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chapter tive newborns no longer going unnoticed Each year nearly 3.3 million babies are stillborn, and more than 4 million others die within 28 days of coming into the world. Deaths of babies during this neonatal period are as numerous as those in the next 11 months or those among children aged 1-4 years. Until recently there has been little real effort to tackle the specific health problems of newborns systematically; the care of the newborn has fallen through the cracks, as the continuity between maternal and child health programmes is often inadequate. Improving the health of newborns, however, does not just mean inserting a new programme: rather, it means adapting the efforts of maternal and child programmes as to scale up services in a seamless continuum of care. this chapter ends by presenting a set of benchmarks and scenarios for scaling up access to both maternal and newborn care, with estimates of the costs that such scenarios would entail THE GREATEST RISKS TO LIFE he conditions causing newborn deaths can also result ARE IN ITS BEGINNING in severe and lifelong disability in babies who survive Although a good start in life begins well before birth, it is just before, While data are limited, it is estimated that each year during, and in the very first hours and days after birth that life is most over a million children who survive birth asphyxia de- at risk. Babies continue to be very vulnerable throughout their first velop problems such as cerebral palsy, learning difficul- week of life, after which their chances of survival improve markedly ties and other disabilities (1). Babies born prematurely (see Figure 5.1) or with low birth weight are more vulnerable to illnesses Globally, the largest numbers of babies die in the South-East Asia in later childhood (2) and often experience impaired Region: 1.4 million newborn deaths and a further 1.3 million stillbirths cognitive development (3). There are indications that each year. But while the actual number of deaths is highest in Asia, poor fetal growth during pregnancy may trigger the de- the rates for both neonatal deaths and stillbirths are greatest in sub- velopment of diabetes, high blood pressure and cardio- Saharan Africa. Of the 20 countries with the highest neonatal mortality vascular disease, consequences that become apparent ates, 16 are in this part of the world. only at a much later age(4 Rubella virus infection dur-
79 chapter five newborns: no longer going unnoticed Each year nearly 3.3 million babies are stillborn, and more than 4 million others die within 28 days of coming into the world. Deaths of babies during this neonatal period are as numerous as those in the next 11 months or those among children aged 1–4 years. Until recently there has been little real effort to tackle the specific health problems of newborns systematically; the care of the newborn has fallen through the cracks, as the continuity between maternal and child health programmes is often inadequate. Improving the health of newborns, however, does not just mean inserting a new programme: rather, it means adapting the efforts of maternal and child programmes so as to scale up services in a seamless continuum of care. This chapter ends by presenting a set of benchmarks and scenarios for scaling up access to both maternal and newborn care, with estimates of the costs that such scenarios would entail. THE GREATEST RISKS TO LIFE ARE IN ITS BEGINNING Although a good start in life begins well before birth, it is just before, during, and in the very first hours and days after birth that life is most at risk. Babies continue to be very vulnerable throughout their first week of life, after which their chances of survival improve markedly (see Figure 5.1). Globally, the largest numbers of babies die in the South-East Asia Region: 1.4 million newborn deaths and a further 1.3 million stillbirths each year. But while the actual number of deaths is highest in Asia, the rates for both neonatal deaths and stillbirths are greatest in subSaharan Africa. Of the 20 countries with the highest neonatal mortality rates, 16 are in this part of the world. The conditions causing newborn deaths can also result in severe and lifelong disability in babies who survive. While data are limited, it is estimated that each year over a million children who survive birth asphyxia develop problems such as cerebral palsy, learning difficulties and other disabilities (1). Babies born prematurely or with low birth weight are more vulnerable to illnesses in later childhood (2) and often experience impaired cognitive development (3). There are indications that poor fetal growth during pregnancy may trigger the development of diabetes, high blood pressure and cardiovascular disease, consequences that become apparent only at a much later age (4). Rubella virus infection dur-
