Volume 94, Issue 3 , Pages 269-276, September 2006
The right to a healthy newborn
Article Outline
- Abstract
- 1. The newborn's right to life
- 2. The case for newborn health
- 3. Interventions that work
- 4. Newborn health is a key to child survival
- 5. The way forward is continuum of care
- 6. Affecting change
- 7. The future of maternal, newborn, and child health
- References
- Copyright
Abstract
A woman's right to health includes her right to a healthy childbirth and newborn, and the baby possesses his or her own right to life as well. While overall child mortality has declined, 4 million newborns still die each year, primarily in the first days of life. Most could be prevented through existing, cost-effective interventions.
Field trials and programs show that low-cost, home- or community-based neonatal care can quickly lead to dramatic decline in neonatal mortality. Newborn health should be integrated with maternal and child health–and these programs should be strengthened and expanded–in order to achieve both the child and maternal survival Millennium Development Goals. Policies and programs should include participatory household and community-based care, with links to the formal health system.
Despite recent attention to newborn health, much remains to be done to achieve sustained, high coverage of effective interventions, especially in poor communities where most newborns are born and die, mostly in the first week of life.
Keywords: Newborn, Community-based, Cost-effective, Health, Interventions, Rights
A woman's right to health includes her right to have a healthy baby. Pregnancy and childbirth should not be a source of fear or apprehension for a woman, but rather a celebration of life. All mothers and newborns deserve competent care during pregnancy and childbirth, as well as immediately after birth when the greatest danger to the mother and child exists. Survival of humankind as a whole is simply impossible without protecting motherhood and saving newborn lives.
1. The newborn's right to life
Countless international agreements have affirmed and reaffirmed the world's commitment to improving the health of women and their children. The 1989 Convention on the Rights of the Child, ratified by every country in the world except two, reflected the international consensus on a new vision for children, where they were no longer simply objects of protection, but human beings with an equal right to health. This right is something a child is born with, and is the same for everyone, everywhere. Quite simply, this right cannot be taken away. The convention [1] states that “Parties recognize the right of the child to the enjoyment of the highest attainable standard of health… Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.” The fourth Millennium Development Goal (MDG-4) underlined this commitment to improve the health of infants and children, as countries pledged to reduce under-5 child mortality by two-thirds by 2015 from the 1990 baseline. Unfortunately, this goal simply cannot be met without reducing newborn mortality by at least one-half [2].
Although the world has begun to see significant improvements in child survival, the burden of mortality in the first month of life remains virtually unchanged. In Bolivia, for example, child mortality declined almost 30% from 1989 to 1998, while the country's neonatal mortality rate (NMR) dropped only 7% in these same years [3]. The right to life of the newborn–and the right of a mother to a safe pregnancy and a healthy baby–have all but been forgotten. Each year, 4 million newborns die–three-quarters during the first week–of which at least 1 million die in their first 24 h [4], [5]. To date, most child survival programs have been focused around causes of death after the first month of life—thus missing the critical window of opportunity to reduce a substantial number of deaths. At the same time, the proportion of deaths of children under the age of 5 that occur during the first 28 days of life has increased to almost 40%.
2. The case for newborn health
Some 99% of all newborn deaths occur in low- and middle-income countries, with two-thirds of those occurring in Asia and Africa [4], [5]. It is the poorest of the poor in these countries that bear the brunt of newborn mortality, and it is their right to a healthy newborn that is not being met (see Fig. 1) [3]. Given the disparity in neonatal outcomes between the rich and the poor (both between countries and within countries) improving newborn health should be part of any poverty reduction strategy. Most newborns die at home, in the absence of any contact with a skilled health provider. Many of the world's 4 million stillbirths and 500,000 maternal deaths also occur close to the time of birth, further increasing the importance of safe delivery. Complications related to pregnancy, delivery and infections each cause about one-third of newborn deaths, so interventions need to address both mothers and newborns.
Figure 1.
Neonatal mortality rates for poorest and richest wealth groups, selected countries. Source: Yinger NV, Ransom EI. Why Invest in Newborn Health? Washington, DC: Population Reference Bureau. 2003 based on data from ORC Macro, Demographic and Health Surveys. Analysis by Shea Rutstein.
