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

Anna D Gage,Margaret E Kruk,John E Ataguba,Günther Fink,Jenny E Myers

doi:10.1371/journal.pmed.1003843

Abstract

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. 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. 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.

Highlights

Despite substantial increases in facility delivery in the past 2 decades, global declines in neonatal mortality have lagged reductions in child mortality [1,2]
After reviewing the contextual variables, we further explored the associations in sub-Saharan Africa with a random slope and random intercept model, allowing the relationship between hospital delivery and early neonatal mortality to vary by country
Hospital births made up 49% of all facility deliveries in sub-Saharan Africa and 64% in South Asia

Summary

Introduction

Despite substantial increases in facility delivery in the past 2 decades, global declines in neonatal mortality have lagged reductions in child mortality [1,2]. The association between hospital delivery and neonatal mortality neonatal survival in these regions [5,6] This is potentially due to the poor quality of maternity care, in primary care clinics, which conduct 30% or more deliveries in low-income countries [7]. 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. We examine the association between hospital delivery and neonatal mortality

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Conclusion