validating neonatal mortality and use of ngo reproductive health outreach services in rural...

Volume 37 Number 2 June 2006 111

Validating Neonatal Mortality and Use ofNGO Reproductive Health Outreach Services

in Rural BangladeshAlex Mercer, Nowsher Uddin, Nafisa Lira Huq, Fariha Haseen,

Mobarak Hossain Khan, and Charles P. Larson

Although the neonatal mortality rate (NMR) in Bangladesh remained steady between 1995–99and 1999–2003 (41–42 deaths per 1,000 live births), evidence from the management informationsystem (MIS) of a large nongovernmental organization (NGO) program indicates that the NMRdeclined by about 50 percent between 1996 and 2002 in the area served. This study aims to validatethe recording of neonatal deaths among the cohort of children registered as born in 2003 and toassess the evidence of a decline in the NMR. It also measures the coverage of reproductive healthoutreach services, focusing on 12 of the 27 NGOs that have provided services in the same areassince 1996. Field-workers’ registers, verbal autopsy reports, and immunization records were checkedto confirm infants’ survival. Interviews were conducted with 142 mothers of children who diedwithin 28 days postpartum and with a random sample of 109 women with registered stillbirths.Out of 11,253 registered live births in 2003, 210 neonatal deaths were found, compared with 194deaths that were reported in the MIS for 2003. The corrected NMR was 19 deaths per 1,000 livebirths, and it was in the range of 15–29 deaths per 1,000 live births in 11 of the NGO areas. Becauseunderreporting of neonatal deaths was probably higher in 1996 when the MIS-reported NMR was39 deaths per 1,000 live births, the decline in the NMR is likely to have been genuine. (STUDIES INFAMILY PLANNING 2006; 37[2]: 111–122)

Alex Mercer is Head, Health Systems and Economics Unit,International Centre for Diarrhoeal Disease Research(ICDDR,B) Centre for Health and Population Research,Health Systems and Infectious Diseases Division, GPOBox 120, Mohakhali, Dhaka, Bangladesh. E-mail:[email protected]. Nowsher Uddin, Nafisa Lira Huq, andFariha Haseen are Operations Researchers in the unit, andCharles P. Larson is Head, Health Systems and InfectiousDiseases Division. Mobarak Hossain Khan is TechnicalOfficer, Partners in Health and Development, Dhaka(formerly the Bangladesh Population and HealthConsortium).

Most neonatal deaths occur in developing countries, forwhich the average neonatal mortality rate (NMR) is 39deaths per 1,000 live births (Yu 2003). Bangladesh is fairlytypical of low-income countries, with neonatal mortalityaccounting for about two-thirds of deaths among infantsand about half of deaths among children younger thanfive years. The Bangladesh Demographic and Health Sur-

veys (BDHS) indicate that the NMR declined in the early1990s, but remained steady between 1995–99 and 1999–2003 at 41–42 deaths per 1,000 live births (NIPORT 2001and 2005). In order to achieve the targets set for child-mortality reduction under the United Nations Millen-nium Development Goals (MDGs) (Haines and Cassels2004), neonatal mortality will have to be reduced.

Data from the management information system (MIS)of a large nongovernmental organization (NGO) pro-gram in rural Bangladesh indicate that the NMR in theNGO-served areas declined from 39 deaths per 1,000 livebirths in 1996 to 20 per 1,000 live births in 2002 and thatcoverage of reproductive health outreach services washigh. If these findings are accurate, the decline in neo-natal mortality may be attributable in some measure tothe impact of the reproductive health outreach services,and scaling up NGO service provision may be warrant-ed. In this study, we assess the validity of neonatal deathrecords from 2003 and consider the strength of the evi-dence that a decline in neonatal mortality occurred in theNGO areas.

REPORT

112 Studies in Family Planning

Background to the NGO Program

In 1988 the British Overseas Development Administra-tion (ODA), which subsequently became the Departmentfor International Development (DFID), established a man-aging agency for NGO service delivery in Bangladeshknown as the Bangladesh Population and Health Con-sortium (BPHC).1 The consortium’s original aim was tofund small and medium-sized local-level NGOs to de-liver maternal and child health and family planning serv-ices in rural areas. More than 100 NGOs have been sup-ported for providing doorstep and satellite-clinic outreachservices and promoting the use of higher-level NGO andgovernment health services. In 1998, DFID integratedBPHC activities into the government’s sectoral programand funded about 40 NGOs to deliver the government’sessential services package. The NGOs focused on four ofthe five components of the package: reproductive healthand family planning, child health, limited curative care,and behavior-change communication (the fifth componentwas communicable disease control). From 2001 to 2005,27 NGOs, selected by means of an open-bidding process,were funded to provide these services to about 340,000households in 27 rural areas throughout Bangladesh.

All NGO partners used a BPHC manual for serviceprovision, which included guidelines on essential new-born care based on recommendations by the WorldHealth Organization (WHO 1996). The NGOs did not fo-cus on neonatal mortality reduction, however, until fourof them began to work on the Saving Newborn Lives Ini-tiative (SNLI), as partners of Save the Children (US). Pre-liminary activities started in 2003, including training forservice providers, introduction of new health-educationmaterials, orientation of staff, and introduction of a reg-ister for neonatal cases at the government subdistricthospital—the upazila (subdistrict) health complex.

BPHC had been developing a management informa-tion system for monitoring the health services providedby its partner NGOs since 1989. A review of the MIS in1997–98 indicated that the deaths of children were un-derreported. Although considerable efforts were madeto improve recording of these data, some level of erroris likely to have persisted. The MIS from which neona-tal mortality rates and coverage of reproductive healthoutreach services were derived was based on household-level data recorded by the NGOs’ female field-workers(known in the NGO areas as family health visitors andreferred to here as field-workers), who updated regis-ters during routine bimonthly visits to 500–800 allocatedhouseholds. The field-workers registered householdmembers, in-migrants, pregnant women, deliveries, anduse of reproductive and child health services, including

immunization. They provided basic health and familyplanning counseling, family planning methods (oral con-traceptives and condoms), and oral rehydration salts towomen in the houses they visited. An important part ofthe field-workers’ job was to promote the use of NGOfixed-location and satellite clinics and government fa-cilities at the subdistrict level where emergency obstet-ric care should be provided.

