Skip to main content

Antenatal and delivery practices and neonatal mortality amongst women with institutional and non-institutional deliveries in rural Zimbabwe: observational data from a cluster randomized trial



Despite achieving relatively high rates of antenatal care, institutional delivery, and HIV antiretroviral therapy for women during pregnancy, neonatal mortality has remained stubbornly high in Zimbabwe. Clearer understanding of causal pathways is required to inform effective interventions.


This study was a secondary analysis of data from the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial, a cluster-randomized community-based trial among pregnant women and their infants, to examine care during institutional and non-institutional deliveries in rural Zimbabwe and associated birth outcomes.


Among 4423 pregnant women, 529 (11.9%) delivered outside a health institution; hygiene practices were poorer and interventions to minimise neonatal hypothermia less commonly utilised for these deliveries compared to institutional deliveries. Among 3441 infants born in institutions, 592 (17.2%) were preterm (< 37 weeks gestation), while 175/462 (37.9%) infants born outside health institutions were preterm (RR: 2.20 (1.92, 2.53). Similarly, rates of stillbirth [1.2% compared to 3.0% (RR:2.38, 1.36, 4.15)] and neonatal mortality [2.4% compared to 4.8% (RR: 2.01 1.31, 3.10)] were higher among infants born outside institutions. Among mothers delivering at home who reported their reason for having a home delivery, 221/293 (75%) reported that precipitous labor was the primary reason for not having an institutional delivery while 32 (11%), 34 (12%), and 9 (3%), respectively, reported distance to the clinic, financial constraints, and religious/personal preference.


Preterm birth is common among all infants in rural Zimbabwe, and extremely high among infants born outside health institutions. Our findings indicate that premature onset of labor, rather than maternal choice, may be the reason for many non-institutional deliveries in low-resource settings, initiating a cascade of events resulting in a two-fold higher risk of stillbirth and neonatal mortality amongst children born outside health institutions. Interventions for primary prevention of preterm delivery will be crucial in reducing neonatal mortality in Zimbabwe.

Trial registration

The trial is registered with, number NCT01824940.

Peer Review reports


Globally, neonatal mortality fell by 51% between 1990 and 2017 from 36.6 to 18.0 deaths per 1000 live births and the absolute number of annual neonatal deaths halved from 5 million to 2.5 million [1]. Despite these gains, more than 60 countries are not on track to meet the neonatal mortality (NNM) target of 12/1000 highlighted in the Sustainable Development Goals (SDGs) [1].

Most neonatal deaths occur during delivery [2, 3] or in the first 24 hours following birth [4, 5]. As such, efforts to reduce neonatal mortality have focused on encouraging and enabling women to deliver in health facilities, in the presence of skilled birth attendants (SBAs) [6, 7], which is associated with lower adverse outcomes in both infants and mothers [8,9,10].

Whilst many studies have focused on the reasons why women choose to deliver at home, there has been less discussion of women who intend to deliver in an institution but end up delivering at home when labour occurs unexpectedly early and /or progresses quickly. This situation may be especially relevant for women living in remote rural settings with poor infrastructure and limited transportation. Indeed in studies in Nepal, Kenya, and Tanzania examining reasons for non-institutional deliveries, one-third [11, 12] to two-thirds [13] of women reported precipitous or unexpectedly early labour as the primary reason they delivered at home.

In Zimbabwe, neonatal mortality has been a particularly stubborn problem: it increased from 27/1000 to 32/1000 live births between 1990 and 2019, in part reflecting economic hardship and high HIV prevalence [14]. This increase occurred despite high coverage of prevention of mother-to-child transmission (PMTCT) interventions (> 90% in 2018) [15], antenatal care (93% with ≥1 visit and 74% with ≥4 visits), and institutional deliveries (88%) [16]. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial was a cluster-randomized community-based trial conducted in two contiguous rural Zimbabwean districts (Chirumanzu and Shurugwi) which tested the independent and combined effects of improved infant and young child feeding (IYCF) and improved water, sanitation, and hygiene (WASH) on child health outcomes. This secondary data analysis from the SHINE trial provides an opportunity to examine the risk factors, birth practices and infant outcomes among women having institutional or non-institutional deliveries.


Sanitation hygiene infant nutrition efficacy (SHINE) trial

The SHINE trial has been previously described [17] and primary outcomes reported [18,19,20]. In brief, mothers and their infants were randomized to standard of care (SOC); IYCF (small-dose lipid-based nutrient supplement and complementary feeding counselling from 6 months of age); WASH (commencing during pregnancy with pit latrine and 2 hand-washing stations, liquid soap and chlorine, a clean play space, and hygiene counselling); or IYCF + WASH (all interventions). Primary outcomes were infant length and haemoglobin at 18 months, with several secondary outcomes, including child neurodevelopment, infant diarrhoea prevalence, incidence, and severity, and adverse birth outcomes.

Data collection and analysis

From November 22nd, 2012, to March 27th, 2015, Village Health Workers (VHWs) employed by the Ministry of Health and Child Care (MoHCC) conducted prospective pregnancy surveillance by visiting all women aged 15–49 years in the study area to identify those who had missed a menstrual period and offering them a urine pregnancy test. New pregnancies were referred to research nurses who obtained written informed consent and enrolled women into the trial.

