












































Nepas Journal 32-1 cs5 final.indd


Original Article

<37>J. Nepal Paediatr. Soc.

Risk Factors of Neonatal Mortality in Bangladesh

Kamal SMM1, Ashrafuzzaman M2, Nasreen SA3

1Dr. S. M. Mostafa Kamal, MSc, PhD, Associate Professor, Department of Mathematics, Islamic University, Kushtia, 
Bangladesh, 2Dr. Md. Ashrafuzzaman, MBBS, MPH, Senior Medical Officer, Islamic University, Kushtia, Bangladesh, 
3Dr. Syeda Anjuman Nasreen, MBBS, M.Phil, Lecturer, Department of Community Medicine, Mymensingh Medical College, 
Mymensingh, Bangladesh.

Address for correspondence: Dr. Mostafa Kamal, E-mail: kamaliubd@yahoo.com

Abstract
Introduction: To address United Nations Millennium Develop ment Goal 4 (MDG 4) on reducing childhood 
mortality rates by two-thirds by 2015, there is a need for better population-based data on the rates and 
causes of neonatal death. This study aims to identify the risk factors of neonatal mortality in Bangladesh. 
Materials and Methods: The study used data from the nationally representative 2007 Bangladesh 
Demographic and Health Survey. The survey gathered information regarding socioeconomic, demographic, 
environmental and maternal and child health care of 10,996 ever married women and 6,058 children. 
Both bivariate and multivariate statistical analyses were used to assess the relationship between neonatal 
mortality and contextual factors. Results: The prevalence of neonatal mortality was 37/1,000. The statistical 
analyses yielded quantitatively important and reliable estimates of neonatal death. The multivariate logistic 
regression analysis yielded significantly increased risk of neonatal mortality for children with mother who 
had no formal education, the Muslims, whose mother were adolescents of age 15-19, first ranked birth 
and twin babies. Conclusion: Emphasis should be given to improve female education in Bangladesh for a 
better chance of satisfying important factors that can improve infant survival: the quality of infant feeding, 
general care, household sanitation, and adequate use of preventive and curative health services.

Key words: Maternal and child health, Female education, MDG 4, Neonatal mortality

Introduction

Each year nearly four million newborns die during the fi rst 4 weeks of life and world-wide neonatal mortality 
makes up 40% of the total child mortality1,2,3,4. This 
means that the overall neonatal mortality rate is about 
30/1,000 with an annual number of births in the world 
reaching 130 million1. Whereas developed countries 
maintain a neonatal mortality rate of 2-3/1,000, it is not 
uncommon that this rate reaches over 60/1,000 in the 
poorer segments of the world5. Of the deaths, 99% are 
accounting the developing countries, especially in sub-
Saharan African and South Asia1,5,6. During the last 30 
years, the reduction in neonatal mortality rates has been 
slower, compared to both under-fi ve and child mortality 
rates after the fi rst month of life6,7,8.

Millennium Development Goal 4 (MDG 4) calls 
for reducing the under-fi ve mortality rate by two-
thirds between 1990 and 2015. As global momentum 
and investment for accelerating child survival grow, 
monitoring progress at the global and country levels has 

become even more critical. The most recent Inter-agency 
Group for Child Mortality Estimation (IGME) estimates 
show that nearly 8.1 million under-fi ve children died in 
2009, implies that more than 22,000 children die per 
day. These fi gures refl ect substantial progress. Globally, 
the under-fi ve mortality rate has fallen from 89 deaths 
per 1,000 live births in 1990 to 60 in 2009. But the rate 
of decline –a one-third reduction over 20 years –is 
insuffi  cient to meet MDG 4, particularly in Sub-Saharan 
Africa, Southern Asia and Oceania.9 Neonatal and post-
neonatal mortality rates declined less10, 3.0% and 2.5% 
decrease respectively. As a consequence there is an 
increasing proportion of infant deaths occurring in the 
neonatal period worldwide, which now accounts for 
two-thirds of deaths in children less than one year old, 
and nearly four-tenths of all deaths in children less than 
fi ve years of age8.

