The introduction of child survival interventions, immunization and oral rehydration among others, has resulted in a sustained decline of infant and child mortality in much of the developing world. One consequence of this decline is that an increasing proportion of infant deaths occurs during the neonatal period. However, there is limited epidemiological information on levels and clinical causes of neonatal and postneonatal deaths from developing countries, although such information is readily available for developed countries.
Infant mortality is the sum of neonatal mortality and postneonatal mortality. However, the clinical causes and determinants, and consequently the preventive public health strategies, for these two phases of infant life differ considerably. Neonatal deaths are generally associated with elements linked to maternal care during pregnancy and delivery, while socioenvironmental factors become more important determinants of infant survival during the postneonatal period. It is estimated that neonatal deaths can account for nearly 50-60% of all infant deaths in developing countries (1). Approximately 30-40% of all neonatal deaths are explained by neonatal infections, amounting to approximately 1.5-2 million neonatal deaths per year (2). WHO has estimated that approximately 400 000 cases of neonatal tetanus occur annually, the vast majority in a limited number of developing countries, resulting in an annual toll of 340 000 neonatal tetanus deaths (3).
Risk factors for neonatal tetanus in developing countries largely relate to lack of immunization of mothers with tetanus toxoid, unhygienic delivery, and unhygienic cord care during the first week of life. Unhygienic cord care may include practices such as the application of ghee to the umbilical cord and bundling of the neonate for prolonged periods in a sheepskin after applying dried cow dung to the lower abdomen (4, 5). Maternal tetanus toxoid coverage (two or more doses) in Pakistan has been reported as 23.3% (6); in the more conservative rural areas, where nearly all deliveries occur at home, it will be much lower.
This study was conducted to determine the levels and clinical causes of infant, neonatal and postneonatal mortality, highlighting the role of neonatal tetanus and concomitant implications for preventive strategies.
Materials and methods
Population-based surveys were conducted in selected sites in the provinces of Balochistan (Pishin, Loralai, Lasbela and Khuzdar; for security reasons, two subdistricts of the Pishin district were excluded from the sampling frame), and the North-West Frontier Province (NWFP) (Dera Ismail Khan, Peshawar and Hazara), including the Federally Administered Tribal Areas (FATA; for security reasons, village clusters were selected in the FATA division of NWFP), to collect information on the level and clinical causes of maternal and infant mortality and their associated risk factors. We conducted the field work during 1990-91 in Balochistan, 1991-93 in NWFP and 1994 in FATA. These regions were selected as they reflect various levels of socioeconomic development, accessibility and availability of health care personnel. However, they are all largely rural and have a poorly developed health services infrastructure, in particular in terms of obstetric and neonatal care. More than 90% of births occur at home, with the assistance of traditional birth attendants or family members (7). Women have limited access to adequate health and family planning services, and fertility, and maternal and neonatal mortality are high.
The sampling technique comprised a simple random cluster sample in each district. Samples of 10-15 village clusters, each with an average of 200
households, were randomly selected. Interviews were conducted in all households in each cluster giving a total of 54 834 households: Balochistan, 20486; NWFP, 26175; and FATA, 8173. The Human Subjects Protection Committee, Aga Khan University, reviewed and approved the study design and verbal informed consent guidelines. …