2.3. Independent Variables
The primary independent variable of interest is the child’s reported place of de-livery. The NFHS survey question on place of delivery includes the following options: Home (respondent’s home or other home); Public Sector (government hospital, gov-ernment health centre, government health post or other public sector); or Private Medical Sector (private hospital or clinic, other private medical facility).
Covariates were included based on previous literature with the primary objective of adjusting for socio-demographic information about the mother, child and house-hold, such as maternal age below 19 and above 30, birth order as 1, 2 and above 3, birth interval as less or more than 24 months, mother BMI under, normal and obesity, ma-ternal education as no education, primary, secondary and higher secondary, sex of child as male/female, child birth weight as low/high, household wealth as poorest, middle and richest, place of residence as rural/urban, caste SCs, STs, OBCs and others, religion as Hindu, Muslim and Christian, mass media (newspaper, television and ra-dio), antenatal care received/not received, assistant by doctor and nurse and delivered by casearation or not.
2.4. Statistical Methods
Descriptive analysis was used to determine the distribution of the variables and bivariate analysis to measure the relationship between each of the independent varia-bles and the main exposure variable at the place of delivery (home vs. facility). Neo-natal and infant mortality rates were estimated based on the simple life table ap-proach using STATA 14.0. This approach builds up a 12–59 month matrix of exposure and deaths for each month that the child was alive between the first and 11 month of life.
The Cox Proportional Hazard Regression Model was used to measure hazard ra-tios (HRs) and 95% confidence intervals (CIs) to assess the odds of neonatal death and infant death by maternal, pregnancy level delivery care and socio-demographic status.
Multivariable analyses were assessed between place of delivery and the other variables in the model. Model 1 describes the adjusted hazard ratios between neonatal deaths, maternal, child, and childbirth characteristics at home, while Model 2 includes place of delivery and pregnancy delivery characteristics, and Model 3 calculates the adjusted hazard ratio by incorporating maternal, sociodemographic, and mater-nal-pregnancy delivery care factors. All analysis was performed using statistical soft-ware package STATA® (Version 14.0).
2.5. Results and Discussion
present the state-wise neonatal and infant mortality by place of delivery 2015–2016. It was found that Overall, 141,028 (54.5%) and 54,338 (20.9%) deliveries occurred in a public and private hospital, and 63,742 deliveries (24.5%) occurred in a home setting. State wise highest percentage of births delivered by public hospital are found in Sikkim (85%), Jammu and Kashmir (77%), Odisha (76%), Madhya Pradesh (69%) and Tripura (68%). Looking at private health facilities, highest percentage of births delivered in southern states, e.g., in Kerala 61% of birth delivered in public hos-pital followed by Telangana 58%, Andhra Pradesh 53% and Tamil Nadu 32%. Gujarat is only state of northern India where 51% births have been delivered in the Public hos-pitals. Similarly, highest percentage of births without health facility for home are found in north-eastern states, such as Nagaland (68%) followed by Arunachal Pradesh (49%), Meghalaya (47%) and Manipur (36%). In complete contract in neo-natal and infant mortality due to health facility highest mortality in public and private hospital both are found in the states of Uttar Pradesh followed by Chhattisgarh and Madhya Pradesh and Bihar respectively. Neonatal and infant mortality rate was significantly higher for home deliveries (39) than for deliveries at health facilities, but the difference is negligible for public and private hospitals, where 27 per thousand live births died in public hospital and 26 per thousand live births died in private hospitals, respectively.
describes the Bio-demographic and Socio-economic factor affecting the neo-natal and infant mortality rate in the five years preceding the survey by place of delivery status. Almost half of the neonatal deaths were of children with mothers between the ages of 15–19 years. Both neonatal and infant mortality rates were higher in both public and private hospitals for mothers with birth intervals of less than 24 months. At both places of delivery, the male child was at greater risk of neonatal death than the female child. There was a higher risk of mortality among mothers living in the rural areas than the mothers living in urban areas due to lower health facilities, low awareness and low maternal education in rural areas as compare to urban areas. With regard to wealth, the quintile risk of mortality relatively higher when the poorest mother given birth at home then in institutional health facilities. Coming into pregnancy and delivery related characteristics higher number of neonatal died for both public and private hospital, those mothers had received less than four antenatal care during the pregnancy. The risk of survival of a new born baby was lower if delivered assistant by doctor as compare to the nurse. Similarly, higher chance of a new born baby died if the birth was delivered by casearation section as compared to normal births for both public and private hospital. Table 2
shows that the risk of neo-natal and infant mortality is the same in both public and private institutions, but the risk of death at home without a health facility is relatively higher than in an institutional health facility.
presents the percentage distribution of live births and per thousand neo-natal mortality rates by place of delivery due to mother’s education across the India. Around 40% of the deliveries in India were carried out at home with mother without education, while 56% in public institutions with primary education and 54% of the deliveries took place on the way to private hospital to mother of higher education. On the contrary home-based delivery mother without education neo-natal mortality rate was higher than those mothers delivered in births in public and private institution respectively. The declined in neo-natal mortality rate for each unit with increased mother education and in the institutional delivery.
depicts the percentage distribution of live births and per thousand neo-natal mortality rates by place of delivery due to place of residence in India. It was identified that only 13% of births in urban areas were delivered at home, while 28% were delivered in rural areas. There was no discernible difference between urban and rural public hospital births, but private institution-based delivery was higher in cities than in rural areas. In the context of a complete neonatal mortality contract based on place of residence, increased mortality rates were found in rural areas compared to urban areas for both place of delivery due to a lack of well-trained personnel, a lack of adequate health care facilities, a lack of medical coverage, and poor transportation facilities.
