Understanding Determinants of Mortality in Preterm Infants: A Mixed Methods Study

Abstract

Background: Prematurity is the leading cause of child deaths, accounting for >30% of neonatal (first 28 days) deaths globally. Social determinants, defined as the social, economic, geographic, and environmental conditions of individuals, play an important role in shaping a preterm infant’s health outcome and their likelihood of survival. However, there remains a gap in understanding the extent to which these determinants impact a preterm infant’s survival. There is also a dearth of evidence to evaluate the effectiveness of the current policies and programs that determine the kind of care provided to newborns, particularly preterm babies. This study aimed to identify determinants (infant, social and demographic, and mother's reproductive and behavioral, country-level factors) of mortality in preterm infants. Methods: This was a mixed-methods study with two parts: 1) Quantitative and 2) Qualitative. The quantitative part consisted of analyzing data from the Demographic Health Survey (DHS) to identify main determinants of survival of preterm babies born in low- and -middle income countries (LMICs). A multilevel mixed-effects survival analysis was performed to find the association of these determinants with mortality in preterm infants within the first 7, 30, 365 days of life. To delve deeper into the country-level factors, qualitative interviews were conducted with policymakers to understand their perspective on the issue of newborn and preterm infant health in one of the selected LMICs, Ethiopia. Interviews were analyzed using thematic analysis. All analysis was performed using Stata version 17 and NVivo version 14. Results: A total of 16,539 preterm births were recorded, within which 1,742 deaths occurred in the first 7 days, 2,036 deaths occurred in the first 30 days, and 2,367 occurred in the first year of life. Being born female (7 days HR: 0.672, CI: 0.602 - 0.750), urban residence (7 days HR = 0.754, CI: 0.627 - 0.907), birth interval of between 24- and 60-months (7 days HR = 0.508, CI: 0.419 - 0.617), breastfeeding (7 days HR: 0.008, CI: 0.005 - 0.011), and higher pregnancy duration (gestational age) of the mother (HR: 0.457, CI: 0.424 - 0.493) were associated with a lower risk of death. Small birthweight babies had a higher risk of death (7 days HR: 1.484, CI: 1.893 - 3.322). The HR for all determinants remained similar for death at 7 days, 30 days, and 365 days. Evidence for within and across country variation was also found, indicating unobserved factors at the country and primary sampling unit level that contribute to differences in mortality among preterm children. Qualitative findings showed that despite a strong national policy for preterm care, critical gaps persist – regional disparities, rural-urban divides, inadequate health infrastructure, budget constraints, limited access to care, low community awareness, and a shortage of skilled professionals hinder effective policy implementation in Ethiopia. International collaboration, increased financial investment, human resource development, and enhanced healthcare infrastructure is required to bolster preterm infant survival outcomes in Ethiopia. Conclusions: This study’s findings highlight the significance of factors such as infant characteristics, social and demographic determinants, and maternal behaviors in influencing survival outcomes and emphasize the need for targeted interventions to address gender disparities, promote breastfeeding practices, and improve access to healthcare services. An alignment between policy development and execution is required to see the effectiveness of efforts done to improve preterm infant health in LMIC settings.