80 The World Health Report 2005 Figure 5. 1 Deaths before five years of age, 2000 ing pregnancy can lead to miscarriage and stillbirth, but also to congenital de tal retardation and heart disease. about 100 000 babies each year are born with congenital rubella syndrome, which is Newborns die from different causes than older children; only pneumonia and respiratory tract infections are common to in weeks both. older infants and children in devel Deaths 1-4 years 23% oping countries generally die of infectious diseases such as acute respiratory infec Postneonatal deaths 2896 tions diarrhoea measles and malaria These diseases are responsible for a much smaller proportion of deaths in newborns Early neonatal deaths 21% deaths from diarrhoea are much less com- Stillbirths 21% mon., and measles and malaria are ex tremely rare. The interventions designed to prevent and treat these conditions in older infants and children have less impact on deaths within the first month of life. Prematurity and congenital anomalies account for more than one third of newborn deaths, and these often occur in the first week of life. a further quarter of neonatal deaths are attributable to asphyxia- also mainly in the first week of life. In the late neonatal period, that is, after the first week, deaths attributable to infection(including igure 5.2 Number of neonatal deaths by cause, 2000-2003 Diarrhoeal □ Neonatal te other neonatal ca □ Severe infection □ Preterm South-East Asia astern Western Pacific Americas Europe
80 The World Health Report 2005 ing pregnancy can lead to miscarriage and stillbirth, but also to congenital defects, including deafness, cataract, mental retardation and heart disease. About 100 000 babies each year are born with congenital rubella syndrome, which is avoidable through widespread introduction of rubella vaccine. Newborns die from different causes than older children; only pneumonia and respiratory tract infections are common to both. Older infants and children in developing countries generally die of infectious diseases such as acute respiratory infections, diarrhoea, measles and malaria. These diseases are responsible for a much smaller proportion of deaths in newborns: deaths from diarrhoea are much less common, and measles and malaria are extremely rare. The interventions designed to prevent and treat these conditions in older infants and children have less impact on deaths within the first month of life. Prematurity and congenital anomalies account for more than one third of newborn deaths, and these often occur in the first week of life. A further quarter of neonatal deaths are attributable to asphyxia – also mainly in the first week of life. In the late neonatal period, that is, after the first week, deaths attributable to infection (including Age in weeks Risk of dying Stillbirths 21% Early neonatal deaths 21% Late neonatal deaths 7% Postneonatal deaths 28% Deaths 1–4 years 23% Figure 5.1 Deaths before five years of age, 2000 Neonatal deaths (thousands) South-East Asia Diarrhoeal diseases Neonatal tetanus 1600 Figure 5.2 Number of neonatal deaths by cause, 2000–2003 Congenital anomalies Other neonatal causes Asphyxia Severe infection Preterm 1400 1200 1000 800 600 400 200 0 Africa Eastern Mediterranean Western Pacific Americas Europe
newborns: no longer going unnoticed 81 diarrhoea and tetanus) predominate; together, these causes are responsible for more than one third of newborn deaths. The importance of tetanus as a cause of neonatal death, however, has diminished sharply, thanks to intensified immunization efforts. Direct causes of newborn death vary from region to region (see Figure 5.2). In gen eral, the proportions of deaths attributed to prematurity and congenital disorders in- crease as the neonatal mortality rate decreases, while the proportions caused by infections, asphyxia, diarrhoea and tetanus decline as care improves Patterns of low birth weight vary considerably between countries (5). Babies with a low birth weight are especially vulnerable to the hazards of the first hours and days of life, particu arly if they are premature. The majority of low-birth-weight babies are not actually premature but have suffered from in utero growth restriction, usually because of the mother's poor health. These babies too are at increased The main causes of neonatal mortality are intrinsically linked to the health of the mother and the care she receives before, during and immediately after giving birth Asphyxia and birth injuries usually result from poorly managed labour and delivery and lack of access to obstetric services. Many neonatal infections, such as tetanus and congenital syphilis, can be prevented by care during pregnancy and childbirth. Inad equate calorie or micronutrient intake also results in poorer pregnancy outcomes (6) It has been argued that nearly three quarters of all neonatal deaths could be prevented if women were adequately nourished and received appropriate care during pregnancy childbirth and the postnatal period (7 Figure 5. 3 Changes in neonatal mortality rates between 1995 and 2000 □1995口200 82 13 South-East Westem Pacific Americas Europe Mediterranean on differed slightly in 1995 and 2000
