Distinct mortality patterns at 0–2 days versus the remaining neonatal period: results from population-based assessment in the Indian state of Bihar

The slower reduction in neonatal deaths than the reduction in under-5 deaths globally in the past two decades has implications on achieving the Every Newborn target of 10 or fewer neonatal deaths per 1000 live births in every country by 2035 [1, 2]. India accounted for the largest number of under-5 deaths in 2016 at 0·9 million (0·8 to 0·9 million) in 2016, and 54.8% of these were neonatal deaths [2]. As part of the India Newborn Action Plan (INAP), in 2014, the Indian Government adopted a target of < 10 neonatal deaths per 1000 live births by 2030 as a commitment to end preventable newborn deaths [3].

With substantial heterogeneity in the magnitude and pattern of disease burden across the states of India, it is necessary for the cause burden interventions to be tailored at the state level [4, 5]. The Indian state of Bihar is the third most populous Indian state with an estimated population of 110 million in 2016, which contributes substantially to neonatal mortality burden in India [4]. The Bill & Melinda Gates Foundation through the Bihar Technical Support Programme (BTSP) supports the long-term goals of the Government of Bihar to reduce maternal, newborn, and child mortality; improve family planning services; and reduce undernutrition rates in the state [6]. At the start of BTSP in 2011, the neonatal mortality rate (NMR) of 32.2 (95% CI 27.6–36.8) was estimated for Bihar in the baseline survey [7]. In this paper, we report on the change in NMR since 2011, risk factors for neonatal mortality, cause of death distribution, and place of death in 2016 in three neonatal age sub-groups (0–2, 3–7, and 8–27 days) for identifying currently relevant interventions and programme priorities. Importantly, such distinction of the early neonatal mortality (0–7 days) into 0–2- and 3–7-day mortality has not been systematically reported previously from India. By presenting neonatal mortality epidemiology for the age sub-groups, these data are not only programmatically relevant for decision-making in Bihar but also have implications for the INAP in the other Indian states with a high burden of newborn deaths.

This study was approved by the Institutional Ethics Committee of the Public Health Foundation of India. All participants provided written informed consent, and for those who could not read or write, the participant information sheet and consent form were explained by the trained interviewer and a thumb impression was obtained.

A total of 23,602 live births in the year 2016 were identified in 182,486 households (96.2% participation) covering a population of 945,216. A total of 564 neonatal deaths were identified giving an estimated NMR of 24.7 (95% CI 21.8–28.0) per 1000 live births for the state (Table 1). A statistically significant reduction of 23.3% (95% CI − 37.3 to − 9.2) in the overall NMR was documented from 2011 to 2016, an annualized compounded reduction of 5.2% (Table 1). Among the neonatal deaths, 330 (58.5%) were within 0–2 days, 111 (19.7%) in 3–7 days, and 123 (21.8%) in 8–27 days of birth. The NMR by the age sub-categories is shown in Table 1. The largest decline in NMR from 2011 to 2016 was in 0–2-day mortality (− 35.3, 95% CI − 52.2 to − 18.4). A decline of borderline significance at 20.1% was documented for NMR in boys, and the NMR for boys and girls was similar in 2016 (Table 1).

The estimated NMR in Bihar was 24.7 deaths per 1000 live births in 2016, a significant reduction of 23% from 2011, which was driven by the reduction in the 0–2-day mortality with no significant change in 3–27 days mortality. The presentation of the risk factors and cause of death based on the age of neonate at the death and place of delivery and the place of death yield useful insights for programming to reduce neonatal mortality further in this population. Importantly, the splitting of the early neonatal age group of 0–7 days into 0–2 and 3–7 days highlights substantial differences not only in the mortality rate but also in the risk factors and causes of death between these sub-groups. These findings offer critical insights for better targeting of interventions in the early neonatal age groups and for monitoring and planning reduction in NMR. From the programme perspective, the fact that 0–2-day mortality is reducing and is still more than half of NMR is an opportunity to enhance this reduction further. In addition, more effective focus on reducing 3–7- and 8–27-day mortality is also needed based on its major risk factors and causes.

