Shane Khan

Does health facility service environment matter for the receipt of essential newborn care? Linking health facility and household survey data in Malawi

Background Health facility service environment is an important factor for newborns survival and well–being in general and in particular in high mortality settings such as Malawi where despite high coverage of essential interventions, neonatal mortality remains high. The aim of this study is to assess whether the quality of the health service environment at birth is associated with quality of care received by the newborn. Methods We used data from the Malawi Millennium Development Goals Endline household survey conducted as part of MICS survey program and Service Provision Assessment Survey carried out in 2014. The analysis is based on 6218 facility births that occurred during the past 2 years. Descriptive statistics, bivariate and multivariate random effect models are used to assess the association of health facility service readiness score for normal deliveries and newborn care with newborns receiving appropriate newborn care, defined for this analysis as receiving 5 out of 6 recommended interventions during the first 2 days after birth. Results Newborns in districts with top facility service readiness score have 1.5 higher odds of receiving appropriate newborn care (adjusted odds ratio (aOR) = 1.52, 95% confidence interval CI = 1.19–1.95, P = 0.001), as compared to newborns in districts with a lower facility score after adjusting for potential confounders. Newborns in the Northern region were two times more likely to receive 5 newborn care interventions as compared to newborns in the Southern region (aOR = 2.06, 95% CI = 1.50–2.83, P < 0.001). Living in urban or rural areas did not have an impact on receiving appropriate newborn care. Conclusions There is need to increase the level of service readiness across all facilities, so that all newborns irrespective of the health facility, district or region of delivery are able to receive all recommended essential interventions. Investments in health systems in Malawi should concentrate on increasing training and availability of health staff in facilities that offer normal delivery and newborn care services at all levels in the country.

Measuring postnatal care contacts for mothers and newborns: An analysis of data from the MICS and DHS surveys

Background The postnatal period represents a vulnerable phase for mothers and newborns where both face increased risk of morbidity and death. WHO recommends postnatal care (PNC) for mothers and newborns to include a first contact within 24 hours following the birth of the child. However, measuring coverage of PNC in household surveys has been variable over time. The two largest household survey programs in low and middle–income countries, the UNICEF–supported Multiple Indicator Cluster Surveys (MICS) and USAID–funded Demographic and Health Surveys (DHS), now include modules that capture these measures. However, the measurement approach is slightly different between the two programs. We attempt to assess the possible measurement differences that might affect comparability of coverage measures. Methods We first review the standard questionnaires of the two survey programs to compare approaches to collecting data on postnatal contacts for mothers and newborns. We then illustrate how the approaches used can affect PNC coverage estimates by analysing data from four countries; Bangladesh, Ghana, Kygyz Republic, and Nepal, with both MICS and DHS between 2010–2015. Results We found that tools implemented todate by MICS and DHS (up to MICS round 5 and up to DHS phase 6) have collected PNC information in different ways. While MICS dedicated a full module to PNC and distinguishes immediate vs later PNC, DHS implemented a more blended module of pregnancy and postnatal and did not systematically distinguish those phases. The two survey programs differred in the way questions on postnatal care for mothers and newbors were framed. Subsequently, MICS and DHS surveys followed different methodological approach to compute the global indicator of postnatal contacts for mothers and newborns within two days following delivery. Regardless of the place of delivery, MICS estimates for postnatal contacts for mothers and newbors appeared consistently higher than those reported in DHS. The difference was however, far more pronounced in case of newborns. Conclusions Difference in questionnaires and the methodology adopted to measure PNC have created comparability issues in the coverage levels. Harmonization of survey instruments on postnatal contacts will allow comparable and better assessment of coverage levels and trends.

The importance of skin–to–skin contact for early initiation of breastfeeding in Nigeria and Bangladesh

Background Skin–to–skin contact (SSC) between mother and newborn offers numerous protective effects, however it is an intervention that has been under–utilized. Our objectives are to understand which newborns in Bangladesh and Nigeria receive SSC and whether SSC is associated with the early initiation of breastfeeding. Methods Demographic and Health Survey (DHS) data were used to study the characteristics of newborns receiving SSC for non–facility births in Nigeria (DHS 2013) and for both facility and non–facility births in Bangladesh (DHS 2014). Multivariable logistic regression was used to study the association between SSC and early initiation of breastfeeding after controlling for key socio–demographic, maternal and newborn–related factors. Results Only 10% of newborns in Nigeria and 26% of newborns in Bangladesh received SSC. In the regression models, SSC was significantly associated with the early initiation of breastfeeding in both countries (OR = 1.42, 95% CI 1.15–1.76 for Nigeria; OR = 1.27, 95% CI 1.04–1.55, for Bangladesh). Findings from the regression analysis for Bangladesh revealed that newborns born by Cesarean section had a 67% lower odds of early initiation of breastfeeding than those born by normal delivery (OR = 0.33, 95% CI 0.26–0.43). Also in Bangladesh newborns born in a health facility had a 30% lower odds of early initiation of breastfeeding than those born in non–facility environments (OR = 0.70, 95% CI 0.53–0.92). Early initiation of breastfeeding was significantly associated with parity, urban residence and wealth in Nigeria. Geographic area was significant in the regression analyses for both Bangladesh and Nigeria. Conclusions Coverage of SSC is very low in the two countries, despite its benefits for newborns without complications. SSC has the potential to save newborn lives. There is a need to prioritize training of health providers on the implementation of essential newborn care including SSC. Community engagement is also needed to ensure that all women and their families regardless of residence, socio–economic status, place or type of delivery, understand the benefits of SSC and early initiation of breastfeeding.