Three causes–infections (36%), preterm birth/low birth weight (28%), and birth asphyxia or problems related to childbirth complications (23%)–account for 87% of all newborn deaths, with deaths in the first week largely due to prematurity and birth asphyxia (see Fig. 2) [5]. Most deaths after the first week of life are from entirely preventable infections. Almost one-quarter of newborns in developing countries already have their growth impaired at the time of birth, largely due to their mothers' poor nutritional status, thus resulting in higher risk of developmental problems and disease later in life [6]. Overall, low birth weight is the underlying cause of 40–80% of neonatal deaths.
Figure 2.
Causes of death in the first month of life. Source: Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet 2005; based on vital registration data for 45 countries and modeled estimates for 147 countries.
Families historically have not limited their fertility until they could trust that their babies would survive—in other words, until infant mortality declined. It is thus unlikely that families in many developing countries will reach a fertility rate low enough to yield a sustainable population size until newborn health and survival improves. Appropriately begun and continued, family planning can benefit both mothers and newborns. Birth intervals of less than 36 months significantly increase the risk of low birth weight, premature babies, and newborn death [7].
3. Interventions that work
Newborn health interventions often are described in terms of modes of delivery which, taken together, constitute a continuum of care from the household to the facility: family/community, outreach, and clinical care. Family/community care includes interventions such as birth and emergency preparedness, counseling on newborn care, clean delivery, skin and cord care, exclusive breastfeeding, and community case management of infections. These are all inexpensive, low-tech solutions that, even taken alone, have the potential to save newborn lives.
Outreach services, including antenatal care (e.g., tetanus immunization, management of syphilis, presumptive treatment of malaria, etc.), postnatal care and early detection and referral can also significantly contribute to the health of mothers and newborns. In Pakistan, for example, just implementing a tetanus immunization initiative prevented 14,000 neonatal deaths per year—cutting annual tetanus deaths from 28,000 to 14,000. Maternal health and health care are important determinants of newborn survival. Although newborn outcomes such as low birth weight are influenced by the mother's health and nutrition throughout her life cycle, complications during labor and delivery, particularly obstructed labor and malpresentation, present the greatest risks. Clinical care is an integral part of newborn care, as it addresses some of the most serious complications, including obstructed labor, infections and birth asphyxia through emergency obstetric and newborn care.
The appropriate provision of family/community and outreach services alone could reduce neonatal mortality by up to 40% [6]. Most newborn deaths due to infection could be prevented by simple, cost-effective interventions such as tetanus toxoid immunization, improved hygienic practices, and antibiotics. Most deaths in babies who are low birth weight (less than 2500 g), many of whom are also born prematurely, could be avoided with simple, home-based care such as breastfeeding, warming, and preventing (or immediately treating) infection. Saving lives from birth asphyxia requires the presence of a birth attendant who can resuscitate, as well as one skilled in obstetric care. As The Lancet Series on Neonatal Survival suggests, up to 72% (or almost 3 million deaths) could be prevented through basic, cost-effective interventions [8] (see Fig. 3). This proposition includes 16 inexpensive, low-tech interventions, which holistically approach the continuum from pregnancy through early infancy. These are all interventions that can be integrated into governmental and non-governmental programs immediately, while simultaneously working on more long-term health systems strengthening.
Figure 3.
Simple, effective newborn health interventions within the continuum of maternal and child health care. Source: Adapted from The Executive Summary of The Lancet Neonatal Survival Series (from the Series Team). Washington, DC: 2005. ⁎ Situational interventions necessary in certain settings, such as high malaria prevalence # Additional interventions for settings with stronger health systems and lower mortality.
Access and utilization of these interventions, however, remains low, especially among the poor. For example, a quarter of a million babies die every year from neonatal tetanus, which can be prevented by giving the mother two 20-cent injections before or during pregnancy [5]. Only 50% of mothers worldwide receive this tetanus toxoid immunization. Sepsis and pneumonia, which cause 26% of newborn deaths, can be treated easily with antibiotics, yet the poorest of the poor often do not have access to them. Still today, less than 25% of mothers practice exclusive breastfeeding for six months, and only half of all births are attended by a skilled birth attendant. Care for mothers and newborns immediately after birth receives little emphasis in programs and is rarely measured in surveys or management information systems. Findings of studies in six countries in South Asia and sub-Saharan Africa indicate that only 3% to 14% of children born at home received care from a trained provider within three days of birth [5], [8], [9].
