The effect of mother’s age and other related factors on neonatal survival associated with first and second birth in rural, Tanzania: evidence from Ifakara health and demographic surveillance system in rural Tanzania

It is estimated that about 2.96 million infants worldwide die each year during first four weeks of life (neonatal period) [1]. About 98% of these deaths occur in low- and middle-income countries; with the highest proportion in sub-Saharan Africa and south-east Asia [1]. In 2012, neonatal mortality accounted for 43% of the under five deaths in developing countries [1, 2]. A recent Tanzania Demographic and Health Survey report showed a decline in under-five mortality rate from 112 per 1000 live births in 2004/05 to 81 per 1000 live births in 2010 [3]. Similarly, the infant mortality rate has dropped from 68 to 45 per 1000 live births during the same period. However, the share of neonatal death has slowly dropped from 32 to 25 per 1000 live births during the survey period 2004/05 to 2010. Reduction in neonatal deaths is an essential step towards effort to accelerate progress towards achievement of MDG 4 for child survival. However, this requires better understanding of major causes and risk factors for neonatal deaths.

Several risk factors have been suggested to influence neonatal mortality including maternal age, parity, race, smoking birth weight, gestational age, labour complications, number of antenatal care visits, previous unfavourable outcomes (stillbirth and neonatal death) and various socio-economic factors [4, 5].

Pregnancy during teenage is a significant problem globally, with the highest incidence rates occurring in developing nations [6]. Tanzania is among the countries with highest teenage pregnancy (44%) and birth rates in the world [7]. National survey reports indicate that about 25% of girls begun child-bearing at 17 years; this figure increases to almost 40 per cent by age 18 [3, 7]. While early childbearing has often been regarded as a social issue, there is evidence that young maternal age may be linked to adverse pregnancy outcomes including low birth weight (LBW), preterm birth, intrauterine growth restriction, stillbirth, neonatal mortality [5]. Other studies have shown relationship between birth orders, birth interval, maternal age and neonatal mortality [8–10]. Previous studies in Tanzania that concentrated on effect of maternal age on neonatal outcome had small sample sizes which are difficult to make inference. Yet, there is scant information about the influence of mothers’ age, birth order, and birth interval on neonatal mortality for the first and second births in Tanzania.

In view of the importance of neonatal survival, epidemiological data regarding the influence of mother’s age on neonatal mortality provide important information to policy makers and program managers when designing interventions to reduce neonatal mortality [1, 7]. Therefore, this paper used longitudinal data generated in Health and Demographic Surveillance Systems to study the influence of mother’s age and other factors on neonatal survival of first and second births in the rural part of south-eastern Tanzania.

In Tanzania, the most recent Demographic and Health Survey conducted in 2010 indicated that neonatal mortality estimates declined from 32 deaths per 1000 in 2001–2005, to 26 deaths per 1000 in 2006–2010 [3, 18]. This indicates 19% improvement in neonatal survival for the period from 2001 to 2010 [3]. Our findings indicates that the neonatal mortality rate was 32 per 1000 live birth during the period of 2004 to 2009 and declined from 36 per 1,000 live births in 2005 to 29 per 1,000 live births in 2009. The possible explanation for this decline could be attributed to different interventions related to maternal and newborns such as Integrated Management of Childhood Illness (IMCI) [19], and increased malaria control efforts, which lead to the decline of malaria morbidity in Kilombero and Ulanga [20].

The higher neonatal mortality rate among infants born to teenage mothers in our study corresponds with previous studies [21–23]. Usually adolescent mothers face financial and social problems that lead to less provision of child care [23]. Also, physiological immaturity of teenage mothers such as small uterus or narrow bony pelvis and lack of social experience on caring newborn can lead to more neonatal deaths [24]. Some scholars have argued that the neonatal deaths observed in teenage pregnancies might have been attributable to socio-demographic factors [25].

The association between birth order and increased neonatal death might be an artefact of overrepresentation of mothers with poor outcomes in their previous birth as reported by previous authors [26]. Previous studies also have shown that women who experience pregnancy loss or poor pregnancy outcome tends to go for next pregnancy after a short time to replace the previous pregnancy loss in order to achieve the desired family size, i.e. selective fertility or reproductive compensation [27–29]. This is an important challenge in reproductive epidemiology, as women who experienced poor outcomes are more likely to continue for the next pregnancy compared with those who had favourable birth outcomes. This results to overrepresentation of high risk group (women) in the subsequent pregnancies. Therefore, outcome of previous pregnancy is an important determinant for neonatal survival in the subsequent pregnancy including through shortening of the birth interval, it also influences the length of interval between pregnancies. The increased neonatal mortality among infants in the second birth order and among women with short birth interval could be explained by the effect of selective fertility.

