Chapter 5

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 sub-Saharan 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 during 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 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 ).

Footnotes

¹ Best practices: detecting and treating newborn asphyxia. Baltimore, MD, JHPIEGO, 2004 (http://www.mnh.jhpiego.org/best/detasphyxia.pdf, accessed 16 February 2005).

² Verhoeff FH, Le Cessie S, Kalanda BF, Kazembe PN, Broadhead RL, Brabin BJ. Post-neonatal infant mortality in Malawi: the importance of maternal health. Annals of Tropical Paediatrics, 2004, 24:161–169.

³ Grantham-McGregor SM, Lira PI, Ashworth A, Morris SS, Assuncao AM. The development of low birth weight term infants and the effects of the environment in northeast Brazil. Journal of Pediatrics, 1998, 132: 661–666.

⁴ Godfrey KM, Barker DL. Fetal nutrition and adult disease. American Journal of Clinical Nutrition, 2000, 71(Suppl.):1344S–1352S.

⁵ UNICEF/WHO. Low birthweight: country, regional and global estimates. New York, NY, United Nations Children’s Fund, 2004.

⁶ Caulfield L. Nutritional interventions in reducing perinatal and neonatal mortality. In: Reducing perinatal and neonatal mortality. Report of a meeting, Baltimore, MD, 10–12 May 1999. Baltimore, MD, Johns Hopkins School of Public Health, 1999 (Child Health Research Project Special Report, Vol. 3, No. 1).

⁷ Tinker A. Safe motherhood is a vital social and economic investment. Paper presented at: Technical Consultation on Safe Motherhood, Safe Motherhood Inter-Agency Group, Colombo, Sri Lanka, 18–23 October, 1997 (http://safemotherhood.org/resources/pdf/aa-06_invest.pdf, accessed 15 February 2004).

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 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 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.

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 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.

Footnotes

⁸ Lawn J, Zupan J, Knippenberg R. Newborn survival. In: Jamison D, Measham AR, Alleyne G, Breman J, Claeson M, Evans DB et al, eds. Disease control priorities in developing countries, 2nd ed. Bethesda, MD, National Institutes of Health, 2005.

⁹ Masuy-Stroobant G. Infant health and child mortality in Europe: lessons from the past and challenges for the future. In: Corsini C, Viazzo PP, eds. The decline of infant and child mortality: the European experience 1750–1990. The Hague, Kluwer Law International/Martinus Nijhoff, 1997.

¹⁰ Hall S. Neonatal mortality in developing countries: what can we learn from DHS data? Southampton, Southampton Statistical Sciences Research Institute, 2005 (Applications & Policy Working Paper, A05/02; http://eprints.soton.ac.uk/14214, accessed 15 February 2005).

¹¹ Hill K, Pande R. The recent evolution of child mortality in the developing world. Arlington, VA, BASICS (Basic Support for Institutionalizing Child Survival), 1997 (Current Issues in Child Survival Series).

¹² Curtis S. An assessment of the quality of data used for direct estimation of infant and child mortality in DHS II surveys. Calverton, MD, Macro International Inc., 1995 (Demographic and Health Surveys Occasional Paper, No. 3).

¹³ Reher D, Perez-Moreda V. Assessing change in historical context: childhood mortality patterns in Spain during demographic transition. In: Corsini C, Viazzo PP, eds. The decline of infant and child mortality: the European experience 1750–1990. The Hague, Kluwer Law International/Martinus Nijhoff, 1997.

¹⁴ Hanmer L, White H. Infant and child mortality in sub-Sarahan Africa. Report to Sida. The Hague, Institute of Social Studies, 1999.

¹⁵ Simms C, Milimo JT, Bloom G. The reasons for the rise in childhood mortality during the 1980s in Zambia. Brighton, University of Sussex, Institute of Development Studies, 1998 (Working Paper 76).

¹⁶ Costello A, White H. Reducing global inequalities in child health. Archives of Disease in Childhood, 2001, 84:98–102.

