A population-based study of effect of multiple birth on infant mortality in Nigeria

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Study Justification:
This study aims to investigate the impact of multiple births on infant mortality in Nigeria. Multiple births, such as twins and higher order multiples, are considered high-risk pregnancies and births. Understanding the relationship between multiple births and infant mortality is crucial for identifying risk factors and developing interventions to improve child survival rates.
Study Highlights:
– The study analyzed data from the 2003 Nigeria Demographic and Health Survey, which included information on 6,219 children born within five years prior to the survey.
– Univariable and multivariable survival regression procedures were used to examine the relationship between multiple births and infant mortality, controlling for various factors such as child’s sex, birth order, prenatal care, delivery assistance, mother’s age, education level, household living conditions, and other risk factors.
– The study found that children born as multiple births were more than twice as likely to die during infancy compared to infants born as singletons, even after controlling for other factors.
– Maternal education and household asset index were associated with a lower risk of infant mortality.
– The study suggests that improving maternal education may be key to improving child survival in Nigeria, as educated mothers are more likely to provide better infant feeding, general care, household sanitation, and use preventive and curative health services.
Recommendations for Lay Reader and Policy Maker:
1. Increase awareness and education about the risks associated with multiple births and the importance of prenatal care for mothers expecting multiple births.
2. Improve access to quality prenatal care and delivery assistance for women expecting multiple births.
3. Enhance maternal education programs to empower women with knowledge and skills to provide better care for their infants.
4. Promote household sanitation and hygiene practices to reduce the risk of infant mortality.
5. Strengthen preventive and curative health services to ensure timely and appropriate healthcare for infants born as multiple births.
Key Role Players:
1. Ministry of Health: Responsible for implementing policies and programs related to maternal and child health.
2. Healthcare Providers: Including doctors, nurses, and midwives, who play a crucial role in providing prenatal care, delivery assistance, and postnatal care.
3. Educators: Involved in developing and implementing maternal education programs to improve knowledge and skills of mothers.
4. Community Health Workers: Engaged in raising awareness, providing education, and delivering healthcare services at the community level.
5. Non-Governmental Organizations (NGOs): Working in collaboration with the government to implement interventions and support maternal and child health programs.
Cost Items for Planning Recommendations:
1. Training and Capacity Building: Budget for training healthcare providers, educators, and community health workers on multiple birth-related care and education.
2. Infrastructure and Equipment: Allocate funds for improving healthcare facilities, including prenatal care clinics, delivery rooms, and neonatal care units.
3. Education Materials: Develop and distribute educational materials for mothers and families, including brochures, posters, and videos.
4. Community Outreach Programs: Allocate resources for community health workers to conduct awareness campaigns, home visits, and group sessions.
5. Monitoring and Evaluation: Set aside funds for monitoring and evaluating the implementation and impact of interventions, including data collection and analysis.
Note: The provided cost items are general categories and do not represent actual costs. The specific budget requirements will depend on the scale and scope of the interventions implemented.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a population-based study using a large sample size and controlling for various risk factors. However, to improve the evidence, the study could have included more recent data and conducted a longitudinal analysis to establish causality.

Background: Multi-foetal pregnancies and multiple births including twins and higher order multiples births such as triplets and quadruplets are high-risk pregnancy and birth. These high-risk groups contribute to the higher rate of childhood mortality especially during early period of life. Methods: We examined the relationship between multiple births and infant mortality using univariable and multivariable survival regression procedure with Weibull hazard function, controlling for child’s sex, birth order, prenatal care, delivery assistance; mother’s age at child birth, nutritional status, education level; household living conditions and several other risk factors. Results: Children born multiple births were more than twice as likely to die during infancy as infants born singleton (hazard ratio = 2.19; 95% confidence interval: 1.50, 3.19) holding other factors constant. Maternal education and household asset index were associated with lower risk of infant mortality. Conclusion: Multiple births are strongly negatively associated with infant survival in Nigeria independent of other risk factors. Mother’s education played a protective role against infant death. This evidence suggests that improving maternal education may be key to improving child survival in Nigeria. A well-educated mother has a better chance of satisfying important factors that can improve infant survival: the quality of infant feeding, general care, household sanitation, and adequate use of preventive and curative health services. © 2008 Uthman et al; licensee BioMed Central Ltd.