Infant and child mortality rates refl ect a country’s 
level of socioeconomic development and quality of life. 
They are used for monitoring and evaluating population 

January-April, 2012/Vol 32/Issue 1
doi: http://dx.doi.org/10.3126/jnps.v32i1.4845



<38> J. Nepal Paediatr. Soc.

and health programmes and policies. The rates are also 
important for monitoring progress towards the United 
Nations MDG to reduce child mortality as expected 
by the year 2015. It would be diffi  cult to achieve MDG 
without reducing child mortality by two-thirds by 
201511. Thus the study on infant and child mortality; in 
particular, neonatal mortality is of great importance to 
monitoring the progress of children’s health status. 

Bangladesh has made substantial progress in the 
reduction of under-fi ve mortality. A recent estimate 
suggests that infant mortality reduced from 88/1,000 
in 2000 to 55/1,000 in 2010. Absolutely, in Bangladesh, 
infant mortality reduced by 3.3% annually in the last 
decade. The neonatal and post neonatal mortality 
reduced from 65/1,000 and 38/1,000 in 1990 to 
31/1,000 and 14/1,000 respectively in 2010.5 Besides, 
the Bangladesh Demographic and Health Surveys 
(BDHSs) reported that under-fi ve mortality reduced from 
133/1,000 in 1993-1994 to 55/1,000 in 2007. In addition, 
the neonatal and post-neonatal mortality rates declined 
from 52/1,000 and 35/1,000 to 37/1,000 and 15/1,000 
respectively during the same period12,13. The successive 
DHS surveys conducted in Bangladesh since 1993-1994 
confi rm a declining trend in childhood mortality. During 
1989-1993 to 2002-2006, infant mortality declined 
by 40% from 87/1,000 live births to 52/1,000. Even 
more impressive are the 72% decline in child mortality 
and the 51% decline in under-fi ve mortality over the 
same period. A comparison of mortality rates over the 
last three years shows that infant and child mortality 
declined by 20% and 42% respectively13. A recent study14 
conducted on rural areas at Matlab using the Health 
and Demographic Surveillance System (HDSS) data has 
shown gradual decline in under-fi ve mortality consistent 
with the reports of the BDHSs.

Whereas literatures on neonatal, post-neonatal, 
infant and child mortality are enormous in other 
developed and developing countries, those are limited 
in Bangladesh. Many studies carried out elsewhere 
on risk factors of neonatal mortality attempt to show 
causal relationship between neonatal mortality and 
utilization of maternal health care facilities, such 
as receiving antenatal care (ANC) services, place of 
delivery, skilled attendance during childbirth15,16. Caste, 
religion and standard of living index are also identifi ed 
as infl uential factors of childhood mortality in India17. 
A number of studies showed signifi cant relationship 
between mother’s level of education6,16,18, maternal 
age19,20,21,22 and early childhood mortality. Mother and 
child characteristics are analysed as determinants of 
child mortality and its components, socioeconomic 
characteristics, type of childbirth and birth defects have 
been extensively investigated22. Regional and social 
diff erences may infl uence the composition of population 

groups and the success of local health promotion 
programmes. Living in poor areas may have negative 
eff ects on children’s health23.

Bangladesh is still far away to achieve the MDG 4. 
To achieve the goal, the infant mortality rate should be 
reduced at 31/100024. It would be diffi  cult to achieve 
MDG of reducing child mortality by two-thirds by 2015 
without reducing neonatal mortality. Despite impressive 
progress, Bangladesh still has higher rate of infant and 
neonatal mortality. In Bangladesh, very few studies have 
reported the causes of early and late neonatal deaths16. 
Knowledge on some of the factors aff ecting child 
mortality is a fundamental requirement for devising 
appropriate policies and strategies to accelerate decline 
in neonatal mortality. This paper aims to investigate the 
risk factors aff ecting neonatal mortality in Bangladesh. 
The fi ndings of this study may help the policy makers, 
programme managers and donors in driving up 
understanding about the risk factors of early childhood 
mortality, particularly neonatal mortality of Bangladeshi 
children. 

