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ORIGINAL ARTICLE
7 (
1
); 165-172
doi:
10.21106/ijma.229

Determinants of Infant Mortality in Southeast Nigeria: Results from the Healthy Beginning Initiative, 2013-2014

University of Nevada, Las Vegas, School of Community Health Sciences. 4505 S. Maryland Pkwy, Las Vegas, NV 89154, USA
Research Resource Centre, University of Nigeria, Enugu, College of Medicine. University Road, 410001, Nsukka, Enugu State, NIGERIA
Institute of Human Virology, University of Maryland School of Medicine. 655 W. Balitimore St, Balitimore, MD 21201, USA

*Corresponding author email: jennifer.pharr@unlv.edu

Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background:

Neonatal mortality due to preventable factors occurs at high rates throughout sub-Saharan Africa. Community-based interventions increase opportunities for prenatal screening and access to antenatal care services (ANC) services. The Healthy Beginning Initiative (HBI) provided congregation-based prenatal screening and health counseling for 3,047 women in Enugu State. The purpose of this study was to identify determinants for infant mortality among this cohort.

Methods:

This was a prospective cohort study of post-delivery outcomes at 40 churches in Enugu State, Nigeria between 2013 and 2014. Risk factors for infant mortality were assessed using chi square, odds ratios, and multiple logistic regression.

Results:

There were 2,436 live births from the 2,379 women who delivered (55 sets of twins and one set of triplets), and 99 cases of neonatal/early postneonatal mortality. The neonatal mortality rate was 40.6 per 1,000 live births. Risk factors associated with neonatal mortality were lack of access to ANC services [OR= 8.81], maternal mortality [OR= 15.28], caesarian section [OR= 2.47], syphilis infection [OR= 6.46], HIV-positive status [OR= 3.87], and preterm birth [OR= 14.14].

Conclusions and Global Health Implications:

These results signify that culturally-acceptable community-based interventions targeted to increase access to ANC services, post-delivery services for preterm births, and HIV and syphilis screening for expectant mothers are needed to reduce infant mortality in resource-limited settings.

Keywords

Infant Mortality
Neonatal Mortality
HIV
Antenatal Care
Nigeria
Healthy Beginning Initiative

1. Introduction

Neonatal mortality due to preventable factors occurs at high rates throughout sub-Saharan Africa. It is estimated that in 2015, 2.8 million infants died during the neonatal period (the first twenty-eight days of life) worldwide.1 While many developing countries successfully attained significant reduction in their maternal and child mortality rates per the Millennium Development Goals 4 and 5, Nigeria faces many challenges in reducing its infant mortality rate.1 Nigeria’s population of over 167 million represents roughly 2.3 percent of the global population, yet the country contributed nearly ten percent of the 2.8 million neonatal deaths which occurred in 2015.2, 3 Nigeria’s national infant mortality rate (death during the first year of life) in 2013 was 74.3 per 1,000 live births.4 The most recent National Demographic and Health Survey (NDHS) data from Nigeria estimates that the average neonatal mortality rate (NMR) was 37 deaths per 1,000 live births between 2009 and 2013.2, 5 The NMR has remained consistent between 1990 and 2013 based on retrospective analysis of the NDHS results.2 Several individual and community-level determinants have been identified as being associated with neonatal mortality in developing countries including Nigeria. These factors include socioeconomic status, infant birth weight, birth spacing, maternal health status, and access to and usage of antenatal care.2,6,7

This study assessed neonatal/early postneonatal mortality during the Healthy Beginning Initiative (HBI), a cluster randomized trial conducted between January 2013 and August 2014 in Enugu state, Nigeria. The main objectives of the HBI trial were to test the effectiveness of the congregation-based program on increasing confirmed HIV testing and ART uptake among pregnant women and their male partners.8 The HBI Baby Shower trial successfully increased prenatal screening for the women and their male partners, but there were also cases of neonatal/early postneonatal and maternal mortality during the study period. The purpose of our study was to determine the maternal factors associated with neonatal/early postneonatal mortality for this population based study of women and their infants.