Previous studies have showed that women who experienced preterm birth, delivery of low birth weight infants and neonatal death in their first pregnancy are more likely to have similar adverse outcome in subsequent pregnancies [26, 30]. Since all these factors are associated with increased risk of neonatal death especially in young maternal age, the observed high risk of neonatal mortality in our study may in part be explained by recurrence of these factors in successive pregnancies [31].

In the present study, short birth interval was associated with increased risk of neonatal death compared with long birth interval [9, 10]. It is generally accepted that if closely spaced births were delayed, particularly in countries where mortality and fertility are still high, child mortality levels would fall [29]. Birth intervals increase mortality of children in two ways: Children born after a short interval are likely to have mothers in poor health, and such children tend to have low birth weight and increased chances of neonatal mortality [30]. On the other hand, women with short intervals between two pregnancies have insufficient time to restore their nutritional reserves, a situation which is thought to adversely affect fetal growth and thereby increases risk of neonatal deaths.

Our study also showed that a mother with no partner at the time of birth had increased risk of neonatal death as compared to her counterpart who had a partner co-resident. Our findings are consistent with previous studies that assessed the impact of father’s involvement on child development, functioning and quality of life [32, 33]. Evidence from the previous studies indicated that mothers with partner were more likely to provide their children with a healthy environment and nutritious food than mothers without partner, even when other conditions are similar [34, 35].

We also found that neonatal mortality was higher for male newborns than females. Our results are in agreement with other studies that showed males had a higher odds of dying than females during the first month of life [36–39]. This increased hazard for newborn males may also be due to the large proportions of neonatal deaths occurring in the first week of life, which is the time when gender differences in neonatal mortality are most pronounced [36]. Biological factors that have been implicated with this increased risk of neonatal death in male infants include immunodeficiency [38] increasing the risks of infectious diseases in males, late maturity [36] resulting in a high prevalence of respiratory diseases in males, and congenital malformations of the urogenital system. Also higher mean birth weight in males as compared to females [39], which leads to more difficult births and more asphyxia and birth trauma, leading to higher neonatal mortality.

We found no evidence to suggest that delivery in health facilities is protective to the newborns. This observation concurs with a previous study in the same area [40] but is contrary to the expected neonatal survival gains conferred through institutional delivery [21]. In Tanzania, lack of safe delivery facilities, shortage of skilled providers as well basic equipment and supplies remain critical [41]. This situation is reflected in the observed high and slightly stable neonatal mortality rate despite some increase in the facility-based. Lack of adequate maternal and neonatal care at health facilities in time critical has been argued to be linked to deaths within the first day of life [42]. Findings from facility based studies in parts of north-eastern Tanzania that assessed unmet need for emergency obstetric care blamed poor quality of care for the negative maternal outcomes and high perinatal mortality [43]. Quality of delivery services and variations in newborn care practices were not included in these analyses but could affect the risk of neonatal deaths. A recent systematic review indicated that over three quartets of intrapartum-related deaths occurred in settings with weak health systems [44]. Scarcity of skilled providers, poor infrastructure and substandard quality of care are some of the critical components of such health systems that constrain progress in maternal and newborn survival [45].

This study revealed that delayed maternal age at birth, presence of mother’s partner, birth order and birth interval are important factors which have an impact on neonatal mortality. These factors are amenable for strategy to promote and improve neonatal health and survival. Teenagers should access reproductive health information and services along with appropriate support to avoid early pregnancies. Women at high risk during first or second pregnancies need specialized care to reduce avoidable neonatal deaths. Sexual and reproductive health education programs should also promote use of family planning methods to enable women adhere to recommended birth interval and avoid unwanted pregnancies, increased age at marriage; and women empowerment in order to have control over their health. On the other hand, public health interventions directed at reducing neonatal death should address community, household and individual level factors such as birth interval, birth order and mother’s age that significantly influence neonatal mortality in Tanzania.