Neonatal and perinatal mortality in the urban continuum: A geospatial analysis of the household survey, satellite imagery and travel time data in Tanzania

Abstract

AbstractIntroductionNeonatal mortality might be higher in urban areas. This paper aims to minimize challenges related to misclassification of neonatal deaths and stillbirths, and oversimplification of the variation in urban environments to accurately estimate the direction and strength of the association between urban residence and neonatal/perinatal mortality in Tanzania.MethodsThe Tanzania Demographic and Health Survey (DHS) 2015-16 was used to assess birth outcomes for 8,915 pregnancies among 6,156 women of reproductive age, by urban or rural categorization in the DHS and based on satellite imagery. The coordinates of 527 DHS clusters were spatially overlaid with the 2015 Global Human Settlement Layer, showing the degree of urbanisation based on built environment and population density. A three-category urbanicity measure (core urban, semi-urban, and rural) was defined and compared to the binary DHS measure. Travel time to the nearest hospital was modelled using least-cost path algorithm for each cluster. Bivariate and multi-level multivariable logistic regression models were constructed to explore associations between urbanicity and neonatal/perinatal deaths.ResultsBoth perinatal and neonatal mortality rates were highest in core urban and lowest in rural clusters. Bivariate models showed higher odds of neonatal death (OR=1.85; 95% CI: 1.12, 3.08) and perinatal death (OR=1.60; 95% CI 1.12, 2.30) in core urban compared to rural clusters. In multivariable models, these associations had the same direction and size, but were no longer statistically significant. Travel time to nearest hospital was not associated with neonatal or perinatal mortality.ConclusionAddressing the higher rates of neonatal and perinatal mortality in densely populated urban areas is critical for Tanzania to meet national and global reduction targets. Urban populations are diverse, and certain neighbourhoods or sub-groups may be disproportionately affected by poor birth outcomes. Research must sample within and across urban areas to differentiate, understand and minimize risks specific to urban settings.Key questionsWhat is already known?-Urban advantage in health outcomes has been questioned, both for adult and child mortality-An analysis of neonatal mortality using Demographic and Health Survey data in Tanzania in 2015-16 showed double risk in urban compared to rural areas-This phenomenon might be occurring in other sub-Saharan African countriesWhat are the new findings?-Categorisation of locations as urban or rural on the 2015-16 Demographic and Health Survey in Tanzania is both simplistic and inaccurate-Risks of neonatal and perinatal mortality are highest in core, densely populated urban areas in mainland Tanzania, and lowest in rural areas-Travel time to nearest public hospital was not associated with neonatal or perinatal mortality in mainland TanzaniaWhat do the new findings imply?-Extent of urbanicity as an exposure follows a spectrum and needs to be measured and understood as such-Explanatory models specific to neonatal and perinatal mortality in core urban areas are urgently needed to guide actions toward reducing existing high rate-Known risk factors such as anaemia and young maternal age continue to play a role in neonatal and perinatal mortality and must be urgently addressed.