Using propensity scores to estimate the effectiveness of maternal and newborn interventions to reduce neonatal mortality in Nigeria.

BACKGROUND: Nigeria is the largest country in sub-Saharan Africa, with one of the highest neonatal mortality rates and the second highest number of neonatal deaths in the world. There is broad international consensus on which interventions can most effectively reduce neonatal mortality, however, there is little direct evidence on what interventions are effective in the Nigerian setting. METHODS: We used the 2013 Nigeria Demographic and Health Survey (NDHS) and the follow-up 2014 Verbal and Social Autopsy study of neonatal deaths to estimate the association between neonatal survival and mothers' and neonates' receipt of 18 resources and interventions along the continuum of care with information available in the NDHS. We formed propensity scores to predict the probability of receiving the intervention or resource and then weighted the observations by the inverse of the propensity score to estimate the association with mortality. We examined all-cause mortality as well as mortality due to infectious causes and intrapartum related events. RESULTS: Among 19,685 livebirths and 538 neonatal deaths, we achieved adequate balance for population characteristics and maternal and neonatal health care received for 10 of 18 resources and interventions, although inference for most antenatal interventions was not possible. Of ten resources and interventions that met our criteria for balance of potential confounders, only early breastfeeding was related to decreased all-cause neonatal mortality (relative risk 0.42, 95% CI 0.32-0.52, p <  0.001). Maternal decision making and postnatal health care reduced mortality due to infectious causes, with relative risks of 0.29 (95% CI 0.09-0.88; 0.030) and 0.46 (0.22-0.95; 0.037), respectively. Early breastfeeding and delayed bathing were related to decreased mortality due to intrapartum events, although these are not likely to be causal associations. CONCLUSION: Access to immediate postnatal care and women's autonomous decision-making have been among the most effective interventions for reducing neonatal mortality in Nigeria. As neonatal mortality increases relative to overall child mortality, accessible interventions are necessary to make further progress for neonatal survival in Nigeria and other low resource settings.

How fast did newborns die in Nigeria from 2009-2013: a time-to-death analysis using Verbal /Social Autopsy data.

BACKGROUND: The slow decline in neonatal mortality as compared to post-neonatal mortality in Nigeria calls for attention and efforts to reverse this trend. This paper examines how socioeconomic, cultural, behavioral, and contextual factors interact to influence survival time among deceased newborns in Nigeria. METHODS: Using the neonatal deaths data from the 2014 Nigeria Verbal/ Social Autopsy survey, we examined the temporal distribution of overall and cause-specific mortality of a sample of 723 neonatal deaths. We fitted an extended Cox regression model that also allowed a time-dependent set of risk factors on time-to-neonatal death from all causes, and then separately, from birth injury/birth asphyxia (BIBA) and neonatal infections, while adjusting for possible confounding variables. RESULTS: Approximately 26% of all neonatal deaths occurred during the first day, 52.8% during the first three days, and 73.9% during the first week of life. Almost all deaths (94.4%) due to BIBA and about 64% from neonatal infections occurred in the first week of life. The expected all-cause mortality hazard was 6.23 times higher on any particular illness day for the deceased newborns who had a severe illness at onset compared to those who did not. While the all-cause mortality hazard ratio of poor vs wealthier households was 0.77 (95% confidence interval (CI) = 0.648-0.922), the BIBA mortality hazard ratio of households with no electricity was 1.79 times higher compared to households with electricity (95% CI = 1.180-2.715). CONCLUSIONS: The findings suggest the need for continued improvement of the coverage and quality of maternal and neonatal health interventions at birth and in the immediate postnatal period. They may also require confirmation in real-world cohorts with detailed, time-varying information on neonatal mortality.

Beyond causes of death: The social determinants of mortality among children aged 1-59 months in Nigeria from 2009 to 2013.

BACKGROUND: Millions of children worldwide suffer and die from conditions for which effective interventions exist. While there is ample evidence regarding these diseases, there is a dearth of information on the social factors associated with child mortality. METHODS: The 2014 Verbal and Social Autopsy Study was conducted based on a nationally representative sample of 3,254 deaths that occurred in children under the age of five and were reported on the birth history component of the 2013 Nigerian Demographic and Health Survey. We conducted a descriptive analysis of the preventive and curative care sought and obtained for the 2,057 children aged 1-59 months who died in Nigeria and performed regional (North vs. South) comparisons. RESULTS: A total of 1,616 children died in the northern region, while 441 children died in the South. The majority (72.5%) of deceased children in the northern region were born to mothers who had no education, married at a young age, and lived in the poorest two quintiles of households. When caregivers first noticed that their child was ill, a median of 2 days passed before they sought or attempted to seek healthcare for their children. The proportion of children who reached and departed from their first formal healthcare provider alive was greater in the North (30.6%) than in the South (17.9%) (p<0.001). A total of 548 children were moderately or severely sick at discharge from the first healthcare provider, yet only 3.9%-18.1% were referred to a second healthcare provider. Cost, lack of transportation, and distance from healthcare facilities were the most commonly reported barriers to formal care-seeking behavior. CONCLUSIONS: Maternal, household, and healthcare system factors contributed to child mortality in Nigeria. Information regarding modifiable social factors may be useful in planning intervention programs to promote child survival in Nigeria and other low-income countries in sub-Saharan Africa.