This study uses data from the 2003 Nigeria Demographic and Health Survey (NDHS) [23]. It is based on information of 6219 children born within five years prior to the survey. The NDHS collected demographic, socio-economic, and health data from nationally representative sample of 7620 women aged 15–49 years in 7864 households included in the survey. The state was stratified into 36 states and the Federal Capital Territory (FCT) of Abuja within the six geopolitical regions. Methods used in the NDHS have been published elsewhere [24]. Briefly, each domain is made up of enumeration areas (EAs) established by a general population and housing census in 1991. The sampling frame was a list of all EAs (clusters). Within each domain, a two-stage sample was selected. The first stage involved selecting 466 clusters (primary sampling units) with a probability proportional to the size, the size being the number of households in the cluster. The second stage involved the systematic sampling of households from the selected clusters. This study is based on an analysis of existing survey data with all identifier information removed. The survey was approved by the Ethics Committee of the ORC Macro at Calverton in the USA and by the National Ethics Committee in the Ministry of Health in Nigeria. All study participants gave informed consent before participation and all information was collected confidentially. Each woman interviewed in the survey was asked to provide a detailed history of all her live births in chronological order, including whether a birth was single or multiple, sex of the child, date of birth, survival status, age of the child on the date of interview if alive, and if not alive, age at death of each live birth. These data from the birth histories were used to calculate infant mortality rate, defined as the probability of dying before completing 12 months of age, using a synthetic cohort life table[25]. The rate was expressed as deaths per 1000 live births. The multiple birth status was analysed as not multiple-birth (singleton) and multiple-birth (twin, triplet, quadruplet, or higher order). Each multiple birth child was analysed as an individual child, and the clustering effect of each group of multiple births was included in the analysis. Because child survival is correlated with pregnancy care, delivery assistance, maternal nutrition, household living conditions, and other child, mother, and household characteristics and socio-economic factors that can also affect morbidity and mortality in children, the association between multiple birth status and infant mortality were estimated after adjusting for the effects of these other risk factors and potentially confounding factors. These factors include child’s sex (boy, girl), professional assistance at delivery (no, yes), birth order (1, 2, 3, 4+), child’s birth size (below average, average, above average), mother’s age at childbirth (13–17, 18–24, 25–34, 35–48), mother’s body mass index (BMI) (<18.5, 18.5–24.9, 25.0+ kg/m2), mother's education (no education, some primary, secondary or higher), household wealth index (highest, fourth, middle, second, lowest), household access to safe drinking water (yes, no), availability of a hygienic toilet (yes, no), cooking fuel type (low pollution fuel, high pollution fuel), ethnic group (Hausa/Fulania, Igbo, Yoruba, others) residence (urban, rural) and geographic division (North central, North East, North West, South East, South South, and South West). We used univariable and multivariable survival regression procedure with Weibull hazard function in Stata version 10[26] to examine the relationship of multiple birth status and other factors on infant mortality. A number of unadjusted hazard regression models were used to assess the unadjusted effect of multiple births and different risk factor and confounding factor, and a full adjusted model to assess the adjusted effect of multiple births controlling for all other factors that were significant in the unadjusted analyses (p < .05). In our analysis, weights were used to restore the representativeness of the sample, in which certain categories of respondents were over-sampled and non-response rates varied from one geographical area to another. Results were presented as hazard ratios (HR) with 95% confidence intervals (CI).

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

1. Education programs for expectant mothers: Implementing educational programs that focus on prenatal care, infant feeding, general care, household sanitation, and the use of preventive and curative health services can help improve maternal and child health outcomes.

