Neonatal Mortality Worldwide February 2, 2012

Millennium Development Goal 4: Reduce child mortality Target: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate

Key facts Over 130 mln. babies born every year In 2010: 7.6 mln. children under 5 years of age died: ‌‌more than 40% die within the first month: 75% of which occur in the first week of life: between 25% to 45% occur within the first 24 hrs Up to two thirds of newborn deaths can be prevented if known, effective health measures are provided at birth and during the first week of life. Between 1990 and 2010, the total number of under-five deaths in the world has declined from more than 12 million in 1990 to 7.6 million in 2010. declined by 35%, from 88 deaths per 1,000 live births in 1990 to 57 in 2010 (2.2% per year). 82% of the world’s under-five deaths in 2010 occurred in Sub-Saharan Africa and Southern Asia. Sub Saharan Africa is still home to the highest rates of child mortality, with 1 in 8 children dying before reaching five – more than 17 times the average for developed regions (1 in 143). Southern Asia has the second highest rates with 1 in 15 children dying before age five.

Neonatal Mortality Rate by MDG region, 1990 and 2010 (deaths per 1,000 live births) Number of deaths among infants under 1 month (28 days) old per 1,000 live births in a given year 3.1 mln. newborns died in 2010 (4.4 mln in 1990) Neonatal mortality is increasingly important because the proportion of under-five deaths that occur during the neonatal period is increasing as under-five mortality declines. It increased about 10% since 1990 to more than 40%. Over the last two decades almost all regions have seen slower declines in neonatal mortality than in under-five mortality. Globally, neonatal mortality has declined 28% from 32 deaths per 1,000 live births in 1990 to 23 in 2010—an average of 1.7% a year, much slower than for under-five mortality (2.2% per year) and for maternal mortality (2.3% per year). While NMRs were halved in the European and Western Pacific regions, the reduction observed in the African region was only of 19%. Progress has been generally slow, and slowest in the region with highest NMR. Source: 2011 Report: Levels and Trends in Child Mortality - Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation.

Daily risk of death during the first month of life Three-quarters of all neonatal deaths occur during the first week of life, 25–45% in the first 24 hours. This is also the period when most maternal deaths occur. 47% of all mothers and newborns in developing countries do not receive skilled care during birth (10), and 72% of all babies born outside the hospital do not receive any postnatal care (11). 10. Countdown to 2015. Tracking progress in maternal, newborn & child survival: the 2008 report. New York, United Nations Children’s Fund, 2008 (http://www.countdown2015mnch.org/). 11. Fort Al, Kothari MT, Abderrahim N. Postpartum care: levels and determinants in developing countries. DHS Comparative Report No. 15. Macro International Inc. Maryland, 2006. Source: Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365:891–900. (Based on 47 DHS surveys conducted from 1995–2003).

Major Causes of Neonatal Deaths ~80% Prematurity and low-birth-weight -31% Infections -25% Birth asphyxia (lack of oxygen at birth) and birth trauma -23% These causes account for nearly 80% of deaths in this age group 4. Congenital anomalies -9% 5. Neonatal tetanus – 3% 6. Diarrheal diseases – 3% 7. Other neonatal – 8% Source: World Health Organization. The Global Burden of Disease: 2004 update. WHO, Geneva, 2008.

The lifecycle continuum of care Interventions Interventions Prior to or During Pregnancy Interventions During Delivery Interventions After Delivery The lifecycle continuum of care

I. Interventions Prior to or During Pregnancy Antenatal care Assess the pregnant woman for pre-eclampsia, anemia, syphilis, HIV status, TB Nutritional Interventions (iron and folic acid, vitamin A) Malaria Prophylaxis Immunizations -tetanus toxoid Detection and treatment of bacteriuria Birth plan – HF delivery or SBA Family planning Using bednets Daily intake of 400 mg through supplements or fortification reduces incidence of neural tube defects such as spina bifida and cleft palate by 72% (1–10% of neonatal deaths due to major congenital anomalies). Two or three injections prior to or during pregnancy reduces incidence of neonatal tetanus by 80–95%. Giving a curative treatment dose of an effective antimalarial drug at predefined intervals during pregnancy prevents up to one third of neonatal mortality and one-quarter of perinatal deaths and reduces LBW by nearly half (among first and second pregnancies). Effectiveness estimates sugges Urinalysis during antenatal visits followed by antibiotic treatment for positive diagnoses averts 40% of cases of prematurity and LBW and 5–14% of deaths due to complications of prematuritt that 10–20% of neonatal deaths due to serious infections may be averted.

