Since 2000, China has encouraged hospital delivery through a safe motherhood programme and nearly all babies are now born in hospital except in the poorest socioeconomic regions. As a result, between 1996 and 2008, mortality rates in neonates (deaths within the first month of life) fell by 62%, and hospital delivery has prevented between half and 70% of newborn deaths depending on the region. The analysis of almost 1.5 million births, published Online First in The Lancet, should be a great incentive to other countries to increase access to and improve quality of hospital-based delivery.
While the number of deaths in children under five has declined globally over the past decade, neonatal deaths (which occur mostly in low-income and middle-income countries) have increased and account for 41% of all deaths in this age group. Strategies to improve newborn survival in low-income countries have mainly focused on community and outreach interventions, and little is known about the potential effect of large-scale hospital-based strategies on newborn deaths.
Over the past 15 years, China's success in improving the quality and access to obstetric care in hospitals has greatly reduced maternal deaths, but until now its effect on neonatal mortality was not known.
Xing Lin Feng and Yan Guo from Peking University, Beijing, China, and Carine Ronsmans from the London School of Hygiene and Tropical Medicine, London, UK, led a team to try and establish the impact of China's hospital-based birth strategy on newborn survival. Between 1996 and 2008, they examined trends in neonatal mortality by cause and socioeconomic region, using data from China's Maternal and Child Mortality Surveillance System (MCMS).
In all regions, hospital births were much safer than home births, with babies born in hospital two to three times less likely to die than babies born at home, irrespective of the socioeconomic region or cause of death (except congenital abnormalities).
However, findings also showed that babies born in hospitals in the poorer rural areas remained almost four times more likely to die than babies born in urban hospitals, where rates of neonatal mortality were low (5.7 per 1000 live births).
The authors suggest that this could be the result of lower quality hospital care (lack of resources and skilled personnel) in rural areas or that facility-based care was sought too late in the poorest areas.
They say: "Other countries can learn from China's substantial progress in reducing neonatal mortality. The major effect of China's facility-based strategy on neonatal mortality is much greater than that reported for community-based interventions."
But the authors caution: "Improvements are still needed. The high rate of neonatal mortality outside hospitals in rural areas exemplifies the substantial breakdown of China's community-based primary-care approach…As China approaches universal hospital delivery, the quality of care in hospitals is the prime concern. Hospital delivery does not save babies' lives unless high-quality neonatal care is available and accessible in the crucial first few days after delivery."
In a Comment, Diego Bassani and Daniel Roth from the Hospital for Sick Children, University of Toronto, Toronto, Canada caution: "Although the investigators report strong associations between neonatal mortality and place of birth (home vs hospital)…Many characteristics differentiate families that choose (or have access to) facility deliveries and those who deliver at home; such differences would be expected to exist within, and not just between, sociodemographic categories."
They add: "The lack of statistical adjustment for key confounders suggests that the estimates of preventable fractions should be cautiously interpreted."
Professor Carine Ronsmans, London School of Hygiene and Tropical Medicine, London, UK. T) +44 (0)207 927 2190 or +44 (0)7731782857 (mobile) E) carine.ronsmans@lshtm.ac.uk
Dr Diego Bassani, Hospital for Sick Children, University of Toronto, Toronto, Canada. T) +1 416 8137654 E) diego.bassani@sickkids.ca
Journal
The Lancet