title: Individual and community determinants of neonatal mortality in Ghana: a multilevel analysis.
abstract: BACKGROUND
  Neonatal mortality is a global challenge; identification of individual and community determinants associated with it are important for targeted interventions. However in most low and middle income countries (LMICs) including Ghana this problem has not been adequately investigated as the impact of contextual factors remains undetermined despite their significant influence on under-five mortality and morbidity.
  
  
  METHODS
  Based on a modified conceptual framework for child survival, hierarchical modelling was deployed to examine about 6,900 women, aged 15 - 49 years (level 1), nested within 412 communities (level 2) in Ghana by analysing combined data of the 2003 and 2008 Ghana Demographic and Health Survey. The aim was to identify individual (maternal, paternal, neonatal, antenatal, delivery and postnatal) and community (socioeconomic disadvantage communities) determinants associated with neonatal mortality.
  
  
  RESULTS
  The results showed both individual and community characteristics to be associated with neonatal mortality. Infants of multiple-gestation [OR 5.30; P-value < 0.001; 95% CI 2.81 - 10.00], neonates with inadequate birth spacing [OR 3.47; P-value < 0.01; 95% CI 1.60 - 7.57] and low birth weight [OR 2.01; P-value < 0.01; 95% CI 1.23 - 3.30] had a lower chance of surviving the neonatal period. Similarly, infants of grand multiparous mothers [OR 2.59; P-value < 0.05; 95% CI 1.03 - 6.49] and non-breastfed infants [OR 142.31; P-value < 0.001; 95% CI 80.19 - 252.54] were more likely to die during neonatal life, whereas adequate utilization of antenatal, delivery and postnatal health services [OR 0.25; P-value < 0.001; 95% CI 0.13 - 0.46] reduced the likelihood of neonatal mortality. Dwelling in a neighbourhood with high socioeconomic deprivation was associated with increased neonatal mortality [OR 3.38; P-value < 0.01; 95% CI 1.42 - 8.04].
  
  
  CONCLUSIONS
  Both individual and community characteristics show a marked impact on neonatal survival. Implementation of community-based interventions addressing basic education, poverty alleviation, women empowerment and infrastructural development and an increased focus on the continuum-of-care approach in healthcare service will improve neonatal survival.
authors.affiliation: Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, P,O, Box 85500, Utrecht, GA 3508, The Netherlands. g.a.kayode@umcutrecht.nl.
authors.forename: Gbenga A
authors.initials: GA
authors.lastname: Kayode
authors.forename: Evelyn
authors.initials: E
authors.lastname: Ansah
authors.forename: Irene Akua
authors.initials: IA
authors.lastname: Agyepong
authors.forename: Mary
authors.initials: M
authors.lastname: Amoakoh-Coleman
authors.forename: Diederick E
authors.initials: DE
authors.lastname: Grobbee
authors.forename: Kerstin
authors.initials: K
authors.lastname: Klipstein-Grobusch
mesh_terms: D000293:Adolescent; D000328:Adult; D001721:Birth Intervals / Q000706:statistics & numerical data*; D001942:Breast Feeding / Q000706:statistics & numerical data; D004522:Educational Status; D005220:Fathers / Q000706:statistics & numerical data; D005260:Female; D005869:Ghana / Q000453:epidemiology; D006801:Humans; D007182:Income; D007223:Infant; D007226:Infant Mortality / Q000208:ethnology; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D008297:Male; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D015233:Models, Statistical; D009035:Mothers / Q000706:statistics & numerical data; D009790:Occupations; D010298:Parity; D011204:Poverty Areas; D011247:Pregnancy; D011272:Pregnancy, Multiple / Q000706:statistics & numerical data*; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D012307:Risk Factors; D055815:Young Adult