7
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
newborns: no longer going unnoticed 83 Box 5.1 Explaining variations in maternal, neonatal and child mortality: care or context? The debate over the contribution of maternal, various contextual or health systems indicators around 50% of the differences in maternal and newborn and child health programmes to sav-(21-24). There are 67 developing countries for neonatal mortality, 37%of those in postneona- ing lives is not new. Historical analyses have which reliable estimates are available of the mortality, and 50% of those in child mor- often indicated the important role of contex- levels of maternal, neonatal, postn and tality, with human resource density the mai ctors such as a hea nent, child mortality in 2000. For each of these coun- single explanatory factor within the care scon women's empowerment, education and poverty tries a care score can be constructed through This suggests that care, and particularty human in reducing mortality levels. It can be difficult to principal components analysis, reflecting finan- resources, plays a larger role in explaining the disentangle these contextual effects from the cial inputs( total and government expenditure inter-country differences in mortality than di contribution of the care provided through health on health per inhabitant), human resource ferences in context. systems. Poverty, for example, is is often part and dens Bond y(midwives and doctors per head of A significant proportion of the variability in parcel of poorly functioning health systems as population) and responsiveness(determined mortality levels is explained by the interaction ers and children live. The current consensus is the same technique it is also possible to con- sis suggests that where the context is particu that both health systems and the environment struct a context score for each country, using larly challenging even strong health systems care and context-play their part, but that the following indicators: income per inhabitant, can have only a limited effect on mortality the balance may be different for the health of female income, female literacy, sanitation and conversely, where there is an enabling con- mothers from that of their children, maternal access to safe water (25 text for health in terms of education. wealth rtality depending more on health systems Variations in country context scores explain environment and women s empowerment, the efforts and less on contextual factors than child between 10% and 15% of the differences a poor health system could hold back mortal tween countries in maternal, neonatal and ity reduction substantially On the whole, the One way to disentangle the relative contri- postneonatal mortality in a series of multiple analysis confirms the importance of investing ution of care and context to mortality is to regressions. They explain 24% of the differ- in health systems to reduce mortality. relate mortality levels across countries with ences in child mortality. Care scores explain Proportion of inter-country variation in levels of mortality explained by indicators of care and context Unexplained variation variation explained by financial and responsiveness on explained by human resource density Variation explained by interaction en care and cont Variation explained by contextual Maternal Neonatal Postneonatal Child mortality ortal
newborns: no longer going unnoticed 83 various contextual or health systems indicators (21–24). There are 67 developing countries for which reliable estimates are available of the levels of maternal, neonatal, postneonatal and child mortality in 2000. For each of these countries a care score can be constructed through principal components analysis, reflecting financial inputs (total and government expenditure on health per inhabitant), human resource density (midwives and doctors per head of population) and responsiveness (determined through individual satisfaction ratings). Using the same technique it is also possible to construct a context score for each country, using the following indicators: income per inhabitant, female income, female literacy, sanitation and access to safe water (25). Variations in country context scores explain between 10% and 15% of the differences between countries in maternal, neonatal and postneonatal mortality in a series of multiple regressions. They explain 24% of the differences in child mortality. Care scores explain The debate over the contribution of maternal, newborn and child health programmes to saving lives is not new. Historical analyses have often indicated the important role of contextual factors such as a healthy environment, women’s empowerment, education and poverty in reducing mortality levels. It can be difficult to disentangle these contextual effects from the contribution of the care provided through health systems. Poverty, for example, is often part and parcel of poorly functioning health systems as well as being part of the context in which mothers and children live. The current consensus is that both health systems and the environment – care and context – play their part, but that the balance may be different for the health of mothers from that of their children, maternal mortality depending more on health systems’ efforts and less on contextual factors than child mortality. One way to disentangle the relative contribution of care and context to mortality is to relate mortality levels across countries