2. Methods

The protocol and outcomes for material, paternal, and infant HIV screening and linkage to care for HBI have been previously published.8-11 In short, HBI leveraged high church attendance and a wide distribution of faith-based institutions to recruit over 3,000 women from 40 Christian churches to participate in the study, in either the intervention group (IG, n=20 churches) or the control group (CG, n=20 churches).8 Participants in the IG were screened for HIV, malaria, Hepatitis B (Hep. B), and sickle cell trait (SCT) during a Baby Shower held at the church prior to delivery while participants in the CG were encourage to go to the nearest health facilities for testing and linkage to care (standard of care) at the Baby Shower. Additionally, at the Baby Shower, participants were encouraged to attend the Baby Reception which occurred six to eight weeks post-delivery. At the Baby Reception, participants in the CG were offered HIV, malaria, Hepatitis B (Hep. B), and sickle cell trait (SCT) screening.8 The women in both groups completed post-delivery questionnaires at the Baby Receptions which included demographic, antenatal care, and delivery questions, and all women were followed for six to eight weeks post-delivery.

This was a prospective cohort study of data collected between January 2013 and August 2014 during HBI in Enugu State, Southeast Nigeria. A total of 3,047 records were collected, reviewed, and collated prior to analysis. These records represent self-reported pregnant women who were enrolled in the study and who delivered or experienced pregnancy loss (miscarriage or stillbirth) during the study period. To be included in analysis, the records had to have evidence of a delivery. All records that had incomplete postnatal data and records that indicated a pregnancy loss prior to delivery were excluded from analysis. The remaining maternal records were expanded to have individual records for each infant delivered during the study period.

Neonatal and early postneonatal mortality was estimated by all recorded live births for this cohort. Due to the short follow-up period (six to eight weeks post-delivery), infant mortality analysis is restricted to neonatal and early postneonatal survival. Using Statistical Package for the Social Sciences (SPSS) 23, descriptive statistics, cross tabulations, and univariate logistic regression were applied to this cohort to identify potential determinants for infant mortality.12 Variables which produced significant chi-square and odds ratios (ORs) were entered into multiple logistic regressions. The study was approved by the Institutional Review Board of the University of Nevada, Reno, and the Nigerian National Health Research Ethics Committee.

3. Results

There were 2,436 live births from the 2,379 women who delivered, including 55 sets of twins and one set of triplets. Of the 2,436 live births, there were ninety-nine cases of neonatal/early postneonatal mortality. For both the IG and the CG, there was a neonatal mortality rate of 40.6 per 1,000 live births. In addition to neonatal deaths, there were eight recorded maternal deaths, which occurred during delivery (n=6), pregnancy (n=1), or outside the postpartum period at six months postdelivery (n=1). The mean age at enrollment in the study for the women in our sample was 29.27 years.

Data for numerous maternal determinants for mortality were available for analysis. Table 1 includes the characteristics of the sample and chi-square analysis to determine significant differences between the women who experienced infant mortality and the women who did not. Women that experienced infant mortality were significantly more likely to have fewer children, have not received ANC, delivered prematurely, delivered a low birth weight infant, have been positive for syphilis and HIV, and have died intrapartum/postpartum.

Table 1 Descriptive characteristics of the study participants
Variable Neonatal/early postneonatal mortality Total Chi square (p-value)
Yes No
N % N % N %
Marital Status 1.26 (0.74)
 Married 91 91.9 2184 93.5 2275 93.4
 Single 8 8.1 140 6.0 148 6.1
 Divorced/separated 0 0.0 13 0.5 13 0.5
Education 0.31 (0.96)
 None 2 2.0 34 1.5 36 1.5
 Primary 25 25.5 573 24.6 598 24.6
 Secondary 56 57.1 1345 57.7 1401 57.7
 Tertiary 15 15.3 379 16.3 394 16.2
Employment status 3.57 (0.17)
 Unemployed 46 47.4 881 38.0 927 38.4
 Part Time 19 19.6 568 24.5 587 24.3
 Full Time 32 33.0 868 37.5 900 37.3
Distance to health facility 2.63 (0.27)
 0-5km 28 28.6 822 35.3 850 35.1
 5-10km 44 44.9 871 37.4 915 37.7
 10+km 26 26.5 633 27.2 659 17.1
Number of ANC visits 0.48 (0.79)
 Only one 1 1.1 21 0.9 22 0.9
 Less than four 9 10.0 180 8.0 189 8.1
 More than 4 80 88.9 2037 91.0 2117 90.9
Received ANC 28.88 (<0.01)
 No 6 6.1 17 0.7 23 0.9
 Yes 93 93.9 2320 99.3 2413 99.1
Gestation 45.57 (<0.01)
 Full term 81 93.1 2290 99.5 2371 99.2
 Preterm 6 6.9 12 0.5 18 0.8
Weight classification 45.00 (<0.01)
 Normal 28 87.5 1369 90.2 1397 90.0
 Low 3 9.4 68 4.4 71 4.6
 High 1 3.1 82 5.4 83 5.4
Maternal outcome 24.23 (<0.01)
 Mother alive 88 96.7 2241 99.8 2329 99.7
 Mother dead 3 3.3 5 0.2 8 0.3
Malaria 0.83 (0.36)
 Yes 70 98.6 1771 99.4 1841 99.4
 No 1 1.4 10 0.6 11 0.6
Syphilis 7.18 (<0.01)
 Yes 2 2.8 8 0.4 10 0.5
 No 69 97.2 1782 99.6 1851 99.5
HIV 13.45 (<0.01)
 Yes 8 10.7 59 3.0 67 3.3
 No 67 89.3 1914 97.0 1981 96.7
Sickle cell 0.49 (0.48)
 Yes 18 25.4 389 21.8 407 22.0
 No 53 74.6 1392 78.2 1445 78.0
Hepatitis B 2.19 (0.15)
 Yes 6 8.5 83 4.6 89 4.8
 No 71 91.5 1708 95.4 1862 95.2
Mean Mean Mean P value
Maternal age at enrollment 29.27 29.02 29.03 0.68
Number of live children 2.08 3.04 3.01 <0.01