Home visits were carried out at baseline (~ 2 weeks after enrolment), at 32 gestational weeks, and at infant ages 1, 3, 6, 12 and 18 months to assess baseline characteristics and trial outcomes. Given the household nature of the WASH intervention, visits were only conducted when the mother was available in the home where she had been recruited, except at the 18-month visit (trial endpoint) when they were visited anywhere in Zimbabwe. Information about the delivery and the infant at birth was collated from the mother’s handheld records, the health facility records and by questionnaire at the 1-month postpartum visit or, for mother-infant dyads not available for the 1-month visit, at their first available postpartum visit. The trial provided Tanita BD-590 infant scales (Arlington Heights, IL, USA) to all institutions in the study area and trained health facility staff to use the scales and record infant birth weight on facility and patient-held records. Recumbent infant length was measured to the nearest 0.1 cm using a Seca 417 infantometer (Weigh & Measure LLC., Olney, MD, USA) by a research nurse during home visits at 1 month as an indicator of fetal linear growth. Gestational age at delivery was calculated from the date of the mother’s last menstrual period; values which were < 24 weeks or > 42 weeks + 6 days were excluded from analyses. Infants were classified as preterm (gestational age at delivery < 37 weeks), small-for-gestational-age (SGA; birthweight <10th percentile for gestational age using the INTERGROWTH reference [21]), or both preterm and SGA. Mean gestational age at delivery and proportion of infants born preterm (< 37 weeks) were estimated among two populations: first, only among infants with complete and plausible data, defined as those with birthweight-for-gestational age > 0.4th centile and < 99.6th centile using INTERGROWTH references (Estimate 1); and second, including infants in Estimate 1 plus infants whose birth weight was missing (Estimate 2). Infant length at 3 month was converted to Z-scores using the WHO reference [22].

Fetal losses and neonatal deaths were identified and reported to the trial by a research nurse, VHW, or the mother. Details of the event were reported by a research nurse to the study physician who reviewed the reports and classified the event as miscarriage (fetal loss before 28 weeks’ gestation), stillbirth (fetal loss after 28 weeks’ gestation), or neonatal death (live birth followed by death within the first 28 days) and reported them to the institutional review boards which approved and oversaw the trial (Medical Research Council of Zimbabwe and Johns Hopkins Bloomberg School of Public Health). Women gave written informed consent to participate.

Statistical analysis

Baseline characteristics, care practices, and birth outcomes of women who had institutional compared to non-institutional deliveries were compared by calculating the mean difference (95% CI) for continuous variables and relative risk (95% CI) for categorical variables. All statistical analyses were performed using STATA version 14 [23]. Selection of care practices was guided by the WHO safe childbirth checklist (ref).


Five thousand, two hundred eighty pregnant women were enrolled from 211 clusters at a median gestational age of 12 (IQR 9–16) weeks (Supplementary Figure). During the antenatal period, 11 women were excluded, and one woman was added to the analysis to correct for enrolment errors; 139 women withdrew from the trial or were lost to follow-up, 4 died during pregnancy and 249 had a miscarriage. With the addition of 82 fetuses in twin/triplet pregnancies there were a total of 4956 fetuses delivered by 4878 mothers. Of these, place and details of the delivery was known for 4494 fetuses (90.7%) (4423 mothers); 3958 fetuses (88.1%) (3894 mothers) were delivered in an institution and 536 fetuses (11.9%) (529 mothers) were delivered outside a health institution.

Compared to women who delivered in a health institution, women who delivered outside a health institution were older, less likely to be primiparous, more likely to have been depressed during pregnancy, more likely to belong to the Apostolic faith and to have a lower socioeconomic status including fewer years of education, and poorer sanitation and drinking water quality (Table 1). Whilst mothers who had non-institutional deliveries were less likely to have had an HIV test prior to joining SHINE (RR 0.91, 95%CI 0.84–0.97), they were 39% more likely to test HIV-positive during the baseline visit of the trial. History of previous neonatal death, miscarriage, and stillbirth did not significantly vary by place of delivery.

Table 1 Characteristics of mothers and their household according to place of delivery

Many conditions and care practices during delivery differed between institutional and non-institutional deliveries (Table 2) [24]. Women who delivered outside a health institution were less likely to have paid for delivery than those who delivered at a health institution. Only a small number (N = 25, 5.1%) of non-institutional deliveries were assisted by a healthcare professional (doctor, nurse, or midwife), compared to almost all (N = 3857, 99.5%) births at health institutions. Instead, non-institutional deliveries were more commonly assisted by VHWs, traditional birth attendants, faith healers, friends, or relatives. Several indicators suggested that fewer hygiene measures were taken during non-institutional births: birthing assistants were less likely to use gloves (RR 0.68, 95%CI 0.64–0.73), sterile blades to cut the cord (RR 0.97, 95%CI 0.93–1.00), or sterile string to tie the cord (RR 0.36, 95%CI 0.32–0.41). Unclean string was used to tie the cord in 22.5% (N = 101) of non-institutional births. Furthermore, infants born outside an institution were less likely to be dried (RR 0.72, 95%CI 0.66–0.79) and placed skin-to-skin with the mother (RR 0.22, 95%CI 0.18–0.28) before delivery of the placenta, which are both important indicators of neonatal hypothermia risk [25, 26]. Among 293 women who provided Information on their reason for having had a home delivery, 221 (75%) reported that precipitous labor was the primary reason for not having an institutional delivery while 32 (11%), 34 (12%), and 9 (3%), respectively, reported distance to the clinic, financial constraints, and religious/personal preference.

Table 2 Conditions and care practices during delivery according to place of delivery

Infants with non-institutional deliveries were more likely to have low birthweight (RR 1.65, 95%CI 1.24–2.19) (< 2.5 kg) and more than 3 times (95%CI 1.48–7.77) as likely to have very low birth weight (< 1.5Kg) (Table 3). Among infants born in institutions, 592/3441 (17.2%) were preterm (< 37 weeks gestation), while 175/462 (37.9%) of infants born outside health institutions were preterm (RR: 2.20 (1.92, 2.53) (Table 3, Estimate 2). Rates were slightly attenuated when infants who did not provide birthweight were excluded 555/3288 (16.9%) and 82/253 (32.4%) (Table 3, Estimate 1). Similarly, rates of stillbirth [1.2% compared to 3.0% (RR:2.38, 1.36, 4.15)] and neonatal mortality [2.4% compared to 4.8% (RR: 2.01 1.31, 3.10)] were higher among infants born outside compared to inside health institutions.

