Newborn deaths: targets, where, why and what to do?

JOY LAWN: In this section, we’re going to look at newborn deaths, the targets of where we need to get to, and the data that we have to drive that change.

This target of 3.2 is part of the one Sustainable Development Goal target on health to end preventable child deaths and, for the first time in history, has a particular focus on newborn deaths to reach a national target every country of the world with a neonatal mortality rate of 12 or less per 1,000 live births in 2030. And this target came from many consultations in country and was published in The Lancet in 2014. The thing is that 100 countries are already below that. And it’s really important to recognise that 12 is not the end of the line because there are countries with neonatal mortality rates of one or two.

So there are still many preventable newborn deaths below the level of 12 and these 100 countries that are already below 12 must carry on pressing forward as fast as they can to close that survival gap for preventable newborn deaths and also in equity gap because it’s usually the poorest families that are left behind. At the other side of that spectrum, the countries with the highest mortality now have the furthest to go in such a short time, only about 10 years ahead. So there are at least 40 countries that need to double their rates of progress. And that includes the country of my birth, Uganda.

However, the most exciting thing is that for the first time in history, not only is there a goal, but there are also countries that are seriously committed to acting to reach those targets. So for the 90 high-burden countries, there are at least 78 that have set a newborn survival target for the year 2030. These countries are really pressing forward to have plans and to do more. This gives us an opportunity like never before. So what data do we have to help drive that change? Where, when, and why did these newborns die? First of all, where?

So this map shows colours of countries based on green, the darkest green, those who are the fastest reducing for newborn deaths, and dark orange, those that are moving the slowest since 2000 until now. So for the two continents that currently have the highest rates of newborn deaths, Africa and Southern Asia, unfortunately, many of the countries are also the slowest reducing. However, in every single one of these continents, there are countries and at least one country that is a fast progressor. So, for example, in Southern Asia, Bangladesh has made remarkable progress on reducing newborn deaths. In sub-Saharan Africa, Rwanda has been the fastest over the last two decades. And all of us can always learn from our neighbours.

And then if we look globally at the 10 fastest progresses for reducing newborn deaths, all of these countries, from China through to Russia, have made significant implementation efforts for care of small and sick newborn in hospital. So this is a fundamental need for getting to lower levels of neonatal mortality. Moving from where to when, your birth day is your day of highest risk. Every year, one million newborns die on their birthday, their only day. And that same day of birth is also the greatest risk for stillbirths, 1.3 million intrapartum stillbirths happening during labour, and the greatest risk for maternal deaths.

And the reason for this large number of deaths is the sensitivity to quality of care, particularly urgency and timing, because women will die within hours, for example, from postpartum haemorrhage. And babies will die within minutes if not resuscitated or if have complications of preterm birth. So this is the time of greatest risk of death and also of disability of brain injury.

However, the optimist angle on that is this is also the time with the greatest return on investment for maternal deaths, maternal health, for reducing stillbirths, for reducing newborn deaths, and also critically for long-term child development and adult health. A wonderful moment that investment will repay.

So moving forward from where and when to why. Why do children die? Children under five years of age– this is the latest cause of death pie. And often, we live in a pie from the past. So we can see that around a quarter of these deaths are due to infections. Critical to still address these. Unacceptable that children are still dying of pneumonia. Around a quarter of chronic infections, chronic conditions, such as cancer or injury or congenital conditions. But strikingly, around half of newborn deaths, 2.5 million worldwide– and, in fact, in Southern Asia, around 60% of under 5 deaths are in the neonatal period. So child survival goals cannot be met without lots more attention to this time period.

And they’re not the same causes of death. And so they do need different strategies and knowledge of how to craft those and put those within health systems and make them work. So the leading cause of deaths for children not just within the neonatal period but for all of childhood up to the age of 5 are preterm births. So preterm direct causes of death include respiratory distress syndrome for babies who their lungs are too immature to breathe well, but also many other aspects of immaturity. For example, vulnerability to infections, jaundice, and other direct complications. Then complications from birth– term or near term babies that have brain injuries, particularly from hypoxic insults during delivery. Neonatal infections.