Table 2 presents ORs for dichotomous variables. Women who did not initiate ANC and attend at least one appointment were 8.8 times more likely to experience infant mortality than those who accessed ANC (95% CI 3.39 – 22.85). Caesarian delivery was also a significant determinant for infant mortality as infants delivered via C-section were 2.5 times more likely to die than those birthed vaginally (95% CI 1.39 – 4.39). Infants born to mothers who died intrapartum/postpartum were 15.28 times more likely to die than those born to mothers who survived (95% CI 3.59 – 64.95). Additionally, infants born preterm were 14.1 times more likely to die than those carried full-term (95% CI 5.18 – 38.61).

Table 2 Determinants of neonatal/early postneonatal mortality among the HBI cohort – univariate analysis to calculate odds ratios (OR)
Variable Odds Ratio OR confidence interval
Education level (none vs primary – tertiary) 1.40 0.33 – 5.90
Employment status (unemployed vs employed) 1.47 0.98 – 2.21
Distance to health facility 0.97 0.61 – 1.53
Mother received ANC (no vs yes) 8.81 3.39 – 22.85
Maternal outcome (died vs lived) 15.28 3.59 – 64.95
Mode of delivery (C-section vs vaginal) 2.47 1.39 – 4.39
Gestation (preterm vs full-term) 14.14 5.18 – 38.61
Maternal malaria infection 0.40 0.05 – 3.13
Maternal syphilis infection 6.46 1.35 – 30.97
Maternal hepatitis B infection 1.90 0.80 – 4.51
Maternal HIV+serostatus 3.87 1.78 – 8.43

Bold indicates significant variables (p<0.05).

Maternal infection status during pregnancy was an important measure throughout the HBI study period. Our analysis found that syphilis infection and positive HIV serostatus were significant risk factors for infant mortality (Table 2). Infants born to mothers who had syphilis were 6.5 times more likely to die than those born to mothers without syphilis (95% CI 1.35 – 30.97). Infants born to HIV+ mothers were 3.9 times more likely to die than those born to HIV- mothers (95% CI 1.78 – 8.43).

Multiple logistic regression analysis was conducted to predict infant mortality using variables that were significant in univariate regression (Table 3). Of the seven variables entered into regression models, five remained statistically significant predictors for infant mortality. Mothers who died intrapartum (p<0.05), delivered preterm (p<0.05), were positive for syphilis (p=0.02) and HIV (p=0.04), and had fewer children (p<0.05) were more likely to experience infant mortality.

Table 3 Results of multiple logistic regression analysis predicting infant mortality for significant univariate variables
Variable B p-value
Mother received ANC (no vs yes) 1.50 0.09
Maternal outcome (died vs lived) 4.29 <0.01
Mode of delivery (c-section vs vaginal) 0.63 0.10
Gestation (preterm vs full-term) 2.93 <0.01
Maternal syphilis infection 2.16 0.02
Maternal HIV+serostatus 1.06 0.04
Number of living children 0.48 <0.01

Bold indicates significant variables (p<0.05).

