study. Adjusted relative risks (ARR) for neonatal death born in a health facility in 2005, 2006 and 2007 were 0.99 (95%CI: 0.58 – 1.70), 0.98 (95%CI: 0.62 – 1.54) and 1.18 (95% CI: 0.76 – 1.85) respectively.Conclusions: We found no evidence to suggest that delivery in health facilities was associated with better survival chances of the neonates. © 2012 Nathan and Mwanyangala; licensee BioMed Central Ltd. This study was done in Ifakara Health and Demographic Surveillance Site located in Southern Tanzania, Morogoro region. The HDSS site was started by conducting baseline census between September and December 1996. Since then every household in the surveillance area has been visited by a trained interviewer every 4 months to record pregnancies, pregnancy outcomes, deaths and migrations that have happened since the previous visit. Date of birth of each individual is included in the household registers and each event is recorded along with specific date it happened. Place of delivery and place of death are recorded as health facility, home or elsewhere. Educational levels of each individual and household assets are recorded annually. Currently (2011), the site includes over 100,000 people living in 25 villages in parts of two districts, Kilombero and Ulanga in Southern Tanzania. The population is predominantly rural and ethnically heterogeneous. Majority of the households earn their living from subsistence farming, few are engaged in fishing and small-scale trading. Detailed description of the study area is presented elsewhere [12]. The population of the study districts is served by a network of health facilities, at the time of the study there were two hospitals, four health centres and twenty one dispensaries in Kilombero district; two hospitals, three health centres and twenty dispensaries in Ulanga district. In 2008, comprehensive EMOC was available in two hospitals in each district. Health facilities with staff available for 24 hours, 7 days per week to perform normal delivery were only 59% and 72% in Kilombero and Ulanga districts, respectively. Within the study population, about 60% of all deliveries occur in health facilities mainly in dispensaries. Use of antenatal services by women in the study area is over 95% (at least one visit to ANC clinic). At the time of study, continuum of care was not fully introduced in the study area. This paper reports analysis of observational data collected in the Ifakara Health and Demographic Surveillance Site (IHDSS) for children born between 2005 and 2007. Three birth cohorts of singleton neonates were extracted from the database including their survival status within the first 28 days of life. Variables of interest included date of birth, date of death, birth order, sex, maternal age at birth, maternal education, household economic status, place of delivery and place of death. Data credibility was ensured at all stages of collection and processing. Up to 5% of randomly selected households were visited by field supervisors for repeated interviews. Other strategies included accompanied interviews as well as surprise field visits by field managers. Data was keyed in computers using a household registration system (HRS), software for relational database with inbuilt consistency and range checks. Captured inconsistencies were referred back to the field. Neonatal death is defined as termination of life of a live-born child within 28 days of life. Place of delivery is classified as “in the health facility” or “in the community”. Health facility includes dispensaries, health centres and hospitals. Delivery at home, TBAs homes or anywhere else besides health facilities are classified here as “in the community”. We included in this paper only singleton live births that occurred between year 2005 and 2007. Neonatal mortality was calculated as the number of neonatal deaths divided by number of live births in a given year and expressed per 1000 live births. Mortality on the same day of life was calculated as the number of neonates that had date of birth same as date of death divided by number of live births in a given year and expressed per 1000 live births. We calculated means and percentages of the background characteristics and performed t tests for means and χ2 tests for proportions to asses differences in the maternal and child background characteristics between the two defined places of delivery (health facility, community). For each year of study, Poisson regression models were fitted to estimate crude relative risks of neonatal death by place of delivery. Adjusted ratios were derived by controlling for maternal age, birth order, maternal schooling, sex of the child and wealth status of the maternal household. Daily survival functions of the neonates born in health facilities and those born in the community were estimated and compared using log rank tests. Ifakara Health and Demographic Surveillance System was established with an initial aim of evaluating the effect of a large-scale social marketing of insecticide-treated nets on child survival in rural Tanzania. The study was approved by local and national ethical committees.

AI Digest

Study Justification:

– The concept of continuum of care is important in maternal, newborn, and child health initiatives.
– Access to care during and after delivery is a challenge in the continuum of care framework.
– Little is known about the association between place of delivery and survival of neonates.

Study Highlights:

– Longitudinal data from a Health and Demographic Surveillance System in rural Southern Tanzania was used.
– Three cohorts of singleton births from 2005 to 2007 were followed up from birth to 28 days.
– Place of birth was classified as either “health facility” or “community”.
– Neonatal mortality rates were calculated for each year and by place of birth.
– Poisson regression was used to estimate relative risks of neonatal death by place of birth.
– Adjusted ratios were derived by controlling for various factors.

Study Recommendations:

– The study found no evidence to suggest that delivery in health facilities was associated with better survival chances of neonates.
– Further research is needed to understand the factors influencing neonatal mortality in rural Southern Tanzania.
– Efforts should be made to improve access to care during and after delivery in both health facilities and the community.
– The implementation of continuum of care initiatives should be evaluated to determine their impact on neonatal survival.