Table 3 Infant birth outcomes by place of delivery


In the SHINE study population, 18.2% of infants were born preterm and 57% of both the neonatal deaths and stillbirths were among infants born prematurely [27]. This preterm birth rate is among the highest in the world. A key insight of the current analysis is that the proportion of infants born preterm was 2.2 (95% CI: 1.92, 2.53) times higher among infants with non-institutional compared to institutional deliveries (37.9% vs 17.2%). While previous studies have focussed on determinants of non-institutional deliveries which then lead to poorer birth outcomes [28,29,30], our observations imply the reverse: the highly prevalent (and unexpectedly early) preterm labor experienced by SHINE mothers may be the reason many of these mothers delivered outside a health institution. Moreover, we observed many of the same risk factors of non-institutional delivery (e.g., lower socioeconomic status) that have been reported by others. This implies that among the many women in Zimbabwe who experience preterm labor, those who are also poorer, less educated, and more depressed, lack the means to reach a health institution quickly, and so are attended by untrained caregivers in less hygienic conditions. This cascade of events likely contributed to the two-fold higher risk of stillbirth and neonatal mortality among non-institutional deliveries in our study. This offers a potential explanation for the findings of a recent study carried out in Zimbabwe which found that women, burdened by multiple interacting vulnerabilities related to poverty, were most likely to deliver ‘on the road’ whilst attempting to reach a healthcare institution [31].

In recent years, substantial progress has been made in scaling up interventions for small and sick neonates. These include affordable devices for continuous positive airway pressure for respiratory distress syndrome [32, 33], training health workers in neonatal resuscitation [34], surfactant therapy for premature infants [35] and steroid [36] and antibiotic [37] therapy for meconium aspiration and severe infection. While these interventions have made huge contributions to improving neonatal survival, all are hospital-based. Our observation that at least 20% of the preterm births in the SHINE study population occurred outside a health institution, demonstrates that in addition to interventions for enhanced neonatal care, there is an urgent need for interventions that prevent preterm labor. There are now three evidence-based interventions for preventing preterm birth which are low cost and safe during pregnancy. In populations with low dietary calcium intake, antenatal calcium supplementation at doses of ≥1 g per day can reduce preterm birth by 24% according to a recent Cochrane Review [38]. Indeed, since 2016, the World Health Organization has recommended 1.5–2.0 g calcium supplementation throughout pregnancy for women with low dietary calcium primarily for its effect on reducing preeclampsia, although this recommendation has not been widely scaled up. In a recent trial among 12,000 pregnant women in 6 LMICs, daily low-dose (81 mg) aspirin reduced preterm birth by 11% [39] without any excess adverse side effects. Replacing iron-folate with multiple micronutrient supplementation may also modestly reduce the risk of preterm birth, [40] especially when initiated early in pregnancy [41]. Other interventions which might be considered in the future include omega-3-poly-unsaturated fatty acids (shown to reduce preterm birth in most [42, 43] but not all [44] trials) and anti-inflammatory drugs (e.g., a trial of cotrimoxazole, which has potent anti-inflammatory effects [45], is underway in Zimbabwe (PACTR202107707978619) and pharmaceutical preparations of specialized proresolving lipid mediators are under development [46, 47]).


This study supports the existing literature in describing the sociodemographic profiles of women who have non-institutional deliveries in rural Zimbabwe. These women are often poorer, less well educated, and more likely to have HIV than those women who give birth at a health institution. As would be expected, the standard of care which women receive outside a health institution is inferior to that provided in health institutions, with poorer access to experienced health professionals and sanitation.

Our findings indicate that preterm birth rates are particularly high amongst non-institutional deliveries, suggesting that premature onset of labor, rather than maternal choice, may be the reason for many home deliveries. Interventions for primary prevention of preterm delivery will be crucial in reducing neonatal mortality in Zimbabwe.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.



Neonatal mortality


Sustainable Development Goals


Skilled Birth Attendants


Prevention of mother-to-child transmission


Sanitation Hygiene Infant Nutrition Efficacy


Infant and young child feeding


Water, sanitation, and hygiene


Standard of care


Village health workers


Ministry of Health and Child Care


Small for gestational age


World Health Organisation


Human Immunodeficiency Virus


Low- and middle-income countries


  1. Hug L, Alexander M, You D, Alkema L. For child UI-aG: national, regional, and global levels and trends in neonatal mortality between 1990 and 2017, with scenario-based projections to 2030: a systematic analysis. Lancet Glob Health. 2019;7(6):e710–20.

    Article  Google Scholar 

  2. Ronsmans C, Graham WJ. Group LMSSs: maternal mortality: who, when, where, and why. Lancet. 2006;368(9542):1189–200.

    Article  Google Scholar 

  3. Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C, Hogan D, et al. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet. 2016;387(10018):587–603.

    Article  Google Scholar 

  4. Filippi V, Ronsmans C, Campbell OM, Graham WJ, Mills A, Borghi J, et al. Maternal health in poor countries: the broader context and a call for action. Lancet. 2006;368(9546):1535–41.

    Article  Google Scholar 

  5. Kinney MV, Kerber KJ, Black RE, Cohen B, Nkrumah F, Coovadia H, et al. On behalf of the science in action: saving the lives of Africa's mothers n, children working g: sub-Saharan Africa's mothers, newborns, and children: where and why do they die? PLoS Med. 2010;7(6):e1000294.

    Article  Google Scholar 

  6. Organization WH. Making pregnancy safer: the critical role of the skilled attendant: a joint statement by WHO: ICM and FIGO: World health organization; 2004.

    Google Scholar 

  7. Organization WH. The world health report: 2005: make every mother and child count: World Health Organization; 2005.

    Google Scholar 

  8. Campbell OMR, Graham WJ. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;368(9543):1284–99.

    Article  Google Scholar 

  9. Moyer CA, Adanu RM, Engmann CM. The relationship between facility-based delivery and maternal and neonatal mortality in sub-Saharan Africa. Int J Gynaecol Obstet. 2013;122(3):263–5.

