Kliniken &… Institute Heidelberger Institut… Groups & Projects Working Groups Research Maternal and child… Distance_Neonatal_Malaw…

Distance to delivery care and neonatal mortality in Zambia and Malawi

Project team: Terhi Lohela, Sabine Gabrysch

External collaborators: Oona Campbell

Funding: Rahel Goitein-Straus fellowship for Sabine Gabrysch from the Medical Faculty of Heidelberg University

Every year, around 3 million newborn babies die within their first month of life, of which most could be saved by currently existing preventive or curative interventions. This study, which started off with Terhi Lohela’s MSc International Health Masters thesis project, linked existing DHS household data and national Health Facility Census data in a Geographic Information System to analyse the influence of distance to care and level of care on early neonatal mortality in Zambia and Malawi.

Surprisingly, we found no effect of distance in Malawi, a protective effect of longer distance on early neonatal mortality in Zambia, and no effect of level of care in either country. In order to better understand these unexpected results, we analysed the role of facility delivery as the mediating factor. As expected, closer distance was strongly associated with higher facility delivery in both countries. We then wanted to know whether higher facility delivery was associated with lower neonatal mortality. It is not straightforward to analyse this link, because facilities attract complicated births with higher risk of neonatal death which can make facility birth look more “risky”.

We came up with an idea to overcome this problem: Stratifying by the frequency of facility delivery in the village or sampling cluster. In villages where facility delivery is rare, a high proportion of facility deliveries tend to be complicated cases, whereas in villages where facility delivery is common, health facilities also get many low-risk normal deliveries. There was a tendency of lower neonatal mortality among facility births from villages where most women deliver in facilities. Overall, however, there was no difference in early neonatal mortality between villages with high and low facility use.

The conclusion from our findings could be that facility delivery is not effective in saving newborn lives, possibly due to low quality of care at facilities. Alternatively, the results could be explained by differential underreporting of neonatal deaths in the DHS.


Lohela TJ, Campbell OMR, Gabrysch S. (2012): Distance to care, facility delivery and early neonatal mortality in Malawi and Zambia. PLoS One, 7(12): e52110. doi:10.1371/journal.pone.0052110.