REGIONAL COMMITTEE
Provisional Agenda item 14.2
Fifty-sixth Session 10-13 September 2003
SEA/RC56/9 2 July 2003
HEALTH OF THE NEWBORN
CONTENTS Page
1. 2.
INTRODUCTION................................................................................................................1 MAGNITUDE OF THE PROBLEM....................................................................................2 2.1 2.2 Epidemiology............................................................................................................2 Health System Response........................................................................................4
3. 4. 5.
PRIORITY AREAS FOR INTERVENTIONS FOR NEWBORN HEALTH.........................4 WAY FORWARD ...............................................................................................................5 ROLE OF WHO .................................................................................................................7
1.
INTRODUCTION
Globally, childhood mortality has declined significantly over the past decades. Effective public health interventions delivered to large numbers of children are responsible for a major part of this success. Nonetheless, in recent years, progress in reducing childhood deaths has slowed down in many countries. In 2000, 10.8 million children died before reaching the age of five years. About 99 per cent of these deaths occurred in low-income countries. Failure to address neonatal mortality is an important reason for this trend. Of the 350 000 babies born each day all over the world, almost 12 000 die within their first month of life - the neonatal period. The majority of these deaths occur within a few hours of birth or during the first week of life. WHO estimates that worldwide, more than 4 million newborns die each year and nearly as many babies are stillborn. The South-East Asia Region accounts for nearly 40 per cent of the global neonatal mortality, with an estimated 1.4 million newborns dying every year. A newborn's chance of survival and well-being begins well before birth and continues through the post-partum period. The health and nutritional status of the mother are major determinants as is the continuum of care that the mother and baby receive before and during pregnancy, during delivery and in the post-partum period. Good care practices, combined with the identification and appropriate management of maternal and newborn complications, are necessary to ensure optimal neonatal health outcomes. The health of newborns is closely linked to that of their mothers and must be addressed by both maternal and child health programmes. Of all the possible interventions that can make an impact on perinatal1 and neonatal health, investing in maternal health and care is likely to yield the greatest dividends. Available information suggests that much of the improvement in perinatal and neonatal health in the developed world preceded the advent of neonatal intensive care and was largely due to the availability of comprehensive maternal and immediate post-partum neonatal care. Newborns, however, need care beyond the immediate post partum period. Child health services need to be able to respond adequately to the health needs of newborns including supporting families in adopting essential care practices and providing effective case management for neonatal illnesses. Efforts to improve newborn health and development include interventions - before and during pregnancy, during birth and in the post-partum period - and should be included in already established programmes for safe motherhood and child survival. Existing maternal health programmes give attention to the neonate in the period immediately after birth. The child survival movement of the past two decades promoted a limited set of interventions (EPI, CDD and ARI control) that benefited primarily older infants and children up to the age of five years. The challenge is to bridge the gap and ensure a continuum of care supporting maternal and newborn health through compatible and mutually reinforcing interventions working through both programme areas and related health sector development initiatives. WHO Member States and partners have examined and made commitments to address problems relating to maternal and newborn health on various occasions in the past.2 1
Perinatal mortality rate: The number of foetal deaths and early neonatal deaths (within 7 completed days after birth) per 1 000 total births. World Health Assembly resolutions WHA31.55, WHA 32.42 and WHA 45.22. Regional Committee for South-East Asia resolutions SEA/RC29/R8, SEA/RC30/R11, SEA/RC34/R8 and SEA/RC39/R5. Consensus statement at the 6 th East-Asia Pacific Ministerial Consultation on Children, Bali, Indonesia, May 2003.
2
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Member Countries, along with national and international partners, reaffirmed their commitment to further reduce infant and child mortality by adopting the Millennium Development Goals (MDGs) and at the United Nations General Assembly Special Session on Children. Public health experts predict that the MDG to reduce under-5 mortality by two-thirds cannot be met unless neonatal mortality is at least halved, which will require greater emphasis on measures to improve newborn health. The challenge is especially significant in many countries of the SEA Region where neonatal mortality represents at least 50 per cent of infant deaths. Most recently, the Fifty-sixth World Health Assembly, in May 2003, adopted a resolution (WHA56.21) on the “Strategy for child and adolescent health and development”, calling upon Member States to strengthen and expand efforts to meet international targets for reduction of maternal and child mortality and malnutrition, and, inter alia , make improvements in neonatal health a priority. It is, therefore, time for concerted efforts for the newborn. Though the magnitude of the problem of newborn health is enormous, solutions are also within reach. The international community and Member Countries are committed to address the case - doing so makes good social and economic sense. With sufficient political will and appropriate investment, neonatal health outcomes can be improved and progress towards the MDGs made a reality.