Materials and Methods

Data for this study have been taken from 2007 BDHS. 
The BDHS is a nationally representative survey of 10,996 
women age 15-49 and 3,771 men age 15-54 from 10,400 
households and 6,058 under-fi ve children born during 
the last fi ve years preceding the survey date covering 
361 sample points (clusters) throughout Bangladesh, 
134 in urban areas and 227 in the rural areas. This 
survey is the fi fth in a series of national-level population 
and health surveys conducted as part of the global 
Demographic and Health Surveys (DHS) programme. It 
was designed to provide data to monitor the population 
and health situation in Bangladesh as a follow up to the 
past four BDHS surveys. The survey utilised a multistage 
cluster sample based on the 2001 Bangladesh Census 
and was designed to produce separate estimates for key 
indicators for each of the six divisions of the country –
Barisal, Chittagong, Dhaka, Khulna, Rajshahi and Sylhet. 
Data collection took place over a fi ve-month period from 
24 March to 11 August, 2007. 

The survey obtained detailed information on 
fertility levels, marriage, fertility preferences, awareness 
and use of family planning methods, breastfeeding 
practices, nutritional status of women and young 
children, childhood mortality, maternal and child health, 
and knowledge and attitudes regarding HIV/AIDS and 
other sexually transmitted infections (STIs). The 2007 
BDHS was conducted under the authority of the National 
Institute for Population Research and Training (NIPORT) 
of the Ministry of Health and Family Welfare. It was 
implemented by Mitra and Associates, a Bangladeshi 

Risk Factors of Neonatal Mortality in Bangladesh



<39>J. Nepal Paediatr. Soc.

research fi rm located in Dhaka. Technical assistance 
was provided by Macro International Inc. through the 
MEASURE DHS programme. Financial support for the 
survey was provided by the U.S. Agency for International 
Development (USAID/Bangladesh). However, the details 
of the survey are given elsewhere13. 

Conceptual Framework

Many researchers such as Mahmood25 and later 
on Titaley and his colleagues6 adapted the conceptual 
framework proposed by Mosley and Chen26 with some 
modifi cations based on the limitations and structure 
of the DHS data. Keeping in view the aforementioned 
frameworks, this study considered the “survival status” 
of children as the outcome variable. According to 
Mosley and Chen26 framework, the socioeconomic 
factors aff ect the outcome variable through the four 
proximate determinants namely, socio-demographic 
factors, environmental factors, nutritional factors and 
health seeking behaviour of mother. Due to scarcity 
of information we also used a modifi ed model to 
investigate the risk factors for neonatal mortality in 
this study. The BDHS could not gather information of 
nutritional status of all living and death children such 
as height, weight or size of children at the time of their 
birth. Rather, the survey gathered information regarding 
nutritional status for the living children at the time of 
survey. Hence, we used mother’s body mass index (BMI) 
as the proxy determinant. 

Study Variables

The primary outcome variable of this study is 
“neonatal death”, which is defi ned as the death of a 
live born infant in the fi rst four weeks of life. In the 
descriptive analyses, the neonatal mortality rate has 
been expressed as percentage. The outcome variable 
“neonatal death” was recorded as a binary variable. The 
explanatory variables included in this study have been 
defi ned in Table 1.

Statistical analyses

Both bivariate and multivariate statistical analyses 
have been used in this study. Bivariate analyses namely 
chi-square tests have been applied to examine the 
association of various independent variables and 
neonatal mortality. This was followed by multivariate 
logistic regression analysis. The logistic regression model 
used in this study is as follows:

1
1 e âX

P
−

=
+ β  

 where, P is the probability of death of a child 
within the fi rst four weeks of his/her born, β is a vector 
of unknown coeffi  cients and X is the vector of covariates 
that aff ect the outcome variable. Thus the general 

multivariate logistic regression model can be expressed 
as:

eLog 1
i

j ji
i

P
âX â X

P
= =

−
∑β β

 
which expresses the log odds of the outcome 

variable as a linear function of the independent 
or explanatory variables. The results of the logistic 
regression analysis have been presented by regression 
coeffi  cient (β), standard error (SE), odds ratios (OR) (expβ) 
with 95% confi dence interval (CI). The data of this study 
have been analysed by means of SPSS v17 software. 

