Effect of Timing of First Postnatal Check on Neonatal Death in

Indonesia: Analysis of IDHS 2002-2003, 2007, and 2012 with

Retrospective Cohort Study

Ira Marti Ayu

, Asri Adisasmita

, Decy Situngkir

and Ratna Djuwita

Departement of Public Health, Faculty of Health Sciences, Universitas Esa Unggul

Department of Epidemiology, Faculty of Public Health, University of Indonesia

Keywords: Neonatal death; Postnatal, Survival, Cohort Study

Abstract: Many of under-five death occurs during the neonatal period. The first week of life after birth, especially the

first day of life is the most vulnerable time for child survival. Neonatal period accounts for more than one

third (over 44%) in under five death. In Indonesia, Neonatal Mortality Rate in 2012 is 19 per 1000 livebirth.

One of the intervention to increasing of neonatal survival is by the timing of first postnatal check-up but from

the previous study showed inconsistent effect. The objective of this study was to identifythe effect timing of

the first postnatal check-up for the newborn on neonatal survival. This study used the data from 2002-2003,

2007, and 2012 IDHS. The design of this study was a retrospective cohort study and assessed the association

of factors related to neonatal death used survival analysis by Cox regression.A total of 35.985 live birth

singleton in IDHS 2002-2003, 2007 and 2012 were analyzed. Multivariate analysis showed that Babies who

received a first postnatal check-up by health professional ≥24 hours up to 7 days after birth has a significant

protective effect on neonatal death (HR=0,09;95%CI: 0,04-0,23). The study also found other finding that birth

weight (HR=13,23; 95%:5,47-32,04)and pregnancy complication (HR=1,66; 95%CI: 1,17-2,36) were

significant associated with neonatal death.In order to get the more accurate timing of first postnatal check-up,

it recommended observing the timing of postnatal check-up directly.

1 INTRODUCTION

One of dimension Human Development Index is long

and healthy life (Badan Pusat Statistik, 2018).

Globally life expectancy at birth in 2013 is 70,8. It

means every child was born in 2013 will survive until

70-71 years(UNDP, 2014). 138 million children born

every year in 2013, but many of them did not survive

like life expectancy estimation. Even over 6,3 million

die before their fifth birthday(UNICEF, WHO, World

Bank, and UN Population Division, 2014).

Many of under-five death occurs during the

neonatal period. Neonatal period (first 28 days after

birth) is the most vulnerable time for child survival

(UNICEF, WHO, World Bank, and UN Population

Division, 2014). Neonatal period account more than

one third (over 44%) in under five death (UNICEF,

2014), two third in child mortality (Mathews et al.,

2000), and three-quarters neonatal death occur in the

first week of life (Lawn et al., 2005). In Jimma zone,

Southwest Ethiopia, Neonatal Mortality Rate was

35,5 per 1000 live birth, and 69,1% die at the first

week of life(Debelew et al., 2014). It showed that it

needs the high-quality care of childbirth(Lawn et al.,

2014).

In Indonesia, Neonatal Mortality Rate in 2012 is

19 per 1000 livebirth(BKKBN et al., 2013). Between

1997-2002, 54,7% infant death occurred in the

neonatal period and it estimates 29,9% occurred in the

first day of life dan 75,6% in the first week of life

(Titaley et al., 2008).

Increasing of neonatal survival can be done by

preventing the cause of death. Many of cause of

neonatal death is preventable with low cost and low-

level technology (Lawn et al., 2005;Darmstadt et al.,

2005)so that it can be implemented in low and

middle-income countries like Indonesia. One of

intervention to improve neonatal survival is postnatal

check for a newborn. WHO recommendation on

timing first postnatal check-up is at least 24 hours

after birth in a health facility and as early as possible

within 24 hours after birth at home(WHO, 2014a).

First postnatal check-up must be done as early as

2680

Marti Ayu, I., Adisasmita, A., Situngkir, D. and Djuwita, R.