with around 50% of the differences in maternal and neonatal mortality, 37% of those in postneonatal mortality, and 50% of those in child mortality, with human resource density the main single explanatory factor within the care score. This suggests that care, and particularly human resources, plays a larger role in explaining the inter-country differences in mortality than differences in context. A significant proportion of the variability in mortality levels is explained by the interaction between care and context. More detailed analysis suggests that where the context is particularly challenging even strong health systems can have only a limited effect on mortality; conversely, where there is an enabling context for health in terms of education, wealth, environment and women’s empowerment, then a poor health system could hold back mortality reduction substantially. On the whole, the analysis confirms the importance of investing in health systems to reduce mortality. Box 5.1 Explaining variations in maternal, neonatal and child mortality: care or context? Proportion of inter-country variation in levels of mortality explained by indicators of care and context % variance explained Unexplained variation Variation explained by financial inputs and responsiveness Variation explained by human resource density Variation explained by interaction between care and context Variation explained by contextual factors Maternal mortality Child mortality Postneonatal mortality Neonatal mortality 100 90 80 70 60 50 40 30 20 10 0
84 The World Health Report 2005 The reversal of progress in neonatal health in sub-Saharan Africa is both concern ing and unusual. Historically, declines in child mortality have often reversed when the social context deteriorated. Within Europe, these reversals mostly affected older children, while remaining modest for neonatal mortality (13 ) The causes of the poor progress in reducing both neonatal and later childhood deaths in sub-Saharan Africa are likely to be many and complex Economic decline and conflict are likely to have played significant roles through their disruptive effect on access to health ser (14-16). The impact of the HIV/AIDS epidemic on mortality is less well established for newborns than for the post-neonatal period, but infants born to HIv-positive mothers are more likely to be stillborn or premature; they are also likely to have low APGAR scores' and very low birth weights(17, 18) Reductions in child mortality in many countries are at least partly driven by socio economic development: improvements in women's education and literacy, household income, environmental conditions(safe water supply, sanitation and housing), along with improvements in health services and child nutrition (19, 20 ). While neonatal mor tality is affected by these factors, they may have a greater impact in the post-neonatal and early childhood periods than for newborns(see Box 5. 1 ). Historical data further support this hypothesis. There is little evidence that the often dramatic reductions in infant and child mortality in Europe during the first few decades of the 20th century i The APGAR test evaluates a newborn' s physical condition Each year more than 4 million babies die within 28 days of coming into the world and nearly 3.3 million babies are stillborn
84 The World Health Report 2005 The reversal of progress in neonatal health in sub-Saharan Africa is both concerning and unusual. Historically, declines in child mortality have often reversed when the social context deteriorated. Within Europe, these reversals mostly affected older children, while remaining modest for neonatal mortality (13). The causes of the poor progress in reducing both neonatal and later childhood deaths in sub-Saharan Africa are likely to be many and complex. Economic decline and conflict are likely to have played significant roles through their disruptive effect on access to health services (14–16). The impact of the HIV/AIDS epidemic on mortality is less well established for newborns than for the post-neonatal period, but infants born to HIV-positive mothers are more likely to be stillborn or premature; they are also likely to have low APGAR scores1 and very low birth weights (17, 18). Reductions in child mortality in many countries are at least partly driven by socioeconomic development: improvements in women’s education and literacy, household income, environmental conditions (safe water supply, sanitation and housing), along with improvements in health services and child nutrition (19, 20). While neonatal mortality is affected by these factors, they may have a greater impact in the post-neonatal and early childhood periods than for newborns (see Box 5.1). Historical data further support this hypothesis. There is little evidence that the often dramatic reductions in infant and child mortality in Europe during the first few decades of the 20th century Each year more than 4 million babies die within 28 days of coming into the world, and nearly 3.3 million babies are stillborn. N. Behring-Chisholm/WHO 1 The APGAR test evaluates a newborn’s physical condition
