Lawn, J. E., Cousens, S., & Zupan, J., for the Lancet Neonatal Survival Steering Team. (2005). Lancet, 365, 891-900.
To reduce neonatal mortality in the developing world, two interlinked processes are required. Shiffman's article reviewed in this column deals with the policy process of getting leaders to make health issues a political priority. The second process involves data and strategies, which is what this article by Lawn and colleagues addresses.
Most neonatal deaths (99%) occur in low- and middle-income countries where there is no formal registration system. Hence, global analysis must be based on estimates. These estimates indicate that 38% of child deaths occur in the neonatal period (the first month of life), and decreasing deaths in the first week of life have shown the least progress. Every year, 4 million babies die in the first 4 weeks of life-a number double the deaths caused by HIV/AIDS. The highest numbers of neonatal deaths are in south-central Asian countries, and the highest rates are generally in sub-Saharan Africa. Estimates indicate that the direct causes of neonatal death are preterm birth (28%), severe infections (26%), and asphyxia (23%), although hypothermia, tetanus, HIV/AIDS, and congenital anomalies also contribute, although allocating one death to one cause is somewhat artificial because many of these deaths are caused by multiple interacting causes. Poverty remains an underlying cause of many of these deaths; hence, rates vary within developing countries between the richest and poorest segments of the population.
So, what to do? One of the most important strategies seems to be ensuring that women deliver with a skilled birth attendant. Globally, 56% of women deliver with a skilled attendant, but in areas with the highest neonatal mortality rates only 30% (south Asia) to 40% (sub-Saharan Africa) of women deliver with skilled care. In countries with the highest mortality rates, an average of 14% of women have skilled care at birth; however, training birth attendants-even if available-is not the only answer. First of all, in the past, brief birth attendant training did not help because attendants were left unsupervised and without links to a referral system when problems arose. The second problem is the competition for resources of many needed interventions: drugs to prevent vertical AIDS transmission, training for traditional birth attendants, investing in systems of community care programs, and money to ensure coordination between safe motherhood and child survival programs.
Other articles in this Lancet series (see all 4 March 2005 issues) are important for understanding the problems and solutions for maternal/child health in the developing world. Of particular interest is the detailed analysis of different strategies for different countries depending on the nature of the problem and the neonatal mortality rates (rates over 45, from 30-45, from 15-29, and under 15). Strategies are grouped into family and community care (e.g., home visiting to promote breastfeeding, thermal care, cord care), population-oriented outreach services (e.g., family planning and immunizations), and individual-oriented clinical care (e.g., skilled birth attendants and connections to referral hospitals). These are complex solutions to a complex problem, but when 450 newborn children die every hour, mainly from preventable causes, something must be done.
Linda Beth Tiedje