4. Discussion

This study found several risk factors for infant mortality. HBI provided prenatal testing for HIV, other infectious diseases, as well as genetic diseases for pregnant women. Despite greater rates of testing and linkage, there were still cases of neonatal/early postneonatal mortality among both the IG and the CG, with a neonatal/early postneonatal mortality rates of 40.6 per 1,000 live births. This rate is similar to neonatal and postneonatal mortality rates published for Nigeria between 2009 and 2013 as well as rates specific to Southeast Nigeria which were 37 and 45, respectively.5 By comparison, the regional neonatal mortality rate for sub-Saharan Africa was 29 per 1,000 live births in 2015.13

Antenatal care (ANC) provided by skilled healthcare providers (doctors, nurses, etc.) exposes women to important health counseling for themselves and their children and provides an opportunity for early screening for health problems that could compromise the pregnancy and the long-term health of the mother and child.14, 15 Lack of initial access to ANC was an important factor that increased mortality among the infants in this study. The new 2016 World Health Organization ANC guideline recommends a minimum of eight antenatal care visits, compared to the previous recommendation of four visits, beginning in the first twelve weeks of pregnancy.5,16 Unfortunately, early initiation of antenatal care services is low in Nigeria. Per the 2013 NDHS, with 34% of women do not receiving ANC, and only 18% of women who receive ANC do so in the first trimester of pregnancy.5 This low rate of initiation is due to several individual and community-level factors, including the age of the mother, parity, and socioeconomic status. Additionally, pregnant women in rural areas are less likely to initiate ANC with 47% of rural women in Nigeria receiving no ANC.5

Birthweight in term and preterm infants is a predictor of mortality in neonates.17 In this study, infant birthweight, classified as low (<2.5kg), normal (2.5kg – 4.5 kg), and high (>4.5kg), was found to be a significant determinant of neonatal mortality. A majority of the low birthweight infants (87.5%) died during the neonatal period. This result is consistent with findings in other studies conducted in resource-limited settings and developed countries.17-19 Low birthweight infants are more susceptible to infections and other health problems (physical and mental), placing them at greater risk of mortality and chronic morbidity when compared to healthy weight neonates.17, 18

In addition to ANC initiation, maternal infection status was a risk factor for infant mortality. This finding reinforces the continued need for prenatal testing and early infant diagnosis (EID) for this population to protect against infant mortality related to HIV/AIDS, Hep B, syphilis, and malaria. Maternal syphilis and HIV increased the likelihood of mortality among infants born to mothers who were found to be positive for either of these infections.

Population-based studies have certain strengths which make them valuable sources of mortality data and estimations. HBI recruited from churches throughout Enugu state, providing data from a diverse study population. Population-based studies produce data that are representative of various socioeconomic statuses, health statuses, and other social determinants of health such as cultural values. The data utilized for analysis for this study is representative of the Christian population living in Enugu state, Nigeria. The NMR for this study population was slightly higher (40.6 per 1,000 live births) than the average national neonatal mortality rate (37 per 1,000 live births) measured between 2009 and 2013. This study found several risk factors that placed infants born to this population at risk of mortality within their first month of life. Through recognizing these risk factors, as well as variables influenced by cultural values, future interventions can be targeted to address this specific population’s needs.

Studies conducted in resource-limited settings presents unique challenges to researchers. For this study, the greatest limitation was the unavailability of clear and complete records. More than 500 of the 3,048 available records were excluded from analysis due to incomplete post-delivery records. This limitation decreased our sample size and may have produced falsely significant results, especially for the maternal infection results. Additionally, women who experienced infant mortality may have decided not to attend the Baby Reception, so there may be an under-reporting of infant mortality. Some information on the post-delivery questionnaire was self-reported, which may have resulted in self-report bias.

5. Conclusion and Global Health Implications

These results indicate that targeted interventions to increase ANC are needed in Nigeria and other countries with low ANC initiation, as mothers who did not receive ANC had a greater risk of neonatal/early postneonatal mortality. ANC programs should provide screening for HIV and syphilis for expectant mothers so that treatment can be started prior to delivery. Post-delivery services for preterm births and post-delivery care for mothers at greatest risk for mortality are needed to reduce infant mortality in resource-limited settings including Nigeria. The congregation-based HBI program successfully increased prenatal screening for the women because it was accepted by the community. Similarly, interventions to increase ANC and post-delivery care should be culturally-acceptable and community-based. Future research should continue to identify and address gaps in ANC coverage and infectious disease screening. In addition, future research should explore other risk factors for pregnancy loss, including miscarriages.