newborns: no longer going unnoticed 85 were fuelled by improvements in health care provision, and most studies argue that they resulted from a number of factors including rising standards of living and nutri tion, reduced fertility, safer water, better sanitation, and improved housing(26, 27) During this time, progress in reducing neonatal mortality was limited and was confined to the late neonatal period. Progress did not accelerate until around the time of the Second World War (28), which coincided with greater provision and use of maternal health care, improved quality of professional midwifery and obstetric services, and access to antibiotics. This suggests that, while some limited progress can be made in the late neonatal period as a result of general improvements in standards of living, progress will not accelerate and spread to the early neonatal period until appropriate maternal and neonatal health care is available and widely used IO LONGER FALLING BETWEEN THE CRACKS It is often argued that a radical reduction of the number of newborn deaths is possible nly where very high expenditure on health allows for large investments in sophist- cated technology. But in actual fact, nurses and doctors can easily acquire the neces ary skills without needing to become specialists. Countries such as Colombia and Sri Lanka, with fewer than 15 neonatal deaths per 1000 live births, have demonstrated that expensive technology is not a prerequisite for success. So have Nicaragua and Viet Nam, which lowered their neonatal mortality rates to 17 and 15 per 1000 births respectively, while their spending on health in the 1990s was only US$ 45 and USS 20 per capita, respectively. In northern European countries, well-coordinated antenatal intrapartum and postnatal care for mothers and newborns coincided with reduced rates of mortality before the introduction of neonatal intensive care in the early 1980s (8). Intensive care facilities, specialists and expensive equipment are useful to re duce neonatal mortality even further only after very low levels have already been achieved. Rather than deploying high-tech instrumentation, the challenge is to find a Box 5.2 Sex selection The low value given to women and girls in some juvenile(0-6 years) sex ratio declined from daughters-in-law and mothers, sex determina for boy children. Over the decades, this has with some of the steepest declines occurring gain control over at least one aspect of their translated into many practices that heavily dis- among the better educated and in economi- lives. criminate against girls, such as neglect in feed- cally better-off districts that also have greater This is a conundrum which cannot be ing, education and health care. The practice of access to commercial health services National resolved by focusing only on medical technol- female infanticide has also been documented records on sex ratio at birth in China and South ogy. The most severely affected countries such in some places Korea have shown similar rapid changes that as China, India and South Korea have all banned apidly declining fertility and the trend are unlikely to be sustainable in the long term. prenatal sex determination through the use of limit families to one or two children has The demographic impact of these adverse sex ultrasound or pre-conception techniques; other increased the desire of couples to have a boy. ratios is beginning to be felt in the form of a measures taken include registration and regu The emergence and increased availability of dearth of young women in some communities, lation of genetic laboratories and ultrasound ultrasound equipment, which can detect the thereby making women in general more vulner- machines and self-regulation by the medical sex of a fetus early in pregnancy, has opened able to violence, including sexual coercion and profession. Such policies have so far been p the opportunity for the commercial use of sale of brides. rgely ineffective because demand continues to medical technology to pre-select and terminate Many women s rights organizations and oth- be high. Various nongovemmental organizations pregnancies of female fetuses, thus reinforcing ers, in India and elsewhere, have seen prenatal and civil society organizations are currently the devaluation of girls and women. x selection as another form of discrimination involved in large-scale awareness and sensi Over the last decade, the ratio of girls to against women, and have been active in moves tization campaigns and in organizing a broader yys in the 0-6 year age group has become to have such selection banned. On the other social debate on the devaluation of females and creasingly skewed in a number of countries. hand, in societies where giving birth to sons the consequences of sex preference. For instance, India' s census revealed that the defines women' s status and rights as wives
newborns: no longer going unnoticed 85 were fuelled by improvements in health care provision, and most studies argue that they resulted from a number of factors including rising standards of living and nutrition, reduced fertility, safer water, better sanitation, and improved housing (26, 27). During this time, progress in reducing neonatal mortality was limited and was confined to the late neonatal period. Progress did not accelerate until around the time of the Second World War (28), which coincided with greater provision and use of maternal health care, improved quality of professional midwifery and obstetric services, and access to antibiotics. This suggests that, while some limited progress can be made in the late neonatal period as a result of general improvements in standards of living, progress will not accelerate and spread to the early neonatal period until appropriate maternal and neonatal health care is available and