Effect of Timing of First Postnatal Check on Neonatal Death in Indonesia: Analysis of IDHS 2002-2003, 2007, and 2012 with Retrospective Cohort Study.

DOI: 10.5220/0009950326802685

In Proceedings of the 1st International Conference on Recent Innovations (ICRI 2018), pages 2680-2685

ISBN: 978-989-758-458-9

possible so professional birth attendant can promote

healthy behavior likes exclusive breastfeeding, early

detection and referral of complication, pneumonia

case management and hypothermia prevention

management including kangaroo mother care for low

birth weight baby (Kerber et al., 2007;Darmstadt et

al., 2005).

The first postnatal checkup is cost-effective and

cost-efficient intervention so it can be used in low and

middle-incomecountries. However, the first postnatal

check-up within two days after birth is only 48%

(WHO, 2014b). In India, only 48,3% newborn

received a first postnatal check-up within 24 hours

after birth (Singh et al., 2012). While in Indonesia in

2012 only 40,5% newborn receive their first postnatal

check-up at less than 24 hours after birth (BKKBN et

al., 2013). It shows that the intervention coverage still

low, whereas this intervention was implemented with

high coverage (99%), it can save the life of newborn

over 41%-72% (Darmstadt et al., 2005).

Effect of timing postnatal check up on neonatal

death has variation result. The previous study by

Baqui et al. show that the risk of neonatal mortality

had a protective effect 0,33 times compared with

newborn did not first receive a postnatalcheck-

up(Baqui et al., 2009). However,Titaley and Dibley

study in Indonesia found that postnatal care is not

related to newborn survival (Titaley and Dibley,

2012). Singla et al. study in India also found that there

was no significant difference in neonatal mortality

among infant received first postnatal check-up within

24 hours compared to infant did not receive a first

postnatal check-up within 24 hours after birth (Singh

et al., 2012).

In Indonesia, neonatal death is still a problem.

Prevention of neonatal death can be done by applying

postnatal check-upas early as possible after birth.A

postnatalcheck-up is used to detect any illness of

danger sign for the baby after birth, so the treatment

can be done as early as possible to prevent death.A

postnatalcheck-up is a cost-effective and cost-

efficient intervention with low cost and low-

leveltechnology so that it can be implemented in a

developing country likes Indonesia. However, there

is inconsistent result about effect timing of first

postnatal on neonatal death, so a study needs to be

done to know the effect of timing first postnatal

check-up in neonatal death.

2 RESEARCH METHOD

This study used secondary data of Indonesia

Demographic and Health Survey (IDHS) in 2002-

2003, 2007, and 2012. This study used a retrospective

cohort study. The subject of this study was women in

reproductive age (15-49 years) and used household

and women questionnaires. IDHS used multi-stage

sampling such as cluster sampling, stratified

sampling, systematic sampling, until simple random

sampling (SRS). First, the sampleis clustered by

choosing provinces in Indonesia. Second, every

province is stratified by rural and urban area,and

every level of stratum has census blocks (CB). In

urban are, CBis chosen by systematic

sampling,andevery CB is chosen 25 households

randomly. In a rural area, there arethreestages to

choose a household sample. First, choosing sub-

district with Probability Proportional to Size (PPS) of

the household. Second, every selected sub-district

take CB by systematic sampling, and every CB is

chosen 25 households randomly

Time to event was the dependent variable, timing

of first postnatal check-up as the independent

variable. The timing of first postnatal check-up is

categorized as received a first postnatal check-up by

health professional <24 hours after birth, received a

first postnatal check-up by health professional ≥24

hours up to 7 days after birth and did not receive first

postnatal check-up or receive postnatal checkup >7

days. This study also considers about potential

confounding factor, such as type residence, maternal

education, maternal age delivery, parity, household

wealth index, desire for pregnancy, delivery

complication, birth weight, antenatal care services,

mode of delivery, place of delivery, delivery

attendant. The data were analyzed with survival

analysis with Cox regression test and analysis using

SPSS and complex sample. This study also presented

probability survival with KaplanMeier curve.

