This study found that the prevalence of neonatal mortality in a nationally representative sample of 10,624 livebirths was 1.8%, expressed as 18 per 1000 live births. Though this is lower than the 2017 GMHS rate of 25 per 1000 live births, it is still far higher than the SDG 3 target of 12 per 1000 live births by 2030 (United Nations, 2015). It is therefore important to strengthen interventions to accelerate reduction of neonatal mortality through the use of evidence-based solutions and cost-effective interventions that have been proven to reduce neonatal mortality in LMICs including Essential Newborn Care (ENC), Kangaroo Mother Care (KMC), breastfeeding, Focus Antenatal care and administration of antenatal corticosteroid .
The results of this study support findings from previous studies that showed that having antenatal care prior to delivery improves neonatal outcomes [23, 24]. It is however important to note that the results of this study did not show that having more antenatal care visits improve neonatal outcome per se. It is not entirely clear why this is the case, and there is a need to carry out further studies to examine the relationship between number of antenatal care visits and the effect on neonatal mortality in Ghana. This said, there are several reasons why ANC attendance may lower the risk of neonatal mortal. For instance, during ANC visits, women are checked (e.g. blood pressure, pulse, foetal pulse, blood chemistry), counselled on maternal and foetal risk factors, diet, exercise, rest and well as given vitamin supplements, immunized against tetanus diphtheria, given dewormers, as well as having foetal growth and presentation checked (WHO, 2016). Thus, while the number of antenatal visits made may not necessarily result in improved maternal and neonatal outcomes because of the quality of the service package , ANC attendance may ensure that risk factors are identified and resolved early to improve maternal and foetal outcomes . It is for this reason that the WHO recently recommended at least eight antenatal visits for pregnant women - an increase from the previously recommended four visits . While increasing the number of antenatal care visits may not be of benefit to women in Ghana because of poor quality of antenatal care , building the capacity of healthcare providers to provide quality antenatal care could be very essential in ensuring that women benefit from services received from the health system. This calls for the government of Ghana and Ghana Health Service to intensify monitoring and coaching visits to ensure that health service providers are providing client-focused quality antenatal care for women. This will go a long way to improve neonatal outcomes.
Female babies were also less likely to die in the neonatal period compared to their male counter parts: females had 32% lower odds of neonatal mortality as compared to their male counterparts. In Bangladesh, males infants were 1.4 times more likely to die as compared to their female counterpart during the neonatal period .In Northern Ghana, the odds of dying during the first 28days was 1.2 times in males as compared with their female counterparts . We are surprised by this finding. Demographically, females have been found to possess better survival advantages compared to their male counterparts . This has given rise to a better sex ratio in their favour globally. It is therefore not surprising to find similar characteristics in the findings of this study. While it is not entirely clear what accounts for the sex differences in risk of neonatal mortality, some previous studies have linked this difference to genetic and developmental disadvantage of male babies, which is more pronounced following birth . These biological factors are particularly associated with the slow development and maturity of male infant lungs compared to their female counterparts [26, 35]. The relevance of this finding is that it could inform healthcare providers to prepare expectant families of the need to provide gender-based care to ensure that male infants receive the needed care to help them thrive and survive. Also, it is important to create community awareness on sex differentiation in survival rates to improve on their knowledge and practices related to neonatal care.
Findings also revealed that babies who did not benefit from immediate skin-to-skin care were 2.6 times more likely to die when compared to those who benefited. Indeed, the current study is one of the few studies to have assessed the effect of immediate skin-to-skin care on neonatal mortality in Sub-Saharan Africa and will thus support the “warm chain” protocols recommended by WHO as part of basic neonatal resuscitation in LMICs particularly in Ghana . Immediate skin-to-skin care, otherwise known as putting baby on mother’s chest immediately after birth, is part of the components of immediate essential newborn care (ENC) . According to the WHO, the first step in saving the life of a baby immediately after birth is to put the baby to the mother’s chest immediately the baby is born with a clean cloth . It provides the infant warmth, thereby preventing neonatal hypothermia, which is one of the three major causes of neonatal mortality . The findings of this study thus provide further empirical evidence to support this cost-effective intervention: that putting babies on their mother’s chest could provide extra-uterine support to newborns by improving their score on Stability of Cardio-Respiratory system during the first six hours post birth suggestive of better infant stabilisation to extrauterine life, blood glucose levels, and infant thermoregulation . Despite the benefits of this ENC intervention, studies reveal that in LMICs, the practice is poor and most healthcare professionals lack the competence to provide quality ENC services in the midst of inadequate equipment to provide ENC services including inadequate bag and mask . It is therefore important from the foregoing for policy makers, particularly, Ghana’s Ministry of Health and Ghana Health Service to strengthen the health system to ensure availability, knowledge and skills on policies on ENC, availability and functional equipment including bag and mask, proficiency of healthcare providers, documentation and improve monitoring and supervision to ensure that quality and client-centred care is provided to improve neonatal outcomes. Community members, family members and opinion leaders should also be sensitised on the relevance of immediate skin-to-skin to prepare themselves before they go into labour.
Finally, this study has a number of limitations. For instance, while several more variables could potentially affect neonatal mortality, reliance on the number of variables available in the 2017 GMHS meant that the analysis was only limited to only 12 independent variables that were measured and fully captured in 2017 GMHS. Also, the design of the study and the reliance on secondary data did not offer an opportunity for exploring reasons that could help understand some of the findings better. Future research could be prospective and use mixed methods to gain better understanding. It is important to acknowledge the fact that errors such as recall bias and social desirability responses could not have been corrected in this study. Therefore, though the results could be important in planning, their application in the general population should be done with caution, taking into consideration, the limitations enumerated. These limitations notwithstanding, the strength of this study included the fact that it had a national character and as a result, the findings could be generalized to the wider population. The study also established a relationship between immediate skin-to-skin and neonatal mortality, which has not been given the needed attention in the provision of empirical evidence to back intervention on ENC. This study has thus added more empirical evidence to the determinants of neonatal mortality in Ghana, and these findings have implications for interventions in neonatal health.