Maryam Siddiqa ( Department of Mathematics and Statistics, International Islamic University Islamabad, Pakistan )
Sana Kanwal ( Department of Mathematics and Statistics, International Islamic University, Islamabad, Pakistan. )
Yusra Liaqat ( Department of Mathematics and Statistics, International Islamic University, Islamabad, Pakistan. )
May 2023, Volume 73, Issue 5
Individual and Community-level Determinants of Neonatal Mortality in Pakistan: indication from Pakistan Demographic and Health Survey (2017-18)
Maryam Siddiqa ( Department of Mathematics and Statistics, International Islamic University Islamabad, Pakistan )
Objective: To evaluate individual and community-level factors influencing neonatal mortality in Pakistan.
Method: The retrospective, secondary-data, quantitative study was done from July 2021 to January 2022 after approval from the ethics review committee of the International Islamic University, Islamabad, Pakistan, and comprised data of live births from November 22, 2017, to April 30, 2018, which was the period covered by the Pakistan Demographic and Health Survey 2017-18. Significant community-level, maternal and proximate determinants of neonatal mortality were identified. Data was analysed using STATA 13.
Results: Among the 12,708 live births covered, the neonatal mortality rate within the first month of birth was 5337(42%), and 3939(31%) neonatal deaths occurred in the first week of life, while 3431(27%) deaths occurred on the first day. Distance to health facility (adjusted hazard ratio: 1.1; 95% confidence interval: 0.8-1.6), unimproved toilet facility (adjusted hazard ratio: 2.0; 95% confidence interval: 0.7-2.1), caesarean section deliveries (adjusted hazard ratio: 1.6; 95% confidence interval: 0.6-1.9) and child’s birth size smaller than average (adjusted hazard ratio: 1.7; 95% confidence interval: 1.1-2.7) carried significantly higher risk of neonatal deaths. Compared to women aged 15-19 years, older women’s child (adjusted hazard ratio: 0.6; 95% confidence interval: 0.2-1.6) and neonates having birth order 3 compared to birth order 1 (adjusted hazard ratio: 0.5; 95% confidence interval: 0.2-0.9) and female gender of child (adjusted hazard ratio: 0.3; 95% confidence interval: 0.2-0.9) were less likely to die.
Conclusions: There was a markedly high prevalence of neonatal mortality rate in Pakistan. Unimproved toilet facility, distance to health facility, caesarean mode of delivery and small size of the child at birth were found linked with increased risk of neonatal mortality.
Key Words: Neonatal mortality, Determinants, Low- and middle-income countries, Pakistan, Health policy. (JPMA 73: 988; 2023) DOI: 10.47391/JPMA.6552
Submission completion date: 11-05-2022 — Acceptance date: 19-11-2022
The neonatal period comprises the first 4 weeks after birth, and is the most susceptible period of human life in terms of diseases. During the neonatal period, which lasts for the first 28 days of life, newborns have the greatest risk of dying1. Neonatal mortality is a major public health issue, with low- middle-income countries (LMICs) accounting for 60% of such deaths2.
Improving neonatal outcomes is a crucial phenomenon for global sustainable development in the fields of maternal, neonatal and child health (MNCH). Despite a global decline in child mortality rates, many countries are missing the global target of eliminating preventable newborn deaths by 2030, and lowering neonatal mortality to as low as 12 per 1000 live births3. There were 5.3 million reported deaths of children aged <5 in 20184. The <5 mortality rate in LMICs was 68 deaths per 1000 live births in 2018; nearly 14 times higher than the average of 5 deaths per 1000 live births in high-income countries (HICs)4.
Despite the fact that Pakistan was falling short of the Millennium Development Goal-4 (MDG4) target, the Pakistan Demographic and Health Survey PDHS (2012-13) found that significant progress had been made in lowering all <5 mortality indicators except neonatal mortality5. Pakistan has the highest neonatal mortality rate (NMR) (61.8%) among 9 LMICs; Zimbabwe, Ghana, Bangladesh, Nepal, Afghanistan, Pakistan, Nigeria, Ethiopia and Tanzania6.
