title: Facility Delivery, Postnatal Care and Neonatal Deaths in India: Nationally-Representative Case-Control Studies.
abstract: OBJECTIVE
  Clinical studies demonstrate the efficacy of interventions to reduce neonatal deaths, but there are fewer studies of their real-life effectiveness. In India, women often seek facility delivery after complications arise, rather than to avoid complications. Our objective was to quantify the association of facility delivery and postnatal checkups with neonatal mortality while examining the "reverse causality" in which the mothers deliver at a health facility due to adverse perinatal events.
  
  
  METHODS
  We conducted nationally representative case-control studies of about 300,000 live births and 4,000 neonatal deaths to examine the effect of, place of delivery and postnatal checkup on neonatal mortality. We compared neonatal deaths to all live births and to a subset of live births reporting excessive bleeding or obstructed labour that were more comparable to cases in seeking care.
  
  
  RESULTS
  In the larger study of 2004-8 births, facility delivery without postnatal checkup was associated with an increased odds of neonatal death (Odds ratio = 2.5; 99% CI 2.2-2.9), especially for early versus late neonatal deaths. However, use of more comparable controls showed marked attenuation (Odds ratio = 0.5; 0.4-0.5). Facility delivery with postnatal checkup was associated with reduced odds of neonatal death. Excess risks were attenuated in the earlier study of 2001-4 births.
  
  
  CONCLUSIONS
  The combined effect of facility deliveries with postnatal checks ups is substantially higher than just facility delivery alone. Evaluation of the real-life effectiveness of interventions to reduce child and maternal deaths need to consider reverse causality. If these associations are causal, facility delivery with postnatal check up could avoid about 1/3 of all neonatal deaths in India (~100,000/year).
authors.affiliation: Centre for Global Health Research, St Michael's Hospital, and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
authors.forename: Shaza A
authors.initials: SA
authors.lastname: Fadel
authors.affiliation: Centre for Global Health Research, St Michael's Hospital, and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Department of Public Health and Mortality Studies, International Institute for Population Sciences, Mumbai, India.
authors.forename: Usha
authors.initials: U
authors.lastname: Ram
authors.affiliation: Division of Infectious Diseases and Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada.
authors.forename: Shaun K
authors.initials: SK
authors.lastname: Morris
authors.affiliation: Centre for Global Health Research, St Michael's Hospital, and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
authors.forename: Rehana
authors.initials: R
authors.lastname: Begum
authors.affiliation: Department of Pediatrics, St. John's Medical College Hospital, Bangalore, India.
authors.forename: Anita
authors.initials: A
authors.lastname: Shet
authors.affiliation: National Health Mission, Government of Maharashtra, Mumbai, India.
authors.forename: Raju
authors.initials: R
authors.lastname: Jotkar
authors.affiliation: Centre for Global Health Research, St Michael's Hospital, and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
authors.forename: Prabhat
authors.initials: P
authors.lastname: Jha
mesh_terms: D000293:Adolescent; D000328:Adult; D016022:Case-Control Studies; D002648:Child; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data*; D006801:Humans; D007194:India; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D066087:Perinatal Death; D011247:Pregnancy; D011795:Surveys and Questionnaires; D055815:Young Adult