Hospital delivery and neonatal mortality in 37 countries in sub-Saharan Africa and South Asia: An ecological study

Abstract

Background Widespread increases in facility delivery have not substantially reduced neonatal mortality in sub-Saharan Africa and South Asia over the past 2 decades. This may be due to poor quality care available in widely used primary care clinics. In this study, we examine the association between hospital delivery and neonatal mortality. Methods and findings We used an ecological study design to assess cross-sectional associations between the share of hospital delivery and neonatal mortality across country regions. Data were from the Demographic and Health Surveys from 2009 to 2018, covering 682,239 births across all regions. We assess the association between the share of facility births in a region that occurred in hospitals (versus lower-level clinics) and early (0 to 7 days) neonatal mortality per 1,000 births, controlling for potential confounders including the share of facility births, small at birth, maternal age, maternal education, urbanicity, antenatal care visits, income, region, and survey year. We examined changes in this association in different contexts of country income, global region, and urbanicity using interaction models. Across the 1,143 regions from 37 countries in sub-Saharan Africa and South Asia, 42%, 29%, and 28% of births took place in a hospital, clinic, and at home, respectively. A 10-percentage point higher share of facility deliveries occurring in hospitals was associated with 1.2 per 1,000 fewer deaths (p-value < 0.01; 95% CI: 0.82 to 1.60), relative to mean mortality of 22. Associations were strongest in South Asian countries, middle-income countries, and urban regions. The study’s limitations include the inability to control for all confounding factors given the ecological and cross-sectional design and potential misclassification of facility levels in our data. Conclusions Regions with more hospital deliveries than clinic deliveries have reduced neonatal mortality. Increasing delivery in hospitals while improving quality across the health system may help to reduce high neonatal mortality.

Genomic transmission analysis of multidrug-resistant Gram-negative bacteria within a newborn unit of a Kenyan tertiary hospital: A four-month prospective colonization study

“…Neonatal mortality rates in sub-Sahara Africa, including Kenya, continue to be among the highest worldwide ( Gage et al., 2021 ) and severe newborn infections are accountable for 37% of these deaths ( Ahmed et al., 2018 ). Due to limited medical infrastructure, reduced treatment options and high patient vulnerability ( Laxminarayan and Bhutta, 2016 ), patients in newborn units (NBU) are at high risk for infections with multidrug-resistant organisms (MDRO).…”

Neonatal and perinatal mortality in the urban continuum: A geospatial analysis of the household survey, satellite imagery and travel time data in Tanzania

“…In the sample of live births, one third of women reported giving birth in hospitals, but this is a combination of women who planned to give birth there and those referred to hospitals due to a maternal or fetal complication. Rather than hospitals being a cause of higher neonatal mortality, 50 the more complicated case mix in hospitals might be reflected in the higher adjusted odds of neonatal death in this facility type (which was not significant). Previous studies show that facility readiness is comparable across urban and rural settings in Tanzania.…”

Determinants of early neonatal mortality (hospital based retrospective cohort study in Somali region of Ethiopia)

“…Neonatal mortality continues to be the highest (17%) among children under the age of five worldwide, with Sub-Saharan Africa accounting for the largest share 2 . Low-income countries continue to have higher rates of neonatal death 3 , 4 .…”