Results

Background characteristics of the children

The characteristics of the study children 
are presented in Table 2 with the prevalence of 
neonatal mortality by socioeconomic, demographic, 
environmental and maternal health care services strata. 
As shown in the table, slightly over two-fi fths were from 
poor households and a slightly less than two-fi fths were 
from rich households. Four in fi ve children were from 
rural areas. The more children were from Dhaka division, 
followed by Chittagong, Rajshahi, Khulna, Sylhet and 
Barisal divisions respectively. With regards to mother’s 
education, slightly over one-fourth had no formal 
education and over two-fi fths had at least secondary 
level of education. The vast majorities were Muslims. 
29% of the mothers were adolescents during childbirth, 
almost one-third were aged 20-24, one-fi fth were aged 
25-29 and the rests were of age 30-49. One-third of the 
children were the fi rst ranked children, one-fi fth were the 
second ranked children and the rest were third or higher 
ranked children. Half of the children were male and half 
were female. Almost 99% of the children were singleton 
birth and slightly over 1% was twin or multiple in terms 
of foetus type. Approximately one-third of the mothers 
were thin, three in fi ve were normal and 8% were 
overweight or obese. One-fourth of the children used to 
defecate in the unhygienic places, only 8% children were 
from households with less polluted cooking fuel and 
only 3% had no facilities of safe drinking water. Over half 
of the mothers received ANC services, whereas less than 
one-fourth sought skilled birth assistance (SBA) and only 
15% births were delivered in medical facility places.

Prevalence of neonatal mortality

The third broad column of Table 2 shows 
the percentage of neonatal mortality by various 
characteristics under socioeconomic, demographic, 
environmental and maternal health care factors. 
Primarily sixteen variables were included in the analyses 
to examine their association with neonatal mortality. 
Overall, the neonatal mortality was 37/1000. Of the 
variables included in the study wealth index, region, 

Kamal SMM et al



<40> J. Nepal Paediatr. Soc.

Table 1: Operational defi nition and categorization of the variables used in the analysis

Variables Defi nition and Categorization
Socioeconomic factors

Wealth index
Household wealth index: 
(1) Poorest; (2) Poorer; (3) Medium; (4) Richer; and (5) Richest.

Residence
Place of residence: 
(1) Urban; and (2) Rural.

Region
Administrative regions: 
(1) Barisal; (2) Chittagong; (3) Dhaka; (4) Khulna; (5) Rajshahi; 
and (6) Sylhet.

Maternal education
Mother’s level of education: 
(1) No education; (2) Primary; (3) Secondary; and (4) Higher.

Religion
Religion of mother: 
(1) Islam; and (2) Others.

Demographic factors

Maternal age
Mother’s age at child birth: 
(1) 15-19; (2) 20-24; (3) 25-29; (4) 30-34; (5) 35-49.

Birth order 
Birth rank of child:
(1) First; (2) Second; (3) Third; (4) Fourth; and (5) Fifth or above

Sex of child
Sex of child:
(1) Male; and (2) Female.

Number of foetus
Whether child is twin: 
(1) Single; and (2) Twin. 

Mother’s BMI
Mother’s body mass index:
(1)Thin (BMI < 18.5); (2) Normal (BMI = 18.5-24.5); and 
Over weight/Obese (BMI > 24.5).

sex of child, mother’s BMI, drinking water facility and 
maternal health care factors did not show to have 
signifi cant association with neonatal mortality. The 
variables identifi ed to have signifi cant association with 
neonatal mortality were place of residence, maternal 
education, religion, maternal age, type of foetus, toilet 
facility and cooking fuel. 