Key Role Players:

– Researchers and data analysts to conduct further research and analyze data.
– Health professionals and policymakers to implement strategies to improve access to care.
– Community leaders and organizations to promote awareness and education on maternal and neonatal health.

Cost Items for Planning Recommendations:

– Training and capacity building for health professionals.
– Infrastructure development and improvement of health facilities.
– Outreach programs and community engagement activities.
– Monitoring and evaluation of the implementation of continuum of care initiatives.
– Research and data collection to assess the impact of interventions.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study uses longitudinal data from a Health and Demographic Surveillance System in rural Southern Tanzania to assess the association between place of delivery and neonatal mortality. The study includes three cohorts of singleton births and uses Poisson regression to estimate relative risks of neonatal death by place of birth. The results show that neonates born in a health facility had similar chances of dying as those born in the community. However, the study does not provide a detailed explanation of the methods used to collect and analyze the data, which could affect the reliability of the results. To improve the strength of the evidence, the authors should provide more information on the data collection process, including how the variables of interest were measured and any potential limitations of the study. Additionally, the study could benefit from a larger sample size and a more diverse population to increase the generalizability of the findings.

Abstract

This study was done in Ifakara Health and Demographic Surveillance Site located in Southern Tanzania, Morogoro region. The HDSS site was started by conducting baseline census between September and December 1996. Since then every household in the surveillance area has been visited by a trained interviewer every 4 months to record pregnancies, pregnancy outcomes, deaths and migrations that have happened since the previous visit. Date of birth of each individual is included in the household registers and each event is recorded along with specific date it happened. Place of delivery and place of death are recorded as health facility, home or elsewhere. Educational levels of each individual and household assets are recorded annually. Currently (2011), the site includes over 100,000 people living in 25 villages in parts of two districts, Kilombero and Ulanga in Southern Tanzania. The population is predominantly rural and ethnically heterogeneous. Majority of the households earn their living from subsistence farming, few are engaged in fishing and small-scale trading. Detailed description of the study area is presented elsewhere [12]. The population of the study districts is served by a network of health facilities, at the time of the study there were two hospitals, four health centres and twenty one dispensaries in Kilombero district; two hospitals, three health centres and twenty dispensaries in Ulanga district. In 2008, comprehensive EMOC was available in two hospitals in each district. Health facilities with staff available for 24 hours, 7 days per week to perform normal delivery were only 59% and 72% in Kilombero and Ulanga districts, respectively. Within the study population, about 60% of all deliveries occur in health facilities mainly in dispensaries. Use of antenatal services by women in the study area is over 95% (at least one visit to ANC clinic). At the time of study, continuum of care was not fully introduced in the study area. This paper reports analysis of observational data collected in the Ifakara Health and Demographic Surveillance Site (IHDSS) for children born between 2005 and 2007. Three birth cohorts of singleton neonates were extracted from the database including their survival status within the first 28 days of life. Variables of interest included date of birth, date of death, birth order, sex, maternal age at birth, maternal education, household economic status, place of delivery and place of death. Data credibility was ensured at all stages of collection and processing. Up to 5% of randomly selected households were visited by field supervisors for repeated interviews. Other strategies included accompanied interviews as well as surprise field visits by field managers. Data was keyed in computers using a household registration system (HRS), software for relational database with inbuilt consistency and range checks. Captured inconsistencies were referred back to the field. Neonatal death is defined as termination of life of a live-born child within 28 days of life. Place of delivery is classified as “in the health facility” or “in the community”. Health facility includes dispensaries, health centres and hospitals. Delivery at home, TBAs homes or anywhere else besides health facilities are classified here as “in the community”. We included in this paper only singleton live births that occurred between year 2005 and 2007. Neonatal mortality was calculated as the number of neonatal deaths divided by number of live births in a given year and expressed per 1000 live births. Mortality on the same day of life was calculated as the number of neonates that had date of birth same as date of death divided by number of live births in a given year and expressed per 1000 live births. We calculated means and percentages of the background characteristics and performed t tests for means and χ2 tests for proportions to asses differences in the maternal and child background characteristics between the two defined places of delivery (health facility, community). For each year of study, Poisson regression models were fitted to estimate crude relative risks of neonatal death by place of delivery. Adjusted ratios were derived by controlling for maternal age, birth order, maternal schooling, sex of the child and wealth status of the maternal household. Daily survival functions of the neonates born in health facilities and those born in the community were estimated and compared using log rank tests. Ifakara Health and Demographic Surveillance System was established with an initial aim of evaluating the effect of a large-scale social marketing of insecticide-treated nets on child survival in rural Tanzania. The study was approved by local and national ethical committees.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile health clinics: Implementing mobile health clinics that can travel to rural areas, providing access to maternal health services closer to the community.

2. Telemedicine: Introducing telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals through video calls, reducing the need for travel.

3. Community health workers: Training and deploying community health workers who can provide basic maternal health services, education, and support in rural areas.

4. Maternal health vouchers: Introducing voucher programs that provide financial assistance to pregnant women, enabling them to access maternal health services at health facilities.