    Article  Google Scholar 

  10. Goudar SS, Goco N, Somannavar MS, Kavi A, Vernekar SS, Tshefu A, et al. Institutional deliveries and stillbirth and neonatal mortality in the global Network's maternal and newborn health registry. Reprod Health. 2020;17(3):179.

    Article  Google Scholar 

  11. Bolam A, Manandhar D, Shrestha P, Ellis M, Malla K, Costello A. Factors affecting home delivery in the Kathmandu Valley, Nepal. Health Policy Plan. 1998;13(2):152–8.

    Article  CAS  Google Scholar 

  12. Moindi RO, Ngari MM, Nyambati VC, Mbakaya C. Why mothers still deliver at home: understanding factors associated with home deliveries and cultural practices in rural coastal Kenya, a cross-section study. BMC Public Health. 2015;16(1):1–8.

    Article  Google Scholar 

  13. Exavery A, Kanté AM, Njozi M, Tani K, Doctor HV, Hingora A, et al. Access to institutional delivery care and reasons for home delivery in three districts of Tanzania. Int J Equity Health. 2014;13(1):1–11.

    Article  Google Scholar 

  14. Makate M, Makate C. The impact of prenatal care quality on neonatal, infant and child mortality in Zimbabwe: evidence from the demographic and health surveys. Health Policy Plan. 2017;32(3):395–404.

    Google Scholar 

  15. Sibanda EL, Webb K, Fahey CA, Kang Dufour M-S, McCoy SI, Watadzaushe C, et al. Use of data from various sources to evaluate and improve the prevention of mother-to-child transmission of HIV programme in Zimbabwe: a data integration exercise. J Int AIDS Soc. 2020;23 Suppl 3(Suppl 3):e25524–4.

    Google Scholar 

  16. (2019) ZNSAZaU: Zimbabwe multiple Indicator cluster survey 2019, survey findings in. Harare Zimbabwe; 2019.

  17. Humphrey JH, Jones AD, Manges A, Mangwadu G, Maluccio JA, Mbuya MN, et al. The sanitation hygiene infant nutrition efficacy (SHINE) trial: rationale, design, and methods. Clin Infect Dis. 2015;61 Suppl 7(Suppl 7):S685–702.

    Google Scholar 

  18. Humphrey JH, Mbuya MNN, Ntozini R, Moulton LH, Stoltzfus RJ, Tavengwa NV, et al. Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial. Lancet Glob Health. 2019;7(1):e132–47.

    Article  Google Scholar 

  19. Prendergast AJ, Chasekwa B, Evans C, Mutasa K, Mbuya MNN, Stoltzfus RJ, et al. Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on stunting and anaemia among HIV-exposed children in rural Zimbabwe: a cluster-randomised controlled trial. Lancet Child Adolesc Health. 2019;3(2):77–90.

    Article  Google Scholar 

  20. Gladstone MJ, Chandna J, Kandawasvika G, Ntozini R, Majo FD, Tavengwa NV, et al. Independent and combined effects of improved water, sanitation, and hygiene (WASH) and improved complementary feeding on early neurodevelopment among children born to HIV-negative mothers in rural Zimbabwe: substudy of a cluster-randomized trial. PLoS Med. 2019;16(3):e1002766–6.

    Article  Google Scholar 

  21. Papageorghiou AT, Ohuma EO, Altman DG, Todros T, Cheikh Ismail L, Lambert A, et al. International standards for fetal growth based on serial ultrasound measurements: the fetal growth longitudinal study of the INTERGROWTH-21st project. Lancet. 2014;384(9946):869–79.

    Article  Google Scholar 

  22. de Onis M, Habicht JP. Anthropometric reference data for international use: recommendations from a World Health Organization expert committee. Am J Clin Nutr. 1996;64(4):650–8.

    Article  Google Scholar 

  23. StatCorp. Stata statistical software, vol. Release 14. College Station: StataCorp LP; 2014.

    Google Scholar 

  24. World Health O. WHO safe childbirth checklist implementation guide: improving the quality of facility-based delivery for mothers and newborns. Geneva: World Health Organization; 2015.

    Google Scholar 

  25. Dahm LS, James LS. Newborn temperature and calculated heat loss in the delivery room. Pediatrics. 1972;49(4):504–13.

    Article  CAS  Google Scholar 

  26. Nimbalkar SM, Patel VK, Patel DV, Nimbalkar AS, Sethi A, Phatak A. Effect of early skin-to-skin contact following normal delivery on incidence of hypothermia in neonates more than 1800 g: randomized control trial. J Perinatol. 2014;34(5):364–8.

    Article  CAS  Google Scholar 

  27. Chasekwa B, Ntozini R, Church JA, Majo FD, Tavengwa N, Mutasa B, et al. Prevalence, risk factors and short-term consequences of adverse birth outcomes in Zimbabwean pregnant women: a secondary analysis of a cluster-randomized trial. Int J Epidemiol. 2021;51(6):1785–1799.

  28. Muchabaiwa L, Mazambani D, Chigusiwa L, Bindu S, Mudavanhu V. Determinants of maternal healthcare utilization in Zimbabwe. Int J Econ Sci Appl Res. 2012;5(2):145–162.

  29. Ng’anjo Phiri S, Kiserud T, Kvåle G, Byskov J, Evjen-Olsen B, Michelo C, et al. Factors associated with health facility childbirth in districts of Kenya, Tanzania and Zambia: a population based survey. BMC Pregnancy Childbirth. 2014;14(1):219.

    Article  Google Scholar 

  30. Khanal V, Lee AH, da Cruz JLNB, Karkee R. Factors associated with non-utilisation of health service for childbirth in Timor-Leste: evidence from the 2009-2010 demographic and health survey. BMC Int Health Hum Rights. 2014;14(1):14.

    Article  Google Scholar 

  31. Webb KA, Mavhu W, Langhaug L, Chitiyo V, Matyanga P, Charashika P, et al. ‘I was trying to get there, but I couldn’t’: social norms, vulnerability and lived experiences of home delivery in Mashonaland Central Province, Zimbabwe. Health Policy Plan. 2021;36(9):1441–50.

