Who Reaches Surgery, Who Survives? Skilled Intrapartum Care and Early Neonatal Death in a National Cohort of Nigerian Facility Births

BackgroundNigeria accounts for one of the worlds largest burdens of neonatal deaths despite rising coverage of facility delivery and skilled birth attendance (SBA). How intrapartum care is allocated within facilities--and what it achieves for early neonatal survival--remains poorly understood. MethodsWe analyzed nationally representative data from the 2018 Nigeria Demographic and Health Survey, restricting to the most recent singleton birth in the preceding 5 years that occurred in a health facility. Exposures were SBA (doctor, nurse, or midwife vs none) and caesarean versus vaginal delivery. The primary outcome was early neonatal death (0-6 days); secondary outcome was maternal report of "very small" size at birth. We used survey-weighted descriptive statistics to characterize socio-economic and obstetric gradients in care, and propensity-score overlap weighting combined with the DHS survey design to estimate absolute and relative associations between intrapartum care and outcomes among women in the region of covariate overlap. Pre-specified subgroup, equity, and scenario analyses explored effect modification and potentially avoidable deaths. ResultsThe analytic cohort comprised 5,860 facility-based singleton births, representing approximately 5.7 million Nigerian facility births. SBA coverage was 96.6% and caesarean delivery accounted for 12.1% of births; both were strongly concentrated among urban, wealthier, and better-educated women. The survey-weighted prevalence of early neonatal death was 3.8% and of very small size at birth 2.7%. In crude analyses, early neonatal mortality was higher among births with SBA than without (risk difference, 2.2 percentage points; 95% CI -0.1 to 4.4), reflecting strong confounding by indication. After overlap weighting, the risk difference comparing SBA with non-SBA was 2.5 percentage points (95% CI 0.2 to 4.8; risk ratio 2.59, 95% CI 0.70 to 9.62). For caesarean versus vaginal delivery, adjusted risk of early neonatal death was 3.9% versus 3.3% (risk difference 0.6 percentage points; 95% CI -1.1 to 2.4; risk ratio 1.20, 95% CI 0.75 to 1.90), ruling out large harmful effects but providing no strong evidence of benefit. Associations with very small size at birth were small and imprecise for both exposures. Joint-pattern analyses showed the lowest mortality for skilled vaginal births and higher risks for both non-skilled vaginal and skilled caesarean births, against a background of steep wealth, geographic, and facility-sector gradients. Scenario models suggested that extending competent SBA and timely, indicated caesarean delivery to poor and rural women could prevent a substantial share of facility-based early neonatal deaths. ConclusionsIn Nigeria, intrapartum expertise and surgical capacity are scarce and inequitably distributed, yet medically indicated caesarean delivery does not appear to confer large additional survival benefit within current system constraints. Early neonatal deaths cluster where SBA and caesarean access are lowest and quality gaps are greatest. Closing Nigerias neonatal survival gap will require not only higher coverage of facility births, but also reliable, equitable access to timely skilled intrapartum care and emergency obstetric services of adequate quality.