After the MDGs expired in 2015, the United Nations General Assembly replaced them with Sustainable Development Goals (SDGs), which prioritised maternal, neonatal, child and adolescent health7. The SDGs' first three health targets were extensions of the MDGs. The most important goal is to bring NMR down to <12 deaths per 1000 live births, and less than 5 mortality to <25 deaths per 1000 live births7,8. Pakistan has consistently fallen short of attaining the global targets seeking reduction in maternal and newborn mortality. The government of Pakistan introduced the National Maternal, Neonatal and Child Health (MNCH) Programme in 20079, which focussed on two key areas: endorsing institutional deliveries and skilled birth attendance, and providing emergency gynaecology services and community midwives in rural areas. Lady health workers (LHWs) provided obstetric and newborn services as well as primary healthcare through home visits9. The targets, however, were not met10. Preterm births combined with complications are the primary causes of poor neonatal health outcomes in Pakistan11. The social and economic status of women and their autonomy level have significant effects on their children's health. In Pakistan, gender inequality still plays an important role in determining the health of women and children. Women in Pakistan have historically performed poorly in comparison to men according to the UN Human Development Index (HDI)12. The cause of newborn death and the factors that contribute to neonatal mortality must be determined for the development of effective strategies to lower the NMR7.
Multiple factors influence newborns’ death, including genetic differences, socio-economic differences, demographic trends, healthcare arrangement, cultural norms, and technologies13. Improved access to high-quality maternal and newborn health services delivered by skilled healthcare professionals, potable water supply, proper antenatal and postnatal nutrition for mothers and newborns, sanitisers, and skin-to-skin interaction have shown to prevent the neonatal mortality13,14.
The current study was planned to evaluate individual and community-level factors influencing neonatal mortality in Pakistan.
Materials and Methods
This, secondary-data, analysis study was conducted from July 2021 to January 2022 after approval from the International Islamic University (IIU), Islamabad, Pakistan, and comprised data of live births from November 22, 2017, to April 30, 2018, which was the period covered by PDHS (2017-18)15, which is a 5-year nationally representative cross-sectional household survey. The PDHS-2017-18 collected data through two-stage stratified sampling frame. Samples were first selected through probability proportional to size sampling, and then units were allocated with the help of systematic sampling frame.
The response variable in the current study was survival information of mortality time/status of a newborn within the first 28 days of life. The NMR was computed as the number of deaths per 1,000 live births in the first month of life. The study outcome was reported as a binary variable, with 'Dead' coded as 1 and 'Survived' coded as 0.
Community-level variables included type of residence (urban and rural), region (Punjab, Sindh, Khyber Pakhtunkhwa [KP], Balochistan, Islamabad Capital Territory [ICT], Gilgit-Baltistan (GB), Azad Jammu and Kashmir [AJK] and Federally-administerd tribal area [FATA]), wealth status (poor, middle and rich), distance to health facility (no problem and big problem), type of toilet facility (improved and unimproved), type of cooking fuels (non-solid and solid), source of drinking water (improved, unimproved) and use of internet (no and yes). Seven maternal factors included mother’s age group (15-19, 20-34, 35-49 years), mother’s occupation (not working, professional/clerical/service, agricultural, manual [skilled/unskilled]), education (not educated, primary or secondary education and higher education), smoking status (non-smokers and smokers), pregnancy desire (then, later and no more), number of tetanus injections before birth (received no injection, 1 TT and 2+ TT) and use of contraceptives (no and yes).
The approximate determinants were prenatal care (no care and some care), antenatal care (ANC) (no and yes), place of delivery (at home, government hospital, rural health centre small braces and private hospital), delivery mode (normal and caesarean section small braces), and delivery assistance (no assistance and some assistance).
Neonatal determinants were birth order (1st child, 2nd child, 3rd child, 4th child and above), gender of child (male and female), size of child at birth (below average, average, above average), status of breastfeeding (never breastfed, ever breastfed, not immediately) and consumption of baby formula (no and yes).
The conceptual model presented by Mosley et al. (1984)16 was used with modifications subject to constraints and layout of the PDHS 2017-18 data (Figure).
