Inequities in neonatal survival interventions: evidence from national surveys.

BACKGROUND: Nearly four million children die during the first four weeks of life every year, yet known and effective interventions exist. Neonatal mortality has to be addressed to reach the millennium development goal for child survival. AIMS: To determine the extent of within-country inequities in neonatal mortality and effective intervention coverage. METHODS: Neonatal, infant and child (under 2 years) mortality rates were calculated from empirical data from Demographic and Health Surveys for eight countries using direct estimation techniques. Wealth groups were constructed using the World Bank wealth index; neonatal mortality inequities were evaluated by comparing low:high quintile ratios; concentration indices were calculated for intervention coverage rates. RESULTS: The proportion of under-2 deaths occurring in the neonatal period ranged from 24.3% (Malawi) to 49.4% (Bangladesh). In all countries (excluding Haiti) inequities in neonatal mortality and intervention coverage were evident across wealth groups with more deaths and less coverage in the poorest, compared with the richest, quintile; the largest mortality differential was 2.1 (Nicaragua) and the smallest was 1.2 (Eritrea). In Nicaragua 33% of the poorest women had a skilled delivery compared with 98% of the richest; in Cambodia for antenatal care this was 18% (poorest) and 71% (richest). Low coverage of interventions tended to show top inequity patterns whereas high coverage tended to show bottom inequity patterns. CONCLUSIONS: Reducing inequity is a necessary step in reducing neonatal deaths and also total child deaths. Intervention efforts need to begin to integrate approaches relevant to equity in programme design, implementation, monitoring and evaluation.