Evaluating the effect of care around labor and delivery practices on early neonatal mortality in the Global Network’s Maternal and Newborn Health Registry
By the end of 2015, global childhood mortality and the maternal mortality ratio (United Nations’ [UN] Millennium Development Goals 4 and 5 respectively) had improved globally, but neither goal target was reached. An estimated 2.5 million neonatal deaths occurred in 2018 accounting for 47% of deaths in children under age 5. The focus on reducing maternal, childhood and particularly neonatal mortality continues to be a part of the UN’s Sustainable Development Goal 3 with new targets for 2030.
High quality of care during pregnancy, labor and delivery, and immediately post-partum is critical to reducing maternal, perinatal and neonatal mortality. This need is being partly addressed by an increase in access to institutional deliveries and presence of a skilled birth attendant at delivery, but access to health care providers does not guarantee that recommended interventions will be provided. The World Health Organization (WHO) has recently developed a framework and standards for health care facilities that includes 8 overarching standards and 352 quality measures. However, it is challenging to assess quality of maternal and newborn care based on these standards and criteria as noted by Brizuela et al. Guidance is needed to address priority measures.
There is a current focus on developing simple and valid indicators of facility-based quality of care at the time of birth to enable rapid assessment of quality and institute data-driven action to improve outcomes. Recently published tools such as the WHO’s Safe Childbirth Checklist address this void but require significant data collection efforts. However, in a large trial in Utter Pradesh, India, use of the Safe Childbirth Checklist program did not result in reduced maternal or perinatal mortality, while a quasi-experimental study of the checklist tool resulted in an 11% reduction in stillbirths and very early neonatal deaths within 3 days of birth.
Prior to the Safe Childbirth Checklist studies, our group had focused on just eight Care Around Delivery (CAD) indicators derived from Essential Newborn Care (ENC) practices and recommended by WHO. All 8 indicators were routinely collected in NICHD’s Global Network’s (GN) Maternal Newborn Health Registry (MNHR) between 2010 and 2013. Five of the indicators were intra-partum and are also known as the 5 “cleans” to reduce the risk of neonatal sepsis. These include clean hands, clean cord tie, clean cord, clean surface and clean blade. The 5 cleans are usually addressed by providing clean delivery kits. Three of the immediate post-partum indicators included early initiation of breast feeding within 1 h of birth, skin to skin practices immediately after birth and bathing delayed until 6 h after birth. Since presence of ENC and immediate neonatal care practices are associated with reduced early neonatal mortality, we evaluated whether occurrence of all of these 8 indicators of ENC that were available in the MNHR would also be associated with reduced early neonatal mortality. Our hypothesis was that occurrence of all 8 CAD indicators (composite index) was associated with early neonatal mortality (days 0–6 of life). We also explored the effects of the individual indicators on very early mortality.
By: Patel AB, Simmons EM, Rao SR, Moore J, Nolen TL, Goldenberg R et al.