Stillbirths and neonatal mortality in LMICs: A community-based mother-infant cohort study

Dynamics of factors associated with neonatal death in Madagascar: A comparative analysis of the 2003, 2008, 2021 DHS

Neonatal mortality remains a major public health challenge, as reductions have stagnated worldwide despite cost-effective interventions in recent years. The temporal evolution of its determinants is insufficiently studied. This study aimed to analyze the dynamics of factors associated with neonatal death in Madagascar between 2003 and 2021. A secondary analysis was conducted using data from the 2003, 2008, and 2021 Demographic and Health Surveys (DHS) of Madagascar. The study population is focused on children under the age of 5 years at the time of these surveys. The death of a newborn within 30 days after birth constitutes the outcome variable. A multilevel binomial logistic regression was performed. The number of children under 5 included in the analysis were 5,415 in 2003, 12,448 in 2008 and 12,399 in 2021. The prevalence of neonatal deaths was 3.1% in 2003, 2.4% in 2008, and 2.6% in 2021. Persistent significant associations with neonatal death were observed for low birth weight, lack of breastfeeding, medium-sized households, large households, and high birth weight. A loss of statistical significance of the association with neonatal death over time was observed for a birth interval of 2-3 years and 4 years and more, mother's age 40-49 years, and use of mosquito net by the mother. In 2021, new significant associations with neonatal mortality were identified in the province of Toliara, absence of geographic barriers to healthcare access, 4-7 ANC visits, and supervised delivery. The factors associated with neonatal mortality, which have worsened over time in Madagascar, include birth weight abnormalities and delivery in the presence of qualified personnel. This deterioration underscores the urgency of improving the quality of perinatal care in healthcare facilities, beyond mere geographical accessibility.

Spatial patterns and temporal trends in stillbirth, neonatal, and infant mortality: an exploration of country-level data from 2000 to 2021

Background

Despite significant progress in improving child survival and health, substantial disparities persist and are being increasingly threatened by a complex and dynamic global environment. In this ecological study, we investigated spatial patterns, temporal trends, and key determinants of disparities in stillbirth, neonatal, and infant mortality rates across 195 countries from 2000 to 2021.

Methods

We sourced our data from two publicly available databases: the United Nations Children's Fund Data Warehouse for mortality indicators and the World Bank for World Development Indicators. We conducted spatial analysis to assess spatial autocorrelation and identify geographical clusters of countries and applied joinpoint regression to evaluate temporal trends in mortality indicators, reported as annual percentage change. We also used forward regression analysis to determine the primary indicators influencing stillbirth, neonatal, and infant mortality rates.

Results

The average stillbirth rate in 2021 was 10.9 per 1000 total births, a significant decrease from 16.3 per 1000 in 2000. Neonatal mortality also declined from 23.6 to 13.5 per 1000 live births during the same period, while infant mortality dropped from 45.0 to 22.5 per 1000 live births. Despite these improvements, spatial analysis showed notable positive spatial autocorrelations for stillbirth, neonatal, and infant mortality rates, indicating that high mortality rates were geographically clustered, particularly in African countries forming hot-spot clusters. Conversely, developed countries in Europe and Asia formed cold-spot clusters characterised by low mortality indicators. Some countries, identified as low-high or high-low clusters, stood out due to dissimilar mortality rates compared to their neighbours, warranting further investigation. Key determinants of mortality rates included the young-age dependency ratio, prevalence of undernourishment, the percentage of women aged 15 and older living with HIV, the incidence of tuberculosis, and the adolescent fertility rate - all of which showed a positive association with higher mortality rates. In contrast, factors such as the use of at least basic sanitation services, mean years of schooling, and government effectiveness had an inverse relationship, contributing to lower mortality rates.

Conclusions

By identifying hotspots and outliers, this study highlights the need for targeted health interventions and efficient resource allocation. This approach ensures that efforts are strategic and impactful, focussing on areas with the greatest need.