Impact of Antenatal Interventions Reduction in Neonatal Mortality Global Sub-Saharan Africa South Asia Routine ANC 4-7% 7-12% 3-5% ALL ANTENATAL CARE SERVICES 5-10% 7-14% 4-9% ANC has a larger impact on maternal mortality than neonatal mortality Source: Darmstadt et al., 2008

II. Interventions During Delivery Skilled birth attendant Prevention and management of hypothermia Clean cord care – clean delivery kit Asphyxia management: Stimulation by quickly drying & wrapping Gentle flicking Open & maintain the airway Antibiotics for PPROM Prevention and management of delivery complications Immediate and thorough drying & wrapping Kangaroo Care Method - skin to skin contact of the newborn with the mother immediately after delivery Skin-to-skin contact between mothers and newborns, particularly LBW and/or preterm newborns, maintains warmth, encourages nursing, discourages over-handling, and enhances maternal recognition of newborn problems, reducing infection rate by about half. “6 cleans” of birth: clean hands, clean perineum, clean delivery surface, clean cord cutting instrument, clean cord care, and nothing unclean introduced to the vagina Open & maintain the airway Position the head with neck slightly extended and initiate mouth-to-mouth resuscitation Suction first the mouth and then the nose and use self-inflating bag and mask Detection and management of breech, multiple pregnancy Maternal corticosteroids (e.g. betamethasone) injections during premature labour hasten development of foetal lungs and avert one-quarter to one-half of deaths due to complications of prematurity. Effectiveness estimates suggest that corticosteroids may avert 20–40% of deaths due to prematurity. Labour surveillance (including partograph) for early diagnosis of complications - Monitoring labour, particularly with the use of a simple chart (partograph) to indicate when intervention is needed, followed by appropriate care, averts up to 40% of perinatal deaths.

Impact of Interventions During Delivery Asphyxia/Sepsis management led to reduction of relative risk of mortality Intervention Reduction in Neonatal Mortality Global Sub-Saharan Africa South Asia Clean delivery 5-8% 6-9% Skilled birth attendance 11-18% 12-20% 12-19% Emergency obstetric care 3-11% 4-11% ALL INTRAPARTUM CARE 19-34% 20-36% Source: Darmstadt et al., 2008

III. Interventions After Delivery Breastfeeding and Nutritional Support: - Early and exclusive breastfeeding (within a 30 min of birth) Prevention and Management of Infections Early identification and timely treatment of neonatal problems Special care for sick newborns, those who are preterm and/or low birth weight Home visits for the newborn Community-based pneumonia casemanagement Immediate (within 1 hour after birth) and exclusive (no prelacteal feeds or other fluids/food) breastfeeding averts nearly 10% of all neonatal deaths. Administration of antibiotics to children with pneumonia by community health workers reduces overall neonatal mortality by an estimated 20–25%, and averts neonatal deaths due to serious infections by 20–55%.

Impact of Post-natal interventions Reduction in Neonatal Mortality Global Sub-Saharan Africa South Asia Clean home childbirth, clean cord care & Community-based care of low birth weight babies 6-19% 5-18% 7-21% Community-based pneumonia management 4-12% 5-13% Emergency neonatal care 9-24% 8-23% 10-26% ALL POSTNATAL CARE 17-39% 16-38% 18-42% Source: Darmstadt et al., 2008

Impact of Post-natal Interventions Mortality in those who received a post-natal visit on first day of life was 67% lower The home visits have improved coverage of key newborn care practices such as early initiation of breastfeeding, exclusive breastfeeding, skin-to-skin contact, delayed bathing and attention to hygiene, such as hand washing with soap and water, and clean umbilical cord care. Evidence: Studies conducted in Bangladesh, India and Pakistan have shown that home visits can reduce deaths of newborns in high mortality, developing country settings by 30 to 61% (3–7). The visits have improved coverage of key newborn care practices such as early initiation of breastfeeding, exclusive breastfeeding, skin-to-skin contact, delayed bathing and attention to hygiene, such as hand washing with soap and water, and clean umbilical cord care. 3. Bang AT et al. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet, 1999, 354(9194):1955–61. 4. Baqui AH et al. Projahnmo Study Group. Effect of community-based newborn-care intervention package implemented through two service delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet, 2008 371(9628):1936–44. 5. Kumar V et al. Saksham Study Group. Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. Lancet, 2008, 372(9644):1151–62. 6. Bhutta ZA et al. Implementing community based perinatal care: results from a pilot study in rural Pakistan. Bull World Health Organ, 2008, 86(6):452–9. Source: Siddhartha Gogia et al., 2008

References: 2011 Report: Levels and Trends in Child Mortality - Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365:891–900. (Based on 47 DHS surveys conducted from 1995–2003). World Health Organization. The Global Burden of Disease: 2004 update. WHO, Geneva, 2008. Gary L Darmstadt, Neff Walker, Joy Saving et al. Newborn lives in Asia and Africa: Cost and impact of phased scale-up of interventions within the continuum of care. Health Policy and Planning 2008; 23:101-117 Siddhartha Gogia, Siddarth Ramji, Piyush Gupta et al. Community Based Newborn Care: A Systematic Review and Meta-analysis of Evidence: UNICEF-PHFI Series on Newborn and Child Health, India. Indian Pediatrics 2011; 48: 537-546