    Article  Google Scholar 

  32. Won A, Suarez-Rebling D, Baker AL, Burke TF, Nelson BD. Bubble CPAP devices for infants and children in resource-limited settings: review of the literature. Paediatr Int Child Health. 2019;39(3):168–76.

    Article  Google Scholar 

  33. Dewez JE, van den Broek N. Continuous positive airway pressure (CPAP) to treat respiratory distress in newborns in low-and middle-income countries. Trop Dr. 2017;47(1):19–22.

    Google Scholar 

  34. Patel A, Khatib MN, Kurhe K, Bhargava S, Bang A. Impact of neonatal resuscitation trainings on neonatal and perinatal mortality: a systematic review and meta-analysis. BMJ Paediatrics Open. 2017;1:e000183.

  35. Van Wyk L, Tooke L, Dippenaar R, Rhoda N, Lloyd L, Holgate S, et al. Optimal ventilation and surfactant therapy in very-low-birth-weight infants in resource-restricted regions. Neonatology. 2020;117(2):217–24.

    Article  Google Scholar 

  36. Singh S, Tripathi S, Kumar M. Outcome of preterm neonates born to women of a developing country at risk of preterm birth exposed to varying doses of antenatal corticosteroid: a prospective observational study. Clin Epidemiol Glob Health. 2020;8(2):623–7.

    Article  Google Scholar 

  37. Seale AC, Berkley JA. Managing severe infection in infancy in resource poor settings. Early Hum Dev. 2012;88(12):957–60.

    Article  Google Scholar 

  38. Hofmeyr GJ, Lawrie TA, Atallah ÁN, Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2018;10(10):Cd001059.

    Google Scholar 

  39. Hoffman MK, Goudar SS, Kodkany BS, Metgud M, Somannavar M, Okitawutshu J, et al. Low-dose aspirin for the prevention of preterm delivery in nulliparous women with a singleton pregnancy (ASPIRIN): a randomised, double-blind, placebo-controlled trial. Lancet. 2020;395(10220):285–93.

    Article  CAS  Google Scholar 

  40. Keats EC, Das JK, Salam RA, Lassi ZS, Imdad A, Black RE, et al. Effective interventions to address maternal and child malnutrition: an update of the evidence. Lancet Child Adolesc Health. 2021;5(5):367–384.

  41. Smith ER, Shankar AH, Wu LS, Aboud S, Adu-Afarwuah S, Ali H, et al. Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries. Lancet Glob Health. 2017;5(11):e1090–100.

    Article  Google Scholar 

  42. Middleton P, Gomersall JC, Gould JF, Shepherd E, Olsen SF, Makrides M. Omega-3 fatty acid addition during pregnancy. Cochrane Database Syst Rev. 2018;11(11):CD003402.

    Google Scholar 

  43. Carlson SE, Gajewski BJ, Valentine CJ, Kerling EH, Weiner CP, Cackovic M, et al. Higher dose docosahexaenoic acid supplementation during pregnancy and early preterm birth: a randomised, double-blind, adaptive-design superiority trial. EClinicalMedicine. 2021;36:100905.

    Article  Google Scholar 

  44. Makrides M, Best K, Yelland L, McPhee A, Zhou S, Quinlivan J, et al. A randomized trial of prenatal n− 3 fatty acid supplementation and preterm delivery. N Engl J Med. 2019;381(11):1035–45.

    Article  CAS  Google Scholar 

  45. Bourke CD, Gough EK, Pimundu G, Shonhai A, Berejena C, Terry L, et al. Cotrimoxazole reduces systemic inflammation in HIV infection by altering the gut microbiome and immune activation. Sci Transl Med. 2019;11(486):eaav0537.

  46. Serhan CN. Treating inflammation and infection in the 21st century: new hints from decoding resolution mediators and mechanisms. FASEB J. 2017;31(4):1273–88.

    Article  CAS  Google Scholar 

  47. Triggs T, Kumar S, Mitchell M. Experimental drugs for the inhibition of preterm labor. Expert Opin Investig Drugs. 2020;29(5):507–23.

    Article  CAS  Google Scholar 

Download references


Not applicable.

Members of the SHINE Trial Team are listed at

The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial Team:

Analysis and Writing Committee:

Jean H. Humphrey3, 4, Andrew D. Jones6, Amee Manges7, Goldberg Mangwadu8, John A. Maluccio9, Mduduzi N. N. Mbuya3, Lawrence H. Moulton4, Robert Ntozini3, Andrew J. Prendergast 1,3,4, Rebecca J. Stoltzfus 10, James M. Tielsch 11, Laura E Smith3.

Technical and Management Team:

Cynthia Chasokela8, Ancikaria Chigumira8, William Heylar3, Preston Hwena3, George Kembo12, Florence D. Majo3, Batsirai Mutasa3, Kuda Mutasa3, Philippa Rambanepasi3, Virginia Sauramba3, Naume V. Tavengwa3, Franne Van Der Keilen3, Chipo Zambezi3.

Field Management Team.

Dzivaidzo Chidhanguro3, Dorcas Chigodora3, Joseph F. Chipanga3, Grace Gerema3, Tawanda Magara3, Mandava Mandava3, Tafadzwa Mavhudzi3, Clever Mazhanga3, Grace Muzaradope3, Marian T. Mwapaura3, Simon Phiri3, Alice Tengende3.

