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Sex differences in morbidity and care-seeking during the neonatal period in rural southern Nepal
Rosenstock, Summer; Katz, Joanne; Mullany, Luke C.; Khatry, Subarna K.; LeClerq, Steven C.; Darmstadt, Gary L. & Tielsch, James M.
Abstract
Background: South Asian studies, including those from Nepal, have documented increased risk of neonatal
mortality among girls, despite their early biologic survival advantage. We examined sex differences in neonatal
morbidity and care-seeking behavior to determine whether such differences could help explain previously observed
excess late neonatal mortality among girls in Nepal.
Methods: A secondary analysis of data from a trial of chlorhexidine use among neonates in rural Nepal was
conducted. The objective was to examine sex differences in neonatal morbidity and care-seeking behavior for
ill newborns. Girls were used as the reference group.
Results: Referral for care was higher during the early neonatal period (ENP: 0–7 days old) (50.7 %) than the late
neonatal period (LNP: 8–28 days old) (31.3 %), but was comparable by sex. There were some significant differences in
reasons for referral by sex. Boys were significantly more often referred for convulsions/stiffness, having yellow body/
eyes, severe skin infection, and having at least two of the following: difficulty breathing, difficulty feeding, fever,
or vomiting during the ENP. Girls were more often referred for hypothermia. During the LNP, boys were
significantly more often referred for having yellow body/eyes, persistent watery stool, and severe skin infection.
There were no referral types in the LNP for which girls were more often referred. Less than half of those referred
at any point were taken for care (47.0 %) and referred boys were more often taken than girls (Neonatal Period
OR: 1.77, 95 % CI: 1.64 - 1.91). Family composition differentially impacted the relationship between care-seeking and
sex. The greatest differences were in families with only prior living girls (Pahadi - ENP OR: 1.78, 95 % CI: 1.29 - 2.45 and
LNP OR: 1.51, 95 % CI: 1.03 - 2.21; Madeshi - ENP OR: 2.86, 95 % CI: 2.28 – 3.59 and LNP OR: 2.45, 95 % CI: 1.84 – 3.26).
Conclusions: Care-seeking was inadequate for both sexes, but ill boys were consistently more often taken for
care than girls, despite comparable referral. Behavioral interventions to improve care-seeking, especially in the
early neonatal period, are needed to improve neonatal survival. Addressing gender bias in care-seeking, explicitly
and within interventions, is essential to reducing neonatal mortality differentials between boys and girls.
Keywords
Gender preference; Neonatal; Morbidity; Care-seeking behavior; Nepal; Early neonatal period; Late neonatal period
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