Abstract

Facility delivery should reduce early neonatal mortality. We used the Slope Index of Inequality and logistic regression to quantify absolute and relative socioeconomic inequalities in early neonatal mortality (0 to 6 days) and facility delivery among 679,818 live births from 72 countries with Demographic and Health Surveys. The inequalities in early neonatal mortality were compared with inequalities in postneonatal infant mortality (28 days to 1 year), which is not related to childbirth. Newborns of the richest mothers had a small survival advantage over the poorest in unadjusted analyses (−2.9 deaths/1,000; OR 0.86) and the most educated had a small survival advantage over the least educated (−3.9 deaths/1,000; OR 0.77), while inequalities in postneonatal infant mortality were more than double that in absolute terms. The proportion of births in health facilities was an absolute 43% higher among the richest and 37% higher among the most educated compared to the poorest and least educated mothers. A higher proportion of facility delivery in the sampling cluster (e.g. village) was only associated with a small decrease in early neonatal mortality. In conclusion, while socioeconomically advantaged mothers had much higher use of a health facility at birth, this did not appear to convey a comparable survival advantage.

Highlights

  • Facility delivery should reduce early neonatal mortality

  • The odds ratios and the absolute differences in mortality that we report in this study refer to differences across the entire wealth and education distributions

  • To investigate the survival benefit associated with facility delivery, we studied associations between average proportion of facility delivery in the sampling cluster and early neonatal mortality using the slope index of inequality (SII) and relative index of inequality (RII)

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Summary

Introduction

We used the Slope Index of Inequality and logistic regression to quantify absolute and relative socioeconomic inequalities in early neonatal mortality (0 to 6 days) and facility delivery among 679,818 live births from 72 countries with Demographic and Health Surveys. The inequalities in early neonatal mortality were compared with inequalities in postneonatal infant mortality (28 days to 1 year), which is not related to childbirth. The majority of early neonatal deaths occur in low- and middle-income countries and the main medical causes are prematurity and intrapartum-related events, such as birth asphyxia, whereas infections are responsible for most late neonatal and infant deaths[2,3,4,5,6]. Early neonatal survival is closely related to care at birth, whereas postneonatal infant survival depends rather on good care practices at home (including feeding and hygiene), and on care-seeking for sickness. We refer to this adverse selection of high-risk deliveries into health facilities as “confounding by case-mix”

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