widely used. NO LONGER FALLING BETWEEN THE CRACKS It is often argued that a radical reduction of the number of newborn deaths is possible only where very high expenditure on health allows for large investments in sophisticated technology. But in actual fact, nurses and doctors can easily acquire the necessary skills without needing to become specialists. Countries such as Colombia and Sri Lanka, with fewer than 15 neonatal deaths per 1000 live births, have demonstrated that expensive technology is not a prerequisite for success. So have Nicaragua and Viet Nam, which lowered their neonatal mortality rates to 17 and 15 per 1000 births, respectively, while their spending on health in the 1990s was only US$ 45 and US$ 20 per capita, respectively. In northern European countries, well-coordinated antenatal, intrapartum and postnatal care for mothers and newborns coincided with reduced rates of mortality before the introduction of neonatal intensive care in the early 1980s (8). Intensive care facilities, specialists and expensive equipment are useful to reduce neonatal mortality even further only after very low levels have already been achieved. Rather than deploying high-tech instrumentation, the challenge is to find a juvenile (0–6 years) sex ratio declined from 945 girls per 1000 boys in 1991 to 927 in 2001, with some of the steepest declines occurring among the better educated and in economically better-off districts that also have greater access to commercial health services. National records on sex ratio at birth in China and South Korea have shown similar rapid changes that are unlikely to be sustainable in the long term. The demographic impact of these adverse sex ratios is beginning to be felt in the form of a dearth of young women in some communities, thereby making women in general more vulnerable to violence, including sexual coercion and sale of brides. Many women’s rights organizations and others, in India and elsewhere, have seen prenatal sex selection as another form of discrimination against women, and have been active in moves to have such selection banned. On the other hand, in societies where giving birth to sons defines women’s status and rights as wives, The low value given to women and girls in some countries is reflected in a marked preference for boy children. Over the decades, this has translated into many practices that heavily discriminate against girls, such as neglect in feeding, education and health care. The practice of female infanticide has also been documented in some places. Rapidly declining fertility and the trend to limit families to one or two children has increased the desire of couples to have a boy. The emergence and increased availability of ultrasound equipment, which can detect the sex of a fetus early in pregnancy, has opened up the opportunity for the commercial use of medical technology to pre-select and terminate pregnancies of female fetuses, thus reinforcing the devaluation of girls and women. Over the last decade, the ratio of girls to boys in the 0–6 year age group has become increasingly skewed in a number of countries. For instance, India’s census revealed that the daughters-in-law and mothers, sex determination and sex selective abortion allow women to gain control over at least one aspect of their lives. This is a conundrum which cannot be resolved by focusing only on medical technology. The most severely affected countries such as China, India and South Korea have all banned prenatal sex determination through the use of ultrasound or pre-conception techniques; other measures taken include registration and regulation of genetic laboratories and ultrasound machines and self-regulation by the medical profession. Such policies have so far been largely ineffective because demand continues to be high. Various nongovernmental organizations and civil society organizations are currently involved in large-scale awareness and sensitization campaigns and in organizing a broader social debate on the devaluation of females and the consequences of sex preference. Box 5.2 Sex selection
86 The World Health Report 2005 better way of setting up the health care system with continuity between care during pregnancy, skilled care at birth, and the care given when the mother is at home with Care during pregnancy Many things can, and must, be done during pregnancy. One of the most cost effective and simple antenatal interventions is immunization against tetanus In areas where malaria is endemic, intermittent presumptive treatment of malaria can reduce incidence of low birth weight, stillbirths, and neonatal and maternal mortality. Rubella vaccination reduces stillbirths and avoids congenital rubella syndrome. Diagnosis and treatment of reproductive tract infections reduce the risk of premature labour, as well as the direct perinatal deaths caused by syphilis. The antenatal period also presents an important opportunity for identifying threats to the unborn baby 's health, as wel as for counselling on nutrition, birth preparedness, parenting skills, and family plan ning options after the birth. Understanding the need for information and services for women who desire birth spacing methods has the potential to reduce neonatal mortality, as closely spaced births have been shown to be detrimental to the survival of the subsequent child(29) These interventions are at the core of an effective antenatal health care package deally, the package of interventions should be