The 0–2-day NMR was 2.3 times higher than the 3–7-day NMR in 2016. Even with a decline of 35% between 2011 and 2016, 0–2 days mortality accounted for 53.4% of the total neonatal mortality in 2016. Though this study was not designed to capture the possible reasons for 0–2-day NMR decline, the decrease corroborates with the increased coverage of facility deliveries, public sector in particular, in this population between 2011 and 2016 [7], and improvements in infection control and intrapartum practices in high delivery volume public sector facilities undertaken through the nurse mentoring in the BTSP in Bihar [19]. With regard to the risk factors, a gestation period of ≤ 8 months was associated with neonatal deaths across the three age sub-groups; however, the highest risk was documented for 0–2-day deaths. It is estimated that 60% of all preterm births are in South Asia and sub-Saharan Africa, and these births account for 80% of neonatal deaths in these regions [20‐22]. A massive 82.8% of the neonatal deaths in India in 2017 could be attributed to low birth weight and short gestation [23], and its contribution to DALYs is higher in Bihar than the national average [4]. As the pregnancy length was captured in months in our study, it is difficult to comment on whether the premature babies were very or moderately preterm [24]. Preterm labour is considered to be a syndrome initiated by multiple mechanisms, and more understanding in the classification of preterm and of its risk factors is needed in this population, both for spontaneous and provider-initiated preterm births [25‐27]. The obstetric complications including breech position presentation, pregnancy with multiple foetuses, cord around the baby’s neck, and deliveries with “push and forceful pull” were associated with 0–2 days mortality, but only pregnancy with multiple foetuses was associated with 3–27 days mortality in this study. In addition to poor skills of staff providing emergency obstetric care in India [28‐32], several other related health system barriers have been identified for emergency obstetric care, including the inadequacy of staff, equipment, and accountability [33]. The need for improving the emergency neonatal care is further highlighted by the causes of death in 0–2 days with birth asphyxia accounting for 61% and preterm births for 22% of these deaths. The proportion of deaths attributed to birth asphyxia decreased thereafter, and home births had a slightly higher proportion of these deaths in 0–2 days. Birth asphyxia and preterm births are known to account for the majority of deaths in the early neonatal period [22, 34]. Emergency neonatal care that includes management of asphyxia and extra care for low birth weight and preterm babies is one of the most cost-effective intervention packages to save newborns [35]. The shortage of appropriately trained human resources is recognized as a major bottleneck by INAP to improve quality of care for complicated deliveries [3, 36]. In addition, these data also point to equip human resources with the ability to manage birth asphyxia and preterm through prompt identification, stabilization, and appropriate referral [22], and to improve the understanding of neonatal mortality by gestation months to develop facility- and community-based interventions to better manage the preterm newborns.

The absence of antiseptic cord care, delivering in the private sector and at home, being a male, and being the firstborn were associated with a higher risk of death in 0–2 days period but not in the 3–27 days period. Despite the dry cord care recommendation for all births by the Ministry of Health in India [37], antiseptic for cord care was reported in one quarter of the deliveries in this study which was associated with a lower 0–2-day mortality. We have previously reported similar results from this population highlighting that the application of readily available gentian violet on the cord after birth in less developed settings should be assessed further for its potential beneficial influence on neonatal mortality [38]. The 0–2-day mortality was higher both in the private facility and home births as compared with the public facility births. In the last 5 years, the proportion of home births has declined significantly by 20.5% but that of private facility births has remained unchanged in this population [7]. The home deliveries were predominately conducted by untrained birth attendants such as untrained Dai, family member, and friends rather than a skilled birth attendant in this population [8]. Ways to promote safe facility deliveries in women preferring home delivery by addressing relevant barriers for facility delivery and improving birth preparedness for those preferring home delivery are needed to address 0–2-day neonatal mortality [39‐41]. Interpretation of a higher 0–2-day mortality in the private facilities should take into account the context of referred deliveries in this population and the finding of higher mortality in deliveries with obstetric complications and among the referred deliveries [8]. It is well known that the private sector provides most of the emergency obstetric care in India and also serves as a referral facility for the public sector for complicated deliveries [42, 43]. To address the neonatal mortality in such deliveries, BTSP is exploring a partnership with the private sector for improved quality of care, which can be considered under the INAP as well [3, 44]. Ensuring quality of care in a private sector is important with the increasing involvement of the private sector in the universal health coverage agenda of the Government of India [45].

A 20.1% decline of borderline statistical significance in overall NMR was seen in boys between 2011 and 2016. Boys accounted for 55.6% of all neonatal deaths in 2016, and the NMR was similar for both sexes in 2016. A higher risk of neonatal mortality in boys accounted for by biological differences between boys and girls that favour girl survival during the neonatal period is known [46] and is seen in 0–2-day mortality in this population. As this study was not designed to capture the reasons for NMR decline by sex, this finding needs to be looked into further given India’s obsession with boy child to explore if access to better services or treatment factors accounts for this differential decline by sex in this population [47].

