Newborn Survival: A Snapshot of Progress Since 2005

Newborn Survival: A Snapshot of Progress Since 2005

by Joy Lawn

Dr. Joy Lawn, B MedSci, MB BS, MRCP (Paeds), MPH, is an African-born paediatrician and perinatal epidemiologist. She completed a medical degree and paediatric postgraduate training in England and then worked as a Lecturer in Child Health in a teaching hospital in Ghana. She was a fellow at the WHO Collaborating Center in Reproductive Health at the CDC Atlanta, USA, and completed a Masters of Public Health at Emory University, Atlanta. While at the Institute of Child Health in London, she co-led the neonatal group in the Child Health Epidemiology Reference Group (CHERG), developing the first systematic cause of death estimates for 4 million neonatal deaths each year, which were then used in the World Health Report 2005. Joy is based in South Africa as a Senior Research and Policy Advisor with the Gates-funded Saving Newborn Lives Initiative of Save the Children-US and works with partners to catalyze the integration and scale up of newborn care, particularly in Africa. She has an honorary post at the South African MRC Health Systems Research Unit and at the Institute of Child Health London.

 

Each year at least 4 million newborn babies die—an unacceptably high number given that low-cost solutions exist to save these lives. Although the number of newborn deaths worldwide is roughly equal to the number of AIDS and malaria deaths combined, the deaths of newborn babies have received remarkably little consideration in international policy. Most of these deaths occur at home, often un-named and uncounted. Over the past two years new evidence of the problem and feasible solutions have begun to stimulate more attention. Awareness of newborn health has increased in many countries where the deaths are highest, particularly in Africa. Hints of progress are appearing in major development institutions. How much progress has been made and is this enough? What are the key actions needed to accelerate progress further?

The State of Newborn Health

Newborn deaths (occurring in the first 28 days of life) account for 38 percent of all child deaths under age 5. The time of birth and the first days of life are the riskiest period in the human lifespan—each year, 3 million babies die in the first week of life and up to two-thirds of these (2 million) die in the first 24 hours of life. Most newborn deaths occur in sub-Saharan Africa and South Asia.

Child deaths after the first 28 days of life are being reduced more quickly than newborn deaths occurring in the first 28 days.¹ In Africa there has been no measurable reduction in the risk of newborn death over the last decade. As a result, the proportion of child deaths that are newborn deaths is increasing. In South Asian settings, where HIV and malaria are not common, newborn deaths account for around two-thirds of the deaths of children under five years of age. In India alone, more than 1 million newborns die every year. More rapid progress in reducing newborn deaths is essential for advancing progress towards Millennium Development Goal 4 (MDG-4).

Up to 70 percent of newborn deaths could be prevented with proven, low-cost interventions, requiring an additional US$1 or less per capita annually to existing maternal and child health programs. Some of the inexpensive and feasible solutions include keeping newborns warm and clean, immediate and exclusive breastfeeding, protecting against infection through proper hygiene, and treating infections promptly with antibiotics. Newborns unable to breathe can be resuscitated with self-inflating bags and masks that cost less than US$5.¹ Unfortunately, widespread awareness of these and other solutions has been lacking, and many policymakers and clinicians have believed incorrectly that highly technical care is needed to save newborn lives. Up to one third of newborn deaths can be prevented with community level interventions feasible even in settings with weak health systems.^1;2

Progress in Information on Newborn Survival Since 2005

To raise awareness of the numbers and causes of newborn deaths as well as the solutions, important evidence has been disseminated worldwide through multiple channels:

- In 2005, The Lancet journal published a series of articles on newborn survival, which spawned numerous meetings and press articles worldwide, a toolkit for action, and implementation guides for program planners.^3;4

- The 2005 World Health Report (of the World Health Organization) entitled “Make Every Mother and Child Count”, focused on maternal, newborn, and child health (MNCH) and promoting a paradigm shift from maternal and child health (MCH) to MNCH.⁵ A chapter on newborns was included: “Newborns No Longer Neglected,” and for the first time cause-of-death estimates for the first month of life were included in the statistical tables.⁶

- In 2006, Disease Control Priorities in Developing Countries, 2nd edition (DCP2) was released with a chapter on newborn survival.¹ DCP2 highlighted the cost-effectiveness and feasibility of interventions in low- and middle-income settings. According to this chapter, in India alone 700,000 lives could be saved each year by scaling up the integrated MNCH package, which would also save large numbers of mothers and children and reduce disabilities. The integrated package would cost an estimated $5.50 per capita per year but only 70 cents per capita would specifically be for the marginal cost for newborn care.¹

In addition, several partnerships and international initiatives have focused attention and action on scaling up available solutions and advancing the evidence concerning newborn deaths. The Saving Newborn Lives program, implemented by Save the Children, received renewed funding from the Bill & Melinda Gates Foundation and is now working with governments and partners in 18 countries. The Partnership for Maternal, Neonatal, and Child Health was launched, bringing together three separate partnerships for maternal, newborn, and child survival. A major international forum on child survival, Countdown 2015, attracted renewed attention to newborn survival at its 2005 meeting, and will track progress in its series of meetings planned for the next decade.

These combined global efforts have put newborn babies on governments’ health policy agendas, in many countries for the first time, and helped to increase interest in reducing newborn deaths. Since 2005 progress can be seen in words, resource allocation, and deeds.

Progress in Words

Leaders of the World Health Organization (WHO), UNICEF, and the World Bank have made public commitments to improve newborn health, raising the profile of the issue in these major institutions. In a symbolic but visible move, the government of India issued a national postage stamp highlighting the health of newborns and made a commitment to address “this national shame.”⁴

UNICEF’s new health and nutrition strategy now recognizes the importance of newborn survival for improving child survival rates, and “Strategic Guidance for Programming in Newborn Health” has been issued in partnership with Save the Children. WHO has also worked with regional and country health advisors to integrate newborn survival into child survival programs.

In addition, the Integrated Management of Childhood Illness (IMCI)—a global strategy established by WHO and UNICEF—has now added a module that was previously missing to address newborn illness. WHO’s Making Pregnancy Safer program has recommended interventions for improving maternal and newborn health, adapted and expanded from the DCP2 newborn survival chapter, with additional programmatic guidance on place of care and provider.

Progress in Resource Allocation

International development funding flows are complex to track, and disaggregating newborn care investments from maternal health or child health is neither reliable nor helpful since newborn care is integral in both. Globally, the investment in general child survival has not been increasing, although large sums have been channeled through vertical global funds, for example for vaccines or malaria bednets, and some may be of direct or indirect benefit to newborn health. For example, the GAVI Alliance (formerly known as the Global Alliance for Vaccines and Immunisation) has earmarked $60 million to advance the elimination of neonatal tetanus.

The key to increased national funding is incorporating newborn health into larger national packages, and this is beginning to happen. For example, the World Bank has made new funding available for newborn health at the program level in some countries. It included interventions for newborn babies in a national project to rehabilitate health systems in the Democratic Republic of the Congo. The basis for the program design was a matrix of essential interventions organized along the time periods of the continuum of care—prepregnancy, during pregnancy, at birth, postnatal care, and child care. The matrix was also adapted from the matrix in the DCP2 newborn survival chapter with additions from The Lancet newborn and child survival series.

The Bill & Melinda Gates Foundation, which has funded much of the global newborn research and dissemination efforts to date, provided grants of $60 million to the Saving Newborn Lives Project and $24 million to Sure Start, a newborn survival project run by the U.S.-based organization, PATH (Program for Appropriate Technology in Health).

Progress in Deeds: Actions in Developing Countries

South Asia has the largest burden of newborn deaths, but most of the countries with the highest rates are in sub-Saharan Africa. Yet with many other competing priorities newborn survival had been invisible on the policy agenda.

In Asia, initiatives were already in place in many countries but have been strengthened in some countries and received major new impetus in other countries:

- India is in the process of training and deploying 300,000 village-based workers, with newborn care as a prime responsibility.

- Pakistan has expanded its successful Lady Health Workers program from 70,000 to 100,000 workers, and strengthened the tasks associated with newborn care, partly informed by an effectiveness trial.⁷ At the same time, the Ministry of Health added a new five-year program on maternal, neonatal, and child health with major new donor funding from the British and American governments.

- In Bangladesh, a comprehensive national policy now supports newborn health; newborn health indicators have been added to the national health information system; and 11 percent of the national health budget for training is allocated to newborn care.

In Africa since 2005, at least 20 countries requested technical assistance to integrate and scale up newborn health programs following the publication of The Lancet newborn survival series, the World Health Report, and DCP2.

Policy and program changes are underway in several countries:

- The government of Uganda in 2005 added a newborn health team to their maternal and child health programs in its health sector reform plan, and specific descriptions in the Health Sector Development Plan publications, attaching a budget line item for newborn health and an annual review process.

- The Kenyan Paediatric Society called for the creation of a national newborn survival group, and a review of policies and programs is underway.

- The Tanzanian Ministry of Health is undertaking a national situation analysis in conjunction with the national MNC partnership and Saving Newborn Lives/Save the Children to design and implement integrated strategies to address newborn deaths. This process will feed into the national Integrated MNC Roadmap, developed in 2007 by the government with inputs from the Partnership for Maternal, Neonatal, and Child Health. The decisionmaking is very decentralized, and district budgets are allocated on the basis of a district planning tool which matches local burden with the district budget. This district tool has now been adapted to show the large number of newborn deaths, and the interest of the district health planners in adding newborn health interventions has rapidly grown.

- The Ethiopian government is in the process of scaling up a comprehensive Health Extension Worker package and has already trained 15,000 of an expected 22,000 female extension workers. Their tasks include maternal, newborn, and child care. The national IMCI package has been adapted to include newborn care and preventive care, and renamed IMNCI (Integrated Management of Newborn and Childhood Illness) following India’s example.¹

The African RoadMap for Accelerating the Reduction of Maternal Deaths—a policy process approved by the African Union—now includes increased emphasis on newborn survival. The RoadMap involves a systematic, stepwise approach to developing, funding, and implementing a national plan. Within 2 years of its launch in 2004, at least 42 African countries have begun the process, and plans are in place in 12 countries. A number of countries—for example Malawi and Tanzania—have attracted new donor funding to implement their national roadmap. Getting results will require strong operational plans, good management, and increased investment given the challenges of lack of human resources and infrastructure, particularly in rural areas in Africa where mortality risks are highest for mothers and babies.

Progress for newborn health in Africa has also been accelerated by the publication and ownership process for Opportunities for Africa’s Newborns.⁸ This book was authored by 60 leading policy and program experts working in or for Africa. Chapters on each of the nine programs related to newborn health examine gaps and opportunities to add and strengthen newborn care and build stronger health systems. One-page data profiles for each of 46 African countries highlight the deaths of mothers, newborns, and children; progress towards the Millennium Development Goals; and coverage of essential care. Wide ownership by the 14 organizations and agencies that were part of the process has been essential to dissemination and ongoing policy and program action.

Tracking Results – Every Baby Counts

Newborn survival advocates recognize the importance of measuring results to hold governments accountable and ensure follow-through on commitments. The Millennium Task Force charged with Goal 4 (Child Survival) and Goal 5 (maternal survival) of the Millennium Development Goals, recommended adding the neonatal mortality rate (NMR) as a core indicator for Goal 4. While this is under consideration, the UN agencies as well as the Countdown to 2015 process have put the neonatal mortality rate on the list of indicators that are essential to track annually in some lists even in preference to the infant mortality rate. Infant and under-five mortality rates tend to run parallel, whereas under-five and NMR may show very different progress, with neonatal being slower and requiring additional solutions. Hence neonatal mortality information is of more policy and programmatic value. Until now NMRs for each country have only been released by WHO every 10 years, and this lack of data has obscured the problem of newborn deaths. From the 2007 report on, UNICEF’s State of the World’s Children will include NMRs every year.

The biannual Countdown to 2015 process had added new indicators for monitoring newborn coverage of care. Large-scale, nationally representative household surveys, such as the Demographic and Health Surveys and UNICEF’s Multiple Indicator Cluster Surveys, are also adding more newborn-related questions to their survey instruments.

More Progress Is Needed

Until recently newborn deaths were not listed in most documents regarding child survival or safe motherhood, global estimates of cause of death were not available, and estimated numbers of death were not known. Within a short period of perhaps two years, rapid changes in words, and to a lesser extent in funding and deeds, have been evident. This progress is partly due to the sudden realization of the large numbers of deaths which had previously been missed, but also because of integrated solutions and consistent messages across several important and well disseminated publications. But to date, have the investments and progress made been adequate? The answer is a clear “no.” Governments around the world continue to invest large sums of money in expensive solutions that address relatively low numbers of deaths, such as high-technology interventions for the less treatable cancers, while newborn babies die invisibly in their homes.

So far, few donor organizations aside from the Bill & Melinda Gates Foundation have invested significant resources to save newborn lives. Discussions about newborn health have not risen to the level of world leaders and finance ministers in the way that AIDS, malaria, and tuberculosis have. Integrating newborn care into maternal, newborn, and child health policies and programs and seizing existing opportunities could save many lives at small marginal cost, such as less than 10 cents per capita to add newborn care to IMCI. But this requires more than money—attention and active champions are needed. Given the 10,000 newborn deaths that occur every day and the low cost of available solutions, resource allocation and action for newborn health is not yet commensurate with the size of the problem or the low cost of the solutions.

 

 

Reference List

(1) Lawn J.E., J. Zupan, G. Begkoyian, and R. Knippenberg. 2005. "Newborn Survival." In Disease Control Priorities in Developing Countries. 2 ed., ed. D.T.Jamison, J.G.Breman, A.R.Measham, G.Alleyne, M.Claeson, D.B.Evans, P.Jha, A.Mills, P.Musgrove, Chapter 27 pp. 531-549. New York: Oxford University Press.

(2) Darmstadt G.L., Z.A. Bhutta, S. Cousens, T. Adam, N. Walker, and L. De Bernis. “Evidence-based, cost-effective interventions: how many newborn babies can we save?” The Lancet 2005; 365(9463):977-988.

(3) Lawn J.E., S. Cousens, and J. Zupan. “4 million neonatal deaths: When? Where? Why?” The Lancet 2005; 365(9462):891-900.

(4) Lawn J.E., S.N. Cousens, G.L. Darmstadt, Z.A. Bhutta, J. Martines, V. Paul et al. “1 year after The Lancet Neonatal Survival Series—was the call for action heard?” The Lancet 2006; 367(9521):1541-1547.

(5) World Health Organization (WHO). 2005. The World Health Report: Make Every Mother and Child Count. Geneva, Switzerland, WHO. Ref Type: Report

(6) Lawn J.E., K. Wilczynska-Ketende, and S.N. Cousens. “Estimating the causes of 4 million neonatal deaths in the year 2000.” International Journal of Epidemiology 2006; 35(3):706-718.

(7) Haines A., D. Saunders, A.K. Rowe, J.E. Lawn, S. Jan, D. Walker et al. “Achieving child survival goals: potential contribution of community health workers.” The Lancet. In press 2006.

(8) Lawn J.E., K. Kerber, eds. Opportunities for Africa's Newborns: practical data, policy and programmatic support for newborn care in Africa. Cape Town: PMNCH, Save the Children, UNFPA, UNICEF, USAID, WHO; 2006.