4. Newborn health is a key to child survival
Judging by the current trends, it is unlikely the world will achieve MDG-4 [10]. In fact, at the present rate of progress, the world would not achieve the two-thirds reduction in child deaths targeted by MDG-4 until 2045—31 years too late. Less than one-fifth of the developing world's population lives in countries that are considered ‘on track’ to their target. No country with a sizeable population in sub-Saharan Africa is on track and, at the current pace, the goal will not be reached until 2115, a century after the agreed date [10]. Thus, the cumulative cost of persisting at the present rate of progress in terms of child survival is 41.1 million avoidable, excess child deaths globally in the next 10 years (including 28.1 million in sub-Saharan Africa).
Given that globally 38% of the under-5 child deaths globally occur in the neonatal period, an obvious reason for poor progress in child survival has been the paucity of action to address neonatal survival in developing countries. This set of circumstance obviously must change for the benefit of these nations and their mothers and children.
Fortunately, the growing realization of this need has led recently to a groundswell of support for the newborn health agenda at country and global levels. The World Health Organization (WHO) has advocated repositioning of MCH (Maternal and Child Health) as MNCH (Maternal, Newborn and Child Health) [11]. The World Health Report 2005 [11], the UN Millennium Project Task Force [12], The Lancet Neonatal Survival Series [13] and the Delhi Declaration on Maternal, Newborn and Child Health [14] all call for increased investment in neonatal health in developing countries. There is strong support to include the neonatal mortality rate (NMR) as an indicator of MDG-4 [12], [13], [14], in recognition of the 50% reduction in neonatal deaths between 2000 and 2015 that is being advocated to attain MDG-4 [2], [13].
5. The way forward is continuum of care
5.1. The mother–baby–child continuum
Biology unites the mother–baby dyad. A neonate's history as a fetus and future as a child in reality is a continuum in life and time. And, only by providing a continuum of care spanning the period before, during, and after birth can society provide an optimum chance for a baby to survive the most hazardous phase of his or her life.
In the past, neonatal health has remained hidden in the ‘no-man's land’ between the safe motherhood and child survival programs because of operational boundaries drawn, often in good faith, by global and country policymakers. However, an integrated approach to maternal, neonatal, and child health is a win–win rubric for both MDG-4 and the goal to reduce the maternal mortality ratio by three-quarters (MDG-5).
The emphasis of safe motherhood programs is primarily based on the presence of skilled birth attendants, the scale-up of which has been hampered by system and resource constraints. As a result, many neonatal deaths that could have been prevented were not, because this strategy avoids using less skilled providers and simple behavior changes to yield effective and demonstrable change. Traditional concepts of emergency obstetric care frequently focus only on the needs of the mother and not the baby—a glaring omission. On the other hand, child survival strategies have traditionally included attention to vaccine preventable diseases, diarrheal disease and acute respiratory infections, ignoring neonatal morbidity. Even Integrated Management of Childhood Illness (IMCI), the flagship child survival strategy promoted by WHO and UNICEF, does not address the first week of life, when three-fourths of newborn deaths (or 30% of child deaths) occur. Because maternal, neonatal, and child health interventions form a logical, evidence-driven, mutually reinforcing continuum. The road to MDGs 4 and 5 must be paved by integrated MNCH action plans at the national and sub-national levels [14].
5.2. Continuum of care from households to facilities
In developing countries, most babies are born at home. In rural India, for example, as many as 74.3% of all deliveries are domiciliary [15], most often at the hands of unskilled traditional birth attendants or family members. Even after a successful birth, there is little postnatal contact with health care providers. Traditional practices, some quite harmful, determine the care the baby receives. Families are often not aware of healthy behaviors that are easy to practice.
In a field trial in rural Maharashtra, India, a home-based neonatal care approach led to a decline in NMR in the intervention population (39 villages, 39,312 population) from a baseline of 62.0 (1993–95) to 36.1 in 1996–97 and as low as 25.2 in 2001–03 [16]. In the control area (47 villages, 42,617 population), there was hardly any change from 65.2 (1995–96) to 50.0 (1996–97) and 64.4 (2001–03). The package of interventions delivered by a village health worker consisted of: antenatal counseling, clean delivery, resuscitation at birth, hygiene/cord care, breastfeeding, extra care of low birth weight babies (warmth, assisted feeding, and more village health worker contacts), and treatment of sepsis/pneumonia with oral cotrimoxazole and intramuscular gentamicin. The study concluded that remarkably high survival of low birth weight babies (95.3%) and babies under 1500 g at birth (60.0%) could be achieved through a home-based newborn care approach [17].