In the period 1996–2003, BPHC provided technicalsupport to partner NGOs on delivery of the essential ser-vices package, in accordance with its manual. NGO field-workers and paramedics gave advice and health educa-tion on the WHO-recommended newborn-care practices,which were included in the manual: cleanliness of de-livery and umbilical cord care, thermal protection, earlyand exclusive breastfeeding, initiation of the newborn’sbreathing and resuscitation, eye care, BCG vaccination,management of the newborn’s illness, and care of pre-term babies and those with low birthweight. Each NGOhad 10 to 15 field-workers, one or two paramedics, su-pervisors for four to five field-workers, several trainedtraditional birth attendants (TBAs) linked with satelliteclinics, and a behavior-change communication (BCC)promoter (in the case of nine of the NGOs) who orga-nized health education.

More than 90 percent of women in the NGO areasgive birth at home, as in rural Bangladesh as a whole(NIPORT 2005). In each NGO area, a paramedic conduct-ed about 18 satellite clinics every month at different sites(usually at people’s houses) with support from the lo-cal field-worker. The main services provided were ba-sic curative care, family planning (including injectablecontraceptives), antenatal care, and postnatal care. Nineof the NGOs also operated a fixed-location clinic serv-ing a larger area with a population of about 25,000; oth-erwise, women and children were referred to the gov-ernment subdistrict hospital.

Under the BPHC program, the NGOs were required tocollaborate with the government’s local service-deliverystructure, and their areas were allocated by the relevantdistrict health and family planning official (the Civil Sur-geon) on the recommendation of the subdistrict healthmanager. Subdistricts are divided into administrative“unions” (each having a population of about 25,000). Usu-ally, sections of unions (wards) were allocated to theNGOs because they were remote from the subdistrict hos-pital or difficult for the government services to reach. Nogovernment female community health workers servedthese NGO areas. Although parts of the NGO areas couldbe reached off-road by cycle-rickshaw, field-workers vis-iting many of the households had to walk several kilo-meters, crossing canals by bamboo pole and using boats.


Methods

The aim of the present study is to validate the record-ing of neonatal deaths in selected areas by using alterna-tive checks that do not rely on collecting birth historiesfrom mothers. We examine the validity of the reportedcoverage of reproductive health outreach services, therecording of neonatal deaths among children born alivein 2003, and the decline in neonatal mortality between1996 and 2003 in 12 of the NGO areas.

Study Areas and Population

The study areas were those served by 12 of the 27 BPHCpartner NGOs, selected because the NGOs had providedreproductive and child health services in the same wardssince at least 1996. The areas served by the other NGOshad changed, so that a relatively long and continuousseries of MIS data for those areas was not available. Inthis respect, the 12 study areas were not representativeof the whole NGO program, and neonatal mortality was30 percent lower than in the other 15 areas, as reportedelsewhere (Mercer et al. 2004). The 12 study areas werelocated in 85 unions of 12 subdistricts distributed across12 different districts. The NGOs aimed to provide ser-vices to the whole population of the study areas: about580,000 people in 105,000 households. Although all 12NGOs had developed referral links with their subdis-trict hospitals for emergency obstetric care, none of thehospitals had a specialized facility or equipment for new-born care, only one had a pediatrician, and only that hos-pital could provide comprehensive emergency obstetriccare. In 2003, on average, 96,642 married women of repro-ductive age (15–49) were registered at any one time inthese 12 areas. Some households were classified by theNGOs as the “poorest” on the basis of annual householdexpenditure per capita of less than Taka 5,000 (less thanUS$85) reported in surveys conducted in 1998.

Study Design

To validate the MIS reporting of neonatal deaths andcoverage of reproductive health outreach services, datain the MIS registers were cross-checked with data fromverbal autopsy reports and information from mothers.To estimate the level of misclassification of neonataldeaths, interviews were conducted with available moth-ers of children registered as having been born alive in2003 who had died within 28 days postpartum (definedas neonatal deaths), and with a random sample of wom-en who had experienced stillbirths registered in 2003.

To confirm neonatal survival and to identify any unre-corded neonatal deaths, a crosscheck was conducted onbirth and immunization records for all children regis-tered as having been born in 2003. The research team vis-ited each of the 12 NGO areas for five to ten days be-tween May and November 2004 to conduct checks onthe MIS records and to interview mothers.

Structured Interviews with Mothers

Structured interviews with mothers of neonates who haddied were conducted by a team of six female interview-ers, overseen by an experienced fieldwork supervisor.The survey was part of a study of factors associated withneonatal mortality in these NGO areas. Data collectedthat were relevant to this validation study includedmonth and year of birth, length of the newborn’s life,and the mother’s use of reproductive health outreachservices. A short interview was conducted with a sampleof women whose babies were stillborn, randomly se-lected from a full list of those with registered stillbirths(using the lottery method). If the mother or another adultpresent at the time of delivery reported that the childhad shown some sign of life (breathing, pulse, or move-ment), more questions were asked of the mother and thefield-workers, as a basis for deciding the appropriateclassification of the death.

Checking Registers and Verbal Autopsies forNeonatal Deaths

Most field-workers had four registers because the house-holds they covered were usually divided into two ar-eas, with registers for 2002–03 and 2003–04. Photocopiesof sections of the registers were made to allow for fur-ther checks after the field visit. The immunization recordsprovided a useful means of checking neonatal survival.Coverage with first vaccination against diphtheria, per-tussis, and tetanus (DPT) was greater than 90 percent inmost of the NGO areas. In light of the high level of su-pervision of field-workers, recording of vaccination waslikely to be valid (a date was recorded for each dosegiven). The assumption was made that if DPT1 vaccina-tion was recorded, the child had survived beyond 28days, because the first dose is to be given six weeks af-ter birth. Field-workers routinely transferred the namesof children from the birth section of their registers to theimmunization section. The researchers checked that allchildren registered as having been born alive in 2003 hadbeen included in the immunization section of the regis-ter. For children whose names were missing or for whomno immunization was recorded, the field-worker wasasked to confirm whether the child had migrated out,


died, or was still alive. If necessary, the household wasvisited to confirm the child’s status.

