Professional attendance at home births and early neonatal survival in Indonesia

Early neonatal mortality has been persistently high in developing countries. Indonesia, with its national policy of home-based, midwife-assisted birth, is an apt context for assessing the effect of home-based professional birth attendance on early neonatal survival. We pooled four Indonesian Demographic and Health Surveys and used multivariate logistic regression to analyze trends in first-day and early neonatal mortality. We measured the effect of the context of delivery, including place and type of provider, and tested for changes in trend when Indonesia's “Midwife in the Village” program was initiated. We found that first-day mortality did not decrease significantly between 1986 and 2002, whereas early neonatal mortality decreased by an average of 2.3 percent annually, from 20.6 to 14.2 per 1000 live births. However, the rate of the decline did not change when the Midwife in the Village program was initiated. In simple and multivariate analyses, there were no significant differences in first-day or early neonatal death rates comparing home-based births with or without a professional midwife. Early neonatal mortality was higher in public facilities, likely due to selection. Biological determinants (multiple birth, male sex, short birth interval, previous early neonatal loss) were important for both outcomes. The lack of effect of professional attendance at home births on newborn death rates in Indonesia suggests a need for increased emphasis on immediate newborn care and emergency referral. Continued support for family planning policies is merited.