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ObjectivesThis prespecified, secondary analysis of the Zambia Chlorhexidine Application Trial (ZamCAT) aimed to determine the proportion of women who did not deliver where they intended, to understand the underlying reasons for the discordance between planned and actual delivery locations; and to assess sociodemographic characteristics associated with concordance of intention and practice.DesignPrespecified, secondary analysis from randomised controlled trial.SettingRecruitment occurred in 90 primary health facilities (HFs) with follow-up in the community in Southern Province, Zambia.ParticipantsBetween 15 February 2011 and 30 January 2013, 39 679 pregnant women enrolled in ZamCAT.Secondary outcome measuresThe location where mothers gave birth (home vs HF) was compared with their planned delivery location.ResultsWhen interviewed antepartum, 92% of respondents intended to deliver at an HF, 6.1% at home and 1.2% had no plan. However, of those who intended to deliver at an HF, 61% did; of those who intended to deliver at home, only 4% did; and of those who intended to deliver at home, 2% delivered instead at an HF. Among women who delivered at home, women who were aged 25–34 and ≥35 years were more likely to deliver where they intended than women aged 20–24 years (adjusted OR (aOR)=1.31, 95% CI=1.11 to 1.50 and aOR=1.32, 95% CI=1.12 to 1.57, respectively). Women who delivered at HFs had greater odds of delivering where they intended if they received any primary schooling (aOR=1.34, 95% CI=1.09 to 1.72) or more than a primary school education (aOR=1.54, 95% CI=1.17 to 2.02), were literate (aOR=1.33, 95% CI=1.119 to 1.58), and were not in the lowest quintile of the wealth index.ConclusionDiscrepancies between intended and actual delivery locations highlight the need to go beyond the development of birth plans and exposure to birth planning messaging. More research is required to address barriers to achieving intentions of a facility-based childbirth.Trial registration numberClinicalTrials.gov Registry (NCT01241318).

In 2018, Pakistan had the world's highest neonatal mortality rate. Within Pakistan, most neonatal deaths occur in rural areas where access to health facilities is limited, and robust vital registration systems are lacking. To improve newborn survival, there is a need to better understand the causes of neonatal death in high burden settings and engage caregivers in the promotion of newborn health. To describe the causes of neonatal death in a rural area in Pakistan and to estimate the effect of an integrated neonatal care kit (iNCK) on cause-specific neonatal mortality. We analyzed data from a community-based, cluster-randomized controlled trial of 5286 neonates in Rahim Yar Khan (RYK), Punjab, Pakistan between April 2014 and August 2015. In intervention clusters, Lady Health Workers (LHW) delivered the iNCK and education on its use to pregnant women while control clusters received the local standard of care. The iNCK included interventions to prevent and identify signs of infection, identify low birthweight (LBW), and identify and manage hypothermia. Verbal autopsies were attempted for all deaths. The primary outcome was cause-specific neonatal mortality. Verbal autopsies were conducted for 84 (57%) of the 147 reported neonatal deaths. The leading causes of death were infection (44%), intrapartum-related complications (26%) and prematurity/LBW (20%). There were no significant differences in neonatal mortality due to prematurity/LBW (RR 0.43; 95% CI 0.15-1.24), infection (RR 1.10; 95% CI 0.58-2.10) or intrapartum-related complications (RR 1.04; 95% CI 0.0.45-2.41) among neonates who died in the intervention arm compared to those who died in the control arm. The major causes of neonatal deaths in RYK, Pakistan mirror the global landscape of neonatal deaths. The iNCK did not significantly reduce any cause-specific neonatal mortality.