3 RESULTS

There was 35985 live birth singleton infant, of which

353 (0,1%) babies die in the neonatal period. Based on

the data there was an increasing probability of

neonatal survival from IDHS 2022-2003 (98,5%),

IDHS 2007 (98,8%) and IDHS 2012 (98,9%) and

probability survival overall (99,0%) (Figure 1).

Effect of Timing of First Postnatal Check on Neonatal Death in Indonesia: Analysis of IDHS 2002-2003, 2007, and 2012 with Retrospective

Cohort Study

2681

Figure 1: Neonatal survival probability curve based on IDHS

The probability of neonatal survival based on the

timing of postnatal check-up is highest in babies who

received first postnatal check-up by health

professional ≥ 24 hours up to 7 days after birth

(99,1%). Moreover, the lowest probability is in babies

who did not receive a first postnatal check-up or

receive a postnatalcheck-up but >7 days after birth

(Figure 2).

Figure 2: Neonatal survival probability curve based on timing first postnatal check up

Table 1: Bivariate and multivariate analysis

Variable HR Crude HR Adjusted

Timing Of First Postnatal Check Up (By Health

Professional)

<24 Hours After Birth 1(Reference)

≥24 Hours-7 Days 0,09 (0,04-0,23)*

0,09 (0,04-0,23)*

No Postnatal check up Or received postnatal

check up>7days

1,30 (0,95-1,77)**

1,004 (0,64-1,58)

ICRI 2018 - International Conference Recent Innovation

2682

Table 1: Bivariate and multivariate analysis (cont.).

Variable HR Crude HR Adjusted

Birth Weight

≥2500 1(Reference)

<2500 8,29 (5,55-12,38)* 13,23(5,47-32,04)*

Not Weighted 3,58 (2,46-5,21)* 4,17(2,32-7,521)*

Don’t Know 14,25(5,91-34,31)* 8,06(5,42-11,99)*

Maternal Age Of Delivery

12-19 1(Reference)

20-35 1,17 (0,70-1,95)

>35 1,91 (1,25-2,91)*

Parity

Primiparous 1(Reference)

Multiparrous 0,96 (0,67-1,38)

Grandmultiparous 2,02 (1,26-3,22)*

Desire For Pregnancy

Wanted Then 1(Reference)

Wanted No More 1,23 (0,79-1,89)

Dont Know 2,130E-009(,083E-009-4,188E-009)*

Antenatal Care (ANC) Visit

≥4 And According To Standard 1(Reference)

< 4 1,69 (1,21-2,38)*

No ANC 3,40 (1,84-6,28)*

Don’t Know 0,89 (0,33-2,42)

Pregnancy Complication

No 1(Reference) 1

Yes 2,65 (1,85-3,80)* 1,66 (1,17-2,36)*

Dont Know 2,074E-009 (9,423E-010-4,564E-

009)*

1,83 (0,99-3,39)*

Delivery Attendant

Health Professional 1(Reference) 1

TBA/ Others 1,32 (0,93-1,87)** 0,61 (0,31-1,22)

Don’t Know 2,205E-009 (5,894E-010-8,248E-

009)*

2,566E-009

(6,002E-010-

1,098E-008)

Place Of Delivery

Hospital 1(Reference)

Other Health Facility 0,33 (0,21-0,54)*

Home 0,65 (0,44-0,97)*

Dont Know 1,82 (0,20-14,46)

Mode Of Delivery

Non-Caesarean Section 1(Reference)

Caesarean Section 1,62 (0,95-2,77)**

Don’t Know 0,13 (0,02-0,92)*

Delivery Complication

No 1(Reference)