Verbal autopsy forms completed by fieldwork su-pervisors in eight of the 12 NGO areas were also checkedto identify any additional neonatal deaths that were notrecorded in the field-workers’ registers. The verbal au-topsies had not been routinely verified by medicallyqualified NGO staff, and data on causes have been dis-cussed elsewhere (Mercer et al. forthcoming). The lengthof the child’s life in days and the date of its death werechecked in the registers, in the verbal autopsy forms, andin the interviews with mothers. Any deaths after 28 dayspostpartum or among children not born in 2003 wereidentified and excluded from the calculation of a cor-rected NMR.

Data Analysis

Data from the MIS for 2003 on births, neonatal deaths,and use of reproductive health outreach services (ante-natal and postnatal care, attendance at delivery, familyplanning, and tetanus toxoid immunization) were checkedagainst data extracted by the researchers from the NGOregisters and against reports from mothers about use ofservices. Discrepancies and errors in registration and re-porting of neonatal deaths were identified, and a cor-rected NMR was calculated based on the total numberof neonatal deaths identified among the cohort of chil-dren registered as born in 2003 (correctly registered neo-natal deaths, unregistered deaths in verbal autopsy re-ports, and an estimate of the number of neonatal deathsmisclassified as stillbirths).

The corrected NMR for 2003 and MIS estimates forthe period 1996–2003 were compared with estimatesfrom an independent household survey conducted aspart of a review of another NGO program (MEASURE2005) and with estimates for rural Bangladesh as a wholefrom the BDHS (NIPORT 1997, 2001, and 2005). The still-birth rate and perinatal mortality rate (PMR) were alsocompared with rates from these sources.2

Results

Checks were conducted on more than 500 registers usedby the 145 field-workers working in the 12 study areas.The registers recorded births occurring in 2003 and theneonatal deaths among these children. Errors in registra-tion and reporting of neonatal death that were detectedthrough examination of the registers, discussion of caseswith the field-workers concerned, and interviews with

women who had experienced neonatal deaths and still-births that were recorded are reported below.

Birth Registration

A total of 11,253 live births recorded as occurring ondates in 2003 were found in the registers, compared with11,137 in the MIS report. This underreporting of 1 per-cent mainly reflects omission of births occurring in thelast week of the year, when the NGOs had to submittheir annual reports to BPHC. Birth registration was con-sidered to be reasonably complete. Field-workers andtheir supervisors reported that they had strong supportfrom people in the villages where they worked and werekept informed of vital events such as families moving inand out, pregnancies, deliveries, and deaths.

Field-workers’ reports and the checks on their reg-isters indicated that they made the required visits tohouseholds every two months. Supervisors reported con-ducting spot checks on a few different households eachmonth to monitor field-workers’ visits. Little turnover offield-workers occurred; most had worked for their NGOfor several years, although replacing one field-workerwho had left her job had proved difficult. Other field-workers and supervisors carried out her work, althoughsome of the most remote households had not been vis-ited for some time, and a few new families and birthshad not been registered.

Immunization Status as a Check on NeonatalSurvival

Immunization records were checked for all 11,253 chil-dren registered as born alive in 2003 to confirm whetherthey survived the neonatal period. Apart from the chil-dren whose deaths as neonates had been recorded in theregisters or on verbal autopsy forms, only 351 childrenwere listed for whom no DPT1 vaccination was recorded.For all other children, a date had been recorded on whichthe vaccination was given, confirming that they had sur-vived the neonatal period. Of the 351 children with norecord of immunization, 14 were known to be alive frominterviews with control mothers in a related study, andthe field-workers confirmed that 260 more were stillalive. Survival could not be confirmed for 77 children:35 had migrated out, and 42 were from the area wherethe field-worker had left her job. Those conducting herfieldwork were not able to confirm the current status ofthese children, although they had no reason to supposethat any had died.


Recording Stillbirths

Interviews were conducted with 109 randomly selectedwomen who had experienced stillbirths registered in2003. These interviews confirmed that 106 deaths oc-curred in 2003 (three were reported by the mothers tohave occurred in December of 2002), and 95 of thesewere confirmed as stillbirths. One woman reported thatthe fetus was aborted and another that she had mis-carried. On the basis of interviews with the women anddiscussion with the field-workers concerned, nine (8.3percent) of the births were reclassified as live and thedeaths as neonatal, because of descriptions of the infants’showing signs of life after delivery. Applying this pro-portion, an estimated 30 of the 354 stillbirths in 2003 inthe 12 study areas as a whole may have been neonataldeaths (95 percent confidence interval [CI]: 11–48).

A further check to determine the accuracy of the re-cording and reporting of stillbirths was a comparisonof the stillbirth rate for the 12 areas combined with thelatest estimates for Bangladesh from the BDHS (see Table1). The average annual stillbirth rate for 2001–03 for theNGO areas (29.5 stillbirths per 1,000 births) falls betweenthe BDHS estimates for rural Bangladesh for 1995–99(28.2 stillbirths per 1,000 births) and 1999–2004 (37.1 still-births per 1,000 births). The combined ratio of stillbirthsand neonatal deaths to births for the NGO areas wasabout two-thirds of the rate estimated for Bangladeshas a whole.

