Improving the quality of maternal and newborn healthcare at the district level: Addressing newborn deaths in Nepal.

Maternal and newborn care quality can be measured in three dimensions (Dimensions 1: care provision, 2: care experience, and 3: human and physical resources); however, little is known about which dimensions are associated with newborn and perinatal deaths. We examined the association between care quality and newborn and perinatal deaths in Nepal. This study incorporated secondary data from Nepal Service Provision Assessments (NSPA) 2015 (623 delivery facilities, facility inventory survey; 1,509 women, ANC clients interviews; 1,544 women, ANC observation) and Nepal Demographic and Health Surveys (NDHS) 2016 (5,038 women who reported having given birth in the five years preceding data collection). The outcome variables were newborn and perinatal deaths derived from the NDHS. The exposure variables were district-level maternal and newborn care quality scores calculated from the NSPA data. Covariates were women's sociodemographic, health, and obstetric characteristics. We applied the administrative boundary method to link these two surveys. We conducted binary logistic regression analyses to examine the association between care quality and newborn/perinatal deaths. In Dimension 1, higher mean and maximum quality scores at the district level were associated with a lower number of newborn deaths (mean: odds ratio [OR] = 0.04, 95% confidence interval [CI]: 0.00-0.76; max: OR = 0.09, 95% CI: 0.01-0.58), but not with perinatal deaths. In Dimensions 2 and 3, the quality score was not significantly associated with newborn deaths and perinatal. Enhancing the quality of care provision at its average and highest levels in each district may contribute to the reduction of newborn deaths, but not perinatal death. Health administrators should assess the quality of care at the administrative division level and focus on enhancing both average and maximum care quality of health facilities in each region in the care provision dimension.