Yes 1,72 (1,21-2,45)*

Don’t Know 3,63 (2,09-6,28)*

Maternal Education

Higher Education Level 1(Reference) 1

Lower Education Level 1,98 (1,16-3,37)* 1.51 (0,85-2,68)

Type Of Residence

Urban 1(Reference)

Rural 1,14 (0,84-1,56)

Wealth Status

Rich (Q4-Q5) 1(Reference)

Poor (Q1-Q3) 1,26 (0,89-1,78)**

* p value <0,05

**p-value <0,025

Effect of Timing of First Postnatal Check on Neonatal Death in Indonesia: Analysis of IDHS 2002-2003, 2007, and 2012 with Retrospective

Cohort Study

2683

According to Table 1, the Multivariate analysis

showed that birth weight and delivery and pregnancy

complication were significantly associated with

neonatal death. Babies who received first postnatal

check-up by health professional ≥24 hours up to 7

days after birth has a significant protective effect on

neonatal death.

4 DISCUSSION

There was 353 neonatal death, of which 283 (80,2%)

occur in the early neonatal period (first week of life)

and 173 (49,0%) in the first day of life. It means most

of the neonatal death occurred in the first week (early

neonatal period) and especially on the first day of

life(Oza et al., 2014). There was an improvement of

neonatal survival from IDHS 2002-2003, 2007 and

2012. This due to an effort to improve maternal and

child health like a continuum of care services.

Continuum of care is integrated service delivery for

mother and children from pre-pregnancy to delivery,

the immediate postnatal period and childhood(WHO,

2011). Pregnancy health service cannotbe separated

with delivery, postnatal period and newborn health

services. Quality of antenatal care services will affect

maternal and fetus during pregnancy, and for baby and

maternal after delivery (Kemenkes RI, 2010).

This study found that pregnancy complication and

birth weight have significant associated with neonatal

death. In developing countries, more than 9 million

babies die every year before birth and during the first

week of life due to a complication during delivery

(Yego et al., 2013). Pregnant women from developing

countries are 36 times more likely suffer a

pregnancycomplication than pregnant women in

developed countries (WHO, 2015). Severe

hypertension, anemia, postpartum hemorrhage,

puerperal fever, abruptio placentae, diabetes mellitus,

are pregnancy complication (Nwankwo et al., 2013).

Birth weight is the weight of baby which weighed

within an hour after birth (Muslihatun, 2010). In

developing countries, almost half (48,7%) of babies

born not weighed and from those who weight only

14% were born with low birth weight (Blanc and

Wardlaw, 2005). According to WHO, babies born

with low birth weight are caused by preterm birth or

small gestational age (SGA) or both (World Health

Organization and others, 2011). The incidence rate of

neonatal mortality with low birth weight is six times

higher than for neonatal mortality with normal weight

(Incidence Rate Ratio=6,4) (Slyker et al., 2014). A

case-control study at the Hawasa University Hospital

showed that baby with very low birth weight, and low

birth weight was 3,95 times increased risk of early

neonatal death than normal weight (Bayou and

Berhan, 2012).

After controlling covariate variables, there was no

associated between babies who did not receive a first

postnatal check-up or receive postnatal checkup >7

days with neonatal survival. The adjusted Hazard ratio

on babies who received postnatal check-up by health

professional ≥24 hours up to 7 days after birth has a

significant protective effect on neonatal death

(HR=0,0995%CI: 0,04-0,23)

The result of this study indicates that babies who

receive postnatal check-up by health professional < 24

hours after birth did not prevent neonatal death

compared with babies who receive a postnatalcheck-

up ≥24 hours-7 days. It was contrary with the study

Baqui et al. (2009) and Singh et al. (2014). Babies who

did not check up were 3,03 times (95%CI;0,23-0,46)

more likely to die than babies who checked up in the

first day of life (Baqui et al., 2009). Also, babies who

checked up in the first week by a health professional

or not were associated with the decline of neonatal

mortality (OR: 0,51; 95%CI: 0,35-0,75; OR 0,34;

95%CI 0,30-0,38) (Singh et al., 2014).