WHO defines the health system as including “all the activities whose primary purpose is to promote, restore or maintain health” [18]. Community participation for improving health of individuals, families and communities, as well as community-based health care activities, constitute an integral part of the health system. After all, people are the raison d'âtre of their own health, and thus, it is imperative to place them at the center of health action. In reality, community participation is sidelined in most programs—and replaced with supply-driven, top down approaches. Not surprisingly, many of these programs fail.
Participatory action helps in identifying local health priorities and innovating site-specific solutions that make the best use of available resources to tackle the most important issues. In a study in Bolivia, participatory planning for mother and infant care reduced perinatal mortality from 117 to 44 per 1000 births [19]. In a study by Manandhar et al. in Nepal, a reduction in neonatal mortality was associated with healthy behaviors in intervention clusters [NMR of 26.2 per 1000 live births in intervention clusters vs. 36.9 in control clusters; adjusted odds ratio 0.70 (95% CI 0.53–0.94)]. The health practices included institutional deliveries, care seeking in the event of maternal and neonatal illness, use of clean delivery kit, etc. [20]. Interestingly, in this study, the maternal mortality ratio also declined dramatically.
Participatory interventions can help families and communities adopt healthier behaviors on a community basis, enabling them to embrace new practices not by being preached to, but by self-discovery and internalization. For changing behaviors pertaining to pregnancy, childbirth and neonatal care—that often stem from centuries of tradition—a dignified, participatory approach that gives voice to the people is crucial.
Even small facilities with modest inputs can achieve high survival rates of babies [21], [22]. In a study in a rural sub-district facility in North India, 98.6% (6652/6746) of all babies born survived. These included 72.3% (73/101) neonates weighing less than 1500 g and 97.8% (245/264) babies weighing 1500–1999 g [21]. Interventions that promote the demand for appropriate services linked to improvement in their provision at the household, community and facility levels could be the key to decisive gains in the quest for MDGs 4 and 5 [23].
6. Affecting change
During the last five years, Saving Newborn Lives (SNL), Save the Children's global initiative to improve newborn health and survival, has sought to address the reality of newborn mortality. Launched with a generous grant from the Bill and Melinda Gates Foundation, SNL has worked in 12 countries through a combination of program, research, advocacy, and partnership to improve expand policies and programs addressing newborn health. Through its experiences in several countries in Asia, sub-Saharan Africa, and Latin America, Save the Children found that low-cost, community-based intervention packages can significantly reduce neonatal mortality in settings with weak health systems and that dramatic changes in household practices are possible in a relatively short time frame.
Overall, Save the Children's SNL initiative reached 20 million women and newborns in 12 countries with essential newborn health services. Five primary activity areas have supported SNL's objective to strengthen and expand proven and cost-effective interventions: (1) training in essential newborn care; (2) Kangaroo Mother Care; (3) essential newborn care services; (4) behavior change communication; and (5) social mobilization for maternal neonatal tetanus immunization. A number of tools were developed, including a Care of the Newborn Reference Manual, the first ever basic education and training tool for newborn care in low-resource settings, a qualitative research guide, and a list of core indicators [24], [25], [26].
Evaluations and endline surveys conducted in 2004 and early 2005 reflect substantial improvements in key household behaviors and care seeking practices to improve newborn health across six SNL-assisted countries (after an average implementation period of about 18 months). For example, between one and three years after implementation, the number of women who breastfed immediately, within an hour of birth, increased in all of six countries (see Fig. 4), as did the percentage of mothers whose infant delivering at home who sought and received newborn care within three days (see Fig. 5). The latter figure more than doubled in five country project areas. In Bangladesh, for example, immediate breastfeeding rose from 39% to 76% and postnatal care rose from 2% to 32% in program areas. In addition, the percentage of mothers whose birth was attended by a skilled provider increased in five of the six focus countries. In the Bolivia project area, for example, it increased from 42% to 76%.
Figure 4.
Improvements in breastfeeding in six countries assisted by Saving Newborn Lives. Source: Annual Report to the Bill and Melinda Gates Foundation. Save the Children, Saving Newborn Lives. Washington, DC: 2005.
Figure 5.
Improvements in postnatal care (within 3 days) in six countries assisted by Saving Newborn Lives. Source: Annual Report to the Bill and Melinda Gates Foundation. Save the Children, Saving Newborn Lives. Washington, DC: 2005.