As expected, the prevalence of neonatal mortality 
was 1.1% higher in rural than urban areas (urban 2.8% vs. 
rural 3.9%). Although, the administrative regions did not 
show signifi cant association with neonatal mortality, the 
prevalence varied 30/1,000 in Khulna division to 52/1,000 
in Sylhet division. Maternal education and maternal age 
showed negative association with neonatal mortality. 
The Muslims had higher rate of neonatal mortality than 
their peer non-Muslims. The prevalence of neonatal 
mortality was higher for the fi rst and fi fth or higher 
ranked births than that of the the second, third or fourth. 
The prevalence of neonatal mortality among twin or 
multiple births was 325/1,000 as against of 33/1,000 for 
singleton birth. Households with unhygienic toilet facility 
and polluted cooking fuel showed higher prevalence of 
neonatal mortality than those with hygienic toilet facility 
and less polluted cooking fuel. 

Results of multivariate logistic regression 
analysis

The results of the multivariate logistic regression 
analysis have been shown in Table 3. All the variables 
identifi ed to have signifi cant association with neonatal 
mortality were included in the multivariate analysis 
to assess their net eff ect. After controlling for other 
confounding factors, the environmental factors and 
maternal health care services appeared to have no 
signifi cant eff ect on neonatal mortality. The variables 
showed to have net eff ect on neonatal mortality were 
maternal education, religion, maternal age, birth order 
and type of foetus.

Maternal education showed negative relationship 
with neonatal mortality. For instance, the odds of 
neonatal death was signifi cantly 28%, 33% and 85% lower 
among children whose mother had primary, secondary 
and higher education than those who had mothers with 
no formal education. The non-Muslim children had 40% 
lower risk of neonatal death as compared to the Muslim 
children. Maternal age showed negative relationship 
with neonatal mortality of the children. As compared 
to fi rst ranked birth, the second ranked birth had 
signifi cantly 50% lower risk of neonatal death, whereas 
the diff erence of likelihood of neonatal death between 
third and higher ranked births and the fi rst ranked had 
no signifi cant eff ect. The twin or multiple births were 
at 15.2 times as likely as to be dying at neonatal period 
than that of the singleton birth. 

Risk Factors of Neonatal Mortality in Bangladesh



<41>J. Nepal Paediatr. Soc.

Kamal SMM et al

Variables Defi nition and Categorization
Environmental factors

Drinking water
Sources of drinking water:
(1) Safe water (Piped, tube well bottle); and (2) Unsafe water (Well, pond, others)

Toilet facility
Type of toilet facilities:
(1) Hygienic (Flush, pit latrine); and (2) unhygienic (Open fi eld, jungle etc.)

Cooking fuel
Type of cooking fuel:
(1) Less polluted (Gas, Kerosin); and polluted (Dried cow dung, leaves, wood etc.) 

Maternal health care behavioural factors

ANC seeking
Sought antenatal care services during pregnancy:
(1) No; and (2) Yes.

SBA seeking
Sought skilled birth assistance during child delivery:
(1) No; and (2) Yes.

Place of delivery
Medically facilitated place of child delivery:
(1) No; and (2) Yes.

Table 1 continued...

Table 2: Background characteristics of under-fi ve children and prevalence of neonatal death, BDHS-2007

Background Characteristics
No. of Children % of Neonatal Death

Chi-square
N % No Yes

Wealth Index 5.07
Poorest 1367 22.6 95.8 4.2
Poorer 1312 21.7 96.3 3.7
Middle 1173 19.4 95.9 4.1
Richer 1149 19.0 96.5 3.5
Richest 1056 17.4 97.3 2.7

Place of Residence 2.94†

Urban 1249 20.6 97.2 2.8
Rural 4809 79.4 96.1 3.9

Region 5.87
Barisal 383 6.3 96.6 3.4
Chittagong 1337 22.1 96.5 3.5
Dhaka 1908 31.5 96.7 3.3
Khulna 578 9.5 97.0 3.0
Rajshahi 1306 21.6 95.8 4.2
Sylhet 547 9.0 94.8 5.2

Maternal Education 11.26**

No education 1658 27.4 95.6 4.4
Primary 1910 31.5 96.3 3.7
Secondary 2122 35.0 96.4 3.6
Higher 366 6.0 99.3 0.7

Religion 3.35*

Islam 5558 91.8 96.2 3.8
Other 499 8.2 97.8 2.2

Maternal Age 16.65***

15-19 1769 29.2 94.8 5.2
20-24 1977 32.6 96.6 3.4
25-29 1254 20.7 97.2 2.8
30-34 714 11.8 96.9 3.1
35-49 343 5.7 98.1 1.9



<42> J. Nepal Paediatr. Soc.