Other team members:

Cynthia Banda3, Bernard Chasekwa3, Leah Chidamba3, Theodore Chidawanyika3, Elisha Chikwindi3, Lovemore K. Chingaona3, Courage K. Chiorera3, Adlight Dandadzi3, Margaret Govha3, Hlanai Gumbo3, Karen T. Gwanzura3, Sarudzai Kasaru3, Rachel Makasi3, Alois M. Matsika3, Diana Maunze3, Exevia Mazarura3, Eddington Mpofu3, Johnson Mushonga3, Tafadzwa E. Mushore3, Tracey Muzira3, Netsai Nembaware3, Sibongile Nkiwane3, Penias Nyamwino3, Sandra D. Rukobo3, Thompson Runodamoto3, Shepherd Seremwe3, Pururudzai Simango3, Joice Tome3, Blessing Tsenesa3, Umali Amadu3, Beauty Bangira3, Daniel Chiveza3, Priscilla Hove3, Horaiti A Jombe3, Didymus Kujenga3, Lenin Madhuyu3, Prince Mandina-Makoni3, Naume Maramba3, Betty Maregere3, Ellen Marumani3, Elisha Masakadze3, Phathisiwe Mazula3, Caroline Munyanyi3, Grace Musanhu3, Raymond C. Mushanawani3, Sibongile Mutsando3, Felicia Nazare3, Moses Nyarambi3, Wellington Nzuda3, Trylife Sigauke3, Monica Solomon3, Tendai Tavengwa3, Farisai Biri3, Misheck Chafanza3, Cloud Chaitezvi3, Tsundukani Chauke3, Collen Chidzomba3, Tawanda Dadirai3, Clemence Fundira3, Athanasios C. Gambiza3, Tatenda Godzongere3, Maria Kuona3, Tariro Mafuratidze3, Idah Mapurisa3, Tsitsi Mashedze3, Nokuthula Moyo3, Charles Musariri3, Matambudzo Mushambadope3, Tawanda R. Mutsonziwa3, Augustine Muzondo3, Rudo Mwareka3, Juleika Nyamupfukudza3, Baven Saidi3, Tambudzai Sakuhwehwe3, Gerald Sikalima3, Jenneth Tembe3, Tapiwanashe E. Chekera3, Owen Chihombe3, Muchaneta Chikombingo3, Tichaona Chirinda3, Admire Chivizhe3, Ratidzai Hove3, Rudo Kufa3, Tatenda F. Machikopa3, Wilbert Mandaza3, Liberty Mandongwe3, Farirai Manhiyo3, Emmanuel Manyaga3, Peter Mapuranga3, Farai S. Matimba3, Patience Matonhodze3, Sarah Mhuri3, Joice Mike3, Bekezela Ncube3, Walter T. S. Nderecha3, Munyaradzi Noah3, Charles Nyamadzawo3, Jonathan Penda3, Asinje Saidi3, Sarudzai Shonhayi3, Clemence Simon3, Monica Tichagwa3, Rachael Chamakono3, Annie Chauke3, Andrew F. Gatsi3, Blessing Hwena3, Hillary Jawi3, Benjamin Kaisa3, Sithembile Kamutanho3, Tapiwa Kaswa3, Paradhi Kayeruza3, Juliet Lunga3, Nomatter Magogo3, Daniel Manyeruke3, Patricia Mazani3, Fungai Mhuriyengwe3, Farisai Mlambo3, Stephen Moyo3, Tawanda Mpofu3, Mishelle Mugava3, Yvonne Mukungwa3, Fungai Muroyiwa3, Eddington Mushonga3, Selestino Nyekete3, Tendai Rinashe3, Kundai Sibanda3, Milton Chemhuru8, Jeffrey Chikunya8, Vimbai F. Chikwavaire8, Charity Chikwiriro8, Anderson Chimusoro8, Jotam Chinyama8, Gerald Gwinji8, Nokuthula Hoko-Sibanda8, Rutendo Kandawasvika8, Tendai Madzimure8, Brian Maponga8, Antonella Mapuranga8, Joana Marembo8, Luckmore Matsunge8, Simbarashe Maunga8, Mary Muchekeza8, Monica Muti8, Marvin Nyamana8, Efa Azhuda8, Urayai Bhoroma8, Ailleen Biriyadi8, Elizabeth Chafota8, Angelline Chakwizira8, Agness Chamhamiwa8, Tavengwa Champion8, Stella Chazuza8, Beauty Chikwira8, Chengeto Chingozho8, Abigail Chitabwa8, Annamary Dhurumba8, Albert Furidzirai8, Andrew Gandanga8, Chipo Gukuta8, Beauty Macheche8, Bongani Marihwi8, Barbara Masike8, Eunice Mutangandura8, Beatrice Mutodza8, Angeline Mutsindikwa8, Alice Mwale8, Rebecca Ndhlovu8, Norah Nduna8, Cathrine Nyamandi8, Elias Ruvata8, Babra Sithole8, Rofina Urayai8, Bigboy Vengesa8, Micheal Zorounye8, Memory Bamule8, Michael Bande8, Kumbirai Chahuruva8, Lilian Chidumba8, Zvisinei Chigove8, Kefas Chiguri8, Susan Chikuni8, Ruvarashe Chikwanda8, Tarisai Chimbi8, Micheal Chingozho8, Olinia Chinhamo8, Regina Chinokuramba8, Chiratidzo Chinyoka8, Xaviour Chipenzi8, Raviro Chipute8, Godfrey Chiribhani8, Mary Chitsinga8, Charles Chiwanga8, Anamaria Chiza8, Faith Chombe8, Memory Denhere8, Ephania Dhamba8, Miriam Dhamba8, Joyas Dube8, Florence Dzimbanhete8, Godfrey Dzingai8, Sikhutele Fusira8, Major Gonese8, Johnson Gota8, Kresencia Gumure8, Phinias Gwaidza8, Margret Gwangwava8, Winnet Gwara8, Melania Gwauya8, Maidei Gwiba8, Joyce Hamauswa8, Sarah Hlasera8, Eustina Hlukani8, Joseph Hotera8, Lovemore Jakwa8, Gilbert Jangara8, Micheal Janyure8, Christopher Jari8, Duvai Juru8, Tabeth Kapuma8, Paschalina Konzai8, Moly Mabhodha8, Susan Maburutse8, Chipo Macheka8, Tawanda Machigaya8, Florence Machingauta8, Eucaria Machokoto8, Evelyn Madhumba8, Learnard Madziise8, Clipps Madziva8, Mavis Madzivire8, Mistake Mafukise8, Marceline Maganga8, Senzeni Maganga8, Emmanuel Mageja8, Miriam Mahanya8, Evelyn Mahaso8, Sanelisiwe Mahleka8, Pauline Makanhiwa8, Mavis Makarudze8, Constant Makeche8, Nickson Makopa8, Ranganai Makumbe8, Mascline Mandire8, Eunice Mandiyanike8, Eunice Mangena8, Farai Mangiro8, Alice Mangwadu8, Tambudzai Mangwengwe8, Juliet Manhidza8, Farai Manhovo8, Irene Manono8, Shylet Mapako8, Evangelista Mapfumo8, Timothy Mapfumo8, Jane Mapuka8, Douglas Masama8, Getrude Masenge8, Margreth Mashasha8, Veronica Mashivire8, Moses