Recording Neonatal Deaths

In the 12 study areas, 194 neonatal deaths were reportedby the MIS for 2003, and 198 were registered by the field-workers. The discrepancy between registered and re-ported deaths was due to the requirement that the MISreports be submitted in the last week of the year. In to-tal, the researchers estimate that 210 neonatal deaths oc-

curred among the cohort of children registered as bornalive in 2003. Different sources account for the discrep-ancy between this figure and the MIS figure of 194: (1)some deaths recorded by a fieldwork supervisor on a ver-bal autopsy form were not recorded by the field-workerin her register, leading to underreporting (–9 deaths);(2) an estimated number of neonatal deaths were mis-classified as stillbirths, leading to underreporting (–30deaths); (3) the MIS reported deaths occurring in 2003,which included the deaths of some children who werenot among the cohort born in 2003, leading to overre-porting (+14 deaths); (4) some overreporting resultedfrom inclusion of deaths occurring beyond 28 days afterdelivery (+6 deaths); (5) one child recorded as a neona-tal death was still alive (+1 death); and (6) two reporteddeaths were stillbirths (+2 deaths). In total, the MIS pro-duced a net underreporting of 16 deaths (7.6 percent).

Corrected Neonatal Mortality Rates

The corrected number of neonatal deaths among chil-dren born in 2003 included 180 known neonatal deathsplus the estimated 30 misrecorded stillbirths. The 95 per-cent confidence interval (11–48) for neonatal deathsmisrecorded as stillbirths was used for calculating up-per and lower limits on the corrected number of neona-tal deaths: 210 (CI: 191–228). Based on this calculation,the corrected NMR for the 12 study areas for the cohortof children born in 2003 was 18.7 deaths (CI: 17.0–20.3)per 1,000 live births.

Perinatal Mortality

Reports from 142 mothers interviewed in the 12 studyareas indicated that 72 percent of the recorded neonataldeaths occurred in the first seven days (in the categoryof early neonatal deaths). Assuming that this propor-tion holds for all 210 neonatal deaths, 151 deaths fall into

Table 1 Stillbirth rates and neonatal mortality for Bangladesh Population and Health Consortium areas (from the program’smanagement information system) and for rural Bangladesh (from the Bangladesh Demographic and Health Surveys)

Number of Number of Number of Stillbirths per Neonatal deaths Stillbirths and neonatalArea/year live births stillbirths neonatal deaths 1,000 birthsa per 1,000 live births deaths per 1,000 birthsa

12 study NGOs2001 11,070 314 216 27.6 19.5 46.62002 11,292 383 180 32.8 15.9 48.22003b 11,253 324 210 28.0 18.7 46.1

Rural Bangladesh1995–99c 5,797 168 (244) 28.2 42.0 69.11999–2004 5,610 206 (230) 37.1 41.0 74.8

a Births are pregnancies of 7+ months’ duration; miscarriages and abortions are not included. b The corrected numbers of neonatal deaths, stillbirths, and births havebeen used for the 12 study NGO areas. Figures for 2003 are cohort rates, whereas those for 2001 and 2002 are ratios of deaths to 1,000 births in the year. c Datafrom the Bangladesh Demographic and Health Surveys (NIPORT 2001 and 2005), which relate to the five years prior to the survey. The number of neonatal deaths areestimated from the neonatal mortality rate and the number of live births.


this category. Taken together with the 354 stillbirths, thetotal is 505 perinatal deaths, yielding a perinatal mor-tality rate (PMR) of 44 deaths per 1,000 births (live birthsand stillbirths).

Sex Differential in Neonatal Mortality

The corrected NMR for males was statistically signifi-cantly higher than that for females (p<0.05): 21.3 deaths(CI: 19.4–23.3) and 16.3 deaths (CI:14.8–17.0) per 1,000live births, respectively. Rates for males and females bornas a twin were about 15 times higher than these rates (asshown in Table 2).

Socioeconomic Differences in Neonatal Mortality and ServiceCoverage

In 1999, the first year for which MIS data were disaggre-gated by socioeconomic status, the NMR for the “poor-est,” with annual household expenditure per capita in1998 of less than Taka 5,000 ($85), was estimated at 37deaths per 1,000 live births, compared with 31 deathsper 1,000 live births for other children (as shown in Table3). Corrected rates for 2003 were 21 deaths (CI:18.8–22.5)and 17 deaths (CI:15.7–18.8) per 1,000 live births, respec-tively. Although neonatal mortality declined among bothsocioeconomic groups, it declined further among thepoorest. Postneonatal mortality had leveled off between1999 and 2002, as discussed elsewhere (Mercer et al.2004), but it was slightly higher in 2003 than in 1999.

Neonatal Mortality in Areas with SNLI Initiatives in 2003

As mentioned above, the relatively low NMR in 2003, in-dicated by the MIS data, occurred before any special in-terventions for newborn survival were implemented bythe NGOs. Clearly, it was too early to expect to see any

impact on neonatal mortality from the SNLI initiative inthe four NGO areas where preliminary activities com-menced in 2003. The NMR in the four SNLI areas in 2003was no lower than it had been in 2002 (23 deaths and 20deaths per 1,000 live births, respectively, as shown inTable 4). The other eight NGOs continued to follow theBPHC manual as before, with no SNLI activities, andreported neonatal mortality for these areas was the samein 2002 and 2003 (14 deaths per 1,000 live births).

