Antenatal iron/folic acid supplements, but not postnatal care, prevents neonatal deaths in Indonesia: analysis of Indonesia Demographic and Health Surveys 2002/2003–2007 (a retrospective cohort study)

BMJ Open

Oct 2012

DOI: 10.1136/bmjopen-2012-001399

Citations:28

Influential Citations:2

Observational Studies (Human)

Enhanced Details

Methods

Retrospective cohort analysis using pooled Indonesia Demographic and Health Surveys (IDHS) from 2002/2003 and 2007; nationally representative; includes 26,591 live-born infants in the 5 years before each survey; participants were ever-married women aged 15–49 and ever-married men aged 15–54; primary outcomes were early neonatal death (days 1–7) and all neonatal death (days 1–31); exposures were antenatal iron/folic acid supplementation and postnatal care; analysis used Cox regression with hierarchical adjustment for demographic, socio-economic, birthing characteristics and perinatal healthcare confounders; data based on maternal recall with sampling weights and cluster design.

Intervention

Oral iron/folic acid tablets during pregnancy; commonly iron 60 mg with folic acid 0.25 mg per tablet; taken for at least 1 day during pregnancy.

Results

Antenatal iron/folic acid supplementation during pregnancy reduced risk of early neonatal death by about 49–51% (HR ~0.49–0.51; 95% CI ~0.30–0.79) and all neonatal deaths by about 48–49% (HR ~0.51; 95% CI ~0.31–0.82). Postnatal care within days 1–7 after birth did not reduce neonatal death overall (HR ≈ 1.00; 95% CI 0.55–1.83). Postnatal care on day 1 by doctors was associated with higher risk for deaths on days 2–7 (likely referral bias). Conclusion: Prioritize antenatal iron/folic acid supplementation to reduce neonatal mortality; postnatal care showed no protective effect in this setting; further research is needed to understand postnatal care impact and to optimize perinatal care strategies.

Limitations

Observational, retrospective design with recall-based data; potential residual confounding due to non-randomized exposure; recall bias; lack of detail on specific postnatal care components; survivor bias as only mothers who survived were interviewed; missing data for 3,307 cases.

Abstract

Objective This study aimed to assess the contribution of postnatal services to the risk of neonatal mortality, and the relative contributions of antenatal iron/folic acid supplements and postnatal care in preventing neonatal mortality in Indonesia. Design Retrospective cohort study. Setting and participants Data used in this study were the 2002–2007 Indonesia Demographic and Health Surveys, nationally representative surveys. The pooled data provided survival information of 26 591 most recent live-born infants within the 5-years prior to each interview. Primary outcomes Primary outcomes were early neonatal mortality, that is, deaths in the first week, and all neonatal mortality, that is, deaths in the first month of life. Exposures were antenatal iron/folic acid supplementation and postnatal care from days 1 to 7. Potential confounders were community, socio-economic status and birthing characteristics and perinatal healthcare. Cox regression was used to assess the association between study factors and neonatal mortality. Results Postnatal care services were not associated with newborn survival. Postnatal care on days 1–7 after birth did not reduce neonatal death (HR=1.00, 95% CI 0.55 to 1.83, p=1.00) and early postnatal care on day 1 was associated with an increased risk of early neonatal death (HR=1.27, 95% CI 0.69 to 2.32, p=0.44) possibly reflecting referral of ill newborns. Early postnatal care on day 1 was not protective for neonatal deaths on days 2–7 whether provided by doctors (HR 3.61, 95% CI 1.54 to 8.45, p<0.01), or by midwives or nurses (HR 1.38, 95% CI 0.53 to 3.57, p=0.512). In mothers who took iron/folic acid supplements during pregnancy, the risk of early neonatal death was reduced by 51% (HR=0.49, 95% CI 0.30 to 0.79, p<0.01). Conclusions We found no protective effect of postnatal care against neonatal deaths in Indonesia. However, important reductions in the risk of neonatal death were found for women who reported use of antenatal iron/folic acid supplements during pregnancy. show less