2.
MAGNITUDE OF THE PROBLEM
2.1 Epidemiology Burden of neonatal mortality The survival and health needs of neonates are being met in varying degrees in the countries of the Region. This is reflected in the wide range of neonatal mortality rates from 12 per 1 000 live births in Sri Lanka to 44 in Nepal. Only three countries - Thailand, Sri Lanka and Indonesia - have neonatal mortality rates below the global average. There is not only wide variation among countries but also within countries. For instance, in India, the neonatal mortality rate (NMR) ranges from 14/1 000 live births in the state of Kerala to 55 in Madhya Pradesh. In Bangladesh, NMR was estimated to be 42 in Chittagong while it was 85 in Sylhet. The high perinatal and neonatal mortality rates in many countries of the Region mostly reflect the limited access to quality services for care during late pregnancy, at birth and in the period immediately after birth. The following gives the estimated annual number of births, infant and neonatal deaths in the Region. Causes of neonatal deaths The major medical causes of neonatal mortality are neonatal infections (33 per cent) i.e. neonatal tetanus, sepsis, meningitis, diarrhoea and pneumonia; birth asphyxia and trauma (28 per cent); pre-term birth and/or low birth weight (24 per cent); congenital anomalies (10 per cent); and other causes (5 per cent). Birth asphyxia, trauma, preterm and low birth weight are major contributors to morbidity in survivors.
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Deaths in newborns during the first week of life are due to conditions originating in pregnancy or during childbirth and are a result of inadequate or inappropriate care during pregnancy, childbirth, or the first critical hours after birth. After the first week, deaths are mostly due to infections acquired after birth, either at health facilities or at home in previously healthy babies. Most neonatal deaths, whether during the period immediately after birth or later can be avoided with low-cost interventions that do not require sophisticated technology and can be implemented at all levels of the health system. Table: Estimated annual number of births, IMR, NNMR and infant and neonatal deaths in the SEA Region Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Total Source: WHO, 2003 (unpublished data)
No. of live births (in million) 4.2 0.07 0.39 25.2 4.5 0.01 1.2 0.81 0.33 1.2
Infant mortality rate 56 70 38 62 44 49 75 54 16 30
Neonatal mortality rate 39 34 18 42 21 29 37 44 12 16
Infant deaths 235 200 4 900 14 820 1 562 400 198 000 490 90 000 43 740 5 280 36 000 2 190 830
Neonatal deaths 163 800 2 380 7 020 1 058 400 94 500 290 44 400 35 640 3 960 19 200 1 429 590
Underlying causes In addition to poor care of newborns, the major underlying cause of neonatal deaths in developing countries, including most Member Countries in the SEA Region, is the poor health of mothers and inappropriate care. Many pregnant women are poorly nourished and may be recovering from a previous pregnancy. Malaria, sexually transmitted infections and HIV/ADIS also play a significant role in excess neonatal morbidity and mortality. Among the other indirect factors that influence neonatal mortality is the high prevalence of preterm birth/low birth weight neonates. Poor feeding practices also play an important role. Evidence shows that there are major health benefits of exclusively breast-feeding neonates. Unfortunately, many mothers and newborns do not receive the help they need to initiate appropriate breast-feeding in a timely manner. Preference for male offspring and a corresponding discrimination against and neglect of female newborns - leading to female infanticide in extreme cases - contribute to higher mortality among female newborns. Socio-cultural factors Cultural beliefs and practices related to pregnancy, childbirth and post-natal care of the newborn and mother have not been studied extensively. However, these practices may have an important role in determining neonatal outcomes. In many traditional societies, women may be denied food during pregnancy, and pregnancy and childbirth are regarded as unclean. The room where the mother and baby are confined is often dark and kept warm by
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burning firewood. Babies who do not cry or breathe immediately after birth may be subjected to various harmful manoeuvres. Various substances like turmeric powder, wood ash, talcum and animal dung are used for cord care. Even in countries where breast-feeding rates are high, initiation of breast-feeding is often delayed beyond the recommended one hour of birth. A significant proportion of mothers discard colostrum and the practice of giving pre-lacteal feeds is prevalent. The mother and baby are often confined together in a room for the first few weeks after delivery, and neonates are not taken out of the house, even for medical assistance, due to socio-cultural beliefs and lack of knowledge of signs of severe illness and when to seek care.