Acknowledgements

We are grateful to HealthySunrise Foundation, Sunrise Foundation, Bishop John Okoye (Catholic Bishop of Awgu Diocese), Archbishop Emmanuel Chukwuma (Anglican Bishop of Enugu), Bishop Callistus Onaga (Catholic Bishop of Enugu) and Archbishop Amos Madu (Anglican Bishop of Oji-River). Their support was instrumental to the successful implementation of HBI. HBI implementation would not have been possible without the support and tireless effort of the priests in the participating churches. The church-based Volunteer Health Advisors took ownership of the program and made the process of recruitment and implementation smooth for our study team and participants. This study would have been impossible to conduct without the support of PeTR-GS (our PEPFAR-supported partner), staff and volunteers.

Conflict of Interest: The authors declare no conflict of interest.

Funding: The research was co-funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Institute of Mental Health (NIMH), the President’s Emergency Plan for AIDS Relief (PEPFAR) under award number R01HD075050.

Ethics Approval: This study was approved by an Institutional Review Board.

References

  1. . United Nations. Millennium Development Goals (MDGs) Report. New York: United Nations; Retrieved November 29, 2016 from http://www.undp.org/content/dam/undp/library/MDG/english/UNDP_MDG_Report_2015.pdf
  2. , , , . Trends in neonatal mortality in Nigeria and effects of bio-demographic and maternal characteristics. BMC Pediatrics. 2015;15(36):1-12.
    [Google Scholar]
  3. , , , . An examination of the maternal social determinants influencing under-5 mortality in Nigeria:Evidence from the 2013 Nigeria Demographic Health Survey. Global Public Health. 2017;12(6):744-756.
    [Google Scholar]
  4. . . Millennium Development Goals Indicators:MDG 5 [Nigeria]. Available from http://mdgs.un.org/unsd/mdg/Data.aspx
  5. . . Nigeria Demographic and Health Survey 2013. Abuja, Nigeria: NPC and ICF International; Available from: https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf
  6. , , , , , . Place of birth or place of death:An evaluation of 1139 maternal deaths in Nigeria. Midwifery. 2013;29:e115-e121.
    [Google Scholar]
  7. , , , , , , . Individual and community determinants of neonatal mortality in Ghana:a multilevel analysis. BMC Pregnancy & Childbirth. 2014;14(165):1-12.
    [Google Scholar]
  8. , , , , , , , , , , , . Impact of a congregation-based intervention on uptake of HIV testing and linkage to care among pregnant women in Nigeria:The Baby Shower cluster randomized trial. Lancet Global Health. 2015;3(11):e692-e700.
    [Google Scholar]
  9. , , , , , , , , , , , . What do you need to get male partners of pregnant women tested for HIV in resource limited settings?the baby shower cluster randomized trial. AIDS and Behavior. 2017;21(2):587-596.
    [Google Scholar]
  10. , , , , , , . Comparative effectiveness of congregation- versus clinic-based approach to prevention of mother-to-child HIV transmission:Study protocol for a cluster randomized controlled trial. Implementation Science. 2013;8(62):1-8.
    [Google Scholar]
  11. , , , , , , , , , , , , , . Linkage to Care, Early Infant Diagnosis, and Perinatal Transmission Among Infants Born to HIV-Infected Nigerian Mothers:Evidence From the Healthy Beginning Initiative. Journal of Acquired Immune Deficiency Syndromes. 2016;72(Suppl 2):S154-S160.
    [Google Scholar]
  12. . . Mortality rate, neonatal [sub-Saharan Africa]. Available from http://data.worldbank.org/indicator/SH.DYN.NMRT?locations=ZG
  13. , , , , . Reducing maternal deaths in a low resource setting in Nigeria. Nigerian Journal of Clinical Practice. 2014;17(1):62-66.
    [Google Scholar]
  14. , , , , , . Orthodox versus unorthodox care:A qualitative study on where rural women seek healthcare during pregnancy and childbirth in southwest, Nigeria. Malawi Medical Journal:The Journal of Medical Association of Malawi. 2014;26(2):45-49.
    [Google Scholar]
  15. . . WHO recommendations on antenatal care for a positive pregnancy experience. Available from http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en
  16. , , , , , . The effects of birth weight and gender on neonatal mortality in north central Nigeria. BMC Research Notes. 2011;4(562):1-5.
    [Google Scholar]
  17. , , , . Determinants of survival in very low birthweight neonates in a public sector hospital in Johannesburg. BMC Pediatrics. 2010;10(30):1-11.
    [Google Scholar]
  18. , , , , , , , , . Trends in neonatal morbidity and mortality for very low birthweight infants. American Journal of Obstetrics and Gynecology. 2007;196(2):147.e1-147.e8.
    [Google Scholar]
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