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  • Two important issues affect our interpretation of these find


    Two important issues affect our interpretation of these findings. First, many women chose institutional delivery (53% of deliveries were at hospitals in Sazawal and colleagues\' trial, and 64% in Semrau and colleagues\' trial). The latest WHO guidelines recommend application of chlorhexidine to the umbilical cord stump for the first week after birth, for infants born at home in environments with high neonatal mortality rates (>30 deaths per 1000 livebirths). Dry cord care is recommended after institutional births or home births in settings with lower neonatal mortality rates. Chlorhexidine might be considered as a replacement for harmful applications to the cord stump, but Cochrane reviews, a meta-analysis, and these two new trials have not supported an effect after hospital births. Second, the neonatal mortality rates were lower than expected. The sample size for the Zambian study was developed on the assumption that the neonatal mortality rate in the control group would be 29·0 deaths per 1000 livebirths. However, the observed rate was 14·4 deaths per 1000 livebirths. The Tanzanian study assumed a control group neonatal mortality rate of 31 deaths per 1000 livebirths. The observed neonatal mortality rate was 11·7 deaths per 1000 livebirths. Both trials increased their sample sizes during implementation, yet confidence intervals around estimates of effects on neonatal mortality rates were nevertheless substantial. To address the issue of underpowering, the research groups combined their estimates in a random-effects meta-analysis, resulting in a relative risk estimate of 0·99 (95% CI 0·80–1·23) for neonatal mortality by day 28. The three major drivers of newborn mortality are infection, preterm birth, and presumed intrapartum-related compromise. The implicit assumption is that antiseptic cleansing will prevent microbial invasion and reduce deaths from infection. However, as neonatal mortality rates decrease, the proportion of deaths explained by infection reduces in relation to the other two causes. What this means is that the yield in terms of neurokinin receptor antagonist in all-cause mortality as a result of cord antisepsis is likely to be lower in settings with low neonatal mortality rates. To test our assumption, we used the published findings of the five trials as a basis for conservative meta-regression. The shows the reduction in mortality associated with varying proportions of home delivery and neonatal mortality rates. Although not significant, the impression is that higher neonatal mortality rates (p=0·109) and a higher proportion of home deliveries (p=0·138) were associated with larger effects of cord cleansing on neonatal mortality rates. Along with the individual trial findings, the is consonant with the current WHO guidelines for cord care, to which we recommend no change. Cord cleanliness is part of the suite of hard-won improvements that accompany the increases in survival being seen worldwide. In settings in which neonatal mortality rates remain high, we recommend the kinds of programme that have been associated with reductions in all-cause mortality. These include improvements in institutional quality of care and efforts to improve community-based practices, both central to the 2014 Every Newborn Action Plan.
    In Magaret E Kruk and colleagues examine a very important aspect of maternal and newborn health that is poorly studied in low-income countries, namely quality of care. Poor quality of care has been a recurrent theme used to explain the prevailing high level of maternal and newborn morbidity and mortality in low-income and middle-income countries (LMICs) for several decades and is aptly articulated in two prevailing models. The authors found that the quality of care in primary care (no caesarean capacity) and low delivery volume facilities was substantially poorer than at secondary care facilities (has caesarean capacity; index score 0·38 in primary care facilities 0·77 in secondary care facilities). Of note, Kruk and colleagues advance a simple composite indicator that they applied in measuring quality of care. The elements in their composite indicator are fully in line with those advanced in the existing guidelines on emergency maternal, obstetrics, and newborn care (EmONC). Thus the findings of this Article are of importance to both researchers, funding organisations, policy makers, and health managers in LMICs.