The result of this can not prove that babies who

receive first postnatal check-up by health professional

≥24 hours have a protectiveeffect on neonatal death.

This is contrary to the objective of this study. The

babies who received checked than ≥24 hours can

influence babies’ life because it cannot detect any

illness of danger sign as early as possible. It is because

there is a limitation of the secondary data. First, when

we used secondary data, we cannot control the quality

of collection data, and there is missing data. Second,

there is a recall bias because the respondentwas asked

about something that happens5 years ago. Mother who

asked about the timing of first postnatal check-up can

not remind the timing exactly. For further study

The study also found others finding that birth

weight, and pregnancy complication can prevent

neonatal death. So to improve neonatal survival, it

needs to prevent risk factors of low birth weight

during pregnancy and also prevent pregnancy

complication through adequate antenatal care.

5 CONCLUSION

The result of this study is babies who receive first

postnatal check-up by health professional longer than

≥24 hours has a protectiveeffect on neonatal death

because of the limitation of secondary data. It

isrecommendedfor further studyto observe the timing

ICRI 2018 - International Conference Recent Innovation

2684

of postnatal check-up directly, so the result is more

accurate.

REFERENCES

Badan Pusat Statistik(2018). Badan Pusat Statistik [WWW

Document]. Available at:

https://www.bps.go.id/subject/26/indeks-

Pembangunan-manusia.html (accessed 7.11.18).

Baqui, A.H., Ahmed, S., Arifeen, S.E., Darmstadt, G.L.,

Rosecrans, A.M., Mannan, I., Rahman, S.M., Begum,

N., Mahmud, A., Seraji, H.R., and others.(2009). Effect

of timing of first postnatal care home visit on neonatal

mortality in Bangladesh: an observational cohort

study. BMJ 339.

Bayou, G., and Berhan, Y.(2012). Perinatal mortality and

associated risk factors: a case-control study. Ethiopian

journal of health sciences, 22(3).

BKKBN, BPS, Kemenkes RI, ICF International.(2013).

Survei Demografi dan Kesehatan Indonesia tahun

2012. Jakarta, Indonesia : BKKBN, BPS, Kemendkes

RI, ICF International.

Blanc, A. K., and Wardlaw, T. (2005). Monitoring low birth

weight: an evaluation of international estimates and an

updated estimation procedure. Bulletin of the World

Health Organization, 83: 178-185d.

Darmstadt, G. L., Bhutta, Z. A., Cousens, S., Adam, T.,

Walker, N., De Bernis, L., and Lancet Neonatal

Survival Steering Team. (2005). Evidence-based, cost-

effective interventions: how many newborn babies can

we save?. The Lancet, 365(9463): 977-988.

Debelew, G. T., Afework, M. F., and Yalew, A. W. (2014).

Determinants and causes of neonatal mortality in

Jimma zone, southwest Ethiopia: a multilevel analysis

of prospective follow up study. PLoS One, 9(9):

e107184.

Kemenkes RI.(2010). Pedoman Pelayanan Antenatal

Terpadu. Jakarta: Direktorat Jenderal Bina Kesehatan

Masyarakat.

Kerber, K.J., de Graft-Johnson, J.E., Bhutta, Z.A., Okong,

P., Starrs, A., and Lawn, J.E.(2007). Continuum of care

for maternal, newborn, and child health: from a slogan

to service delivery. The Lancet, 370: 1358–1369.

Lawn, J. E., Blencowe, H., Oza, S., You, D., Lee, A. C.,

Waiswa, P., ... and Mathers, C. (2014). Every Newborn:

progress, priorities, and potential beyond survival. The

Lancet, 384(9938): 189-205.