Finally, results of the hazard regression models 1, 2 and 3 for neonatal and infant mortality were presented in Table 3
and Table 4
, where Model 1 shows maternal level characteristics at home delivery, and Models 2 is pregnancy and delivery-based characteristics and Model 3 was adjusted with maternal socio-demographic, pregnancy and delivery characteristics. Model 1 revealed that the risk of neonatal mortality among children born to mothers who gave birth at home is 1.26 times higher than the risk of neonatal mortality among children born to women who have access to health care (HR: 1.26; 95 percent CI: 1.19, 1.34). The results also showed that mother age at births, birth interval more than 24 months, mothers’ highest level of education, wealth quintile, place of birth (urban-rural), caste and religion emerged as statistically significant predictors of early-neonatal deaths in India in multivariate analysis.
Hazard result Model 2 showed that the risk of neonatal death in a private hospital was 0.12 times higher than in a public hospital, with no statistically significant 95 percent confidence interval. Those mothers had received at least 4 ANC components during antenatal visits had 22 percent lower risks as compared to babies born to mothers who had not received any components of ANC during their visits (HR 0.78; 95 percent CI: 0.73, 0.83). The risk of new born baby dying 1.01 times higher when delivered by nurse as compare to assistant by doctor without statistically significant. At the same time risk of new born babies delivered by casearation section as compared to normal birth delivery (HR 1.01; 95 percent CI: 0.919–1.102) respectively.
After adjustment maternal socio-demographic, pregnancy and delivery characteristics in Model 3, depicts those mother who had given birth in a private or public facility had significantly lower value of neonatal death than those who had given birth at home (HR 0.86 95 percent CI 0.76–0.97 and HR 1.24, 95 percent CI 1.08–1.43 respectively).The risks of neo-natal death has increased, while at the same time increasing the maternal age of birth, birth order and mother BMI in 0.59, 0.88 and 1.44 time with statistical significance respectively. On the contrary higher maternal age with education decreased by 22 percent in the early neo-natal death with 95 percent statistically significant. The hazard risks of dying in the early-neonatal period is 43 percent lower for a child born in the richest wealth quintile compared to a child born in the poorest wealth quintile group. It depicts from the results that babies born to women who had received more than 4 ANC components during antenatal visits had 32 percent lower risks of neo-natal mortality compared to babies born to mothers who had not received any components of ANC during their visits (HR 0.68; 95 percent CI: 0.61, 0.76).The odds of neonatal mortality among women who gave birth with assistant of doctor at health institutions was 1.03 lower than among those who gave birth attendants by nurses at institution, and this difference was not statistically significant.
The results of hazard models for infant mortality are presented in Table 4
. Like neo-natal mortality, for model 1 we found mother age at birth, birth interval, mothers’ highest level of education, wealth quintile, place of birth (urban-rural), religion, are statistically significant predictors of infant deaths in India in multivariate models.
For model 2, adjusted with pregnancy and delivery-based characteristics showed that the differential risk of infant death between public and private hospital was narrowed. The mothers who had received more than 4 antenatal care 46 percent have lower risk then who had not received any antenatal care.
For model 3 presented adjusted maternal, socio-demographic and delivery level characteristics. A significant association was found between mother’s age and infant mortality; birth order and interval were also significantly associated with infant mortality. Irrespective of the birth order, new-borns with a birth interval less than 24 months had a higher risk of mortality during infancy than new-borns with a birth interval of 24 months or more. Another variable that was significantly associated with infant mortality was the region of residence.
presents the AHRs (with 95% confidence interval) of neo-natal and infant mortality by place of delivery controlling for all other socio demographic correlations between the states of India. These results are robust with the pattern obtained at the national level. The results clearly indicate that there is a higher risk of neo-natal and infant death at home as compared to those who gave birth in public and private health facilities. The higher risk neonatal died at home found in the state of Delhi, Meghalaya, Tamil Nadu and Jammu and Kashmir. When comparing public and private hospital health facilities, it was found that a private health institution had a higher risk of new-born babies than a public health institution due to untrained health workers and a lack of hospital facilities. These hospitals belonged to backward states such as, Mizoram, Bihar, Tripura, Arunachal Pradesh and Odisha. On contrary Delhi is one of the state, where risk of neo-natal mortality is lower than that of other states in private institution. While considering public health institution, higher risk of neo-natal death found in north-eastern states like Tripura, Mizoram, and Nagaland etc. similarly, results were found in infant mortality, the hazard risks of infant death higher at home as compared to health institution. The difference in infant mortality risk between public and private health institutions varied by state.