A large number of deaths, different organisms. Some of these are hospital-acquired. Some, at home. Early-onset sepsis, for example, from group B streptococcus we now know occurs all over the world. And innovations, such as immunisation, could play a significant role in reducing burden. Congenital conditions. Also important to recognise preventability, notably, for example, folic acid fortification for prevention of neural tube defects. So what to do to end these preventable newborn deaths within the next decade?

Moving forward, it’s always good to look back and learn from history. And we should learn from history what not to do as well as what to do. And this graph shows the UK and the US from 1900, so almost ancient history now, with the trends for what happened for neonatal mortality rate. And then the neonatal mortality rate currently in sub-Saharan Africa and Southern Asia is just under 30. So that same level was seen in the UK and the US just before the Second World War. So the time between 1940 and close to 1980 when those countries hit the target of neonatal mortality rate of 12– that’s around 40 years.

And what we need to do now is to make that progress within 10 years for many countries in sub-Saharan Africa and South Asia. We have more in our hands. We have more evidence. We have both tools and systems solutions that can be applied. But we need to understand how we’re going to do that. So the first phase here is public health approaches. And this includes breastfeeding. It includes infection prevention, particularly around the time of birth, cord care, preventing neonatal tetanus, including immunizations, things that are in the control of women and families, notably breastfeeding. The second phase– really critical– improved care during pregnancy and at the time of birth for the mother and also for the baby.

This is fundamental and makes a really significant difference and is impossible to achieve later phases without doing this well. And then the last phase, special and intensive newborn care, taking those small and sick vulnerable newborns and providing the necessary care. We cannot get to below probably 15 per 1,000 neonatal mortality rate without bringing small and sick newborn care to scale. Things to learn not to do. Really important to have a focus from the beginning on disability-free survival. For example, retinopathy of prematurity, marker of quality of care, and safety of oxygen use and the systems both to prevent and to address that so that we don’t create disability.

So what newborn care content do we need by levels of the health system? Here, we see that the bedrock is basic care for all newborns, then special care for vulnerable small and sick newborns, and then building on that, neonatal intensive care. At all levels, this principle of zero separation for the mother and her baby, skin to skin for all newborns with breastfeeding. And then for babies who are less than 2,000 grammes, kangaroo mother care has very strong evidence base for mortality reduction, for prevention of infections, for breastfeeding, and also for improved maternal mental health.

But as we come up to the scale up of neonatal intensive care, this requires critical attention to health systems, infrastructure, human resources, medical devices and supplies, and the information systems to track and to drive that change with safety and the principle of family-centred care. So to provide that, how many do we have to reach? Every year, 140 million newborns are born. 30 million of those will need some sort of special care– resuscitation at birth, infection treatment, kangaroo mother care. But eight to 10 million are at risk of dying without having intensive newborn care. And if we look at how that looks around the world in high income countries around 12 million births, lots of machines that go ping.

In the upper and middle income countries, we have most births now happening in hospital. Neonatal intensive care is available, although there may be cost barriers. And we have a double-edged sword with over-medicalization, lots of C-sections, and also some aspects of newborn care that maybe don’t empower families in the way that they should. And then if we come to lower and low and middle income countries, we have still 44 million births that are happening at home for the poorest and particularly in humanitarian settings. We have 45 million facility births where we have had this massive drive of births coming into hospitals. And yet, we have still not got the right space.

Maybe the newborn care ward is a sluice room off labour ward. We’re crowding babies– four per incubator, as you can see here. We have one oxygen cylinder with lots of tubing. Really, we are infecting babies often so that missed opportunities and quality gap is huge here. That’s the negative side. The positive side is if we could address this, we could dramatically reduce deaths for babies who are already in hospital. And this is one of those babies. Chigonjetso, one day old. Preterm, about 28 weeks gestation, so three months early. And to save him, we need technologies, yes, that are sustainable and that work and that people can use. But we need more than that. We need space. We need basic infrastructure.

We need health workers that are skilled. We need data systems to measure and to drive the change– also for disability-free survival. We need families involved. And we need a strong principle of do no harm. Here is Chigonjetso. And his name in Chichewa means the conqueror. Aged 2 years, thriving, almost smiling. And this is our vision that any child, wherever they are born, every newborn has the right to survive, to thrive, and to grow. Our generation has the potential to transform the health of all the world’s newborns. Will we deliver?