Table 3: Multivariate logistic regression analysis showing the risk of neonatal mortality among under-fi ve children of 
Bangladesh, BDHS-2007

Background Characteristics  β  SE  OR  95% CI
Maternal Education

No education Reference --- --- ---
Primary -0.33 0.18 0.72* 0.50-1.03
Secondary -0.41 0.19 0.67* 0.46-0.97
Higher -1.93 0.65 0.15** 0.04-0.52

Religion
Islam Reference --- --- ---
Other -0.51 0.32 0.60† 0.32-1.12

Background Characteristics
No. of Children % of Neonatal Death

Chi-square
N % No Yes

Birth Order 16.12**

First 2050 33.8 95.2 4.8
Second 1568 25.9 97.7 2.3
Third 1009 16.7 96.5 3.5
Fourth 648 10.7 96.6 3.4
Fifth+ 782 12.9 95.9 4.1

Sex of Child 0.62
Male 3021 49.9 96.1 3.9
Female 3036 50.1 96.5 3.5

Number of Foetus 197.50***

Single 5975 98.6 96.7 3.3
Twin 83 1.4 67.5 32.5

Mother’s BMI 1.75
Thin (BMI <18.5) 1935 32.3 96.1 3.9
Normal (BMI 18.5-24.9) 3593 60.0 96.4 3.6
Over weight (BMI =>25.0) 462 7.7 97.5 2.5

Drinking Water§ 0.01
Safe 5251 96.6 96.2 3.8
Unsafe 185 3.4 96.3 3.7

Toilet Facility§ 4.08*

Hygienic 4309 79.3 96.5 3.5
Unhygienic 1127 20.7 95.2 4.8

Cooking fuel§ 4.97*

Less polluted 436 8.0 98.2 1.8
Polluted 5000 92.0 96.0 4.0

Sought ANC services‡ 1.97
No 2365 48.3 97.9 2.1
Yes 2535 51.7 98.5 1.5

Sought SBA‡ 0.38
No 4957 81.9 96.2 3.8
Yes 1093 18.1 96.6 3.4

Delivery setting‡ 0.13
Home 5164 85.3 96.3 3.7
Hospital 887 14.7 96.5 3.5

Total 6058 100.0 96.3 3.7
Note: level of signifi cance *** p<0.001; ** p<0.01; * p<0.05; and † p<0.10.
§ The fi gures do not round to 6,058 due to exclusion of non-dejure residents.
‡ The fi gures do not round to various missing information.

Table 2 continued …

Risk Factors of Neonatal Mortality in Bangladesh



<43>J. Nepal Paediatr. Soc.

Kamal SMM et al

Table 3 continued …

Maternal Age
15-19 Reference --- --- ---
20-24 -0.35 0.20 0.70* 0.48-1.03
25-29 -0.62 0.28 0.54* 0.31-0.93
30-34 -0.80 0.35 0.45** 0.23-0.89
35-49 -1.40 0.50 0.25** 0.09-0.66

Birth Order
First Reference --- --- ---
Second -0.70 0.22 0.50*** 0.32-0.76
Third -0.25 0.26 0.78 0.47-1.29
Fourth -0.28 0.33 0.75 0.40-1.42
Fifth+ 0.14 0.35 1.14 0.58-2.26

Number of Foetus
Single Reference --- --- ---
Twin 2.72 0.26 15.20*** 9.16-25.22

Note: level of signifi cance *** p<0.001; ** p<0.01; * p<0.05; and † p<0.10.