Differences in Neonatal Mortality in the 12 NGO Areas

The corrected NMRs for 11 of the study areas ranged be-tween 15 and 29 deaths per 1,000 live births (not shown).In one area, Kotalipara (Gopalganj District), no neona-tal deaths were recorded among children born in 2003,although it was estimated that one death may have beenmisclassified as a stillbirth. Few neonatal deaths or still-births had been recorded in 2000–03 (11 neonatal deathsamong 2,133 live births and eight stillbirths). The NMRfor this period was 5 deaths per 1,000 live births, lowerthan rates found in much more developed countries. Par-ticular attention was paid to checking the records for thisarea and discussing the possibility of underreportingwith the NGO’s staff. No evidence was found of under-registration of deaths or deliberate misreporting, how-ever. Immunization records were found for 672 of the695 children registered as having been born alive in 2003.For 652 children, a date was recorded on which the DPT1vaccination had been given. The field-workers confirmedthat the other 20 children in the immunization registerfor whom no DPT1 vaccination date was recorded werestill alive. Of the 23 children whose names had not beentransferred to the immunization register, 22 had mi-grated out and one had died after 42 days (as recordedin the register). Survival could not be confirmed for about

Table 2 Neonatal mortality rates, by sex, for males andfemales born in 2003, 12 NGO areas, Bangladesh

Number of NMR per 1,000Number of neonatal deaths live births a

Sex of baby live births (95 percent CIs) b (95 percent CIs) b

Corrected data for 2003Males 5,674 122 (111–132) 21.3 (19.4–23.3)Females 5,357 88 (80–96) 16.3 (14.8–17.9)

Males born as a twin 52c 16 308Females born as a twin 54 14 259

MIS report for 2003Males 5,726 113 19.7Females 5,411 81 15.0

a The figures from the management information system reports are estimates ofneonatal mortality rates (ratios of deaths to 1,000 live births reported in the year).b The range is based on the 95 percent confidence intervals for the estimatednumber of stillbirths that may, in fact, have been neonatal deaths (CI: 11–48).c Two males born as a twin were stillborn.

Table 3 MIS-reported neonatal and infant mortality rates, bysocioeconomic status (1999 and 2003) in 12 NGO areas,compared with the most recent BDHS estimates for ruralBangladesh

Rural12 NGO areas (MIS data) Bangladesh

Deaths per 1999 2003 1999–2003b

1,000 live birthsa Poorest c Others Poorest c Others All women

Number of live births (n) (3,026) (5,030) (4,567) (7,448) (not reported)Neonatal 36.8 30.6 20.7 17.3 47Postneonatal 16.0 11.0 19.0 15.6 26Infant 52.8 41.6 39.7 32.9 72

MIS = Management information system. BDHS = Bangladesh Demographicand Health Survey.a MIS estimates are ratios of deaths to 1,000 births reported for the year.b BDHS (2005) data on mortality for the five-year period preceding the survey.c Those designated as “poorest” reported an annual household expenditure percapita of less than Taka 5,000 ($85) in 1998.


50 children born in the area covered by an absent field-worker whose registers were not accessible; only twoneonatal deaths would be expected to have occurredamong them based on the national rate.

Data on Coverage of Reproductive Health OutreachServices

In 2003, 201 mothers gave birth to 210 children who wereborn alive and died during the neonatal period (ninetwin pairs were among those who died). Interviews wereobtained with 142 (71 percent) of the mothers. A total of184 mothers were identified for interview;3 46 of thesewomen were not available, either because they had out-migrated (20), died (6), or were absent from the area dur-ing the interview period, which included up to three vis-its (20). The interviewed mothers were well covered byreproductive health outreach services, and the percent-age corresponded reasonably well with that for all moth-ers, based on data extracted from the field-workers’ reg-isters (see Table 5).

Most (93 percent, not shown) of the mothers who hadexperienced neonatal deaths reported that they had hadat least one antenatal checkup prior to their delivery in2003, most of which took place at the NGO clinics. Table5 shows that coverage of mothers with at least three an-tenatal checkups as reported by these mothers (67 per-cent) was much the same as that found by checking the

data recorded in the registers (64 percent). The MIS re-ported a higher coverage for all married women whodelivered in 2003 (79 percent), most of whom had notlost their baby, although the difference was not signifi-cant at the 5 percent level. Among the mothers surveyedwhose babies had died, most (88 percent) reported hav-ing received a second or booster tetanus toxoid vacci-nation, and the proportion was the same as that foundby using the checked data from the registers. Again, thisproportion was only slightly smaller than the coveragereported in the MIS (94 percent) for all married womenaged 15–49 who gave birth in 2003.

The data in Table 6 indicate little difference betweencoverage of the poorest and of other women who gavebirth in 2003, with three antenatal care visits (77 percentversus 79 percent), tetanus toxoid vaccination (91 per-cent versus 96 percent), one postnatal care check-up (82percent versus 80 percent), and use of a modern contra-ceptive (62 percent versus 65 percent). The poorest wom-en were less likely than others to have had a qualifiedattendant at delivery (9 percent versus 15 percent) andmore likely to have had a trained traditional birth atten-dant (70 percent versus 65 percent). Coverage of servicesin the whole NGO program (27 NGO areas) was simi-lar, apart from slightly lower use of trained traditionalbirths attendants. For all services, coverage in the 27NGO areas was much higher than for rural Bangladeshas a whole.

Table 5 Among women in 12 NGO areas who gave birth in 2003, percentage who received selected reproductive healthservices, by type of service, comparing women whose child died during the neonatal period (up to 28 days after delivery) with allwomen who gave birth, according to data source

Women in 12 NGO areas who gave birth in 2003

Child died in neonatal period All mothers

Interviews with mothers Checked data from NGO NGO MIS reportReproductive health service (n = 142) MIS registers (n = 210) (n = 11,450)

Three antenatal check-ups 67.2 64.2 78.5Second or booster tetanus toxoid vaccination 88.5 88.3 93.8Qualified delivery attendant (midwife, nurse, or doctor) 13.1 13.1 12.7Delivery attended by trained traditional birth attendant 42.6 35.8 67.3

MIS = Management information system.

Table 4 Neonatal mortality estimates for 2002 and 2003 for four NGO areas where SNLI activities began in 2003, and for eightother NGO areas, and the corrected NMR for 2003, Bangladesh

2003 (Corrected)2002 (MIS) a 2003 (MIS) NMR c (95 percent

Area Births NMR Births NMR Births b confidence intervals)

Four SNLI areas 3,350 19.7 3,979 22.6 3,979 22.1 (20.1–24.0)Eight non-SNLI areas 7,942 14.1 7,158 14.2 7,158 17.0 (15.5–18.4)12 NGO areas 11,292 15.9 11,137 17.2 11,253 b 18.7 (17.0–20.3)

SNLI = Saving Newborn Lives Initiative.a The management information system estimates are ratios of deaths to 1,000 live births reported for the year. b Figure based on the researchers’ checks of registers.c Figures indicate the NMR for the cohort of children born in 2003; the range is based on an estimate of 11–48 stillbirths that may have been neonatal deaths.


