Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes

Abstract

Objective To assess the rates, timing and causes of neonatal deaths and the burden of stillbirths in rural Uttar Pradesh, India. We discuss the implications of our findings for neonatal interventions. Methods We used verbal autopsy interviews to investigate 1048 neonatal deaths and stillbirths. Findings There were 430 stillbirths reported, comprising 41% of all deaths in the sample. Of the 618 live births, 32% deaths were on the day of birth, 50% occurred during the first 3 days of life and 71% were during the first week. The primary causes of death on the first day of life (i.e. day 0) were birth asphyxia or injury (31%) and preterm birth (26%). During days 1-6, the most frequent causes of death were preterm birth (30%) and sepsis or pneumonia (25%). Half of all deaths caused by sepsis or pneumonia occurred during the first week of life. The proportion of deaths attributed to sepsis or pneumonia increased to 45% and 36% during days 7-13 and 14-27, respectively. Conclusion Stillbirths and deaths on the day of birth represent a large proportion of perinatal and neonatal deaths, highlighting an urgent need to improve coverage with skilled birth attendants and to ensure access to emergency obstetric care. Health interventions to improve essential neonatal care and care-seeking behavior are also needed, particularly for preterm neonates in the early postnatal period.Bulletin of the World Health Organization 2006;84:706-713.Voir page 711 le résumé en français. En la página 712 figura un resumen en español. IntroductionEvery year, there are an estimated 4 mill l lion neonatal deaths, accounting for all l most 40% of deaths in children younger than 5 years.1,2 About a quarter of global neonatal deaths occur in India, which has a neonatal mortality of 43 per 1000 live births. 1,3 Therefore, interventions to address neonatal mortality are crucial if child mortality is to be reduced globally and in India. 2,4l6 Globally, the main causes of neonal l tal deaths are thought to be preterm birth (28%), sepsis or pneumonia (26%), and birth asphyxia (23%).1,2 In the Southl East Asia Region, WHO has attributed 30% of neonatal deaths to preterm birth, 27% to sepsis or pneumonia, 23% to birth asphyxia, 6% to congenital abnorl l malities, 4% to tetanus, 3% to diarrhoea and 7% to other causes. 7 However, most stillbirths or neonatal deaths occur at home and vital registration systems are incomplete, 3,4,8 and as such current estimates have been generated from a limited set of data.2,9,10Verbal autopsies, which are interl l views with caregivers, 11,12 have been used to establish causes of neonatal deaths. 8,[13][14][15][16][17][18][19][20][21] Data on timing and causes of neonatal deaths are very important for the design of interventions to reduce mortality, yet only one study with a small sample size (n = 40) has previously described causes of neonatal deaths by day. 13 Here, we describe the rates, causes and timing of 1048 neonatal deaths and stillbirths in a rural population in Uttar Pradesh, India, where the neonatal mortality...

Ascertaining causes of neonatal deaths using verbal autopsy: current methods and challenges

“…VA interviewer training ranged from several days to 1-3 weeks. [12][13][14][15] Local women with secondary level schooling [12][13][14][15][16][17][18][19] were primary interviewers, however, nurses, physicians [20][21][22][23][24] and men 14,23,25 -27 were sometimes used. Interviews were conducted from several days 24 or weeks after the death 10,12,13,15,19,20,23,25,26,28 -30 to 5 years postmortem.…”

“…28 Computer-programmed combinations of signs and symptoms (computer algorithms) of the fatal illness were also used to assign neonatal causes of death. 12,15,26 Cases that met the algorithm's definitions for each cause were identified.…”

“…12,16,17,32,33 A hierarchy arranges causes of death in a particular order based primarily on the specificity of the causal definition or perceived certainty of each diagnosis, as well as the sensitivity of the causal definition and the presumed physiological precedence of each cause's contribution to a death. The Child Health Epidemiology Research Group (CHERG) has identified a commonly used hierarchy (congenital abnormality-neonatal tetanus-preterm-birth asphyxia-sepsis/pneumoniadiarrhea-other) to estimate the cause distribution of neonatal deaths.…”

“…29 In addition to the lack of a validated algorithm for stillbirths, deaths due to some causes are often included as a subset of another condition due to a lack of cases. For example, birth injury is often grouped with birth asphyxia, 12,18,21,32 Thus, the data for a single category of death may reflect more than one distinct condition with different risk factors. Similarly, deaths attributed to prematurity may involve a variety of disease processes including respiratory distress syndrome (RDS), intracranial hemorrhage, necrotizing enterocolitis, hypothermia and hypoglycemia, for which different interventions are needed.…”

“…Limitations of hierarchy to assign causes of death Use of a hierarchy has limitations, as the cause of death distribution can vary widely depending on how the hierarchy is selected. Using the CHERG hierarchy which was used to estimate 4 million causes of neonatal deaths 36 (congenital abnormalityneonatal tetanus-preterm-birth asphyxia-sepsis/ pneumonia-diarrhea-other), Baqui et al 12 found a similar cause of death distribution in India. However, using the same data, and reordering the hierarchy by placing prematurity last, we found that the percentage of deaths due to preterm birth decreased from 27 to 9%.…”