Research Article: Obstetric Facility Quality and Newborn Mortality in Malawi: A Cross-Sectional Study

Date Published: October 18, 2016

Publisher: Public Library of Science

Author(s): Hannah H. Leslie, Günther Fink, Humphreys Nsona, Margaret E. Kruk, Jenny E Myers

Abstract: BackgroundEnding preventable newborn deaths is a global health priority, but efforts to improve coverage of maternal and newborn care have not yielded expected gains in infant survival in many settings. One possible explanation is poor quality of clinical care. We assess facility quality and estimate the association of facility quality with neonatal mortality in Malawi.Methods and FindingsData on facility infrastructure as well as processes of routine and basic emergency obstetric care for all facilities in the country were obtained from 2013 Malawi Service Provision Assessment. Birth location and mortality for children born in the preceding two years were obtained from the 2013–2014 Millennium Development Goals Endline Survey. Facilities were classified as higher quality if they ranked in the top 25% of delivery facilities based on an index of 25 predefined quality indicators. To address risk selection (sicker mothers choosing or being referred to higher-quality facilities), we employed instrumental variable (IV) analysis to estimate the association of facility quality of care with neonatal mortality. We used the difference between distance to the nearest facility and distance to a higher-quality delivery facility as the instrument.Four hundred sixty-seven of the 540 delivery facilities in Malawi, including 134 rated as higher quality, were linked to births in the population survey. The difference between higher- and lower-quality facilities was most pronounced in indicators of basic emergency obstetric care procedures. Higher-quality facilities were located a median distance of 3.3 km further from women than the nearest delivery facility and were more likely to be in urban areas.Among the 6,686 neonates analyzed, the overall neonatal mortality rate was 17 per 1,000 live births. Delivery in a higher-quality facility (top 25%) was associated with a 2.3 percentage point lower newborn mortality (95% confidence interval [CI] -0.046, 0.000, p-value 0.047). These results imply a newborn mortality rate of 28 per 1,000 births at low-quality facilities and of 5 per 1,000 births at the top 25% of facilities, accounting for maternal and newborn characteristics. This estimate applies to newborns whose mothers would switch from a lower-quality to a higher-quality facility if one were more accessible. Although we did not find an indication of unmeasured associations between the instrument and outcome, this remains a potential limitation of IV analysis.ConclusionsPoor quality of delivery facilities is associated with higher risk of newborn mortality in Malawi. A shift in focus from increasing utilization of delivery facilities to improving their quality is needed if global targets for further reductions in newborn mortality are to be achieved.

Partial Text: Eliminating preventable infant mortality is a global health priority, reaffirmed in Sustainable Development Goal 3.2, which aims to reduce neonatal mortality to 12 per 1,000 live births by 2030 [1]. This is an ambitious goal: currently, over 2.5 million infants die each year in the first month of life [2]; neonatal mortality rates are estimated at 29 deaths per 1,000 live births in sub-Saharan Africa [3]. Globally, reductions in deaths within 28 days of birth have lagged decreases in postneonatal mortality. As a result, neonatal mortality now accounts for the largest share (44%) of under-5 mortality [2,4]. Achieving global targets in infant and child survival requires a redoubled focus on deaths in the first month of life.

The SPA assessed 977 of 1,066 health facilities in Malawi (92.2% response rate); 3% of facilities refused assessment, while the remainder were closed, empty, or inaccessible. Delivery services were provided by 540 facilities in total. The MES interviewed 24,230 of 25,430 eligible women (95.3% response rate), 7,576 of whom reported giving birth in the two years preceding the survey. Fig 1 shows the distribution of MES clusters and health facilities throughout Malawi; EAs are by construction small, with a target population of approximately 1,000 and an average size of 6.7 km2. Most women (6,935, 91.5%) reported a facility-based delivery; of these, 160 reported a facility that could not be matched to the SPA facility types, 102 lived in EAs that we were not able to match to census EAs, and 138 were matched to delivery facilities over 50 km away. The analytic sample comprised 6,535 women with live births (6,686 neonates with twins) matched to 467 unique delivery facilities; 6,668 neonates with complete data on covariates were retained in regression analyses.

This study is, to our knowledge, the first to link nationally representative data on births to detailed data of delivery facility quality in a sub-Saharan African setting. Our results suggest that delivery facilities in Malawi are both accessible and highly utilized, but that facility quality falls substantially short of global standards of evidence-based care. We found that higher-quality facilities, in the top 25% of our quality scale, were associated with 23 fewer neonatal deaths per 1,000 live births than other facilities in Malawi. This suggests improvements in facility quality could reduce mortality substantially among women who would deliver in higher-quality facilities were such facilities available.



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