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Where and when do they die?

Listen to Professor Joy Lawn describe where and when newborn deaths and and stillbirths occur.
JOY LAWN: So in this step, we will look at more of the data to inform action– where, when, and why do these deaths occur, starting with where. These 10 countries alone account for 2/3 of neonatal deaths worldwide and also around 60% of the worlds maternal deaths. But sometimes, not counted are 2/3 of the global total of stillbirths also occurring in these countries. And you may say, well, this is obvious. These countries have the biggest number of births. But it isn’t births alone that determine either the situation on this list or also progress over time. So for example, India and China have a similar number of total population.
However, in China, both the risk for neonatal deaths, for stillbirths, and for maternal deaths have reduced overtime, but so has the number of births. And so China has dropped further down this list. In fact, Brazil has graduated from this list of top 10 within the last decade by reducing both unwanted pregnancies and the risk for women and their babies. So these 10 countries alone are the biggest numbers. But if we shift from the biggest numbers alone to also thinking about risk– on this map, we can see the red countries. Darker red is higher risk. The blue countries are those with the biggest numbers, so India alone with almost 800,000 newborn deaths every year.
Not a top position that India would want to be proud of. So the good news, on the right-hand side here, is that you can see that of these 10 countries with the highest numbers of deaths, in fact, many of them are now coloured in blue. So in the short amount of time since the Every Newborn Action Plan was launched, each of these countries has made a major shift in what they’re going to do for newborn deaths. India has taken a very ambitious plan to get to a single-digit neonatal mortality rate by 2030, to get to 9 by 2030, with a plan that involves a comprehensive scale up of facility-based maternal and newborn care, but also community linkages.
And so this is the good news. With these top 10 countries, many of them are really poised for significant change in the years ahead. But if we turn to the other side and look at the countries with the highest neonatal mortality rates, the riskiest places in the world to be born, what we can see is the riskiest place to be a baby is in Sierra Leone. And for at least the last five years, we have been saying that your neonatal mortality rate is your most sensitive outcome indicator of the quality of your health system. What a health system does for a newborn baby, who’s your most vulnerable user of the health system, is a sensitive marker.
But in fact, that baby, with no noise, literally a non-crying baby has not been heard in the data. But over the last year or so, the noise that is made by Ebola, which has been a catastrophic disaster in Sierra Leone, has brought onto the global agenda the weaknesses of this health system and the critical issue of dealing with that. And yet to keep this in perspective, all the Ebola deaths so far in this epidemic are similar to the global number of newborn deaths in one day. So if our health systems are equitable and are addressing the things that matter, things that don’t make a noise should also be counted.
And in the post-Ebola reconstruction phase in West Africa and the improved surveillance of health systems that go forward, there are opportunities to also improve outcomes for maternal and newborn deaths. And so as we move from the countries with the highest risk and the greatest numbers and look forward– looking forward, we want to say, which of these countries are moving the slowest now, and what can be done to change those? And as someone who is an African, it’s sad to see that Africa has both the highest rates, the darkest red on the last map, but also the slowest progress, the darkest red on this map.
And we have seen that it will take at least 110 years, with current rates of change, for Africa to reach the same risk of newborn deaths as the highest income countries. So this is something that urgently needs to be changed. So what’s the best way to change that? Well, it’s to look at what your neighbours are doing. So in each of these regions, there are countries that are making rapid progress. So for example, over the lifespan of the Millennium Development Goals, Malawi has made the most consistent and more rapid progress than their neighbours for reducing neonatal mortality rate, an average of 3.2% per year over this time period. And Malawi is one of the lowest income countries in Africa.
At the start of this time period, it had probably– if not the lowest, one of the lowest human resource densities, and yet this has been intentionally changed over this time. We will be looking later this week at Peru and trying to understand what they have done. Nepal also has shown dynamic leadership and innovation, particularly at community level. So Malawi may have worked more at facility level, Nepal at community level. And both these are needed and make progress. And then in terms of when these deaths occur– and this is a really critical message. In your whole human lifespan, your riskiest day of death is the day you are born.
75% of newborn deaths, so deaths in the first month of life, of those, 75% happen in the first week. But most shockingly, around 40% happen on the first day. So 1 million babies who die on their birth day, their only day of life. And this coincides with the time when intrapartum stillbirths occur, babies who die during labor, and also the highest risk for maternal deaths. So the pessimist view here is that your birth day is your greatest risk of death and disability. The optimist view here is that if you invest in this critical day, you’re getting a triple return on investment.
Maternal lives saved, stillbirths averted, neonatal deaths– or even a quadruple return if you count the critical risk to disability on this day. So when to invest? Birth is the most risky, but also the greatest investment return in the whole of your lifecycle.

The riskiest day to die is that on which you are born, and 40% of newborn deaths occur at this time.

Ten countries account for around two-thirds of the world’s neonatal deaths and stillbirths. However, total population size and a high birth rate are not simple or direct explanations for this. Some very populous nations have quite rapidly reduced their risk of neonatal mortality over time through successful implementation of family planning strategies, for example.

We know it is important to understand where and when these deaths occur, so why do you think birth is the riskiest time of life for death and future disability? How can an increased focus on quality of care at birth offer a return on investment?

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