Antenatal and delivery practices and neonatal mortality amongst women with institutional and non-institutional deliveries in rural Zimbabwe: observational data from a cluster randomized trial
Authors: Noble Christie , Mooney Ciaran , Makasi Rachel , Ntozini Robert , Majo Florence D. , Church James A. , Tavengwa Naume V. , Prendergast Andrew J. , Humphrey Jean H. ,   for the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial Team, Jones Andrew D. , Manges Amee , Mangwadu Goldberg , Maluccio John A. , Mbuya Mduduzi N. N. , Moulton Lawrence H. , Stoltzfus Rebecca J. , Tielsch James M. , Smith Laura E. , Chasokela Cynthia , Chigumira Ancikaria , Heylar William , Hwena Preston , Kembo George , Mutasa Batsirai , Mutasa Kuda , Rambanepasi Philippa , Sauramba Virginia , Van Der Keilen Franne , Zambezi Chipo , Chidhanguro Dzivaidzo , Chigodora Dorcas , Chipanga Joseph F. , Gerema Grace , Magara Tawanda , Mandava Mandava , Mavhudzi Tafadzwa , Mazhanga Clever , Muzaradope Grace , Mwapaura Marian T. , Phiri Simon , Tengende Alice , Banda Cynthia , Chasekwa Bernard , Chidamba Leah , Chidawanyika Theodore , Chikwindi Elisha , Chingaona Lovemore K. , Chiorera Courage K. , Dandadzi Adlight , Govha Margaret , Gumbo Hlanai , Gwanzura Karen T. , Kasaru Sarudzai , Matsika Alois M. , Maunze Diana , Mazarura Exevia , Mpofu Eddington , Mushonga Johnson , Mushore Tafadzwa E. , Muzira Tracey , Nembaware Netsai , Nkiwane Sibongile , Nyamwino Penias , Rukobo Sandra D. , Runodamoto Thompson , Seremwe Shepherd , Simango Pururudzai , Tome Joice , Tsenesa Blessing , Amadu Umali , Bangira Beauty , Chiveza Daniel , Hove Priscilla , Jombe Horaiti A. , Kujenga Didymus , Madhuyu Lenin , Mandina-Makoni Prince , Maramba Naume , Maregere Betty , Marumani Ellen , Masakadze Elisha , Mazula Phathisiwe , Munyanyi Caroline , Musanhu Grace , Mushanawani Raymond C. , Mutsando Sibongile , Nazare Felicia , Nyarambi Moses , Nzuda Wellington , Sigauke Trylife , Solomon Monica , Tavengwa Tendai , Biri Farisai , Chafanza Misheck , Chaitezvi Cloud , Chauke Tsundukani , Chidzomba Collen , Dadirai Tawanda , Fundira Clemence , Gambiza Athanasios C. , Godzongere Tatenda , Kuona Maria , Mafuratidze Tariro , Mapurisa Idah , Mashedze Tsitsi , Moyo Nokuthula , Musariri Charles , Mushambadope Matambudzo , Mutsonziwa Tawanda R. , Muzondo Augustine , Mwareka Rudo , Nyamupfukudza Juleika , Saidi Baven , Sakuhwehwe Tambudzai , Sikalima Gerald , Tembe Jenneth , Chekera Tapiwanashe E. , Chihombe Owen , Chikombingo Muchaneta , Chirinda Tichaona , Chivizhe Admire , Hove Ratidzai , Kufa Rudo , Machikopa Tatenda F. , Mandaza Wilbert , Mandongwe Liberty , Manhiyo Farirai , Manyaga Emmanuel , Mapuranga Peter , Matimba Farai S. , Matonhodze Patience , Mhuri Sarah , Mike Joice , Ncube Bekezela , Nderecha Walter T. S. , Noah Munyaradzi , Nyamadzawo Charles , Penda Jonathan , Saidi Asinje , Shonhayi Sarudzai , Simon Clemence , Tichagwa Monica , Chamakono Rachael , Chauke Annie , Gatsi Andrew F. , Hwena Blessing , Jawi Hillary , Kaisa Benjamin , Kamutanho Sithembile , Kaswa Tapiwa , Kayeruza Paradhi , Lunga Juliet , Magogo Nomatter , Manyeruke Daniel , Mazani Patricia , Mhuriyengwe Fungai , Mlambo Farisai , Moyo Stephen , Mpofu Tawanda , Mugava Mishelle , Mukungwa Yvonne , Muroyiwa Fungai , Mushonga Eddington , Nyekete Selestino , Rinashe Tendai , Sibanda Kundai , Chemhuru Milton , Chikunya Jeffrey , Chikwavaire Vimbai F. , Chikwiriro Charity , Chimusoro Anderson , Chinyama Jotam , Gwinji Gerald , Hoko-Sibanda Nokuthula , Kandawasvika Rutendo , Madzimure Tendai , Maponga Brian , Mapuranga Antonella , Marembo Joana , Matsunge Luckmore , Maunga Simbarashe , Muchekeza Mary , Muti Monica , Nyamana Marvin , Azhuda Efa , Bhoroma Urayai , Biriyadi Ailleen , Chafota Elizabeth , Chakwizira Angelline , Chamhamiwa Agness , Champion Tavengwa , Chazuza Stella , Chikwira Beauty , Chingozho Chengeto , Chitabwa Abigail , Dhurumba Annamary , Furidzirai Albert , Gandanga Andrew , Gukuta Chipo , Macheche Beauty , Marihwi Bongani , Masike Barbara , Mutangandura Eunice , Mutodza Beatrice , Mutsindikwa Angeline , Mwale Alice , Ndhlovu Rebecca , Nduna Norah , Nyamandi Cathrine , Ruvata Elias , Sithole Babra , Urayai Rofina , Vengesa Bigboy , Zorounye Micheal , Bamule Memory , Bande Michael , Chahuruva Kumbirai , Chidumba Lilian , Chigove Zvisinei , Chiguri Kefas , Chikuni Susan , Chikwanda Ruvarashe , Chimbi Tarisai , Chingozho Micheal , Chinhamo Olinia , Chinokuramba Regina , Chinyoka Chiratidzo , Chipenzi Xaviour , Chipute Raviro , Chiribhani Godfrey , Chitsinga Mary , Chiwanga Charles , Chiza Anamaria , Chombe Faith , Denhere Memory , Dhamba Ephania , Dhamba Miriam , Dube Joyas , Dzimbanhete Florence , Dzingai Godfrey , Fusira Sikhutele , Gonese Major , Gota Johnson , Gumure Kresencia , Gwaidza Phinias , Gwangwava Margret , Gwara Winnet , Gwauya Melania , Gwiba Maidei , Hamauswa Joyce , Hlasera Sarah , Hlukani Eustina , Hotera Joseph , Jakwa Lovemore , Jangara Gilbert , Janyure Micheal , Jari Christopher , Juru Duvai , Kapuma Tabeth , Konzai Paschalina , Mabhodha Moly , Maburutse Susan , Macheka Chipo , Machigaya Tawanda , Machingauta Florence , Machokoto Eucaria , Madhumba Evelyn , Madziise Learnard , Madziva Clipps , Madzivire Mavis , Mafukise Mistake , Maganga Marceline , Maganga Senzeni , Mageja Emmanuel , Mahanya Miriam , Mahaso Evelyn , Mahleka Sanelisiwe , Makanhiwa Pauline , Makarudze Mavis , Makeche Constant , Makopa Nickson , Makumbe Ranganai , Mandire Mascline , Mandiyanike Eunice , Mangena Eunice , Mangiro Farai , Mangwadu Alice , Mangwengwe Tambudzai , Manhidza Juliet , Manhovo Farai , Manono Irene , Mapako Shylet , Mapfumo Evangelista , Mapfumo Timothy , Mapuka Jane , Masama Douglas , Masenge Getrude , Mashasha Margreth , Mashivire Veronica , Matunhu Moses , Mavhoro Pazvichaenda , Mawuka Godfrey , Mazango Ireen , Mazhata Netsai , Mazuva David , Mazuva Mary , Mbinda Filomina , Mborera John , Mfiri Upenyu , Mhandu Florence , Mhike Chrispen , Mhike Tambudzai , Mhuka Artwell , Midzi Judith , Moyo Siqondeni , Mpundu Michael , Msindo Nicholas Msekiwa , Msindo Dominic , Mtisi Choice , Muchemwa Gladys , Mujere Nyadziso , Mukaro Ellison , Muketiwa Kilvera , Mungoi Silvia , Munzava Esline , Muoki Rosewita , Mupura Harugumi , Murerwa Evelyn , Murisi Clarieta , Muroyiwa Letwin , Muruvi Musara , Musemwa Nelson , Mushure Christina , Mutero Judith , Mutero Philipa , Mutumbu Patrick , Mutya Cleopatra , Muzanango Lucia , Muzembi Martin , Muzungunye Dorcus , Mwazha Valeliah , Ncube Thembeni , Ndava Takunda , Ndlovu Nomvuyo , Nehowa Pauline , Ngara Dorothy , Nguruve Leonard , Nhigo Petronella , Nkiwane Samukeliso , Nyanyai Luckson , Nzombe Judith , Office Evelyn , Paul Beatrice , Pavari Shambadzirai , Ranganai Sylvia , Ratisai Stella , Rugara Martha , Rusere Peter , Sakala Joyce , Sango Prosper , Shava Sibancengani , Shekede Margaret , Shizha Cornellious , Sibanda Tedla , Tapambwa Neria , Tembo John , Tinago Netsai , Tinago Violet , Toindepi Theresa , Tovigepi John , Tuhwe Modesta , Tumbo Kundai , Zaranyika Tinashe , Zaru Tongai , Zimidzi Kamurayi , Zindo Matilda , Zindonda Maria , Zinhumwe Nyaradzai , Zishiri Loveness , Ziyambi Emerly , Zvinowanda James , Bepete Ekenia , Chiwira Christine , Chuma Naume , Fari Abiegirl , Gavi Samson , Gunha Violet , Hakunandava Fadzai , Huku Constance , Hungwe Given , Maduke Grace , Manyewe Elliot , Mapfumo Tecla , Marufu Innocent , Mashiri Chenesai , Mazenge Shellie , Mbinda Euphrasia , Mhuri Abigail , Muguti Charity , Munemo Lucy , Musindo Loveness , Ngada Laina , Nyembe Dambudzo , Taruvinga Rachel , Tobaiwa Emma , Banda Selina , Chaipa Jesca , Chakaza Patricia , Chandigere Macdonald , Changunduma Annie , Chibi Chenesai , Chidyagwai Otilia , Chidza Elika , Chigatse Nora , Chikoto Lennard , Chingware Vongai , Chinhamo Jaison , Chinhoro Marko , Chiripamberi Answer , Chitavati Esther , Chitiga Rita , Chivanga Nancy , Chivese Tracy , Chizema Flora , Dera Sinikiwe , Dhliwayo Annacolleta , Dhononga Pauline , Dimingo Ennia , Dziyani Memory , Fambi Tecla , Gambagamba Lylian , Gandiyari Sikangela , Gomo Charity , Gore Sarah , Gundani Jullin , Gundani Rosemary , Gwarima Lazarus , Gwaringa Cathrine , Gwenya Samuel , Hamilton Rebecca , Hlabano Agnes , Hofisi Ennie , Hofisi Florence , Hungwe Stanley , Hwacha Sharai , Hwara Aquiiline , Jogwe Ruth , Kanikani Atanus , Kuchicha Lydia , Kutsira Mitshel , Kuziyamisa Kumbulani , Kuziyamisa Mercy , Kwangware Benjamin , Lozani Portia , Mabuto Joseph , Mabuto Vimbai , Mabvurwa Loveness , Machacha Rebecca , Machaya Cresenzia , Madembo Roswitha , Madya Susan , Madzingira Sheneterai , Mafa Lloyd , Mafuta Fungai , Mafuta Jane , Mahara Alfred , Mahonye Sarudzai , Maisva Admire , Makara Admire , Makover Margreth , Mambongo Ennie , Mambure Murenga , Mandizvidza Edith , Mangena Gladys , Manjengwa Elliot , Manomano Julius , Mapfumo Maria , Mapfurire Alice , Maphosa Letwin , Mapundo Jester , Mare Dorcas , Marecha Farai , Marecha Selina , Mashiri Christine , Masiya Medina , Masuku Thembinkosi , Masvimbo Priviledge , Matambo Saliwe , Matarise Getrude , Matinanga Loveness , Matizanadzo John , Maunganidze Margret , Mawere Belinda , Mawire Chipiwa , Mazvanya Yulliana , Mbasera Maudy , Mbono Magret , Mhakayakora Cynthia , Mhlanga Nompumelelo , Mhosva Bester , Moyo Nomuhle , Moyo Over , Moyo Robert , Mpakami Charity , Mpedzisi Rudo , Mpofu Elizabeth , Mpofu Estery , Mtetwa Mavis , Muchakachi Juliet , Mudadada Tsitsi , Mudzingwa Kudakwashe , Mugwira Mejury , Mukarati Tarsisio , Munana Anna , Munazo Juliet , Munyeki Otilia , Mupfeka Patience , Murangandi Gashirai , Muranganwa Maria , Murenjekwa Josphine , Muringo Nothando , Mushaninga Tichafara , Mutaja Florence , Mutanha Dorah , Mutemeri Peregia , Mutero Beauty , Muteya Edina , Muvembi Sophia , Muzenda Tandiwe , Mwenjota Agnes , Ncube Sithembisiwe , Ndabambi Tendai , Ndava Nomsa , Ndlovu Elija , Nene Eveln , Ngazimbi Enniah , Ngwalati Atalia , Nyama Tafirenyika , Nzembe Agnes , Pabwaungana Eunica , Phiri Sekai , Pukuta Ruwiza , Rambanapasi Melody , Rera Tambudzai , Samanga Violet , Shirichena Sinanzeni , Shoko Chipiwa , Shonhe More , Shuro Cathrine , Sibanda Juliah , Sibangani Edna , Sibangani Nikisi , Sibindi Norman , Sitotombe Mercy , Siwawa Pearson , Tagwirei Magret , Taruvinga Pretty , Tavagwisa Antony , Tete Esther , Tete Yeukai , Thandiwe Elliot , Tibugari Amonilla , Timothy Stella , Tongogara Rumbidzai , Tshuma Lancy , Tsikira Mirirayi , Tumba Constance , Watinaye Rumbidzayi , Zhiradzango Ethel , Zimunya Esther , Zinengwa Leanmary , Ziupfu Magret , Ziyambe Job 
Published: December 2022