Matunhu8, Pazvichaenda Mavhoro8, Godfrey Mawuka8, Ireen Mazango8, Netsai Mazhata8, David Mazuva8, Mary Mazuva8, Filomina Mbinda8, John Mborera8, Upenyu Mfiri8, Florence Mhandu8, Chrispen Mhike8, Tambudzai Mhike8, Artwell Mhuka8, Judith Midzi8, Siqondeni Moyo8, Michael Mpundu8, Nicholas Msekiwa Msindo8, Dominic Msindo8, Choice Mtisi8, Gladys Muchemwa8, Nyadziso Mujere8, Ellison Mukaro8, Kilvera Muketiwa8, Silvia Mungoi8, Esline Munzava8, Rosewita Muoki8, Harugumi Mupura8, Evelyn Murerwa8, Clarieta Murisi8, Letwin Muroyiwa8, Musara Muruvi8, Nelson Musemwa8, Christina Mushure8, Judith Mutero8, Philipa Mutero8, Patrick Mutumbu8, Cleopatra Mutya8, Lucia Muzanango8, Martin Muzembi8, Dorcus Muzungunye8, Valeliah Mwazha8, Thembeni Ncube8, Takunda Ndava8, Nomvuyo Ndlovu8, Pauline Nehowa8, Dorothy Ngara8, Leonard Nguruve8, Petronella Nhigo8, Samukeliso Nkiwane8, Luckson Nyanyai8, Judith Nzombe8, Evelyn Office8, Beatrice Paul8, Shambadzirai Pavari8, Sylvia Ranganai8, Stella Ratisai8, Martha Rugara8, Peter Rusere8, Joyce Sakala8, Prosper Sango8, Sibancengani Shava8, Margaret Shekede8, Cornellious Shizha8, Tedla Sibanda8, Neria Tapambwa8, John Tembo8, Netsai Tinago8, Violet Tinago8, Theresa Toindepi8, John Tovigepi8, Modesta Tuhwe8, Kundai Tumbo8, Tinashe Zaranyika8, Tongai Zaru8, Kamurayi Zimidzi8, Matilda Zindo8, Maria Zindonda8, Nyaradzai Zinhumwe8, Loveness Zishiri8, Emerly Ziyambi8, James Zvinowanda8, Ekenia Bepete8, Christine Chiwira8, Naume Chuma8, Abiegirl Fari8, Samson Gavi8, Violet Gunha8, Fadzai Hakunandava8, Constance Huku8, Given Hungwe8, Grace Maduke8, Elliot Manyewe8, Tecla Mapfumo8, Innocent Marufu8, Chenesai Mashiri8, Shellie Mazenge8, Euphrasia Mbinda8, Abigail Mhuri8, Charity Muguti8, Lucy Munemo8, Loveness Musindo8, Laina Ngada8, Dambudzo Nyembe8, Rachel Taruvinga8, Emma Tobaiwa8, Selina Banda8, Jesca Chaipa8, Patricia Chakaza8, Macdonald Chandigere8, Annie Changunduma8, Chenesai Chibi8, Otilia Chidyagwai8, Elika Chidza8, Nora Chigatse8, Lennard Chikoto8, Vongai Chingware8, Jaison Chinhamo8, Marko Chinhoro8, Answer Chiripamberi8, Esther Chitavati8, Rita Chitiga8, Nancy Chivanga8, Tracy Chivese8, Flora Chizema8, Sinikiwe Dera8, Annacolleta Dhliwayo8, Pauline Dhononga8, Ennia Dimingo8, Memory Dziyani8, Tecla Fambi8, Lylian Gambagamba8, Sikangela Gandiyari8, Charity Gomo8, Sarah Gore8, Jullin Gundani8, Rosemary Gundani8, Lazarus Gwarima8, Cathrine Gwaringa8, Samuel Gwenya8, Rebecca Hamilton8, Agnes Hlabano8, Ennie Hofisi8, Florence Hofisi8, Stanley Hungwe8, Sharai Hwacha8, Aquiiline Hwara8, Ruth Jogwe8, Atanus Kanikani8, Lydia Kuchicha8, Mitshel Kutsira8, Kumbulani Kuziyamisa8, Mercy Kuziyamisa8, Benjamin Kwangware8, Portia Lozani8, Joseph Mabuto8, Vimbai Mabuto8, Loveness Mabvurwa8, Rebecca Machacha8, Cresenzia Machaya8, Roswitha Madembo8, Susan Madya8, Sheneterai Madzingira8, Lloyd Mafa8, Fungai Mafuta8, Jane Mafuta8, Alfred Mahara8, Sarudzai Mahonye8, Admire Maisva8, Admire Makara8, Margreth Makover8, Ennie Mambongo8, Murenga Mambure8, Edith Mandizvidza8, Gladys Mangena8, Elliot Manjengwa8, Julius Manomano8, Maria Mapfumo8, Alice Mapfurire8, Letwin Maphosa8, Jester Mapundo8, Dorcas Mare8, Farai Marecha8, Selina Marecha8, Christine Mashiri8, Medina Masiya8, Thembinkosi Masuku8, Priviledge Masvimbo8, Saliwe Matambo8, Getrude Matarise8, Loveness Matinanga8, John Matizanadzo8, Margret Maunganidze8, Belinda Mawere8, Chipiwa Mawire8, Yulliana Mazvanya8, Maudy Mbasera8, Magret Mbono8, Cynthia Mhakayakora8, Nompumelelo Mhlanga8, Bester Mhosva8, Nomuhle Moyo8, Over Moyo8, Robert Moyo8, Charity Mpakami8, Rudo Mpedzisi8, Elizabeth Mpofu8, Estery Mpofu8, Mavis Mtetwa8, Juliet Muchakachi8, Tsitsi Mudadada8, Kudakwashe Mudzingwa8, Mejury Mugwira8, Tarsisio Mukarati8, Anna Munana8, Juliet Munazo8, Otilia Munyeki8, Patience Mupfeka8, Gashirai Murangandi8, Maria Muranganwa8, Josphine Murenjekwa8, Nothando Muringo8, Tichafara Mushaninga8, Florence Mutaja8, Dorah Mutanha8, Peregia Mutemeri8, Beauty Mutero8, Edina Muteya8, Sophia Muvembi8, Tandiwe Muzenda8, Agnes Mwenjota8, Sithembisiwe Ncube8, Tendai Ndabambi8, Nomsa Ndava8, Elija Ndlovu8, Eveln Nene8, Enniah Ngazimbi8, Atalia Ngwalati8, Tafirenyika Nyama8, Agnes Nzembe8, Eunica Pabwaungana8, Sekai Phiri8, Ruwiza Pukuta8, Melody Rambanapasi8, Tambudzai Rera8, Violet Samanga8, Sinanzeni Shirichena8, Chipiwa Shoko8, More Shonhe8, Cathrine Shuro8, Juliah Sibanda8, Edna Sibangani8, Nikisi Sibangani8, Norman Sibindi8, Mercy Sitotombe8, Pearson Siwawa8, Magret Tagwirei8, Pretty Taruvinga8, Antony Tavagwisa8, Esther Tete8, Yeukai Tete8, Elliot Thandiwe8, Amonilla Tibugari8, Stella Timothy8, Rumbidzai Tongogara8, Lancy Tshuma8, Mirirayi Tsikira8, Constance Tumba8, Rumbidzayi Watinaye8, Ethel Zhiradzango8, Esther Zimunya8, Leanmary Zinengwa8, Magret Ziupfu8, Job Ziyambe8.

