Improving neonatal survival.

Abstract

Better care should result in better outcomes. Therefore, intuitively, skilled birth attendance should lead to better newborn survival, compared with settings where no such care is provided, and if care is provided in facilities where complications can be managed better, the results should be better still. Unfortunately, a recent large analysis by Fink et al. (Int J Epidemiol 2015;44:1879–88) of 192 Demographic and Health Surveys (DHS) found only a weak association between such improved care and neonatal survival. The paper by Bellizzi and colleagues takes this further: they look at neonatal outcomes of women who deliver at home with or without the help of a skilled birth attendant (SBA), or in a health facility, in nine DHS where delivery complications were reported. They could therefore adjust their findings for these, and found increasing mortality at lower levels of care, after their adjustment. The problem of the analysis of data from cross-sectional surveys such as the DHS is that people don't randomly choose where they deliver. The place of delivery is influenced by, and a result of, the course of delivery. Particularly poor and rural women might first try to deliver at home without help. Only if they perceive a problem, and delivery does not progress as anticipated, do they call for help in the form of a skilled birth attendant (SBA). And only after additional problems and a further delay in time might they consider delivering in a health facility. Therefore, complications and adverse outcomes are more common in women delivering with an SBA or at a health facility. The authors tried to adjust for this by taking into account recorded complications. However, the course of events (delays before a decision is taken to seek care from a SBA or attend at a health facility) does not constitute ideal care. A lot of time is lost by taking this approach. Time, if saved, should lead to better outcomes. WHO and other international agencies have been arguing for skilled birth attendance and institutional (health facility-based) delivery for years, as only in this way can more sophisticated care be provided without delay if complications arise (Global Strategy for Women's, Children's and Adolescent Health, WHO: Geneva, 2016). The acceptance of this approach by the population and uptake of institutional care at the time of birth depends critically on the quality of care provided. If hospitals are perceived as ‘death traps’, both for the mother and her newborn, nobody is going to go there except in dire circumstances. This is turn strengthens the bad reputation of health facilities. Improvement in the quality of care is addressed in several regional frameworks, for example in the European region (WHO/EURO: Improving the Quality of Care for Reproductive, Maternal, Neonatal, Child and Adolescent Health in the European Region, Copenhagen 2016). Where infection control measures are lax or, quite contrarily, antibiotics are given indiscriminately, the risk of acquiring nosocomial infections arises, and a newborn might be better off being delivered at home. There, no multi-resistant organisms are around when the neonate acquires initial skin and intestinal bacterial flora, having left the sterile environment of the amniotic cavity. Magic bullets solving complex problems would be nice, but often improvements have to address multiple factors to lead to better outcomes. Quality improvement is indispensable. The author is a WHO staff member. The opinions expressed are his and do not necessarily reflect the positions and policies of the World Health Organization. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.