Background

Despite achieving relatively high rates of antenatal care, institutional delivery, and HIV antiretroviral therapy for women during pregnancy, neonatal mortality has remained stubbornly high in Zimbabwe. Clearer understanding of causal pathways is required to inform effective interventions.

Methods

This study was a secondary analysis of data from the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial, a cluster-randomized community-based trial among pregnant women and their infants, to examine care during institutional and non-institutional deliveries in rural Zimbabwe and associated birth outcomes.

Results

Among 4423 pregnant women, 529 (11.9%) delivered outside a health institution; hygiene practices were poorer and interventions to minimise neonatal hypothermia less commonly utilised for these deliveries compared to institutional deliveries. Among 3441 infants born in institutions, 592 (17.2%) were preterm (< 37 weeks gestation), while 175/462 (37.9%) infants born outside health institutions were preterm (RR: 2.20 (1.92, 2.53). Similarly, rates of stillbirth [1.2% compared to 3.0% (RR:2.38, 1.36, 4.15)] and neonatal mortality [2.4% compared to 4.8% (RR: 2.01 1.31, 3.10)] were higher among infants born outside institutions. Among mothers delivering at home who reported their reason for having a home delivery, 221/293 (75%) reported that precipitous labor was the primary reason for not having an institutional delivery while 32 (11%), 34 (12%), and 9 (3%), respectively, reported distance to the clinic, financial constraints, and religious/personal preference.

Conclusions

Preterm birth is common among all infants in rural Zimbabwe, and extremely high among infants born outside health institutions. Our findings indicate that premature onset of labor, rather than maternal choice, may be the reason for many non-institutional deliveries in low-resource settings, initiating a cascade of events resulting in a two-fold higher risk of stillbirth and neonatal mortality amongst children born outside health institutions. Interventions for primary prevention of preterm delivery will be crucial in reducing neonatal mortality in Zimbabwe.

Trial registration

The trial is registered with ClinicalTrials.gov, number NCT01824940.