The 3–27 days mortality accounted for 47% of all neonatal mortality in 2016 in this population with illness during the neonatal period being its most significant predictor. This is also reflected in the cause of death distribution with pneumonia and meningitis/sepsis accounting for a major proportion of these deaths in addition to preterm births. Though home visitation during the neonatal period by a health worker to check on the baby for early identification of danger signs and prompt treatment and referral is meant to be part of the routine health system [48], its coverage is quite poor [49, 50]. In this population, only one third of the neonates who survived > 2 days received a postnatal care visit in the first week of birth. The latest DHS survey 2015–2016 reported coverage of postnatal care visit in 24 h after birth at 11.2% for Bihar [16]. Babies who were sick and not treated and those who needed hospitalization suggesting increased severity of illness were significantly more likely to die during this period. The preterm deaths continued to account for 26–33% of deaths in 3–27 days, thereby highlighting the need for effective postnatal care in these babies. In addition, the illness- and treatment-seeking patterns presented for various illness symptoms in the community offer insight into the challenges at the community level for early identification and treatment of sick babies. In addition to targeting the families of low birth weight and premature babies for extra care, the INAP could also include babies who are put in the incubator post-delivery for extra postnatal care attention and consider intervening at the community level to improve early identification of danger signs and prompt treatment and referral [3, 49].

Two doses of TT immunization are among the established and cost-effective interventions to save newborn babies [35]. Pregnancies without the TT doses were significantly more likely to result in 0–2- and 3–7-day mortality in this study. Over the last 5 years, a significant decline of 12.1% in TT immunization coverage during pregnancy was seen in this population [7]. This drop in coverage reflects poor quality of ANC services as TT doses are administered under the ANC interventions. Furthermore, pregnancies with no ANC were associated with a higher risk of 3–7-day mortality in this study. Improving ANC services is imperative to reduce adverse pregnancy outcomes as the specific interventions delivered in this period are meant to prevent or identify and treat infections, pregnancy-induced conditions, and undernutrition [36, 51, 52]. The possible reasons for the inadequacy of assessment or knowledge of the risk factors such as syphilis, diabetes, and hypertension in pregnant women have been previously reported by us from this population [8], highlighting that neonatal mortality cannot be addressed fully unless the quality of ANC services improves to deliver maternal interventions. In this direction, the Government of India has recently taken steps to address the coverage and quality of ANC services to pregnant women through a specific programme [53].

In order to address neonatal mortality comprehensively, it is important to understand where the babies die in addition to the cause of death and risk factors for neonatal mortality. Overall, 42% of the neonates died at home, and babies who were born at home were also most likely to die at home irrespective of the age at death. This finding is of concern as it highlights not only the limited access to emergency obstetric care but also the limited access to illness treatment during the neonatal period for this sub-group of babies. Targeting the barriers to uptake of institutional delivery and understanding health-seeking behaviour practices in this group would be important to reduce neonatal mortality in home deliveries [54‐58]. A significantly different pattern was seen for facility births by age sub-groups. Though the majority of 0–2-day deaths occurred at the facility irrespective of the type of health facility, the proportion of public sector births dying at the facility was significantly lower than the private sector births for 3–27-day deaths. Also, as the mean days of stay were significantly lower in the former than the latter, further in-depth exploration would be useful to understand the context of duration of facility stay in relation to the delivery complications or other barriers such as costs and quality of care in addition to the treatment-seeking behaviour to develop strategies to reduce neonatal mortality [59].

There are some limitations to the study findings. As is the case with surveys, the findings should be interpreted within the context of recall bias of the respondent. The gestational age was captured in months instead of weeks as the pregnancy length in India is reported in months. The last menstrual period forms the basis for most and is considered a reliable estimate for measuring gestational age in both developing and developed country settings [60, 61]. Strengthening of the numerator and denominator for neonatal mortality estimation by documenting all in/out-migration among the reproductive age women with pregnancy outcome in the period of interest and differentiation of stillbirth from immediate neonatal death from enumeration through the analysis is a major strength. Presenting the findings by the three age sub-groups supports the need for a continuum of care as the core principle to address the further decline in neonatal mortality [62]. We used a hierarchical approach to the risk factor analysis that gave importance to distal determinants of neonatal mortality and have presented results in a manner that allows for better understanding of the association of various risk factors of interest [13].

With the variations highlighted in the decline in NMR, and in drivers and causes of death of neonatal mortality by the age sub-groups, we strongly recommend that the INAP monitor neonatal mortality in these age sub-groups by splitting the early neonatal period into 0–2 and 3–7 days. Such monitoring will also ensure that every newborn is taken into account through a framework of integrated packages of service delivery for the health of mothers and newborn babies along the continuum of care [1, 62]. Our data on neonatal mortality epidemiology by the age sub-groups can be used to specifically adapt the evidence-based intervention framework to deliver across the continuum of care from pregnancy to the neonatal period [62]. Furthermore, as the neonates belonging to wealth index strata other than the highest were more likely to die in this population, it is imperative to address inequity across the continuum of care by reaching every newborn to further reduce neonatal mortality [63].

Given the variations in the risk factors and causes of death in the three age sub-groups as shown in this study, it would be useful to rethink the current categorization of neonatal age groups and split the early neonatal group of 0–7 days into 0–2 days and 3–7 days groups to plan interventions and monitor mortality changes more specifically in these two periods.