Discussion

The study found that the corrected NMR for 2003 rangedbetween 15 and 29 deaths per 1,000 live births in 11 of thestudy areas. This variation is not surprising in light ofthe relatively small number of deaths and the wide geo-graphical differentials in mortality found in Bangladesh.Although district-level NMRs are not available from theBDHS, infant mortality rates for 1999–2001 show consid-erable variation among the districts where the 12 NGOareas are located, from 58 deaths per 1,000 live births inNoakhali to 105 deaths per 1,000 live births in Bogra.Little correlation was found, however, between neona-tal mortality for the NGO areas and infant mortality forthe corresponding district. In fact, the two NGO areaswith the lowest corrected NMRs (Kotalipara in Gopal-ganj District and Gongachara in Rangpur District) werein districts with relatively high infant mortality (91deaths per 1,000 live births), suggesting that very local-ized factors accounted for the relatively low neonatalmortality (fewer than 16 deaths per 1,000 live births) inthese two areas.

The exceptionally low NMR (5 deaths per 1,000 livebirths lives births in 2000–03) found in Kotalipara ap-pears unlikely, because it was lower than the NMR formuch more developed countries. No evidence was foundof any unreported deaths among children born in 2003,however. The program manager acknowledged that field-workers can make mistakes in recording, as did the man-agers in other areas. The thorough checking of immuni-zation records revealed, however, that any unreporteddeaths among the 695 children born in 2003 would haveto have occurred among 22 children who had migratedout or among about 50 in the area covered by an absentfield-worker whose registers could not be checked. Evenif the NMR among these 72 children were twice the na-

tional rate (six deaths), the NMR for all 695 childrenwould still have been only 9 deaths per 1,000 live birthsin 2003. Clearly, annual rates are subject to variation insmall populations, and higher mortality might be ob-served over a longer period than 2000–03. On the otherhand, the low neonatal mortality occurring in recent yearscould, in part, reflect a higher level of education amongthe largely Hindu population in the area and women’saccess to a subdistrict hospital that has been well staffedin recent years, in addition to the intensive NGO out-reach services similar to those found in the other studyareas (Mercer et al. 2004 and forthcoming).

Misclassification of stillbirths was found to be thegreatest source of error in recording neonatal death inthe study areas in 2003. Given the relatively large num-ber of stillbirths and the high proportion of neonataldeaths occurring in the first seven days postpartum, theperinatal mortality rate may be a more useful indicator.The difficulties of recording the PMR accurately havebeen described in several studies (Carvalho and Silver1995; Borrell et al. 1997; Contreras-Lemus et al. 2001).Misclassification of stillbirths in low-income countriesis recognized (Barker and Hall 1991), although it has notbeen well documented. The estimate of the PMR for the12 study areas in 2003 of 44 deaths per 1,000 births (atmore than seven months’ gestation) was considerablylower than the latest estimate of 65 deaths per 1,000births for rural Bangladesh in 1999–2004 (NIPORT 2005).Data from the independent MEASURE survey indicatea PMR of 62 deaths per 1,000 births for the 12 study ar-eas in a similar period, 1999–2003.

Although cross-sectional household surveys can pro-vide independent evidence of changes in neonatal mor-tality, conducting such surveys can be expensive becauseof the large sample sizes required to identify statisticallysignificant changes in neonatal mortality. More often such

Table 6 Percentage of eligible Bangladeshi women who received selected reproductive health services in 12 NGO areas in2003, and latest estimates for rural Bangladesh, by type of service, according to socioeconomic status

Women who gave birth in 2003 Rural Bangladesh12 NGO areas 27 NGO areas (BDHS 2004)

Reproductive health service Poorest a Others Total Total All women

Number of deliveries (n) (4,524) (6,926) (11,450) (36,008) (5,610)Three antenatal check-ups 77.1 79.4 78.5 81.1 21.7Second/booster tetanus toxoid vaccination 91.0 95.7 93.8 94.3 84.8 b

One postnatal check-up within 42 days 81.7 80.0 80.7 80.3 17.8Qualified delivery attendant 8.6 15.3 12.7 15.6 9.4Trained traditional birth attendant 70.2 65.4 67.3 56.7 14.0Number of eligible women (n) (132,288) (254,251) (386,539) (334,692) (8,210)Using modern contraceptives c 62.3 65.0 64.1 63.5 46.0

BDHS = Bangladesh Demographic and Health Survey.a Those designated as “poorest” reported an annual household expenditure per capita of less than Taka 5,000 ($85) in 1998. b One or more tetanus toxoid vaccina-tions were received during the most recent pregnancy in the five years before the survey. c The contraceptive acceptance rates for BPHC areas have been convertedto contraceptive prevalence rates by dividing by 1.034, the conversion factor found in a data-validation survey in 1997–98 (BPHC 1999).


surveys (including the BDHS) provide estimates of mor-tality for a period of five or ten years prior to the sur-vey, rather than for the most recent year. Collecting dataon infants’ deaths by interviewing women about theirpregnancies is also subject to recall error, so that the ex-act year of birth and death may be difficult to determineaccurately. Alternative approaches may be useful forchecking field-workers’ records of neonatal deaths inorder to correct some of the underrecording. This studydemonstrates that in the context of high coverage of first-dose DPT vaccination, checking immunization recordswas a useful means of confirming whether children sur-vived the neonatal period. The validation methods pro-vided a corrected estimate of the NMR for the most re-cent year (2003), rather than for a five-year period.