provided by the same health worker the midwife -who will attend the mother during childbirth; this is the best way to ensure seamless care through pregnancy and childbirth. Technically, however, ante- natal care can be delegated to other health workers who would not necessarily qualify as having the required skills for attending childbirth. As multipurpose health workers are not in such short supply as midwives, they can help to increase coverage. In such cases, it is imperative, however, to establish links with those who will be in charge of mother and baby at birth the mother needs to prepare for the birth, and the health services have to be ready to respond Professional care at birth Skilled professional care at birth is as critical for the newborn baby as it is for the mother. For example, effective midwifery ensures non-traumatic birth and reduces mortality and morbidity from birth asphyxia, while at the same time strict asepsis at delivery and cord care reduce the risk of infection. Skilled care makes it possible to resuscitate babies who cannot breathe at birth and to deal with or refer unpredict- able complications as they happen to mother or baby. when the birth is appropriately managed by a skilled health worker, it is safer for both mother and newborn. What then, are the problems? First, less than two thirds of women in less developed countries and only one third in the least developed countries have their babies delivered by a skilled attendant. Despite recent improvements in some countries, the development of effective ma- ternal health services in many parts of the world has often been hampered by limited resources, lack of political will, and poorly defined strategies (30): services have not kept up with the need for care at birth and not even with the expansion of antenatal care. Even when services do exist, quality is often poor, or social and financial barriers prevent women from making use of them. Some countries have shown high-level com mitment to improving maternal health services and impressive progress in the uptake of professional care at birth(e. g. Bolivia, Egypt, Indonesia, Morocco and Togo).The general picture in Africa, however, where newborn mortality is high, is less positive
86 The World Health Report 2005 better way of setting up the health care system with continuity between care during pregnancy, skilled care at birth, and the care given when the mother is at home with her newborn. Care during pregnancy Many things can, and must, be done during pregnancy. One of the most costeffective and simple antenatal interventions is immunization against tetanus. In areas where malaria is endemic, intermittent presumptive treatment of malaria can reduce incidence of low birth weight, stillbirths, and neonatal and maternal mortality. Rubella vaccination reduces stillbirths and avoids congenital rubella syndrome. Diagnosis and treatment of reproductive tract infections reduce the risk of premature labour, as well as the direct perinatal deaths caused by syphilis. The antenatal period also presents an important opportunity for identifying threats to the unborn baby’s health, as well as for counselling on nutrition, birth preparedness, parenting skills, and family planning options after the birth. Understanding the need for information and services for women who desire birth spacing methods has the potential to reduce neonatal mortality, as closely spaced births have been shown to be detrimental to the survival of the subsequent child (29). These interventions are at the core of an effective antenatal health care package. Ideally, the package of interventions should be provided by the same health worker – the midwife – who will attend the mother during childbirth; this is the best way to ensure seamless care through pregnancy and childbirth. Technically, however, antenatal care can be delegated to other health workers who would not necessarily qualify as having the required skills for attending childbirth. As multipurpose health workers are not in such short supply as midwives, they can help to increase coverage. In such cases, it is imperative, however, to establish links with those who will be in charge of mother and baby at birth: the mother needs to prepare for the birth, and the health services have to be ready to respond. Professional care at birth Skilled professional care at birth is as critical for the newborn baby as it is for the mother. For example, effective midwifery ensures non-traumatic birth and reduces mortality and morbidity from birth asphyxia, while at the same time strict asepsis at delivery and cord care reduce the risk of infection. Skilled care makes it possible to resuscitate babies who cannot breathe at birth and to deal with or refer unpredictable complications as they happen to mother or baby. When the birth is appropriately managed by a skilled health worker, it is safer for both mother and newborn. What, then, are the problems? First, less than two thirds of women in less developed countries and only one third in the least developed countries have their babies delivered by a skilled attendant. Despite recent improvements in some countries, the development of effective maternal health services in many parts of the world has often been hampered by limited resources, lack of political will, and poorly defined strategies (30): services have not kept up with the need for care at birth and not even with the expansion of antenatal care. Even when services do exist, quality is often poor, or social and financial barriers prevent women from making use of them. Some countries have shown high-level commitment to improving maternal health services and impressive progress in the uptake of professional care at birth (e.g. Bolivia, Egypt, Indonesia, Morocco and Togo). The general picture in Africa, however, where newborn mortality is high, is less positive