Bann C, Bozdar MH, Raza J, Dhaded SM, Goudar SS, Gowdar G, Yasmin H, McClure EM, Goldenberg RL. Predictors of Preterm Neonatal Mortality in India and Pakistan: A Secondary Analysis of Data from PURPOSe Study

Objective. To create a prediction model for preterm neonatal mortality. Methods. A secondary analysis was conducted using data from a prospective cohort study, the Project to Understand and Research Preterm Pregnancy Outcome South Asia. The Cox proportional hazard model was used and adjusted hazard ratios (AHR) with 95% confidence intervals (95% CI) were reported. Results. Overall, 3446 preterm neonates were included. The mean age of preterm neonates was 0.65 (1.25) hours and 52% were female. The preterm neonatal mortality rate was 23.3%. The maternal factors predicting preterm neonatal death was any antepartum hemorrhage, AHR 1.99 (1.60-2.47), while neonatal predictors were preterm who received positive pressure ventilation AHR 1.30 (1.08-1.57), temperature <35.5°C AHR 1.18 (1.00-1.39), and congenital malformations AHR 3.31 (2.64-4.16). Conclusion. This study identified key maternal and neonatal predictors of preterm neonatal mortality, emphasizing the need for targeted interventions and collaborative public health efforts to address disparities and regional variations.

Stillbirth rates and their determinants in a national maternity hospital in Phnom Penh, Cambodia in 2017-2020: a cross-sectional assessment with a nested case-control study

BACKGROUND

In Cambodia, stillbirths and their underlying factors have not been systematically studied. This study aimed to assess the proportion and trends in stillbirths between 2017 and 2020 in a large maternity referral hospital in the country and identify their key determinants to inform future prevention efforts.

METHODS

This was a retrospective cross-sectional analysis with a nested case-control study of women giving birth at the National Maternal and Child Health Centre (NMCHC) in Phnom Penh, 2017-2020. We calculated percentages of singleton births at ≥ 22 weeks' gestation resulting in stillbirth and annual stillbirth rates by timing: intrapartum (fresh) or antepartum (macerated). Multivariable logistic regression was used to explore factors associated with stillbirth, where cases were all women who gave birth to a singleton stillborn baby in the 4-year period. One singleton live birth immediately following each case served as an unmatched control. Multiple imputation was used to handle missing data for gestational age.

RESULTS

Between 2017 and 2020, 3.2% of singleton births ended in stillbirth (938/29,742). The stillbirth rate increased from 24.8 per 1000 births in 2017 to 38.1 per 1000 births in 2020, largely due to an increase in intrapartum stillbirth rates which rose from 18.8 to 27.4 per 1000 births in the same period. The case-control study included 938 cases (stillbirth) and 938 controls (livebirths). Factors independently associated with stillbirth were maternal age ≥ 35 years compared to < 20 years (aOR: 1.82, 95%CI: 1.39, 2.38), extreme (aOR: 3.29, 95%CI: 2.37, 4.55) or moderate (aOR: 2.45, 95%CI: 1.74, 3.46) prematurity compared with full term, and small-for-gestational age (SGA) (aOR: 2.32, 1.71, 3.14) compared to average size-for-age. Breech/transverse births had nearly four times greater odds of stillbirth (aOR: 3.84, 95%CI: 2.78, 5.29), while caesarean section reduced the odds by half compared with vaginal birth (aOR: 0.50, 95%CI: 0.39, 0.64). A history of abnormal vaginal discharge increased odds of stillbirth (aOR: 1.42, 95%CI: 1.11, 1.81) as did a history of stillbirth (aOR: 3.08, 95%CI: 1.5, 6.5).

CONCLUSIONS

Stillbirth prevention in this maternity referral hospital in Cambodia requires strengthening preterm birth detection and management of SGA, intrapartum care, monitoring women with stillbirth history, management of breech births, and further investigation of high-risk referral cases.