Both the MEASURE survey and the validation checksconducted for the current study were subject to the limi-tation of being based on registered births only. No othersampling frame was available for conducting a surveyof a sample of all households in the study areas, and acomplete census was not feasible. The most effective wayof monitoring neonatal mortality accurately is probablythrough a dedicated health and demographic surveil-lance system, such as the one operating in Matlab,Bangladesh, which minimizes the problem of recall. TheBPHC MIS was based on a similar system of (bimonthly)household visits, and the registration of married womenaged 15–49 is reasonably complete. A census of all house-holds in eight BPHC areas in 1997–98 found that only 2percent of married couples were not registered by theNGOs (BPHC 1999). The present study revealed that pro-cedures to ensure that registration was kept up-to-datewere thorough. Nearly all of the field-workers had workedfor the NGOs for several years, were well known in theirareas, and received considerable support from villagersin keeping track of vital events, including the migrationof families into and out of the areas. One field-workerhad left her job and had not been replaced, and one wasabsent. Because other field-workers were conducting thehousehold visits of these two in addition to their own,some of the remote and new households may not havebeen visited for some time. Even if neonatal mortalitywere twice the national rate among births in householdsnot visited, it would have little effect on the overall NMRfor the 12 study areas, because the denominator—11,253registered live births—is so large (the NMR would in-crease from 19 to 21 deaths per 1,000 live births). Anyunderreporting of births would tend to overestimate,rather than underestimate, the NMR.

The NMR for the period 1999–2003 based on uncor-rected MIS data for the 12 NGO areas combined was 22deaths per 1,000 live births, much lower than the BDHS

estimate of 47 deaths per 1,000 live births for rural Bang-ladesh as a whole for this period. Data for the 12 NGOareas from the independent MEASURE survey conduct-ed in 2003 also indicated an NMR of 47 deaths (CI: 37–58) per 1,000 live births for the five years prior to thesurvey (approximately 1999–2003). This estimate wasbased on pregnancy histories reported in interviews witha random sample of ever-married women aged 10–49 se-lected from the NGO field-workers’ registers (MEASURE2005). The results of these surveys suggest that the MISmay have underreported neonatal mortality in the pe-riod 1999–2003 by about 53 percent, although underre-porting probably was reduced during this period.

Validity of the Evidence of Neonatal Mortality Decline

The MIS data indicate a decline in the NMR in the 12 NGOareas of about 50 percent between 1996 and 2003, andother data suggest that a substantial decline is plausible.Unpublished estimates from the MEASURE survey in-dicate an NMR of 57 deaths (CI: 31.8–81.4) per 1,000 livebirths in 1999, compared with 31 deaths (CI: 8.3–53.1)per 1,000 live births in 2003. The estimates lack preci-sion because the survey was not designed to estimatemortality for only 12 NGO areas or for single years. Mor-tality fluctuated considerably for the relatively small sam-ple population, and a chi-square test for linear trend wasnot significant (p = 0.2). Nevertheless, the estimate of theNMR for 1999 (for 48–59 months before the survey) isconsistent with that for rural Bangladesh (52 deaths per1,000 live births) from the BDHS conducted in 1999–2000, relating to the previous five years (NIPORT 2001).The MEASURE estimate of 31 deaths per 1,000 live birthsfor 2003 (for 0–12 months before the survey) was con-siderably higher than the corrected MIS rate of 19 deathsper 1,000 live births for the 12 study areas, although thedifference was not statistically significant (p>0.05). TheMIS neonatal mortality rate may be more accurate forthis single year (2003) than the MEASURE survey esti-mate, which was based on birth histories.

The thorough checking of the NGO immunizationrecords revealed that, apart from the children known tohave died in the first 28 days, only 337 of the 11,253 chil-dren registered as having been born in 2003 had norecord of having been given the DPT1 vaccination. If theMEASURE estimate of the NMR for 2003 of 31 deathsper 1,000 live births were accurate, 139 more neonataldeaths would have occurred than the 210 deaths esti-mated in the present study. Assuming the NGO field-workers did not falsify the immunization records (whichwould be difficult to do with consistency), these 139 un-reported and missing deaths would have occurred among


only 337 children who had not been accounted for inthe immunization records, which is extremely unlikely.The NMR for 2003 was probably closer to the correctedMIS rate of 19 deaths per 1,000 live births than to theMEASURE estimate of 31 deaths per 1,000 live births.

Correcting MIS estimates for earlier years is diffi-cult because the level of underreporting is likely to havechanged from an unknown level. The uncorrected MISestimate of the NMR for the 12 NGO areas in 1996 (39deaths per 1,000 live births) was similar to that estimatedfor the Matlab surveillance area, where the NMR was41 deaths per 1,000 live births in 1996 and 33 deaths per1,000 in 2003 (ICDDR,B 2004). The NMR in the 12 NGOareas in 1996, however, may have been subject to greaterunderreporting than the NMR in Matlab, which wasbased on an already well-established surveillance sys-tem designed to support scientific research. An indepen-dent review of the quality of data from BPHC NGOs es-timated that deaths of children aged zero to four yearswere underreported by about 28 percent in 1997–98(BPHC 1999). Although no separate data were obtainedon neonatal deaths, this suggests that underreportingof them was probably greater in 1996 than in 2003. Fol-lowing the review, which identified specific sources ofrecording and reporting error, BPHC provided trainingand technical support for the NGOs to reduce the levelof error. If the level of net underreporting of neonataldeaths were reduced, this would tend to increase, ratherthan decrease, the reported NMR.

Coverage of Reproductive Health Services

The NGOs in all study areas had been developing theirreproductive and child health outreach services since 1996with considerable technical support from BPHC. The MISdata indicate that by 2003, the NGOs had achieved highcoverage, which was confirmed in this study by check-ing field-workers’ registers and interviewing mothers.

