Social autopsy of neonatal mortality suggests needed improvements in maternal and neonatal interventions in Balaka and Salima districts of Malawi

Abstract

Background: The Every Newborn Action Plan calls for reducing the neonatal mortality rates to fewer than 10 deaths per 1000 live births in all countries by 2035. The current study aims to increase our understanding of the social and modifiable factors that can be addressed or reinforced to improve and accelerate the decline in neonatal mortality in Malawi.

Methods: The data come from the 2013 Verbal and Social Autopsy (VASA) study that collected data in order to describe the biological causes and the social determinants of deaths of children under 5 years of age in Balaka and Salima districts of Malawi. This paper analyses the social autopsy data of the neonatal deaths and presents results of a review of the coverage of key interventions along the continuum of normal maternal and newborn care and the description of breakdowns in the care provided for neonatal illnesses within the Pathway to Survival framework.

Results: A total of 320 neonatal deaths were confirmed from the VASA survey. While one antenatal care (ANC) visit was high at 94%, the recommended four ANC visits was much lower at 41% and just 17% of the mothers had their urines tested during the pregnancy. 173 (54%) mothers of the deceased newborns had at least one labor/delivery complication that began at home. The caregivers of 65% (n = 75) of the 180 newborns that were born at home or born and left a health facility alive perceived them to be severely ill at the onset of their illness, yet only 44% (n = 80) attempted and 36% (n = 65)could reach the first health provider after an average of 91 minutes travel time. Distance, lack of transport and cost emerged as the most important constraints to formal care-seeking during delivery and during the newborn fatal illness.

Conclusions: This study suggests that maternal and neonatal health organizations and the local government of Malawi should increase the demand for key maternal and child health interventions, including the recommended 4 ANC visits, and ensure urine screening for all pregnant women. Early recognition and referrals of women with obstetric complications and interventions to promote maternal recognition of neonatal illnesses and care-seeking before the child becomes severely ill are also needed to improve newborn survival in Balaka and Salima districts of Malawi.

Figure 1

Quality gap for at least one antenatal care visit (n = 299). For women who went to at least one antenatal care (ANC) (n = 299) visit, a quality gap (or missed opportunity) exists and represents the difference between the expected maximum coverage and the actual coverage proportion. Asterisk indicates that quality ANC includes blood pressure checked, urine and blood tested, counseled about nutrition, and counseled about pregnancy danger signs.

Figure 2

Preventive care of the mothers and newborns (n = 320).

Figure 3

Maternal complications and care-seeking during the pregnancy and delivery (n = 320). Asterisk indicates the following: Maternal complications – Maternal sepsis = Fever+(Severe abdominal pain OR Smelly vaginal discharge); Eclampsia/ Pre-eclampsia = Severe headache+(Blurred vision OR Puffy face OR Convulsions OR High blood pressure); Maternal anemia = Severe anemia or pallor and shortness of breath+(Too weak to get out of bed OR Fast or difficult breathing); Ante–partum hemorrhage (APH) = Any bleeding before labor; Intra-partum hemorrhage (IPH) = Excessive bleeding during labor or delivery.

Figure 4

The “Pathway to Survival” for 180 neonatal deaths (born at home or left the delivery facility alive), Malawi 2008-2011. Notes: ^§Illness severity at onset; ^§§Illness severity at onset and when caregiver decided to seek formal care; N/M – normal/mild, Mod – moderate, Svr – severe.

Figure 5

Main care–seeking constraints for the delivery and for the neonatal illness.