Giving birth at home is the most significant risk factor for neonatal deaths in major sections of Africa – a continent that continues to be plagued by the highest neonatal mortality rates in the world, indicates a Michigan State University study.
In both East and West Africa, a substantial proportion of births are still delivered without a doctor or other health-care professional. Unprotected water sources and older mothers giving birth also help explain why home-births are so dangerous.
The findings are meant to provide guidance toward the UN’s longstanding goal of reducing deaths among children under 5. Worldwide, child mortality rates decreased 53% between 1990 and 2015, according to the UN.
Africa, however, had the smallest reductions in child morality rates during that 25-year period and still has the highest neonatal morality rate of 28 deaths per 1,000 live births. Nearly half of under-5 child deaths occur during the neonatal period (the first 30 days of life). The UN’s newest goals – the Sustainable Development Goals, a 15-year strategy launched in early 2016 – include reducing the neonatal mortality rate in all countries to 12 deaths per 1,000 live births.
“Africa still has quite a way to go in terms of reducing neonatal mortality and where interventions are targeted is going to be very important,” said Sue Grady, associate professor of geography and lead investigator of the study.
Grady and a team of students analysed demographic and health-survey data for mothers in 14 sub-Saharan African countries, for a total sample of 344,264 births.
Among the findings and recommendations are that women reported unreliable transportation services to a health-care facility and inability to pay for the high cost of maternity care, including prenatal visits. Public officials should continue focusing on enhancing the availability, accessibility and quality of health-care services, the authors argue.
Also, officials should focus on ensuring the availability of affordable clean water and sanitation for hygienic delivery conditions, particularly in rural communities. Exposure to unclean water after birth can contribute to umbilical cord and intestinal infections in the baby.
The study recommends that health-care financing should include training of health professionals such as midwives and even relatives who can recognise and address complications, including asphyxia, infections and the need for child warmth and breastfeeding immediately after delivery.
And given the trend toward women having children later in life, health officials should emphasise improvements in prenatal care, including family planning education and increased training of birth attendants to manage and encourage deliveries for women of advanced maternal age at health-care facilities.
Cultural barriers pertaining to neonatal mortality should be addressed – the study found that female babies in West Africa were more likely to die, perhaps due partly to a gender bias and preference for sons. Mothers also reported not wanting their last child.
Interventions should include continuing to provide education to women and empowering them to make their own decisions on contraceptive use, Grady said. Further research should explore the reasons why some mothers express not wanting their last child.
Under-five child mortality declined 47% since 2000 following the implementation of the United Nation’s (UN) Millennium Development Goals. To further reduce under-five child mortality, the UN’s Sustainable Development Goals (SDGs) will focus on interventions to address neonatal mortality, a major contributor of under-five mortality. The African region has the highest neonatal mortality rate (28.0 per 1000 live births), followed by that of the Eastern Mediterranean (26.6) and South-East Asia (24.3). This study used the Demographic and Health Survey Birth Recode data (http://dhsprogram.com/data/File-Types-and-Names.cfm) to identify high-risk districts and countries for neonatal mortality in two sub-regions of Africa – East Africa and West Africa. Geographically weighted Poisson regression models were estimated to capture the spatially varying relationships between neonatal mortality and dimensions of potential need i) care around the time of delivery, ii) maternal education, and iii) women’s empowerment. In East Africa, neonatal mortality was significantly associated with home births, mothers without an education and mothers whose husbands decided on contraceptive practices, controlling for rural residency. In West Africa, neonatal mortality was also significantly associated with home births, mothers with a primary education and mothers who did not want or plan their last child. Importantly, neonatal mortality associated with home deliveries were explained by maternal exposure to unprotected water sources in East Africa and older maternal age and female sex of infants in West Africa. Future SDG-interventions may target these dimensions of need in priority high-risk districts and countries, to further reduce the burden of neonatal mortality in Africa.
Sue C Grady, April N Frake, Qiong Zhang, Matlhogonolo Bene, Demetrice R Jordan, Joshua Vertalka, Thania C Dossantos, Ameen Kadhim, Judith Namanya, Lisa-Marie Pierre, Yi Fan, Peiling Zhou, Fatoumata B Barry, Libbey Kutch