¹⁷ Ticconi C, Mapfumo M, Dorrucci M, Naha N, Tarira E, Pietropolli A et al. Effect of maternal HIV and malaria infection on pregnancy and perinatal outcome in Zimbabwe. Journal of Acquired Immune Deficiency Syndromes, 2003, 34:289–294.

¹⁸ Brocklehurst P, French R. The association between maternal HIV infection and perinatal outcome: a systematic review of the literature and meta-analysis. British Journal of Obstetricts and Gynaecology, 1998, 105:836–848.

¹⁹ Rutstein SO. Factors associated with trends in infant and child mortality in developing countries during the 1990s. Bulletin of the World Health Organization, 2000, 78:1256–1270.

²⁰ Cornia A, Mwabu G. Health status and health policy in sub-Saharan Africa: a long-term perspective. Helsinki, United Nations University/World Institute for Development Economics Research, 1997.

²¹ Anand S, Bärnighausen T. Human resources and health outcomes: cross country econometric study. Lancet, 2004, 364:1603–1609.

²² Bulatao RA, Ross JA. Which health services reduce maternal mortality? Evidence for ratings of maternal health services. Tropical Medicine & International Health, 2003, 8:710–721.

²³ Shiffman J. Can poor countries surmount high maternal mortality? Studies in Family Planning, 2000, 31:274–289.

²⁴ Filmer D, Pritchett L. The impact of public spending on health: does money matter? Social Science and Medicine, 1999, 49:1309–1323.

²⁵ Matthews Z, Ensor T, Amoako-Johnson F, Van Lerberghe W. socioeconomic and health system determinants of maternal, newborn and child mortality (unpublished IMMPACT/ WHO background paper for The World Health Report).

²⁶ Werner D, Sanders D. Questioning the solution: the politics of health care and child survival. Palo Alto, CA, Heathwrights, 1987.

²⁷ Loudon I. Death in childbirth: an international study of maternal care and maternal mortality, 1800–1950. Oxford, Clarendon Press, 1992.

²⁸ MacFarlane A. Birth counts: statistics of pregnancy and child birth [CD-Rom]. London, The Stationery Office, 2000.

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 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 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 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. 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 difficult 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 actively promote breastfeeding. Where quality is satisfactory, such places are much safer for mother and child than a home birth without professional assistance.

Universal access to professional, skilled care at birth for all mothers has, in combination with antenatal care, an enormous potential for reducing the burden of stillbirths and early neonatal deaths that form the majority of fetal and neonatal mortality. In most countries, the mortality of babies whose mothers benefit from antenatal care and skilled care at childbirth tends to be less than half that of babies whose mothers do not benefit from such care (see Figure 5.5). The consistency of these differences across a wide range of countries suggests that it is access to a continuum of skilled care that makes the difference.

Caring for the baby at home

Professional care at birth has less effect, however, on later neonatal deaths, which occur when the mother and newborn are at home, without professional support. Care within the household is very important for the newborn’s health. If the mother has good parenting skills (which can be enhanced during the antenatal care consultations) and if she can breastfeed and keep the baby warm, it will be mostly fine: being a newborn is not a disease. In societies where women have extensive social networks, mobility, and the autonomy to control resources as well as access to good health care and information, mothers are in a better position to care for their babies. To move in that direction it helps to mobilize communities, for example through women’s groups ( ³⁴ ). In Bolivia, encouraging women to participate in groups involved in promoting the health of the newborn contributed to a reduction in perinatal mortality from 117 to 44 per 1000 live births ( ³⁵ ). In Nepal, the development of a network of women’s groups led to a 30% reduction in neonatal mortality rates, mainly through better uptake of services ( ³⁶ ).

An important aspect of caring for newborns is to seek help when problems occur. Even newborns who are not especially at risk may become ill in the days after birth: it is then important to seek professional care immediately. All high-risk babies, such as those with low birth weight, require professional care, and advice must be available to their mothers. The early weeks of life are particularly problematic because there is often no clear delineation of professional responsibilities to provide assistance to newborns in need of extra care.