Evidence from household surveys for measuring coverage of newborn care practices

Background Aside from breastfeeding, there are little data on use of essential newborn care practices, such as thermal protection and hygienic cord care, in high mortality countries. These practices have not typically been measured in national household surveys, often the main source for coverage data in these settings. The Every Newborn Action Plan proposed early breastfeeding as a tracer for essential newborn care due to data availability and evidence for the benefits of breastfeeding. In the past decade, a few national surveys have added questions on other practices, presenting an opportunity to assess the performance of early breastfeeding initiation as a tracer indicator. Methods We identified twelve national surveys between 2005–2014 that included at least one indicator for immediate newborn care in addition to breastfeeding. Because question wording and reference populations varied, we standardized data to the extent possible to estimate coverage of newborn care practices, accounting for strata and multistage survey design. We assessed early breastfeeding as a tracer by: 1) examining associations with other indicators using Pearson correlations; and 2) stratifying by early breastfeeding to determine differences in coverage of other practices for initiators vs non–initiators in each survey, then pooling across surveys for a meta–analysis, using the inverse standard error as the weight for each observation. Findings Associations between pairs of coverage indicators are generally weak, including those with breastfeeding. The exception is drying and wrapping, which have the strongest association of any two interventions in all five surveys where measured; estimated correlations for this range from 0.47 in Bangladesh’s 2007 DHS to 0.83 in Nepal’s 2006 DHS. The contrast in coverage for other practices by early breastfeeding is generally small; the greatest absolute difference was 6.7%, between coverage of immediate drying for newborns breastfed early compared to those who were not. Conclusions Early initiation of breastfeeding is not a high performing tracer indicator for essential newborn care practices measured in previous national surveys. To have informative data on whether newborns are getting life–saving services, standardized questions about specific practices, in addition to breastfeeding initiation, need to be added to surveys.

Thermal care of newborns: drying and bathing practices in Malawi and Bangladesh

Background Thermal care of newborns is one of the recommended strategies to reduce hypothermia, which contributes to neonatal morbidity and mortality. However, data on these two topics have not been collected at the national level in many surveys. In this study, we examine two elements of thermal care: drying and delayed bathing of newborns after birth with the objectives of examining how two countries collected such data and then looking at various associations of these outcomes with key characteristics. Further, we examine the data for potential data quality issues as this is one of the first times that such data are available at the national level. Methods We use data from two nationally-representative household surveys: the Malawi Multiple Indicator Cluster Survey 2014 and the Bangladesh Demographic and Health Survey 2014. We conduct descriptive analysis of the prevalence of these two newborn practices by various socio-demographic, economic and health indicators. Results Our results indicate high levels of immediate drying/drying within 1 hour in Malawi (87%). In Bangladesh, 84% were dried within the first 10 minutes of birth. Bathing practices varied in the two settings; in Malawi, only 26% were bathed after 24 hours but in Bangladesh, 87% were bathed after the same period. While in Bangladesh there were few newborns who were never bathed (less than 5%), in Malawi, over 10% were never bathed. Newborns delivered by a skilled provider tended to have better thermal care than those delivered by unskilled providers. Conclusion These findings reveal gaps in coverage of thermal care and indicate the need to further develop the role of unskilled providers who can give unspecialized care as a means to improve thermal care for newborns. Further work to harmonize data collection methods on these topics is needed to ensure comparable data across countries.

Linking household survey and health facility data for effective coverage measures: a comparison of ecological and individual linking methods using the Multiple Indicator Cluster Survey in Côte d’Ivoire

Background Population-based measures of intervention coverage are used in low- and middle-income countries for program planning, prioritization, and evaluation. There is increased interest in effective coverage, which integrates information about service quality or health outcomes. Approaches proposed for quality-adjusted effective coverage include linking data on need and service contact from population-based surveys with data on service quality from health facility surveys. However, there is limited evidence about the validity of different linking methods for effective coverage estimation. Methods We collaborated with the 2016 Côte d’Ivoire Multiple Indicator Cluster Survey (MICS) to link data from a health provider assessment to care-seeking data collected by the MICS in the Savanes region of Côte d’Ivoire. The provider assessment was conducted in a census of public and non-public health facilities and pharmacies in Savanes in May-June 2016. We also included community health workers managing sick children who served the clusters sampled for the MICS. The provider assessment collected information on structural and process quality for antenatal care, delivery and immediate newborn care, postnatal care, and sick child care. We linked the MICS and provider data using exact-match and ecological linking methods, including aggregate linking and geolinking methods. We compared the results obtained from exact-match and ecological methods. Results We linked 731 of 786 care-seeking episodes (93%) from the MICS to a structural quality score for the provider named by the respondent. Effective coverage estimates computed using exact-match methods were 13%-63% lower than the care-seeking estimates from the MICS. Absolute differences between exact match and ecological linking methods were ±7 percentage points for all ecological methods. Incorporating adjustments for provider category and weighting by service-specific utilization into the ecological methods generally resulted in better agreement between ecological and exact match estimates. Conclusions Ecological linking may be a feasible and valid approach for estimating quality-adjusted effective coverage when a census of providers is used. Adjusting for provider type and caseload may improve agreement with exact match results. There remain methodological questions to be addressed to develop guidance on using linking methods for estimating quality-adjusted effective coverage, including the effect of facility sampling and time displacement.