2. Mobile health (mHealth) interventions: Utilizing mobile technology to provide maternal health information, reminders for prenatal visits, and access to healthcare professionals through telemedicine can improve access to maternal health services, especially in remote areas.

3. Community health worker programs: Training and deploying community health workers who can provide essential maternal health services, such as prenatal care, delivery assistance, and postnatal care, can help bridge the gap in access to healthcare in underserved communities.

4. Improved healthcare infrastructure: Investing in the development and improvement of healthcare facilities, including maternity clinics and hospitals, can ensure that pregnant women have access to quality maternal healthcare services.

5. Financial incentives for healthcare providers: Implementing financial incentives for healthcare providers who offer quality maternal health services can help improve the availability and accessibility of these services.

6. Transportation support: Providing transportation support, such as ambulances or transportation vouchers, to pregnant women in remote areas can help ensure timely access to healthcare facilities for prenatal care, delivery, and emergency obstetric care.

7. Maternal health awareness campaigns: Conducting awareness campaigns to educate communities about the importance of maternal health, the availability of services, and the benefits of seeking timely care can help increase demand for and utilization of maternal health services.

These innovations, if implemented effectively, can contribute to improving access to maternal health and reducing infant mortality rates in Nigeria.
AI Innovations Description
Based on the study described, the recommendation to improve access to maternal health and reduce infant mortality in Nigeria is to focus on improving maternal education. The study found that children born from multiple births were more than twice as likely to die during infancy compared to singleton births. However, maternal education was associated with a lower risk of infant mortality.

Improving maternal education can have a positive impact on child survival by enabling mothers to have a better understanding of important factors that can improve infant health, such as quality of infant feeding, general care, household sanitation, and the use of preventive and curative health services. Educated mothers are more likely to make informed decisions regarding their own health and the health of their children.

Therefore, implementing programs and initiatives that prioritize maternal education can contribute to improving access to maternal health and reducing infant mortality in Nigeria. These programs can include providing educational resources and support to pregnant women and new mothers, promoting awareness of the importance of maternal education, and integrating maternal health education into existing healthcare services.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Increase access to prenatal care: Implement strategies to ensure that pregnant women have access to regular prenatal check-ups, screenings, and necessary interventions to monitor their health and the health of their babies.

2. Improve delivery assistance: Enhance access to skilled birth attendants, such as midwives or obstetricians, who can provide safe and effective care during childbirth. This includes ensuring that women have access to appropriate medical facilities for delivery.

3. Enhance maternal education: Promote programs that focus on educating women about pregnancy, childbirth, and postnatal care. This can empower women to make informed decisions about their health and the health of their babies.

4. Improve household living conditions: Address socio-economic factors that can impact maternal health, such as poverty, inadequate housing, and lack of access to clean water and sanitation facilities. This can be done through targeted interventions and policies aimed at improving living conditions.

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 will be used to measure the impact of the recommendations. For example, indicators could include the percentage of pregnant women receiving prenatal care, the percentage of births attended by skilled birth attendants, and the infant mortality rate.

2. Collect baseline data: Gather data on the current status of maternal health and the selected indicators. This can be done through surveys, interviews, or existing data sources.

3. Develop a simulation model: Create a simulation model that incorporates the recommendations and their potential impact on the selected 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 can involve adjusting variables such as the percentage of women accessing prenatal care or the availability of skilled birth attendants.

5. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommendations on improving access to maternal health. This can include assessing changes in the selected indicators and identifying any potential challenges or limitations.

6. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it using additional data or expert input. This will help ensure the accuracy and reliability of the model.

7. Communicate findings and make recommendations: Present the findings of the simulation study, including the potential impact of the recommendations on improving access to maternal health. Use this information to make evidence-based recommendations for policy and programmatic interventions.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and available data. Additionally, the simulation results should be interpreted with caution and considered alongside other evidence and expert input when making decisions about improving access to maternal health.

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