Data was analysed using STATA 13. Descriptive statistics were expressed by frequencies and percentages. The association of neonatal, community and maternal factors with neonatal mortality was investigated using the Cox-proportional hazard model (1975)17. Using step-wise backward elimination process, a multivariate model was built that initially contained all the study variables. The exponential of the regression coefficients was used to estimate the 95% confidence interval (CI) and hazard ratio (HR). p-value <0.05 was considered statistically significant.
Among the 12,708 live births covered, the neonatal mortality rate within the first month of birth was 42 %(n=5,337), and 31%(n=3,939) neonatal deaths occurred in the first week of life, while 27%(n=3,431) deaths occurred on the first day.
Majority of mothers belonged to Punjab, aged 20-34 years, were uneducated, belonged to poor families, were non-smokers, lived in rural areas, were housewives, used solid cooking fuels, did not use the internet, did not use any contraceptives, received no ANC service, and delivered in private hospitals (Table 1).
HRs and adjusted HRs (AHRs) for NMR in relation to the study variables were worked out and compared (Table 2).
Distance to health facility (AHR: 1.1; 95% CI: 0.8-1.6), unimproved toilet facility (AHR: 2.0; 95% CI: 0.7-2.1), CS deliveries (AHR: 1.6; 95% CI: 0.6-1.9) and child’s birth size smaller than average (HR: 1.7; 95% CI: 1.1-2.7) carried significantly higher risk of neonatal deaths (p<0.05). Compared to women aged 15-19 years, older women’s child (AHR: 0.6; 95% CI: 0.2-1.6), neonates having birth order 3 compared to birth order 1 (AHR: 0.5; 95% CI: 0.2-0.9) and girls compared to boys (AHR: 0.3; 95% CI: 0.2-0.9) were less likely to die (Table 3).
Compared to community characteristics, maternal and neonatal characteristics explained a higher proportion of neonatal death variations in the current study. Mother’s age, unimproved toilet facility, distance to health facility, birth order, gender of child, size of child at birth and mode of delivery had a significant effect on neonatal death.
The availability of unimproved toilet systems was significantly related to neonatal mortality. Improved sanitation lowers the risk of death in newborns by exposing them to less contamination, making them more susceptible to illnesses, infections and eventual death19.
Women aged >19 years were less likely than women aged <19 to experience neonatal mortality in their child. The finding is supported by other studies18,19-22.
Children having birth order 3 had a lower risk of neonatal death than the first-borns. It has been reported earlier as well16 and the likely reason could be the young age and inexperience of the mother at the time and duration of the first pregnancy and childbirth12.
Boys were more likely than girls to die within the first month of birth, which has been widely reported in literature7,13,17,21,23-25. Inherited biological differences between the genders were found to play a big role in the development of the risk of male infant mortality22.
Children who were smaller than average in size had a greater risk of death during the neonatal period than children who were of average size. The findings are in line with previous research12,19,26. A detailed analysis of PDHS 2017-18 by the National Institute of Population Studies (NIPS) revealed a clear link between small birth size and neonatal mortality. However, over half of the newborns were not weighed at the time of birth, and birth size is an essential proxy for birthweight14. Besides, in contrast to the current findings, studies17,26 have reported that neonates of above-average size had higher risk of death.
In the current study, those delivered through CS were more likely to die than those through the normal mode. This could be due to autoimmune prematurity or life-threatening pregnancy-related issues that necessitate an emergency CS27. However, a cross-sectional, ecological study reported that CS delivery rates were inversely connected to newborn deaths28.
The current study has several limitations. Because of the study's cross-sectional design, causality was not explored. The dates of birth and death were calculated using retrospective data derived from mothers' self-reporting, which could lead to recall and misclassification bias. Also, the mothers' description of the size of their babies was speculative. Finally, the data did not include information on the health condition and nutritional status of the neonates and their mothers. Besides, the cause of death was not covered.
Despite the limitations, however, the study based on a nationally representative survey, the findings may lead to informed policy priorities.
Distance to health facility, unimproved toilet facility, CS deliveries and child’s birth size smaller than average carried significantly higher risk of neonatal deaths. Besides, compared to women aged 15-19 years, older women’s child, neonates having birth order 3 compared to birth order 1, and girls compared to boys were less likely to die.
Conflict of Interest: None.
Source of Funding: None.
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