newborns: no longer going unnoticed 81 diarrhoea and tetanus) predominate; together, these causes are responsible for more than one third of newborn deaths. The importance of tetanus as a cause of neonatal death, however, has diminished sharply, thanks to intensified immunization efforts. Direct causes of newborn death vary from region to region (see Figure 5.2). In general, the proportions of deaths attributed to prematurity and congenital disorders increase as the neonatal mortality rate decreases, while the proportions caused by infections, asphyxia, diarrhoea and tetanus decline as care improves. Patterns of low birth weight vary considerably between countries (5). Babies with a low birth weight are especially vulnerable to the hazards of the first hours and days of life, particularly if they are premature. The majority of low-birth-weight babies are not actually premature but have suffered from in utero growth restriction, usually because of the mother’s poor health. These babies too are at increased risk of death. The main causes of neonatal mortality are intrinsically linked to the health of the mother and the care she receives before, during and immediately after giving birth. Asphyxia and birth injuries usually result from poorly managed labour and delivery and lack of access to obstetric services. Many neonatal infections, such as tetanus and congenital syphilis, can be prevented by care during pregnancy and childbirth. Inadequate calorie or micronutrient intake also results in poorer pregnancy outcomes (6). It has been argued that nearly three quarters of all neonatal deaths could be prevented if women were adequately nourished and received appropriate care during pregnancy, childbirth and the postnatal period (7). Figure 5.3 Changes in neonatal mortality rates between 1995 and 2000a � �� �� �� �� Africa Eastern Mediterranean South-East Asia Western Pacific Americas Europe World Neonatal deaths per 1000 live births 1995 2000 � Methods of calculation differed slightly in 1995 and 2000
82 The World Health Report 2005 PROGRESS AND SOME REVERSALS Neonatal mortality has not been measured for long enough to reach reliable conclu- sions on trends, but WHO estimates from 1995 to 2000 suggest that most countries in the Region of the Americas, and the South-East Asia, European and Western Pacific Regions have made some progress in reducing the mortality rate among newborns (see Figure 5.3). Improvements may have been less marked in the Eastern Mediter- rican Region may actually have experienced an increase in its neonatal mortality rate Consecutive household surveys from 34 developing countries show that most exper- ienced a decrease in neonatal mortality over recent decades. Much of the progress in survival has been made in the late neonatal period, with little improvement in the first week of life (8). This echoes the historical experience of many developed coun tries, where neonatal mortality (and particularly early neonatal mortality) did not begin to fall substantially until some years after a decline in post-neonatal and childhood mortality had been achieved (9) In many countries, neonatal mortality has fallen at a lower rate than either post-neonatal or early childhood mortality(10-12) Household surveys also suggest that there has been reversal and stagnation in ewborn mortality across sub-Saharan Africa since the beginning of the 1990s(see Figure 5.4). Indeed, the actual number of deaths has increased substantially in the African Region. In only five years, the dramatic drop in deaths in South-East Asia has meant that this region no longer has the highest neonatal mortality rate in the world this place has been taken by Africa, where almost 30% of newbon deaths now occur. Figure 5. 4 Neonatal mortality in African countries shows stagnation and some unusual reversals .... Benin g 0 1976 1981 2001
82 The World Health Report 2005 PROGRESS AND SOME REVERSALS Neonatal mortality has not been measured for long enough to reach reliable conclusions on trends, but WHO estimates from 1995 to 2000 suggest that most countries in the Region of the Americas, and the South-East Asia, European and Western Pacific Regions have made some progress in reducing the mortality rate among newborns (see Figure 5.3). Improvements may have been less marked in the Eastern Mediterranean Region (but regional averages mask variations between countries), and the African Region may actually have experienced an increase in its neonatal mortality rate. Consecutive household surveys from 34 developing countries show that most experienced a decrease in neonatal mortality over recent decades. Much of the progress in survival has been made in the late neonatal period, with little improvement in the first week of life (8). This echoes the historical experience of many developed countries, where neonatal mortality (and particularly early neonatal mortality) did not begin to fall substantially until some years after a decline in post-neonatal and childhood mortality had been achieved (9). In many countries, neonatal mortality has fallen at a lower rate than either post-neonatal or early childhood mortality (10–12). Household surveys also suggest that there has been reversal and stagnation in newborn mortality across sub-Saharan Africa since the beginning of the 1990s (see Figure 5.4). Indeed, the actual number of deaths has increased substantially in the African Region. In only five years, the dramatic drop in deaths in South-East Asia has meant that this region no longer has the highest neonatal mortality rate in the world; this place has been taken by Africa, where almost 30% of newborn deaths now occur. Figure 5.4 Neonatal mortality in African countries shows stagnation and some unusual reversals Data source: (10). Neonatal deaths per 1000 live births Côte d'Ivoire Mali Benin Cameroon Uganda Kenya 0 10 20 30 40 50 60 70 1976 1981 1986 1991 1996 2001