Health Policy and Planning Advance Access originally published online on August 30, 2006
Health Policy and Planning 2006 21(6):432-443; doi:10.1093/heapol/czl024
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Risk factors for neonatal mortality in rural areas of Bangladesh served by a large NGO programme
1Centre for Health and Population Research (ICDDR,B), Dhaka, Bangladesh, 2Partners in Health and Development, Dhaka, Bangladesh and 3Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Canada
Correspondence: Alex Mercer, c/o HSID, Centre for Health and Population Research, ICDDR,B, Mohakali, Dhaka 1000, Bangladesh. Tel: +880-2–8811751–60 (ext 2531), +880-2–9887928 (direct); Fax: +880-2–8823116, +880-2–8811568; E-mail: amercer{at}icddrb.org
Neonatal deaths account for about half of all deaths among children under 5 years of age in Bangladesh, making prevention a major priority. This paper reports on a study of neonatal deaths in 12 areas of Bangladesh served by a large NGO programme, which had high coverage of reproductive health outreach services and relatively low neonatal mortality in recent years. The study aimed to identify the main factors associated with neonatal mortality in these areas, with a view to developing appropriate strategies for prevention. A case-control design was adopted for collection of data from mothers whose children, born alive in 2003, died within 28 days postpartum (142 cases), or did not (617 controls). Crude and adjusted odds ratios (AOR) were calculated as estimates of relative risk for neonatal death, using ‘neighbourhood’ controls (241) and ‘non-neighbourhood’ controls (376). A similar proportion of case and control mothers had received NGO health education and maternal health services. The main risk factors for neonatal death among 122 singleton babies, based on the two sets of controls, were: complications during delivery [AOR, 2.6 (95% CI: 1.5–4.5) and 3.1 (95% CI: 1.8–5.3)], prematurity [AOR, 7.2 (95% CI: 3.6–14.4) and 8.3 (95% CI: 4.2–16.5)], care for a sick neonate from an unlicensed ‘traditional healer’ [AOR, 2.9 (95% CI 0.9–9.5 and 5.9 (95% CI: 1.3–26.3)], or care not sought at all [AOR, 23.3 (95% CI: 3.9–137.4)]. The strongest predictor of neonatal death was having a previous sibling not vaccinated against measles [AOR, 5.9 (95% CI: 2.2–15.5) and 12.0 (95% CI: 4.5–31.7)]. The findings of this study indicate the need for identification of babies at high risk and early postpartum interventions (40.2% of the deaths occurred within 24 hours of delivery). Relevant strategies include special counselling during pregnancy for mothers with risk characteristics, training birth attendants in resuscitation, immediate postnatal check-up in the home for high-risk babies identified at delivery, advice for mothers on appropriate care-seeking for sick babies, improving the capacity of sub-district hospitals for emergency obstetric and newborn care, and promotion of institutional deliveries.
Key Words: neonatal mortality, risk factors, NGO, maternal, newborn, child care, outreach, health services, care seeking
1Now Partners in Health and Development, an independent, not-for-profit organization.
2The number of stillbirths reclassified as neonatal deaths was an estimate based on a random sample of mothers of stillbirths in 2003. Of 109 mothers interviewed, 9 (8.3%) reported signs of life. Based on this proportion, it was estimated that 30 of the 354 stillbirths registered in the 12 areas in 2003 could have been neonatal deaths: the nine identified mothers were interviewed and 21 were not identified (Mercer et al. 2006).
3The corrected figure for neonatal deaths among 11 031 singleton births in 2003 was 180, an NMR of 16.3 per 1000 live births. Interviews were conducted with 122 (67.8%) of these case mothers. Assuming they were representative, the 122 deaths occurred among 7479 singleton births (11 031x0.678). Based on the proportion found in the survey, we would expect 2618 (35%) of these mothers to have a previous child aged under 5 years who had not died. Based on the coverage in the 12 study areas, 2304 (88%) would have been vaccinated against measles, and 314 would not. There were 21 neonatal deaths among babies with their previous sibling vaccinated, and 17 among those with their previous sibling not vaccinated: NMRs of 9.1 and 54.1 per 1000, respectively, and 14.5 per 1000 for the two groups combined.
4As in footnote 3, it was assumed that the 122 deaths occurred among 7458 singleton births in 2003. Based on the survey proportion, we would expect 2814 (37.6%) of the mothers to have babies who had sickness in the first 28 days that was considered serious. Again, based on the survey proportions, we would expect 1002 (35.6%) of these mothers to have sought care from a qualified provider, and 841 (29.9%) to have sought care from a traditional healer or not all. There were 36 and 63 neonatal deaths, respectively, among the children of these two groups of women: NMRs of 35.9 per 1000 and 74.9 per 1000, respectively; and 53.7 per 1000 for the three groups combined.
5A study of Community-based Interventions to Reduce Neonatal Mortality in Bangladesh (Projahnmo) is being conducted by ICDDR,B Centre for Health and Population Research in Sylhet Division, in collaboration with NGOs and other partners. The study aims to evaluate the impact of a package of obstetric and neonatal care practices, including management of serious neonatal infections by first-line health workers, and to improve practices, including management of serious neonatal infections by first-line health workers, and to improve newborn care and the recognition of serious infections in neonates by mothers and trained first-line workers.