6 University of Michigan, USA.

7 University of British Columbia, BC, Canada.

8 Ministry of Health and Child Care, Zimbabwe.

9 Middlebury College, USA.

10 Cornell University, USA.

11 George Washington University, USA.

12 Food and Nutrition Council, Harare, Zimbabwe.


The SHINE trial is funded by the Bill & Melinda Gates Foundation (OPP1021542 to Johns Hopkins Bloomberg School of Public Health and OPP1143707 to Zvitambo Institute for Maternal and Child Health Research), the UK Department for International Development, the Wellcome Trust (093768/Z/10/Z and 108065/Z/15/Z), the Swiss Agency for Development and Cooperation (8106727), and UNICEF (PCA-2017-0002).

Author information

Authors and Affiliations




CN designed the study, and contributed to analysis and writing. CM wrote the first draft of the manuscript. RM undertook data analysis. RN oversaw all data analysis. FM oversaw all data collection. JC designed the study and contributed to analysis and interpretation. NVT oversaw all fieldwork. AJP designed the study, and contributed to interpretation and writing. JHH designed the study, and contributed to interpretation and writing. The author(s) read approved the final manuscript.

Authors’ information

Christie Noble is a paediatric trainee, currently on a clinical rotation, with an interest in paediatric infectious disease research and global health.

Ciaran Mooney MB BCh BAO MSc is an academic foundation doctor working in Northern Ireland. He has an interest in infectious diseases and global health.

Rachel Makasi BS is a Data Management Specialist at the Zvitambo Institute for Maternal and Child Health.

Robert Ntozini MPH is a Biostatistician and Computer and Data Scientist. He is Associate Director for IT, Data Management, and Statistics at Zvitambo Institute for Maternal and Child Health.

Florence D. Majo RN is a Trial Manager at Zvitambo Institute for Maternal and Child Health.

James Church PhD MRCPCH is an Honorary Research Fellow and Specialty Trainee in Paediatric Gastroenterology. Dr. Church has a primary research interest in gut structure and function and how these impact on health and immunity of children living in low-income countries.

Naume Tavengwa MSW is Associate Director of Field Operations at the Zvitambo Institute for Maternal and Child Health.

Andrew Prendergast MA DPhil MRCPCH DTM&H is a paediatrician and laboratory immunologist with interests in the interplay between infection, immunity, and malnutrition, particularly in settings of high HIV prevalence. Professor Prendergast has experience in clinical trials and mechanistic laboratory work.

Jean Humphrey ScD is a nutritionist, a professor of Human Nutrition, and founder and former Director of the Zvitambo Institute for Maternal and Child Health. Professor Humphrey’s research focusses on finding feasible solutions to the underlying causes of undernutrition, morbidity and mortality of infants and young children in low-income countries.

Corresponding author

Correspondence to Ciaran Mooney.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the Medical Research Council of Zimbabwe and Johns Hopkins School of Public Health. All methods were performed in accordance with guidelines set out by Medical Research Council of Zimbabwe and Johns Hopkins.

Consent for publication

Consent was obtained from study participants for anonymised data to be published.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: 

Supplementary Figure. Participant flow for analyses examining antenatal and delivery practices among non-institutional and to institutional deliveries.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Noble, C., Mooney, C., Makasi, R. et al. Antenatal and delivery practices and neonatal mortality amongst women with institutional and non-institutional deliveries in rural Zimbabwe: observational data from a cluster randomized trial. BMC Pregnancy Childbirth 22, 981 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: