Why do newborn deaths occur?

JOY LAWN: Now we move onto, why do newborn deaths occur? Now part of the problem for newborns is that the global pie chart for causes of child death– which was used until as recently as 2005– totally hid newborns. So if you look at this pie chart– and in epidemiology 101 we learn that any pie chart where ‘other’ is the biggest slice is not a useful pie chart– and in this pie chart, between ‘other’ and ‘perinatal causes’, are around 36% of deaths happening in the neonatal period, without clearly defined causes that can be addressed. And perinatal causes is just what happens to be in the WHO ICD-10 chapter called ‘P causes’.

So it’s some codes, specific codes, for neonatal cause of death, but isn’t something that the average policy maker understands looking at this pie chart. So until relatively recently, it’s not surprising that either the proportion of deaths that were neonatal– It’s not surprising that it wasn’t clear what proportion of deaths were neonatal, but also, it wasn’t clear that there were programmatic and addressable causes. So moving forward and leaping lightly through about four years of very painful analysis, a pie chart, at global level, was published in The Lancet Neonatal Series in 2005, and also in the World Health Assembly report that year.

And this pie chart took estimates from 195 countries and was able to split out the causes, programmatically relevant causes, of neonatal deaths within this time period. And as we have moved forward, WHO have carried on, leading those estimates with academics working with them, many from The London School involved in this. And generating estimates for under five deaths each year, by each country, also with neonatal deaths. And these estimates show that around 44%, in fact more than that now, of child deaths are in the neonatal period. And in this nicely yellow, jaundice looking slice, we can see there are specific causes. And the leading cause of not just newborn deaths, but child deaths, is now preterm complications.

Now this is a critical message. So, if you speak to the average high level policy maker, including some eminent global philanthropists who fund a lot of this work, such as Bill Gates, and say, what are the main causes of child death, most of them will still say infections. They’ll tell you about malaria, or HIV, vaccines. And we’re going to be studying next week, about infectious diseases. And because of great progress in reducing these, still an unfinished agenda but great progress, a lack of progress in this time period, more of the deaths are in the neonatal period. And particularly, preterm birth, which has had one of the slowest rates of change, is now the leading overall cause of child deaths.

And this signifies a transition. An epidemiological transition for the child, particularly, where infectious diseases still remain. But shifting not just to deaths within the neonatal period, but to ones where we have to do something differently also, with maternal health through the life cycle and care. The other leading causes here, intrapartum related events, what used to be called birth asphyxia. So birth asphyxia simply means not breathing at birth, can also happen because you’re extremely preterm. And what we’re trying to do here is to split out those term babies that have a hypoxic related intrapartum event.

And then there’s a large slice here if you put the infections together, particularly the pneumonia, the sepsis, and some of the other syndromes where– we’re just grouping this as a syndromic diagnosis, and we really need to be able to move to much better studies looking at aetiology. And better reporting and analysis of this is critical and is something that is raising up the global agenda. So these are the current causes of neonatal deaths, showing a really critical piece of information that’s, actually, poorly understood still at higher level policy.

But if we look at how this varies around the world, so what this stacked bar chart shows you is on the left hand side, all the countries that have a neonatal mortality rate of less than five. And this is basically industrialised countries. Going through to the right hand side with all the countries that have a neonatal mortality rate of more than 30. So this is predominantly in Sub-Saharan Africa and south Asia. And looking at this, it’s very clear that while preterm birth is still the leading cause in each of these places, so the pink and the purple bar in the middle here is still the biggest group, but the proportion that are attributed to infections is very different.

So in high mortality settings, we still have many babies who are dying needlessly from lack of prevention of infection, so clean birth, breastfeeding, and so on, but also treatment. So giving antibiotics to these babies, identifying them, treating them, and providing the antibiotic and supportive care that are needed. And this is the single biggest disparity across the neonatal period for cause-specific mortality. A 30 fold risk in dying from neonatal sepsis if you’re in a rich country, through to these lower income, lower resource settings, and this is the first thing we should be acting on.

Tetanus has made remarkable progress, not just because we have an immunisation, but because data has been used to ensure that every district is reached with that immunisation target. So not only knowing what the causes are, but having the data to be able to drive coverage is really critical. So this is variation in causes of neonatal mortality, but I want to underline, particularly, this survival gap. So around the world, if you take a preterm baby, over 90% of preterm babies less than 28 weeks will survive in a high income country, even less than 25 weeks. But if we go to a low income setting, less than 10% of these are surviving. And this isn’t just about intensive care.

It’s about the lack of effective care

of small and sick newborns: warmth, feeding support, prevention and management of infections.