Elsevier

Seminars in Perinatology

Volume 43, Issue 5, August 2019, Pages 252-259
Seminars in Perinatology

Place of delivery and perinatal mortality in Kenya

https://doi.org/10.1053/j.semperi.2019.03.014Get rights and content

Abstract

Background: Increasing access to skilled birth attendants is a key goal in reducing perinatal mortality. In Kenya, where 40% of births occur at home, efforts toward this goal have focused on providing free maternity services in government facilities and discouraging home births. Purpose: To identify trends in facility deliveries and determine the association between delivery location and PM in Kenya. Methods: We utilized data on 36,375 deliveries from the Kenya site of the Global Network for Women's and Children's Health Research, which maintains a prospective, population-based observational study of pregnancy and neonatal outcomes. We identified temporal trends in facility utilization and perinatal mortality. We then assessed associations between delivery location and PM using generalized linear mixed equations. Results: The percentage of facility births increased from 38.4% in 2009 to 47.6% in 2013, with no change in perinatal mortality. Infants delivered in a facility had a higher risk of perinatal mortality than infants delivered at home (aOR = 1.41, p = 0.005). In stratified analyses, hospital deliveries had a higher adjusted odds of perinatal mortality than home and health center deliveries, with no difference between health center and home deliveries. Conclusion: The increase in facility deliveries between 2009 and 2013 was not associated with a decline in perinatal mortality. Infants born in facilities had a 41% greater risk of perinatal mortality than infants born at home. Further research is needed to assess possible explanations for this finding, including delays in referring and caring for complicated pregnancies, higher risk infants delivering at facilities, and poor quality of care in facilities.

Section snippets

Background

Despite significant reductions in under-5 child mortality around the world, neonatal mortality has decreased at a far slower pace.1, 2 An increasing proportion of early childhood mortality occurs within the first month of birth: neonatal deaths now account for 45% of all under-5 deaths, up from 40% in 1990.2 Disparities in neonatal mortality remain stark: of the estimated 2.7 million infants who die in the first month of life, two-thirds of these deaths occur in 12 low- and middle-income

Methodology

We utilized data from the Kenya site of the Maternal Newborn Health Registry (MNHR), a prospective, population-based observational study of pregnancy and neonatal outcomes supported by the Eunice Kennedy Shriver Global Network for Women's and Children's Health Research in 6 countries.16 In Kenya, the MNHR staff recruits approximately 7000-8000 women per year from 16 well-defined geographic clusters in the former Western province. Each cluster is served by a single health center that provides

Results

Table 1 presents the outcome characteristics of the 36,375 deliveries included in the analysis. Overall, 14,147 deliveries (38.9%) occurred in a facility (hospital or health center), and 21,766 (59.8%) occurred in a home setting. The remaining 462 deliveries (1.3%) occurred in other locations. A total of 1085 perinatal deaths occurred during the included time frame, for an overall perinatal mortality rate of 29.8 deaths per 1000 deliveries. Of these 1085 perinatal deaths, 700 were stillbirths

Discussion

This analysis of the association between birth location and birth outcomes represents the largest cohort study available in a LMIC. Results show that the significant increase in facility deliveries in western Kenya between 2009 and 2013 was not associated with a decrease in the overall perinatal mortality rate (PMR). Furthermore, results of the adjusted analyses indicate that mortality was significantly higher among facility deliveries, compared to home deliveries, driven by the high PMR at

Conclusion

In this study using a large prospective birth registry from western Kenya, we showed that facility deliveries are increasing in this region, but that this increase was not accompanied by the expected decrease in perinatal mortality. Further analysis demonstrated that perinatal mortality is significantly higher in hospital deliveries than in home deliveries, even when accounting for important maternal, pregnancy, delivery, and neonatal characteristics. The highest odds of perinatal mortality,

Ethics approval and consent to participate

The MNHR has been approved by the Indiana University Institutional Review Board (IRB), the Moi University Institutional Review Ethics Committee, and the IRB of the data coordinating center at RTI International. All women provide informed consent prior to their enrollment in the MNHR.

Not applicable

Availability of data and material

The MNHR datasets analysed during the current study are available in the NDASH repository, https://dash.nichd.nih.gov/. Datasets generated during analyses of the current study are

Funding

This study was supported by grant funding through the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): U10 HD076461 and U01 HD040636. Representatives of NICHD participated in study design, assisted with conduct of the study, data analysis, and manuscript preparation. NICHD officials approved the final version of the manuscript.

Authors’ contributions

MK conceptualized and designed the study, performed data analysis and interpretation, drafted the initial manuscript, and approved the final manuscript as submitted.

IM assisted with study design and interpretation, coordinated data collection, reviewed and revised the manuscript, and approved the final manuscript as submitted.

EC assisted with study design, data analysis, and data interpretation; reviewed and revised the manuscript; and approved the final manuscript as submitted.

SB coordinated

Acknowledgments

This work, including the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, and approval of the manuscript, was supported by grant funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development: U10 HD076461 and U01 HD040636.

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