Lawn, J. E., Cousens, S., Zupan, J., and Lancet Neonatal

Survival Steering Team. (2005). 4 million neonatal

deaths: when? Where? Why? The Lancet, 365(9462):

891-900.

Mathews, T. J., Curtin, S. C., and MacDorman, M. F.

(2000). Infant mortality statistics from the 1998 period

linked birth/infant death data set. National vital

statistics reports, 48(12): 1-125.

Muslihatun, W.N. (2010). Asuhan neonatus bayi dan

balita. Fitramaya, Yogyakarta.

Nwankwo, T. O., Aniebue, U. U., Ezenkwele, E., and

Nwafor, M. I. (2013). Pregnancy outcome and factors

affecting vaginal delivery of twins at University of

Nigeria Teaching Hospital, Enugu. Nigerian journal of

clinical practice, 16(4).

Oza, S., Cousens, S. N., and Lawn, J. E. (2014). Estimation

of daily risk of neonatal death, including the day of birth,

in 186 countries in 2013: a vital-registration and

modeling-based study. The Lancet Global Health,

2(11): e635-e644.

Singh, A., Yadav, A., and Singh, A. (2012). Utilization of

postnatal care for newborns and its association with

neonatal mortality in India: an analytical appraisal. BMC

pregnancy and childbirth, 12(1): 33.

Singh, K., Brodish, P., and Haney, E. (2014). Postnatal care

by provider type and neonatal death in sub-Saharan

Africa: a multilevel analysis. BMC public health, 14(1):

941.

Slyker, J. A., Patterson, J., Ambler, G., Richardson, B. A.,

Maleche-Obimbo, E., Bosire, R., ... and John-Stewart,

G. (2014). Correlates and outcomes of preterm birth,

low birth weight, and small for gestational age in HIV-

exposed uninfected infants. BMC pregnancy and

childbirth, 14(1): 7.

Titaley, C. R., Dibley, M. J., Agho, K., Roberts, C. L., and

Hall, J. (2008). Determinants of neonatal mortality in

Indonesia. BMC public health, 8(1): 232.

Titaley, C. R., and Dibley, M. J. (2012). Antenatal iron/folic

acid supplements, but not postnatal care, prevent

neonatal deaths in Indonesia: analysis of Indonesia

Demographic and Health Surveys 2002/2003–2007 (a

retrospective cohort study). BMJ Open, 2(6): e001399.

UNDP.(2014). Human development report 2014: Sustaining

human progress: Reducing vulnerabilities and building

resilience. United Nations Development Programme,

New York.

UNICEF.(2014). Committing to Child Survival : A Promise

Renewed. United Nations Children’s Fund, New York.

UNICEF, WHO, World Bank, and UN Population

Division.(2014). Levels and Trends in Child Mortality

2014. New York, USA : UNICEF, WHO, World Bank,

& UN Population Division.

WHO.(2015). Pregnancy-related complications [WWW

Document]. WHO. Available at: http://www.who.int/

surgery/challenges/esc_pregnancycomp/en/ (accessed

6.16.15).

WHO.(2014a). WHO recommendations on the postnatal

care of the mother and newborn. World Health

Organization, Geneva.

WHO.(2014b). World Health Statistic 2014. World Health

Organization, Geneva.

WHO.(2011). WHO | PMNCH Fact Sheet: RMNCH

Continuum of care [WWW Document]. WHO.

Available at: http://www.who.int/pmnch/about/

continuum_of_care/en/ (accessed 7.12.18).

Yego, F., Williams, J. S., Byles, J., Nyongesa, P., Aruasa, W.,

and D'Este, C. (2013). A retrospective analysis of

maternal and neonatal mortality at a teaching and referral

hospital in Kenya. Reproductive health, 10(1): 13.

Effect of Timing of First Postnatal Check on Neonatal Death in Indonesia: Analysis of IDHS 2002-2003, 2007, and 2012 with Retrospective

Cohort Study

2685