Following on a systematic review of the evidence for effective interventions, the focus of Save the Children's SNL research has been to (1) develop, test, and disseminate cost-effective models of newborn care delivery; and (2) test strategies for behavior change communication. For example, a pilot study in Hala, Pakistan (population 700,000) effectively introduced essential newborn care into the existing service delivery system using the lady health worker. In addition, in one site in rural India (population 104,000), a simple package, made up entirely of behavior change interventions, succeeded in reducing newborn mortality substantially (preliminary results suggest approximately 50%).
Research is also aimed at creating and testing new, cost-effective solutions to prevent newborn mortality from the major causes–infections, birth asphyxia, and low birth weight–as well as developing appropriate measurement and costing tools. For example, a costing manual has been developed for assessing the costs of newborn care and is being used in program and research sites [27].
Because newborn health has only recently begun receiving attention in health development programs, key efforts have included ensuring that newborn health is incorporated in appropriate health policies and strategies and adding the NMR as an explicit indicator of each country's path of achieving the MDGs. For example, Nepal has now adopted a Neonatal Health Policy and is developing a long-term operational plan to integrate newborn health into the national maternal and child health program. Malawi has now adopted “National Guidelines for Care of the Neonate,” and essential newborn care, including Kangaroo Mother Care (skin-to-skin contact), has been included in the Ministry's work plan for 2005/2006. In six countries, essential newborn care is being integrated into national plans, and also into training curricula for various levels of health providers.
In 2000, Save the Children created the Healthy Newborn Partnership (HNP), comprising over 30 organizations, to promote awareness and attention to newborn health, exchange technical information, and support the incorporation of newborn care into health policies and programs. In early 2005, the HNP served as a mechanism for consensus building around The Lancet Series on Neonatal Survival. In September 2005, the HNP joined forces with the Partnership for Safe Motherhood and Newborn Health and the Child Survival Partnership to create a unified Partnership for Maternal, Newborn and Child Health.
Some key lessons from the first five years of the Saving Newborn Lives initiative are as follows:
7. The future of maternal, newborn, and child health
Despite the recent progress in newborn health advocacy, research, and programming, much remains to be done before sustained, high coverage of effective newborn health interventions is achieved, especially in the poor communities where most newborns die. Newborn care needs to become an integral part of maternal and child health programs, which in turn need to be strengthened and expanded. In particular, more focused strategies and resources are needed to improve care during childbirth and the first week of life—the time of greatest risk that remains the time of lowest coverage for mothers and babies alike. Many lives can be saved by putting existing solutions into general practice, while the search continues for the most effective way to bring about behavioral change and to prevent and treat certain complications, such as birth asphyxia. National decision-makers, community leaders, health care professionals, and assistance agencies must take joint responsibility for ensuring that the next generation of children will survive and thrive.
References
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- . Fourth report on the world nutrition situation: nutrition throughout the life cycle. Geneva: ACC/SCN; 2000;
- . In: Essential Newborn Care. Washington, DC: World Bank; 2004;p. 1
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- . National family health survey (1998–99). Mumbai; 2000;
- . Neonatal and infant mortality in ten years (1993–2003) of the Gadchiroli field trial: effect of home-based newborn care. J Perinatol. 2005;25:582–591
- . Low birth weight and preterm neonates: can they be managed at home by mother and a trained village health worker?. J Perinatol. 2005;25:S72–S81
- . The World Health Report 2000 — health systems: improving performance. Geneva; 2005;
- . The Warmi project: a participatory approach to improve maternal and neonatal health: an implementer's manual. Westport: John Snow International Mothercare project, Save the Children; 2002;
- Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomized controlled trial. Lancet. 2004;364:970–979
- . Neonatal outcomes at sub-district hospital in north India. J Trop Pediatr. 2002;48:43–48
- . Development and effects of a neonatal care unit in rural India. Lancet. 2005;366:27–28
- . Health systems and community: community participation holds the key to health gains. Br Med J. 2004;329:1117–1118
- . Care of the newborn reference manual. Washington, DC: Save the Children; 2004;
- . Qualitative research to improve newborn care practices: a guide for program managers. Washington, DC: Save the Children; 2004;
- . Essential newborn care: at a glance. 2004;Washington, DC
- . Saving newborn lives initiative project costing guidelines. 2004;Washington, DC
PII: S0020-7292(06)00157-3
doi:10.1016/j.ijgo.2006.04.007
© 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Inc. All rights reserved.
Volume 94, Issue 3 , Pages 269-276, September 2006
