Improving neonatal survival in East Africa Analysis of maternal service utilization, effectiveness of care and risk factors for neonatal mortality in Kenya, Uganda, and Tanzania.

Despite profound progress made in reducing neonatal mortality, it remains one of the major global health challenges. In 2019, the World Health Organization estimated that 2.4 million neonatal deaths occurred, accounting for over 45 percent of under-5 deaths worldwide. Most of these neonatal mortalities occur in low-and middle-income (LMIC) with East African countries of Kenya, Uganda and Tanzania among countries reporting persistent slow decline in neonatal death rates. The major causes of neonatal deaths include prematurity, infections and birth complications, most of which are preventable. Very limited population-based research has been conducted to examine determinants of continued care utilization from pregnancy to postnatal period, effectiveness of care as well as the impact of leading risk factors for neonatal deaths in Kenya, Uganda and Tanzania. Thus, the aim of this thesis was to examine the determinants of maternal care utilization, effectiveness of care and risk factors for neonatal mortality in Kenya, Tanzania, and Uganda. The findings, of which are contributing to further research around the world and could have significant implications for policy development, prioritization and resource allocations in public health and care systems in the three most populated East African Community countries. We used nationally representative cross-sectional data from the demographic and health surveys in the respective countries. In Study I we found that lack of antenatal (ANC) attendance, unskilled ANC provision and lack of check-ups for pregnancy complications were among the leading indirect risk factors for preventable neonatal mortality in Kenya. Study II concluded that low birthweight contributes a substantial proportion of neonatal deaths in Uganda. Study III reported that the disproportionate access to caesarean delivery has widened along socioeconomic lines in Tanzania and Kenya. Higher risk of caesarean-related deaths exists. Out of the findings of Study IV, we suggested the need for a comprehensive review to develop a toolkit using care utilization information to enable classification of maternal care-seeking behaviour and adopt new strategies to close the care-seeking gaps. Study V found much higher neonatal deaths among married adolescents with unintended pregnancies adolescent-born neonates from unintended pregnancies and proposed strengthening of existing strategies and use of new approaches to reduce adolescent pregnancies and provide focused obstetric care for adolescents. The thesis suggests an array of evidence-based interventions to improve neonatal survival ranging from education and contraceptive use to improved ANC and postnatal care attendance.