Neonatal mortality in low and lower-middle income countries : which areas require further attention? Evidence from Bangladesh

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Background: The global neonatal mortality rate (NMR) is still high, estimated at 19 deaths per 1,000 live births in 2015, which accounts for 45 percent of under-five deaths. Neonatal deaths are projected to increase to 52 percent of under-five deaths in 2030, with most deaths occurring in low and lower-middle income countries (LMICs). This research aimed to examine the key factors that affect the neonatal mortality in LMICs, with a focus on Bangladesh. Methods: This study comprised a systematic review and statistical analyses. The systematic review, using a narrative synthesis methodology, first examined the impact of workforce interventions on neonatal outcomes in LMICs. Statistical analyses of the 2011 Bangladesh Demographic and Health Survey (DHS) data (n=17,842) investigated the key components of health care services, including facility-based delivery, skilled birth attendants (SBAs), essential newborn care (ENC), antenatal care (ANC) and postnatal care (PNC). In addition, statistical analyses of DHS data from Nepal (n=12,674) and Pakistan (n=13,558) were undertaken to compare the impact of facility-based delivery and/or SBAs in reducing NMR in those countries. A separate statistical analysis of the 2014 Bangladesh DHS data (n=17,863) investigated the changes over time in newborn health care practices, from 2011 to 2014. Statistical analyses used in this research included chi-square tests, multiple logistic regression models and Cox proportional hazards regression models. Results: The systematic review found that competency assessment, the acquisition of appropriate skills and supervisory guidelines can improve health professional performance. An empirical investigation of Bangladesh DHS data revealed an improvement in health care practices over time for all socio-demographic groups in the country. A detailed investigation suggested that neonatal mortality significantly decreased for newborns whose mothers received ANC services (HR=0.52; 95% CI: 0.29, 0.96). The ENC practice of delayed bathing significantly contributed to reducing neonatal mortality in Bangladesh (OR=0.14; 95% CI: 0.03, 0.68). However, other ENC practices including PNC and skilled assistance during delivery were not found to be significantly associated with neonate deaths. Furthermore, neonatal mortality was significantly higher for facility deliveries compared to home deliveries in Bangladesh (OR=2.43; 95% CI: 1.09, 5.41). Nepal and Pakistan DHS data also failed to confirm any significant effect of facility delivery and/or SBAs on neonatal mortality. Conclusions: This is the first study to examine the impact of different components of health care practices on neonatal mortality in Bangladesh at a national level and provides important recommendations for saving newborn lives. First, guidelines related to the fabric used for the immediate drying and wrapping of newborns are required to improve hygiene at a baby’s birth. Second, increased emphasis on parental education is required to improve the uptake of ENC services. Third, investment in promoting ANC is important to accelerate the reduction of neonatal deaths. Fourth, revisiting current health intervention programs related to PNC in Bangladesh are essential to better understand the impact of PNC on neonatal mortality. Finally, standardized workforce training and staff supervision are required to improve the performance of health providers. Nevertheless, more research is required to better understand neonatal mortality in LMICs, particularly the reasons why the risk of neonatal deaths increases for deliveries at health facilities and why some ENC practices do not have any impact on neonatal mortality.
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