Discussion

To address United Nationas MDG 4 on reducing 
childhood mortality, there is a need for better population-
based data on the rates and causes of neonatal death27. 
In this study it was our aim to identify the risk factors 
of neonatal death in Bangladesh using the nationally 
representative 2007 BDHS data. Both bivariate and 
multivariate statistical analyses were employed to 
examine the factors aff ecting neonatal death. Findings 
showed that the prevalence of overall neonatal death 
was 37/1,000. Our analyses revealed that socioeconomic 
and demographic factors rather than environmental 
factors and maternal health care services had signifi cant 
net eff ect on neonatal death. The variables infl uencing 
neonatal death are maternal education, religion, 
maternal age, birth order and type of foetus. 

Consistent with earlier studies18,28,29,30, the fi ndings 
of this study revealed that the higher the mother’s 
education the lower the risk of neonatal mortality. A 
review of the literature shows that while the higher 
socioeconomic status of better educated women explains 
about half of the magnitude of the relationship between 
maternal education and child survival31, the domestic 
health practice of individual women is probably the new 
most salient mechanism in the maternal education child 
mortality relationship. The fact that mother’s education 
is a more important determinant of child survival 
than father’s education: explains that there is greater 
maternal involvement in child-health related care32. The 
mother’s education infl uences her choices and skills in 
health care practices32,33. For instance, both educated 
and illiterate mothers recognize when their child is sick 
but an educated mother more frequently will take action 
“without waiting for (her) husband or mother-in-law to 
notice the child’s condition too” 32. This is partly because 

illiterate women do feel a lack of capability when dealing 
with the modern world.

We found that being born to a mother who 
practiced Islam was signifi cantly associated with an 
increased risk of neonatal death. The infl uence of religion 
on neonatal mortality may be linked to the beliefs and 
myths they may have concerning child birth. This was 
the case with the Faith Assembly people in Indiana, U.S., 
who believed that child bearing was an act of God not 
to be interfered with34. It is evident that Muslim women 
have higher fertility, lower use rate of contraceptive 
method, early age at marriage and motherhood and 
lower access to maternal health care services than 
their peer non-Muslim sisters in Bangladesh35,36. Hence, 
we explored this association further by introducing an 
interaction term between religion and maternal age 
(results not shown). We found that children who were 
born to Muslim adolescent mothers had a higher risk 
of neonatal deaths compared to children born to non-
Muslim mothers (results not shown). Despite this, it is 
diffi  cult to say whether or not this fi nding refl ects the 
early motherhood among the subgroup of traditional 
Muslim women and thus further qualitative research 
may be useful.

Our fi ndings showed signifi cant increased risk 
between adolescent motherhood and neonatal 
mortality. This result is comparable to numerous studies 
conducted elsewhere which found higher risk of 
neonatal mortality in younger adolescents than older 
mothers19,20,22. This is partially explained by diff erences in 
socioeconomic factors in younger versus older women 
and is mediated primarily through preterm delivery, 
small for gestational age (SGA) and low birth weight 
(LBW) or some interaction of these variables37. The 
signifi cance of young and old maternal ages at childbirth 



<44> J. Nepal Paediatr. Soc.

as risk factors for adverse neonatal health outcomes 
remains largely socioeconomic, environmental and 
cultural context dependent. Previous research that 
aimed at providing an explanation to the frequently 
observed association between mother’s age and various 
quality-of-life measures, including perinatal, neonatal 
and infant mortality38,39, preterm delivery38,40, and low 
birth weight41,42 have yielded inconsistent results.

Birth order of a child showed controversial results 
for neonatal mortality. Some studies showed that fi rst 
or lower ranked births were at higher risk of neonatal 
mortality, whereas some others showed that higher 
ranked births were at increased risk of neonatal mortality. 
For instance, in a study to determine the impact of 
maternal and child health (MCH) services on child 
survival in a socio-economically poor rural Pondicherry, 
India, infants of fi rst birth had higher risk of neonatal 
mortality than fourth or higher ranked births. The study 
further showed that second ranked births had the least 
mortality risk42. A study conducted in Taiwan44 showed 
that children with fi rst and fi fth ranked births were at 
higher risk of early neonatal deaths, while in Nigeria45, 
the children with sixth or higher order births were at 
increased risk of neonatal mortality. It is argued that, in 
most of the developing countries, higher mortality risks 
were found for the fi rst-born children compared to birth 
order two through six46. Our study showed that children 
with fi rst ranked birth were signifi cantly at increased 
risk of dying at early infancy than the second or higher 
ranked births. Social and cultural contexts may be partly 
attributed to the infl uence on birth order on neonatal 
mortality. However, our studies are consistent with most 
of the earlier studies as mentioned above.