2.2 Health System Response In most countries of the Region, the capacity of existing health systems to respond to the needs of mothers and newborns is limited, inadequate or unevenly distributed and, in some instances deteriorating. Access to health services is a major constraint, particularly for poor and marginalized groups of the population - the ones whose burden of ill-health is the highest. In several countries of the Region, the majority of deliveries occur at home, attended by grandmothers, mothers and other relatives, or traditional birth attendants. Typically, they occur without the assistance of a skilled birth attendant. Absence of skilled care providers, lack of access to essential care, including care in emergencies, poor quality of care, unreliable or limited supplies and equipment, and non-functional referral systems have eroded public confidence in the health services and may have resulted in low utilization of existing facilities.
3.
PRIORITY AREAS FOR INTERVENTIONS FOR NEWBORN HEALTH
A relatively recent development has been the accumulation of evidence regarding the effectiveness of interventions. WHO has identified priority areas for intervention through the life course in various publications 3. These interventions should be considered for programmatic implementation by countries taking into consideration the prevalent epidemiology, available resources and capacity of the health system to undertake the tasks. The following are the priority areas identified: Before and during pregnancy • • • • • •
Delayed child-bearing Well-timed, well-spaced and wanted pregnancies Well-nourished and healthy mother Pregnancy free of drug abuse, tobacco, and alcohol Tetanus and rubella immunization Prevention of mother-to-child transmission of HIV
During pregnancy •
Early contact with health system.
3
Strategic Directions for Improving the Health and Development of Children and Adolescents, WHO/FCH/CAH/02.21 Rev. 1, and Mother-Baby Package (WHO/FHE/MSM/94.11, REV.1)
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Improved maternal nutrition Birth and emergency preparedness Early detection and treatment of maternal complications Monitoring of foetal well-being and timely interventions for foetal complications Tetanus immunization Prevention and treatment of anaemia Prevention and treatment of infections (malaria, hookworm, syphilis and other STIs)
During and soon after delivery • • • • • • • • •
Safe delivery by skilled attendant Early detection and prompt management of delivery and foetal complications Emergency obstetric care Newborn resuscitation Newborn care ensuring warmth, cleanliness Early initiation of exclusive breast-feeding Early detection and treatment of complications of the newborn Special care for infants born too early or too small and/or complications Prevention of mother-to-child transmission of HIV
During the first month of life • • • • •
Early postnatal contact with appropriate home practices Promotion and support of exclusive breast-feeding Prompt detection and management of diseases in newborn infant Immunization Prevention of mother to child transmission of HIV
4.
WAY FORWARD
In implementing the above interventions, the international community, national governments and its related development partners should consider the following strategic needs: (1) Creating a supporting environment
Neonatal health and survival is a public health issue. Member Countries will need to take full responsibility and translate international commitment into reality. This includes adopting adequate policies and strategies and creating a socio-political environment for the health system to respond to the needs of the population. Success or failure in achieving the MDGs for reduction of under-5 mortality will depend on political will and adequate investment, with a greater emphasis on the needs of mothers and newborns.
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(2)
Improving health system response and quality
Improving newborn health will require a continuum of care starting from before pregnancy to after delivery. Pregnancy and birth are normal physiological processes but complications can occur at any time. Therefore, access to a well-functioning health care system is necessary to facilitate response to the needs of mothers and newborns and maintain their health. The following areas need to be addressed to improve maternal and neonatal health outcomes: (a) Improving access to skilled birth attendance: Skilled attendants with adequate supplies, equipment and access to referral facilities are necessary to provide adequate and timely care before pregnancy, during pregnancy and during and after delivery. The attendant should be able to manage most of the complications, provide appropriate first aid measures and ensure timely referral to higher facilities when appropriate. (b) Improving access to essential neonatal care including management of newborn illnesses and complications: Health care providers need to have the skills to support mothers and other care-givers in adopting essential care practices for newborn health. They also need to be able to recognize and appropriately manage neonatal illnesses and complications on time at different levels of health care facilities. A functional referral system needs to be established. (c) Improving quality of care, management and logistics: Improving quality of existing health care services will go a long way in improving maternal and newborn health. Effective and efficient management and logistics, including adequate supplies, will be necessary to provide appropriate and timely care. (d) Improving monitoring: Lack of information and data hampers programme planning and implementation. Maternal and newborn health information for monitoring needs to be integrated into the existing health information system. (3) Supporting family and community responses
Individuals, families and communities need to mobilize their collective efforts and resources to adequately respond to the needs of mothers and their newborns. They can be empowered to minimize socio-cultural practices and norms which have an adverse impact on mothers and newborns and to promote practices that are beneficial. They can be instrumental in creating a demand for and improving access to adequate health care services. They can command resources to ensure: • • • • • • • • • •
