A Regional Multilevel Analysis: Can Skilled Birth Attendants Uniformly Decrease Neonatal Mortality?
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Globally 40 % of deaths to children under-five occur in the very first month of life with three-quarters of these deaths occurring during the first week of life. The promotion of delivery with a skilled birth attendant (SBA) is being promoted as a strategy to reduce neonatal mortality. This study explored whether SBAs had a protective effect against neonatal mortality in three different regions of the world. The analysis pooled data from nine diverse countries for which recent Demographic and Health Survey data were available. Multilevel logistic regression was used to understand the influence of skilled delivery on two outcomes—neonatal mortality during the first week of life and during the first day of life. Control variables included age, parity, education, wealth, residence (urban/rural), geographic region (Africa, Asia and Latin America/Caribbean), antenatal care and tetanus immunization. The direction of the effect of skilled delivery on neonatal mortality was dependent on geographic region. While having a SBA at delivery was protective against neonatal mortality in Latin America/Caribbean, in Asia there was only a protective effect for births in the first week of life. In Africa SBAs were associated with higher neonatal mortality for both outcomes, and the same was true for deaths on the first day of life in Asia. Many women in Africa and Asia deliver at home unless a complication occurs, and thus skilled birth attendants may be seeing more women with complications than their unskilled counterparts. In addition there are issues with the definition of a SBA with many attendants in both Africa and Asia not actually having the needed training and equipment to prevent neonatal mortality. Considerable investment is needed in terms of training and health infrastructure to enable these providers to save the youngest lives.
KeywordsAntenatal care Early neonatal mortality Health systems strengthening Scale-up and skilled birth attendant
This study was funded by the United States Agency for International Development (USAID) through a cooperative agreement (GHA-A-00-08-00003-00) with MEASURE Evaluation. The views expressed in this paper do not necessarily reflect those of USAID. This work was also supported in part by an R24 Center Grant to the Carolina Population Center at the University of North Carolina at Chapel Hill. The authors would like to thank Lily Kak, Lisa Maniscalco and Allisyn Moran for comments on earlier drafts of the paper, and Erica Haney for assistance with the literature review.
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