Multiple births are relatively rare events, but 
contribute substantially to mortality in both neonatal 
and post-neonatal periods28. Our study showed a 
reduced risk of neonatal mortality for singleton baby 
compared to twins or multiples. Twins are more likely to 
be born with low birth weight and biological immaturity. 
Possibly, the use of the curative services, which are 
needed in emergency situations, could be under-
utilized by mothers of twins47. However, one possible 
reason for this observed association is that multi-foetal 
pregnancy and multiple births including twins and 
higher order multiples such as triplets and quadruplets 
are high-risk pregnancy and birth. These high-risk births 
are frequently accompanied by a number of associated 
foetal and neonatal complications that require special 
and expensive medical care48. In addition, multiple-
birth children are at greater risk of birth defects and/
or disabilities and accounted for larger percentage of 
prenatal deaths49. Therefore, mortality of these high-
risk groups contributes to the higher rate of childhood 
mortality especially during the early period of life. This 

fi nding is consistent with earlier studies conducted 
elsewhere28,47,48,49,50.

It is important to discuss the limitations of 
this study as well as its strengths. The fi rst potential 
limitation of this study is the cross-sectional nature of 
the analyses. Second, the information used in this study 
is based on the retrospective birth history of children 
and reported characteristics of mothers and households 
by the mother’s of the children, which may cause 
underreporting in age. Third, only surviving women were 
interviewed, which may have lead to an underestimate 
of the neonatal mortality rate, because of the association 
of neonatal deaths with maternal deaths. This could also 
have lead to an underestimate of the eff ect of some of 
the associated factors, such as delivery complications6. 
Fourth, as a secondary data set, we could not include 
weight of child at the time of birth which is an important 
predictor in the study of neonatal mortality. Another 
limitation with household wealth indices derived from 
DHS is that those are based on current status data so 
that the variable might not capture the true level of 
household wealth during the infancy of children born 
several years before the survey. However, since these 
analyses are restricted to births within fi ve years of the 
surveys, this biasness will not be substantial. Despite 
these limitations, the strength of the study is that it dealt 
with a large nationally representative sample size with 
stratifi ed random sampling gathered by international 
standardized method, which are mostly used in public 
health research.

Conclusion

In summary, we found that twin or multiple births 
are more likely to be dying during the fi rst four weeks 
of life as compared to singleton children. Maternal 
education, religion, maternal age and birth order are 
also important determinants of neonatal mortality in 
Bangladesh. This evidence suggests that improving 
maternal education may be key factor to improving 
child survival in Bangladesh. A well educated mother 
has a better chance of satisfying important factors that 
can improve infant survival: the quality of infant feeding, 
general care, household sanitation, and adequate use 
of preventive and curative health services. Adolescents 
should be discouraged to initiate childbearing at the teen 
ages not only for the reduction of neonatal mortality, 
also for their physical and psychological maturity that 
may bring overall wellbeing to mother and child health. 

Acknowledgements: None
Funding: Nil
Confl ict of Interest: None

Permission from IRB: Data used in this study have 
been taken from a nationally representative survey. The 

Risk Factors of Neonatal Mortality in Bangladesh



<45>J. Nepal Paediatr. Soc.

survey was conducted by a Bangladeshi government 
run institution. It followed all criteria and ethical issues 
prescribed by World Health Organization. This data set 
is widely used for public health research in home and 
abroad.

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Risk Factors of Neonatal Mortality in Bangladesh

How to cite this article ?
Kamal SMM, Ashrafuzzaman M, Nasreen SA. Risk Factors of Neonatal Mortality in Bangladesh. J Nepal Paediatr Soc 
2012;32(1):37-46.