Coverage of key reproductive health services, suchas antenatal care and tetanus toxoid vaccination, wasmuch the same for the poorest women as for others. Thepoorest households were 34 percent of the total in 2003,slightly higher than the 28 percent of households inBangladesh classified as “extremely poor” in a nationalsurvey in 2000 on the basis of annual expenditure percapita of less than Tk 4,877 (CIET 2001). This figure sug-gests that the population of the 12 NGO areas was atleast as poor as that living elsewhere in the country. Cer-tainly, the majority of households in the NGO areaswould be considered poor by any international defini-tion based on income (for example, less than $1 per per-son per day). The NMR declined slightly further among

the poorest than among others between 1999–2003, andin 2003 the NMR among the poorest was only slightlyhigher than among other households. A given percent-age reduction in mortality is probably more readilyachieved from a higher level, and good coverage of re-productive health outreach services may be relativelymore important for the poorest women than for others.

A recent review and classification of neonatal mor-tality levels and the interventions required at these lev-els suggests that NMRs of 15–30 deaths per 1,000 livebirths are found in populations with a high proportionof deliveries that are assisted by skilled attendants, wherethe majority of births take place in health-care facilities,where community health workers provide outreach serv-ices, or where strong community-based support organi-zations are functioning (Knippenberg et al. 2005). In thecurrent study, NMRs in this range were found amongregistered births in NGO areas where few deliveries wereassisted by medically trained midwives or by nurses ordoctors, where nearly all deliveries took place in the home,and where subdistrict government health-care facilitieswere not equipped to deal with obstetric and neonatalemergencies. Women in the study areas, however, hadextensive access to well-supervised reproductive healthoutreach services, receiving regular home visits fromfield-workers, antenatal care, and tetanus toxoid vacci-nation, and being provided with reliable satellite-clinicsessions conducted by paramedics.

Plausible mechanisms whereby high coverage ofsuch services could have contributed to relatively lowneonatal mortality in the NGO areas have been consid-ered elsewhere (Mercer et al. 2004). Other potential ex-planations can be suggested for a decline, including in-creased birth intervals, any improvement in standardsof living or maternal nutrition, and access to emergencycare at the subdistrict level, although no data have beengathered from the NGO areas to indicate such changes.

The high coverage of reproductive health outreachservices in the NGO areas was the product of a numberof factors. Underlying the development of service de-livery in the NGO areas were technical support from themanaging agency and strong community support for theNGOs’ health-care activities. The system of service de-livery (home visits and satellite clinics) was basically thatenvisaged under the government’s current sectoral pro-gram for 2003–07. Government service provision suffersfrom many constraints, including low staff morale, poorattendance, unfilled vacancies, inadequate supervision,and lack of decentralized authority at the subdistrict levelto control the use of resources. Important components ofthe NGOs’ service provision included the regularity ofhome visits from committed field-workers, their efforts


to identify pregnant women and promote use of antena-tal services, the use of trained traditional birth attendantslinked with satellite clinics, paramedics conducting clinicsessions according to a reliable schedule, and good su-pervision of outreach activities and record keeping.

Conclusions

A management information system based on data re-corded by field-workers may underreport neonatal mor-tality considerably unless it includes regular checks andclose supervision. Allowing for underreporting, the NMRfor most of the study NGO areas was less than 30 deathsper 1,000 live births in 2003. Because the level of underre-porting of deaths is more likely to have been reduced thanincreased since 1996, the decline in NMR of about 50 per-cent based on the MIS data seems likely to be genuine.

This study provides evidence that NGOs with a strongcommunity base can achieve high coverage of reproduc-tive health outreach services. Additionally, the study val-idates that a substantial decline in neonatal mortality oc-curred in 12 areas in rural Bangladesh in which NGOsprovided reproductive health outreach services. Anycausal link between improved reproductive health out-reach services and neonatal mortality decline cannot bedemonstrated retrospectively; other factors could havecontributed to the decline. Even so, evidence from sev-eral other studies suggests that the type of outreach serv-ices provided by the NGOs could have contributed to pre-vention of neonatal deaths (Bhuiya and Streatfield 1992;Alam and van Ginnekin 1999; Jamil et al. 1999; Bhuiya andChowdhury 2002). The high coverage of services, amongthe poorest and others, and the relatively low neonatalmortality, compared with that observed for rural Bangla-desh as a whole, represent a considerable achievement,given that the areas were allocated to the NGOs becausethey were difficult to reach with government services.

The system of NGO outreach services through homevisits and satellite clinics, or some modification of thismodel with fixed-site clinics serving a population ofabout 6,000 (Mercer et al. 2005), may be applicable inother countries where governments lack capacity to pro-vide universal coverage at this level, and where subdis-trict health-care facilities lack adequate resources. Byscaling up NGO outreach services and including othercommunity and home-based approaches for improvingneonatal survival that are currently being developedunder the Saving Newborn Lives Initiative and throughother research in Bangladesh,4 the impact on neonatalmortality could be much greater.

Notes

1 BPHC has been transformed into an independent not-for-profitorganization, Partners in Health and Development, which spe-cializes in NGO contracting and capacity building, project man-agement, and community development.

2 The perinatal mortality rate is the number of stillbirths occurringafter 22 weeks of gestation plus the number of early neonatal deaths(within zero to seven days) divided by the number of births, ex-pressed as a rate per 1,000. The estimate for the 12 study areasdoes not take into account length of gestation. A few stillbirthsmay have occurred before 22 weeks of gestation, although anyoverestimation resulting from this occurrence is likely to be small.

3 The total number of mothers (201) is an estimate; it includes anestimate of 30 mothers whose registered stillbirth was probablya misclassified neonatal death. Not all these mothers were iden-tified for interview.

4 A study, Community-based Interventions to Reduce NeonatalMortality in Bangladesh (the PROJAHNMO Project), is being con-ducted by the ICDDR,B Centre for Health and Population Re-search in Sylhet Division, in collaboration with NGOs and otherpartners.

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Acknowledgments

This research was funded by the UK Department for Interna-tional Development (DFID) in Bangladesh. ICDDR,B acknowl-edges with gratitude the commitment of DFID to the Centre’sresearch.

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