5. Improving transportation: Implementing transportation solutions such as ambulances or transportation vouchers to ensure pregnant women can reach health facilities in a timely manner.

6. Strengthening health facilities: Investing in infrastructure, equipment, and staffing of health facilities in rural areas to ensure they can provide quality maternal health services.

7. Maternal health education: Conducting community-based education programs to raise awareness about the importance of maternal health and the available services.

8. Task-shifting: Training and empowering non-specialist healthcare providers, such as nurses and midwives, to perform certain maternal health services, expanding access to care.

9. Maternal health incentives: Introducing incentives for healthcare providers to work in rural areas, encouraging them to provide maternal health services in underserved communities.

10. Public-private partnerships: Collaborating with private sector organizations to improve access to maternal health services through innovative solutions, such as telemedicine or mobile clinics.

It’s important to note that the specific context and needs of the community should be considered when implementing these innovations.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health and develop innovation could include the following:

1. Strengthening the continuum of care: The study highlights the importance of the continuum of care in improving maternal and neonatal health outcomes. To enhance access to maternal health, it is crucial to ensure a seamless transition of care from pregnancy to delivery and postpartum period. This can be achieved by integrating antenatal, intrapartum, and postpartum services, and promoting the use of skilled birth attendants.

2. Enhancing access to health facilities: The study reveals that access to health facilities is critical for the survival of both mothers and neonates. Therefore, efforts should be made to improve the availability and accessibility of health facilities, particularly in rural areas. This can be achieved by increasing the number of health centers, hospitals, and dispensaries, and ensuring that they are adequately staffed and equipped to provide comprehensive maternal and neonatal care.

3. Addressing barriers to facility-based deliveries: The study found no evidence to suggest that delivery in health facilities was associated with better survival chances for neonates. This indicates that there may be barriers preventing women from accessing health facilities for delivery. It is important to identify and address these barriers, which may include financial constraints, lack of transportation, cultural beliefs, and inadequate awareness about the benefits of facility-based deliveries.

4. Promoting community-based interventions: Since a significant proportion of deliveries in the study area occurred in the community, it is important to implement community-based interventions to improve maternal and neonatal health outcomes. This can include training and empowering traditional birth attendants (TBAs) to provide basic emergency obstetric care, promoting birth preparedness and complication readiness, and conducting community awareness campaigns on the importance of skilled birth attendance.

5. Utilizing technology and innovation: Technology and innovation can play a crucial role in improving access to maternal health. This can include the use of telemedicine to provide remote consultations and support for healthcare providers in rural areas, mobile health (mHealth) interventions to deliver maternal health information and reminders, and the development of innovative solutions for transportation and communication in remote areas.

Overall, the recommendation is to focus on strengthening the continuum of care, enhancing access to health facilities, addressing barriers to facility-based deliveries, promoting community-based interventions, and utilizing technology and innovation to improve access to maternal health and reduce neonatal mortality.

AI Innovations Methodology

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

1. Strengthening Health Facilities: Improve the availability and quality of health facilities in rural areas, including hospitals, health centers, and dispensaries. This could involve increasing the number of skilled healthcare providers, ensuring the availability of essential medical supplies and equipment, and improving infrastructure.

2. Community-Based Interventions: Implement community-based interventions to increase access to maternal health services. This could include training and empowering community health workers to provide basic maternal healthcare services, conducting outreach programs to raise awareness about the importance of maternal health, and facilitating transportation for pregnant women to reach health facilities.

3. Telemedicine and Mobile Health: Utilize telemedicine and mobile health technologies to provide remote access to maternal health services. This could involve setting up telemedicine centers in rural areas, where healthcare providers can remotely consult with pregnant women and provide guidance and support. Mobile health applications can also be used to provide information and reminders about antenatal care, postnatal care, and emergency services.

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 key indicators to measure the impact of the recommendations, such as the number of women accessing antenatal care, the number of skilled deliveries, and the neonatal mortality rate.

2. Collect baseline data: Gather data on the current status of maternal health access in the target area, including the number of health facilities, the availability of skilled healthcare providers, and the utilization of maternal health services.

3. Develop a simulation model: Create a simulation model that incorporates the recommendations and their potential impact on the identified indicators. This model should consider factors such as population size, geographical distribution, and existing healthcare infrastructure.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations. This could involve varying parameters such as the number of health facilities, the coverage of community-based interventions, and the utilization of telemedicine and mobile health technologies.

5. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommendations on improving access to maternal health. This could include comparing the indicators before and after the implementation of the recommendations, as well as assessing the cost-effectiveness of the interventions.

6. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it using real-world data. This could involve comparing the simulated results with actual data from pilot projects or similar interventions implemented in other settings.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different recommendations on improving access to maternal health and make informed decisions on which interventions to prioritize and implement.

Author

Dima Health

Statistics:

Citations: 20

Identifiers:

DOI: 10.1186/1471-2393-12-18

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:

Tanzania

Study Design:

Cohort Study, Cross Sectional Study

Participants Gender:

Female