Obstetric Facility Quality and Newborn Mortality in Malawi: A Cross-Sectional Study

BackgroundEnding preventable newborn deaths is a global health priority, but efforts to improve coverage of maternal and newborn care have not yielded expected gains in infant survival in many settings. One possible explanation is poor quality of clinical care. We assess facility quality and estimate the association of facility quality with neonatal mortality in Malawi.Methods and FindingsData on facility infrastructure as well as processes of routine and basic emergency obstetric care for all facilities in the country were obtained from 2013 Malawi Service Provision Assessment. Birth location and mortality for children born in the preceding two years were obtained from the 2013–2014 Millennium Development Goals Endline Survey. Facilities were classified as higher quality if they ranked in the top 25% of delivery facilities based on an index of 25 predefined quality indicators. To address risk selection (sicker mothers choosing or being referred to higher-quality facilities), we employed instrumental variable (IV) analysis to estimate the association of facility quality of care with neonatal mortality. We used the difference between distance to the nearest facility and distance to a higher-quality delivery facility as the instrument.Four hundred sixty-seven of the 540 delivery facilities in Malawi, including 134 rated as higher quality, were linked to births in the population survey. The difference between higher- and lower-quality facilities was most pronounced in indicators of basic emergency obstetric care procedures. Higher-quality facilities were located a median distance of 3.3 km further from women than the nearest delivery facility and were more likely to be in urban areas.Among the 6,686 neonates analyzed, the overall neonatal mortality rate was 17 per 1,000 live births. Delivery in a higher-quality facility (top 25%) was associated with a 2.3 percentage point lower newborn mortality (95% confidence interval [CI] -0.046, 0.000, p-value 0.047). These results imply a newborn mortality rate of 28 per 1,000 births at low-quality facilities and of 5 per 1,000 births at the top 25% of facilities, accounting for maternal and newborn characteristics. This estimate applies to newborns whose mothers would switch from a lower-quality to a higher-quality facility if one were more accessible. Although we did not find an indication of unmeasured associations between the instrument and outcome, this remains a potential limitation of IV analysis.ConclusionsPoor quality of delivery facilities is associated with higher risk of newborn mortality in Malawi. A shift in focus from increasing utilization of delivery facilities to improving their quality is needed if global targets for further reductions in newborn mortality are to be achieved.

背景：终结可预防的新生儿死亡是全球卫生优先事项，但在诸多地区，提升孕产妇和新生儿护理覆盖率的努力并未在婴儿存活层面取得预期成效。其中一项可能的解释为临床护理质量欠佳。本研究评估马拉维的医疗机构质量，并估算医疗机构质量与新生儿死亡率之间的关联。

方法与结果：本研究从2013年马拉维服务提供评估（Malawi Service Provision Assessment）中获取该国所有医疗机构的基础设施数据，以及常规与基本急诊产科护理流程数据；从2013-2014年千年发展目标（Millennium Development Goals）终期调查中获取前两年出生儿童的分娩地点与死亡结局数据。本研究以25项预设质量指标构建综合评分指数，将排名前25%的分娩机构划分为高质量机构。为解决风险选择偏倚（病情更危重的孕产妇主动选择或被转诊至高质量医疗机构）问题，本研究采用工具变量（instrumental variable, IV）分析，以“前往最近医疗机构的距离”与“前往高质量分娩机构的距离”之差作为工具变量，估算医疗机构护理质量与新生儿死亡率之间的关联。马拉维540家分娩机构中的467家（含134家获评高质量的机构）与人口调查中的分娩记录完成关联匹配。高质量与低质量医疗机构的差异在基本急诊产科护理操作类指标中最为显著。相较于最近的分娩机构，高质量医疗机构与孕产妇的中位距离远3.3公里，且更大概率位于城区。本研究共纳入6686名新生儿进行分析，总体新生儿死亡率为17‰。在控制孕产妇与新生儿特征后，在高质量（前25%）机构分娩与新生儿死亡率降低2.3个百分点相关（95%置信区间[CI]：-0.046, 0.000，P值=0.047）。据此估算，低质量机构的新生儿死亡率为28‰，前25%的高质量机构为5‰，该估算适用于其母亲若能更便捷地抵达高质量机构，则会选择从低质量机构转至高质量机构的新生儿群体。尽管本研究未发现工具变量与研究结局之间存在未测关联的迹象，但这仍是工具变量分析的潜在局限性。

结论：马拉维分娩机构的临床护理质量欠佳与新生儿死亡风险升高显著相关。若要实现进一步降低新生儿死亡率的全球目标，需将工作重心从提升分娩机构利用率转向改善其护理服务质量。