adequate nutrition tetanus immunization safe and clean delivery exclusive breast-feeding safe and clean environment timely seeking of skilled health care, and transportation for mother and the newborn improvement of the health and status of women prevention of early marriage and early child-bearing promotion of safe sexual practices promotion of female education
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(4)
Fostering strategic alliances and partnerships
Strategic alliances and partnerships will minimize duplication of efforts and maximize utilization of scarce resources. Such partnerships will help countries to have a collective, coherent and resourceful response to the needs of the newborn. Global initiatives like GAVI and EPI, GFATM, Roll Back Malaria, STD/HIV/AIDS, Tobacco Free Initiative and other relevant initiatives have significant programme overlap and implications on maternal and newborn health. Improving newborn health will require strategic alliances with all relevant initiatives for programme synergy and maximizing resource utilization. Grassroots organizations, NGOs, institutions, professional bodies, donors, UN agencies and development partners should be actively involved at all levels in efforts to achieve the MDGs and improve maternal and newborn health. (5) Narrowing knowledge gaps
Many effective clinical interventions for newborn care are known. However, sociobehavioural factors influencing health care practices and health care seeking need further investigation. There are important knowledge gaps about essential requirements for effective community-based care, scaling-up of interventions, and facilitation of an essential health system response including management. Further investments are needed at all levels to analyse programme implementation, identify lessons learned, and conduct additional research to improve effectiveness of intervention delivery. (6) Measuring progress
In order to measure progress in achieving goals and targets for improved maternal and neonatal health, countries need to improve vital registration. Making use of existing systems, they should carefully decide and select indicators that are relevant to the interventions they plan to implement. Data on process indicators are less complex and costly to collect than mortality data; the information is usually available (or can be integrated) through routine health information collected at the facility level. Data on process indicators are useful to policy and programme planners since they provide information about factors and major pathways for mortality and morbidity prevention. They generate information on the availability, accessibility, utilization and quality of care and can support programme management at the local level.
5.
ROLE OF WHO
WHO will work with countries and its partners in improving newborn health and towards achieving the Millennium Development Goals. The focus will be mainly on the following areas: (1) Advocacy
WHO will take all necessary measures to highlight why newborn health deserves and requires special investment, and what those investments should be. It will provide necessary evidence-based information to countries to facilitate political commitment, policy formulation and programme development, and to the partners and donors for their active involvement and increased support.
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(2)
Development of norms and standards when necessary
WHO headquarters has developed a number of technical and managerial tools and guidelines for maternal and newborn health care for different levels e.g. Integrated Management of Pregnancy and Childbirth (IMPAC) and Integrated Management of Childhood Illness (IMCI). The Regional Office will focus on the adaptation, dissemination and utilization of these guidelines and tools. Additional tools and guidelines will be developed selectively to address Region-specific issues, in collaboration with WHO headquarters, expert institutions and WHO collaborating centres. (3) Capacity building through technical support
WHO will build national capacity by providing technical support, training and fellowship programmes for technical staff to enable them to adapt and utilize evidence-based best practices; select strategies and priorities; conduct effective programme planning; improve quality of care; build on lessons learned; scale up interventions; improve accountability; mobilize resources and monitor and evaluate programme implementation. (4) Partnership
WHO will be actively involved in promoting partnerships with various global and national initiatives, UN partners, particularly UNICEF and UNFPA, and other development partners, the World Bank, the Asian Development Bank and donor agencies. Partnerships with international, national and local NGOs, institutions, and professional bodies will be fostered in order to help governments get maximum support, coordinate various inputs, create synergy and complementarity of efforts, minimize duplication and maximize resources. (5) Research support and generation of evidence
WHO is known for its scientific expertise in medical, clinical, social and operational research and its support for in-country research capacity building. The Regional Office will collaborate with WHO headquarters in research capacity building, promote relevant research and generate evidence of best practice. It will help countries to disseminate evidence and bring about changes in policies and practices for improved newborn health. (6) Measuring progress
WHO will work with countries and its partners in improving vital registration, country-specific surveillance and monitoring capacity, adapting and integrating indicators on newborn health in existing health information systems, improving quality of data, data collection and analysis and their utilization for measuring progress and programme planning. WHO will also maintain information on regional progress in improving maternal and newborn health and report to Member Countries on a regular basis.