Limitations of These Data and Analyses
The analysis presented here is post-hoc and narrowly focused. The available BetterBirth data do not allow us to compare normal and excess mortality—that is, deaths among otherwise similar newborns who did and did not receive an intervention. Such a comparison would allow us to better discern if an intervention has protective or otherwise positive effect. Similarly, comprehensive data was unavailable for sick newborns who do not receive a referral, therefore this data set does not allow for us to compare mortality outcomes between sick newborns who are referred and those who are cared for at home or at the primary care facility.
Due to small sample size, we were unable to analyze the relationship between oxytocin use and c-section, postpartum hemorrhage, or maternal mortality. A broader description of the BetterBirth dataset and its limitations is available.
BRINGING IT ALL TOGETHER: MEDICAL INTERVENTIONS AND NEWBORN HEALTH OUTCOMES
Overall, intervention is made more frequently for women than it is for newborns. At-risk women seem to be appropriately identified and referred, with challenges in the implementation of the referral. While we don’t have a benchmark for rates of referral or antibiotic administration for newborns in this setting, the rates observed in the BetterBirth study were critically low.
In reality, few c-sections are occurring during the night.
C-sections are largely, and appropriately, not being conducted on stillbirths.
When broken out by intervention received, the primary causes of death for newborns in the BetterBirth trial were similar to those for all newborns regardless of intervention. Asphyxia was the most common cause of death across the interventions, followed by sepsis, complications of prematurity and pneumonia.
“Normal” groups who receive a medical intervention have the greatest relative risk of perinatal mortality, which may signal that early danger signs in “normal” infants are more likely to be overlooked or dismissed compared to those in traditional at-risk groups (for example referred singletons have an increased relative risk of mortality compared with referred twins).
Actionable Findings and Further Areas for Exploration
So how do we apply the findings above into future programming and research?
Referral and C-section Rates
Pursue further investigation and intervention into the low rates of referral and c-section.
- Are the low referral and c-section rates linked to a lack of recognition of complications, or is it related to wider health system factors that discourage these interventions?
- What are the gaps in our knowledge on the patient experience and hesitancy around referral?
- What are the barriers to referral or gaps in care for sick, normal birthweight newborns?
Delineate referral guidance and intervention for women and newborns. For referrals for women, work is needed on ensuring the referral process is functional, timely, and ensures the continuity of care. In the case of newborns, increased focus is needed on ensuring recognition of newborn complications and issuing a referral.
Target complication recognition and management at the primary-level for increased investment.
- What is causing the higher relative risk of perinatal mortality in normal birthweight newborns who receive neonatal resuscitation, particularly compared with the relative risk in low birthweight newborns? Are resuscitation efforts less effective among normal birthweight newborns? Are there other factors for low birthweight newborns that increase the relative impact of resuscitation efforts?
- What are the expected or recommended rates of referral, c-section, antibiotic use, resuscitation and oxytocin in a primary-level, low resource setting?
- Pursue targeted solutions to improve the timely and high-quality treatment and referral of asphyxia, sepsis and complications of prematurity, including a way to track, treat, and refer newborns after they have left the facility.
- Provide additional resources and support regarding the treatment and referral of women and newborns not from at-risk sub-groups.
- Prioritize ongoing intervention in provider knowledge and behavior around the proper administration of oxytocin. In the longer term, build towards improved oxytocin monitoring capacity and access to c-section deliveries at frontline facilities.
Ensuring quality complications management at frontline facilities is a complex issue and worthy of careful intervention and research. Moving forward and creating reductions in perinatal mortality are possible by acting with existing evidence and proven interventions in existing systems. ■