Dynamics of factors associated with neonatal death in Madagascar: A comparative analysis of the 2003, 2008, 2021 DHS

Neonatal mortality remains a major public health challenge, as reductions have stagnated worldwide despite cost-effective interventions in recent years. The temporal evolution of its determinants is insufficiently studied. This study aimed to analyze the dynamics of factors associated with neonatal death in Madagascar between 2003 and 2021. A secondary analysis was conducted using data from the 2003, 2008, and 2021 Demographic and Health Surveys (DHS) of Madagascar. The study population is focused on children under the age of 5 years at the time of these surveys. The death of a newborn within 30 days after birth constitutes the outcome variable. A multilevel binomial logistic regression was performed. The number of children under 5 included in the analysis were 5,415 in 2003, 12,448 in 2008 and 12,399 in 2021. The prevalence of neonatal deaths was 3.1% in 2003, 2.4% in 2008, and 2.6% in 2021. Persistent significant associations with neonatal death were observed for low birth weight, lack of breastfeeding, medium-sized households, large households, and high birth weight. A loss of statistical significance of the association with neonatal death over time was observed for a birth interval of 2-3 years and 4 years and more, mother's age 40-49 years, and use of mosquito net by the mother. In 2021, new significant associations with neonatal mortality were identified in the province of Toliara, absence of geographic barriers to healthcare access, 4-7 ANC visits, and supervised delivery. The factors associated with neonatal mortality, which have worsened over time in Madagascar, include birth weight abnormalities and delivery in the presence of qualified personnel. This deterioration underscores the urgency of improving the quality of perinatal care in healthcare facilities, beyond mere geographical accessibility.