Early neonatal mortality is a global problem that could be solved
Increasing the number of institutional deliveries has not reduced early neonatal mortality in many low- and middle-income countries, a recent doctoral dissertation suggests. The findings indicate deficiencies in management of deliveries and newborn care.

Every year, approximately two million babies globally die during birth or their first week of life. Early neonatal mortality is highest in low- and middle-income countries in Africa and Asia.

“A large share of early neonatal deaths are preventable by high-quality delivery care,” says Terhi Lohela, a specialist in anaesthesiology with a master’s degree in international health who completed her doctoral dissertation on the subject.

Lohela collected data from 64 maternity hospitals in rural Ghana in 2010. The dissertation also studied the effects of geographical distance on access to care at birth and early neonatal mortality using cross-sectional Demographic and Health Survey (DHS) data collected from rural areas of Malawi and Zambia and linked it to Health Facility Census data in both countries. Socioeconomic inequalities in early neonatal deaths and institutional deliveries were investigated using DHS data from 72 low- and middle-income countries. The analyses included approximately 680,000 births between 1990 and 2016.

Considerable geographical and socioeconomic inequalities in access to care

Pregnant women living far away from health facilities are less likely to seek care at birth compared with women living close because long distances often increase expenses for the family or are difficult to overcome. Furthermore, mothers often have to leave their older children behind to seek care.

In Lohela’s studies, geographical and socioeconomic inequalities in access to care were indeed found to be large.

“Given the huge differences in access to care, it was really surprising how small the differences in early neonatal mortality rates were between the highest and lowest socioeconomic groups. In many countries, the risk of early neonatal death was similar between babies of the richest and poorest mothers despite the large differences in their use of delivery care. The poorest mothers often delivered at home where childbirth is managed by untrained individuals or, in the worst cases, by no one at all,” Lohela says.

Deficiencies in staff skills, equipment and drugs

The data collected by Lohela revealed that, in many cases, hospital staff were lacking in skills to manage emergencies during childbirth and that assisting personnel were often not trained as midwives, nurses or physicians. There were also deficiencies in the equipment and drugs used.

In low- and middle-income countries, centralising deliveries is much more complex than in Finland. The roads can be in poor condition, the emergency medical services are often deficient or there is no emergency call centre. Not everyone can afford travelling by car. In Brong Ahafo region in Ghana, access to care at birth has been improved by building small delivery facilities in rural areas. These small facilities only managed a few dozen deliveries per year. Even though 68% of the region’s children were born in health facilities, only less than one-fifth of them were born in hospitals providing high-quality care.

“The goal has been to increase the number of facility deliveries, sometimes at the cost of quality of care. However, a house with ‘maternity’ painted on the wall does not automatically save lives. The goal should be to decrease mortality and morbidity, not to increase the number of institutional deliveries. What’s more, every health facility must manage enough deliveries to acquire and maintain the necessary competence,” Lohela notes.

Newborn mortality reflects on the entire healthcare system

In line with the objectives of the United Nations, over 75% of the world’s children are already born in health facilities. And yet, global newborn mortality has not decreased in parallel with the increased coverage of institutional deliveries. Lohela points out that other patient groups would also benefit from measures aimed at decreasing newborn mortality.

“Newborn mortality serves as an indicator of the entire health system; it measures emergency care, care provided for mothers and newborns, as well as the effectiveness of consultations and patient transfers.

First, you have to focus on improving quality of care. The next step is to improve access to care particularly among the poorest and uneducated mothers and those living in remote areas. New methods for reaching the mothers who live furthest away should be developed. In remote areas, mobile clinics could be an alternative worth looking into, Lohela suggests.

“It is worthwhile to keep in mind that considerable progress has been made in many areas; extreme poverty, for instance, has been halved in just a couple of decades. The birth rate has also dropped, and decreased child mortality is an important reason for this.”

Terhi Lohela, LM, MSc, will defend her doctoral dissertation entitled "Quality of care and access to care at birth in low- and middle-income countries” in the Faculty of Medicine, University of Helsinki, on 22 March at 12 noon. The public defence will take place at the Haartman Institute, lecture hall 2, Haartmaninkatu 3. Professor Wendy Graham from the London School of Hygiene & Tropical Medicine will serve as the opponent and Professor Juha Pekkanen as the custos.

The dissertation is a collaborative project by the University of Helsinki and Heidelberg University. The dissertation abstract can be accessed through the E-thesis service at https://helda.helsinki.fi/handle/10138/299688?locale-attribute=en.

Contact details of the doctoral candidate:

terhi.lohela@helsinki.fi