Dr. Saverio Bellizzi successfully defended his PhD entitled 'The effect of health facility based childbirth on early neonatal mortality in low- and middle-income countries' on March 13th 2019, at Ghent University.
The first week of life represents the riskiest period in the human lifespan and include the 75% of the total neonatal deaths.
Despite the global enhanced interest and programmatic attention, there is a dearth of data regarding the neonatal period, with most of information in low and middle income countries coming from cross-sectional surveys. Quality is also an issue for the exact estimation of the causes of death, which are mostly represented by prematurity, intrapartum complications, infections, and congenital defects.
Scientific reviews using data from high income countries have clearly demonstrated the benefit of pregnancy and childbirth packages, with specific emphasis on skilled birth care at birth, on the survival in the first days of life; however, evidence is lacking for low and middle income countries.
This thesis was undertaken to better define the role of institutional delivery on early neonatal mortality as well as to explore the impact of puerperal infections, maternal hypertensive disorders, and congenital malformations.
The first four studies of this thesis utilized Demographic and Health Surveys (DHS) data and include country surveys with information on reported life threatening obstetric complications during birth of the last infant. The fifth study was a secondary data analysis of the WHO Multicountry Survey on maternal and newborn health (WHOMCS), which included health facility data from 29 countries.
The first study comprises information for 71,758 women of reproductive age and confirmed the high variability of skilled attended birth rates across the world regions, with health facility deliveries ranging from less than 50% in Bangladesh, Mali and Niger, up to 90% in Colombia. This analysis revealed no association between place of birth and early neonatal mortality; after adjustment for obstetrical complications, delivering in a health facility with a skilled birth attendant (SBA) was of benefit on survival when compared to birth at home with no SBA (OR 1.3;95% CI 1.1–1.5), and birth at home with SBA (OR 1.2 ; 95% CI 1.0–1.5).
The second study showed a twofold risk of early neonatal death for women reporting signs and symptoms compatible with puerperal infection; the calculation of the population attributable fraction (PAF) suggested that around five percent of all deaths in the first week of life were attributable to intrapartum fever.
The study population of the third report of this thesis consisted of 55,384 deliveries and showed the highest prevalence of signs suggestive of eclampsia in the African WHO Region (2.5%; 95% CI 2.3-2.7), followed by the South East Asian WHO Region (1.7%; 95% CI 1.5-2.1), and the American WHO Region (1.2; 95% CI 1.0-1.3). Eclampsia was associated with a 2.1 (95% CI 1.4-3.2) risk of early neonatal mortality.
The fourth secondary DHS analysis included data of 521,867 singleton and 14,312 twin births from 60 countries. Early neonatal mortality among twins was around eight times higher than singleton neonates and reduced to around three times when adjusting for birthweight in a sub-population of 20 countries with less than 20% missing values on weight at birth. In countries with lower caesarean section rates, particularly below 5%, caesarean section for twins was not found to have a benefit on early neonatal mortality.
The WHOMCS secondary analysis involved 310,401 livebirths distributed across 359 facilities. The occupied territories of Palestine presented the highest rates of congenital malformation. The multivariate logistic regression provided evidence of a strong association of both chronic maternal hypertension and chronic hypertension with superimposed preeclampsia with renal, limb and lip/cleft/palate malformations. The plausible reason for these statistical findings lays on uteroplacental insufficiency caused by hypertension, which translates into a compromised blood flow to the developing fetus.
This thesis findings help clarify the specific context of many middle and low income countries where a consistent proportion of deliveries occur at home, with those seeking care at facilities may well be complicated cases (referral bias), which in turn will be more at risk of a negative outcome when compared to non-complicated deliveries.
Based on these assumptions, it is not surprise that the WHO African Region registered the highest prevalence of convulsions around childbirth, as a result of more home-based deliveries, and therefore fewer chances of induction of labour and fewer elective caesarean sections.
The results of the studies included in this thesis are in line with the literature based on data from high income countries: competent care during pregnancy, labour and delivery, is crucial for achieving the reduction of early neonatal mortality. However, to reach the Sustainable Development Goal 3.2 target of at least as low as 12 neonatal deaths per 1,000 live births, quality, coverage and equity must be pursued simultaneously.
Efficiency of antenatal care is a key factor to identify and treat maternal risk factors like asymptomatic bacteriuria, overweight, diabetes and hypertension. Additionally, school-based and community based screening/healthy life style programs are strongly needed in many LMICs because of the high burden of chronic conditions like overweight and hypertension.
Availability of quality data on maternal and neonatal health care outcomes and processes remains a crucial point for the monitoring of activities and documentation of achievements. Improvement on the quality of health services’ could represent a valid and very important alternative or complementary source of data for the routine cross sectional surveys.