New Lancet Series finds counting births and deaths is an indicator of progress towards ending 3 million preventable infant deaths
LONDON—Each year, 5.5 million babies enter and leave the world without being recorded and one in three newborns—over 45 million babies—do not have a birth certificate by their first birthday. Babies who are stillborn, born too early, or who die soon after birth are least likely to be registered, even in high-income countries.
Findings from the Every Newborn Series, published today in The Lancet, paint the clearest picture to date of a newborn’s chance of survival and the steps that must be taken to end preventable infant deaths. New analyses indicate that 3 million maternal and newborn deaths and stillbirths can be prevented each year with proven interventions—including the promotion of breastfeeding, neonatal resuscitation, kangaroo mother care for preterm babies, antenatal corticosteroids, and the prevention and treatment of infections. These interventions can be implemented for an annual cost of US$1.15 per person. Providing quality care at birth yields a triple return on investment—saving mothers and newborns, and preventing stillbirths—and protects babies from disability.
The research was led by Professor Joy Lawn, Director of the MARCH Centre at the London School of Hygiene & Tropical Medicine in the UK, and senior adviser to Save the Children, and by Professor Zulfiqar Bhutta, from the Centre for Global Child Health, Hospital for Sick Children, Canada, and the Centre of Excellence in Women and Child Health, the Aga Khan University, Pakistan, in collaboration with 55 global health experts, researchers, and policymakers from 27 institutions in 18 countries.
“Every day, 15,000 babies are born and die without ever receiving a piece of paper. The lack of recording reflects the world’s acceptance that these deaths are inevitable. This fatalism, lack of attention, and lack of investment are the reasons behind lagging progress in reducing newborn deaths – and even slower for progress in reducing stillbirths. In reality, these deaths are nearly all preventable,” said Professor Lawn of the London School of Hygiene & Tropical Medicine and senior health advisor to Save the Children. “Counting and naming every newborn is a statement that we expect that baby to survive and receive the care he or she needs, especially around birth.”
Slower progress for newborn survival
Worldwide, nearly 3 million newborns die each year and an additional 2.6 million babies are stillborn. Nearly half of these deaths occur during labour and almost all go unrecorded. Over the last decade, the rate of reduction for newborn deaths has been about half the rate of reduction achieved for children under age five. As a result, newborn deaths now account for a larger proportion of under-five child deaths—44% in 2012, compared to 36% in 1990. In most regions of the world, more than half of child deaths are among newborns.
If current trends continue, it will be more than 110 years before an African baby has the same chances of survival as a baby born in North America or Europe. Progress in Africa has been three times slower than what has been achieved in high-income countries, even before the advent of intensive care.
Without greater investments to improve birth outcomes around the world, by 2035 there will be 116 million newborn deaths, 31 million surviving babies and children with disabilities, and 68 million with lost development potential because of stunting.
“We have made dramatic progress improving child survival in recent years, but it is clear that newborns have been left behind,” said Dr Mickey Chopra, UNICEF’s Chief of Health. “To continue improving child survival, health, and development, we must now ensure every newborn has a healthy start. Investing in the health and wellbeing of newborns is a down payment on the future.”
Prioritising the day of birth to reduce preventable deaths and disabilities
The day of birth is the most dangerous day for women and their babies—resulting in nearly half of maternal and newborn deaths and stillbirths. Each year, one million babies die on their birth day. It is also the day babies face the greatest risk of disability. The majority of newborn deaths are preventable, caused by complications related to prematurity, birth, and severe infections. Preterm and small babies are at much higher risk of death and disability, and are at long-term risk of stunting and non-communicable diseases such as diabetes and hypertension as adults.
Where and when action is needed
South Asia and sub-Saharan Africa are the regions with the highest burden of newborn deaths, with India (779,000), Nigeria (267,000), and Pakistan (202,400) leading the ranks among countries. These three countries also have the most births and have exhibited the slowest rates of progress in reducing deaths. In 2012, eight of the nine countries with neonatal death rates greater than 40 for every 1,000 live births were in sub-Saharan Africa; half of these countries were affected by conflict.
The greatest opportunity for saving lives is to invest in high impact care during the time just before and immediately after birth. Quality care at birth accounts for 41% of the estimated 3 million lives saved. Providing special care for small and sick newborns accounts for 30%. Additionally, family planning services and meeting the unmet need for family planning would be synergistic by reducing the annual number of births and, therefore, deaths by about half.
“High coverage of interventions before conception, as well as before, during, and after pregnancy, could prevent 3 million deaths—that’s 54% of maternal deaths, 33% of stillbirths, and 71% of newborn deaths—at an annual running cost of US$ 5.65 billion. This is a triple return on investment which amounts to US$ 1,928 for each life saved,” stated Professor Bhutta. “The increasing number of women who are giving birth at healthcare facilities presents the most immediate opportunity for action. Our analysis shows that by increasing facility births and closing the quality gap at healthcare facilities by 2020, we could prevent an estimated 113,000 maternal deaths, 531,000 stillbirths and 1.325 million newborn deaths each year. This should clearly be an immediate priority.”
A systematic assessment of challenges in eight high-burden countries—Afghanistan, Bangladesh, Democratic Republic of Congo, India, Kenya, Nigeria, Pakistan, and Uganda—revealed that the most common barriers to improving survival were related to the health workforce, financing, and service delivery. Countries that have made recent, rapid reductions in newborn and maternal deaths—such as Malawi, Nepal, and Peru—have done so by expanding their skilled workforce (especially midwives and nurses), rolling out innovative mechanisms to reach the poorest families, and focusing on improving care for small and sick newborns.
The health and wellbeing of women, newborns, and children is closely linked, and they must be prioritised,” said Melinda Gates, co-Chair of the Bill & Melinda Gates Foundation. “We have proven solutions that we know will save newborn lives and accelerate progress for women and children, and we have seen that where there is political will around these solutions significant progress is possible.”
First-ever global action plan to end newborn deaths
This week, at the World Health Assembly in Geneva, governments will review the Every Newborn Action Plan. The plan is based on a series of measures that are already proving effective in keeping women and children healthy–from preconception and pregnancy through to childhood and adolescence,” said Dr. Elizabeth Mason, Director of the Department for Maternal, Newborn, Child and Adolescent Health at the World Health Organization. “Our goal is to end preventable newborn deaths within a generation.”
The Lancet authors point to the unprecedented opportunity for progress today. Rooted in the evidence presented in the Series, the Every Newborn Action Plan (ENAP), co-led by the World Health Organization (WHO) and UNICEF, will be presented at the Partners’ Forum hosted by the Partnership for Maternal, Newborn & Child Health (PMNCH) in Johannesburg, South Africa on June 30. The ENAP is based on epidemiology, evidence, and global and country learnings from the Series and sets a framework to end preventable deaths for newborns and stillbirths by 2035 as part of the A Promise Renewed effort. It also provides interim targets for 2030 to align with the forthcoming post-2015 development framework. The ENAP will lead to practical standards for quality of care, improved measurement of births and deaths, and increased programmatic coverage with accountability for results.
Justine Greening, UK Secretary of State for International Development states that, “Having explicit targets to reduce newborn deaths and stillbirths is crucial for saving the lives of mothers and their babies. Targets mean governments can be held accountable for the promises they make. We are already seeing progress, and by scaling up the right interventions we can make a real difference.”
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