newborns: no longer going unnoticed 87 The improvement of coverage to underserved communities is likely to prove a majo challenge to many resource-poor countries for years to come The second problem is that the training of professional health workers who attend childbirth and the focus of their work have often been directed almost exclusively towards the safety of the mother at the moment of childbirth itself, to the neglect of the newborn and the critical week after the birth(31). Newborn care is part of the riculum and responsibility of midwives, nurse-midwives and the doctors who function as their equivalents, but in practice many of these professionals do not get the training r experience to ensure that they are competent to carry out all of the key procedures for newborns In Benin, Ecuador, Jamaica and Rwanda, for example only 57% of all doctors, midwives, nurses and medical interns who routinely assist at births lately tested ( 32). Alth the technology that is needed is actually quite simple and inexpensive, health workers can be unsure of how to deal with the sudden complications that may become life-threatening in a couple of hours, and ally even less readily available than they are for the care a mother may need in case of complications. Even within a hospital, the back-up services for maternal and neonatal care that should be triggered when a com plication arises are often not organized quickly enough; hospitals may not be set up to care for newborns in terms of staff training and equipment. Giving birth in a health facility(not necessarily a hospital) th professional staff is safer by far than doing so at home. But the same environ- ment that makes for a safer birth also may put newborns at increased risk of iatrogenic infections, overmedicalization and inappropriate hospital practices. In all too many hospitals, mother and baby may be separated, which makes it diffi cult for mothers to bond with and provide warmth to their newborns, Babies born in hospitals in some settings are actu- ally less likely to be breastfed than those rn elsewhere (33). Maximizing synergies between mater. nal and neonatal health will require birth- ing facilities to give special attention to appropriate training of staff and the orga- nization of care that takes account of the needs of the newborn Facilities will also need to improve infection control, keep medical interventions to a minimum and Professional care for newboms is often hard to get
newborns: no longer going unnoticed 87 The improvement of coverage to underserved communities is likely to prove a major challenge to many resource-poor countries for years to come. The second problem is that the training of professional health workers who attend childbirth and the focus of their work have often been directed almost exclusively towards the safety of the mother at the moment of childbirth itself, to the neglect of the newborn and the critical week after the birth (31). Newborn care is part of the curriculum and responsibility of midwives, nurse-midwives and the doctors who function as their equivalents, but in practice many of these professionals do not get the training or experience to ensure that they are competent to carry out all of the key procedures for newborns. In Benin, Ecuador, Jamaica and Rwanda, for example, only 57% of all doctors, midwives, nurses and medical interns who routinely assist at births were able to resuscitate a newborn adequately when their skills were tested (32). Although the technology that is needed is actually quite simple and inexpensive, health workers can be unsure of how to deal with the sudden complications that may become life-threatening in a couple of hours, and essential drugs and equipment are usually even less readily available than they are for the care a mother may need in case of complications. Even within a hospital, the back-up services for maternal and neonatal care that should be triggered when a complication arises are often not organized quickly enough; hospitals may not be set up to care for newborns in terms of staff training and equipment. Giving birth in a health facility (not necessarily a hospital) with professional staff is safer by far than doing so at home. But the same environment that makes for a safer birth also may put newborns at increased risk of iatrogenic infections, overmedicalization and inappropriate hospital practices. In all too many hospitals, mother and baby may be separated, which makes it diffi- cult for mothers to bond with and provide warmth to their newborns. Babies born in hospitals in some settings are actually less likely to be breastfed than those born elsewhere (33). Maximizing synergies between maternal and neonatal health will require birthing facilities to give special attention to appropriate training of staff and the organization of care that takes account of the needs of the newborn. Facilities will also need to improve infection control, keep medical interventions to a minimum, and Professional care for newborns is often hard to get. P. Virot/WHO