Perspectives and implications of the Improving Coverage Measurement Core Group’s validation studies for household surveys

Background Formal validation studies are of critical importance in determining whether or not household survey questions are providing accurate information on what they intend to measure. These studies supplement an array of methods used to evaluate survey questions. Methods and Findings This paper summarizes the methods used by the two major international household survey programmes – The Demographic and Health Surveys Program (DHS) and the Multiple Indicator Cluster Surveys (MICS) – to decide on possible modifications to the survey questions, nomenclature, tables, and interpretation of findings over time as additional information on the validity of the questions becomes available. Conclusions Validation studies are most useful if they are conducted in a variety of different settings in low- and middle-income countries, preferably using representative samples and procedures that replicate DHS and MICS field conditions. Pilot tests, pre-tests in each country, feedback from interviewers and survey staff, and cognitive interviewing provide additional information about how well survey questions are understood and provide accurate information. The paper provides specific examples of changes that have been made in response to findings from validation studies and changes in international recommendations.

Measuring coverage of essential maternal and newborn care interventions: An unfinished agenda

Over the past few decades, the agenda for newborn health has shifted remarkably, taking newborns from being nearly invisible in the global health agenda of 1990s to being central in discussions today. Despite this change, the decline in neonatal mortality from 1990 to 2016 has been slower than that of post–neonatal under–five mortality: 49% compared with 62% globally [1]. Newborn deaths represent 46% of all under–five deaths–of the 5.6 million under–5 deaths in 2016, nearly 2.7 million deaths occurred in the neonatal period, with a large proportion dying within the first week following birth [1,2]. Preterm birth complications (35%), intrapartum–related events (24%) and sepsis (15%) – most of which are preventable–have been identified as leading causes of neonatal deaths [3]. Although maternal mortality was estimated by the UN inter–agency group to have declined by 44% between 1990 and 2015, the reduction was far below the 75% MDG target. Approximately 303 000 women die each year from complications of pregnancy and childbirth, with 99% of deaths in low– and middle–income countries, making maternal mortality one of the indicators with the largest disparity between rich and poor countries [4]. With the majority of maternal and newborn deaths occurring around the time of birth, quality and equitable maternal and newborn care are essential to improve survival. Several global partnerships and initiatives such as the United Nations Every Woman Every Child movement (EWEC) and Every Newborn Action Plan (ENAP) have called for more focused attention on newborn health in order to end preventable newborn and child deaths [5,6]. The 2030 agenda of Sustainable Development Goals (SDG) and accompanying Global Strategy for Women’s Children’s and Adolescents’ Health (2016–2030) include a specific target for all countries to reduce neonatal mortality to at least as low as 12 per 1000 live births, further reinforcing and strengthening commitment to neonatal survival [7].

Does postnatal care have a role in improving newborn feeding? A study in 15 sub–Saharan African countries

Background Breastfeeding is known as a key intervention to improve newborn health and survival while prelacteal feeds (liquids other than breastmilk within 3 days of birth) represents a departure from optimal feeding practices. Recent programmatic guidelines from the WHO and UNICEF outline the need to improve newborn feeding and points to postnatal care (PNC) as a potential mechanism to do so. This study examines if PNC and type of PNC provider are associated with key newborn feeding practices: breastfeeding within 1 day and prelacteal feeds. Methods We use data from the Demographic and Health Surveys for 15 sub–Saharan African countries to estimate 4 separate pooled, multilevel, logistic regression models to predict the newborn feeding outcomes. Findings PNC is significantly associated with increased breastfeeding within 1day (OR = 1.35, P < 0.001) but is not associated with PLFs (OR = 1.04, P = 0.195). PNC provided by nurses, midwives and untrained health workers is also associated with higher odds of breastfeeding within 1 day of birth (OR = 1.39, P < 0.001, (OR = 1.95, P < 0.001) while PNC provided by untrained health workers is associated with increased odds of PLFs (OR = 1.20, P = 0.017). Conclusions PNC delivered through customary care may be an effective strategy to improve the breastfeeding within 1 day but not to discourage PLFs. Further analysis should be done to examine how these variables operate at the country level to produce finer programmatic insight.