Ensuring continuity of care

The handover of responsibilities of the newborn to child health services – typically from the midwife to the health centre – is a critical stage in the continuum of care. Newborn care often falls between the cracks. Maternal health services consider that their responsibility ends after childbirth or when the mother is discharged from hospital with her baby. Child health programmes, on the other hand, have been primarily aimed at preventing mortality in older children, focusing on vaccine-preventable diseases, diarrhoea and acute respiratory tract infections and less on the problems of newborns. The health workers in these programmes often tend to wait until the mother presents her child at the health centre for vaccination. Even when newborns are taken to facilities, health staff often lack confidence or have been inadequately trained to treat very young babies. Where mother and baby are confined to the home after birth, which is the case in many parts of the world, care is inaccessible unless the health worker is willing to make a home visit. In many settings there are no mechanisms for establishing communication and handover between maternal and child programmes.

There is a pressing need to develop and evaluate effective strategies for establishing a continuum of care that bridges the critical first weeks of life. In many countries – particularly in the industrialized world – there is a long tradition of home visits by health staff to check up on mother and newborn in the immediate postpartum period. In some countries this is part of the work of the midwife; in others, paediatric nurses or health visitors have the responsibility. The relative advantages of each solution are unclear, and probably depend on the local and historical contexts; all pose problems of coordination to prevent care of the newborn from slipping between fragmented services. The current shortages of professional skilled attendants mean that much of the postnatal follow-up of mothers and babies, and particularly the postnatal follow-up at home, will most often be shifted from birthing centres to health centre staff – nurses, general practitioners or paediatricians. This creates a need for attention to skills, job descriptions and mechanisms to ensure continuity of care.

Many countries today face a dilemma: either invest in the continuum of care and in access to skilled care at birth or, given the present unavailability of skilled professionals, go part of the way by investing in lay workers who could provide some of the care newborns need that mothers cannot provide themselves. Activities through which lay workers help to improve living conditions, enable women and their families to provide good care in the home, and promote uptake of services have been clearly shown to supplement professional care effectively ( ³⁶ ). Evidence for the usefulness of non-professional community workers providing treatment for newborns under routine circumstances is scantier and is subject to debate. Strategically, the question is whether this brings an added value and whether the opportunity cost is not too high, compared to focusing on expanding professional care and improving care within the home.

In countries and areas where professional skilled attendance at birth is high and increasing, developing a strategy that promotes lay community health workers would have little popular or political support compared to one that aims for universal access. It makes more sense, in such countries, to concentrate on speeding up coverage further, improving quality of professional newborn care by maternal and child health services, and establishing continuity with care at home.

The dilemma is real, however, in areas where present levels of professional skilled attendance coverage are very low. Betting on non-professional care has the appeal of doing something immediately. Ultimately, though, the objective is to roll out networks of effective professional services, to catch up with countries that started to do so in earlier decades. The existence of such professional services is in itself a precondition for lay workers to be effective. Care should be taken to avoid the mistake made in the 1980s, when a strategy of scaling up professional birthing services was replaced rather than complemented by working with traditional birth attendants (see Box 4.4). Likewise, local community health workers can complement professional services in caring for newborns, but they are not an alternative to building up professional services: the opportunity cost would be too high.

The weakest link in the care chain today is skilled attendance at birth. The main thrust of strategies aimed at improving the health of newborns should be to improve access to and uptake of professional care at birth by all pregnant women. It will be necessary to refocus care at birth to make sure that the interests of the newborn are given due attention. This needs to be done at first level and for the back-up services: timely referral here is just as important as it is in dealing with unpredictable maternal emergencies.

Overcoming the present fragmentation of care for newborns is no easy task. What is done before and at childbirth should be linked with what will happen afterwards in the home and within the services that assume responsibility for providing health care for the newborn and, later, the child. The first challenge, though, is to roll out skilled maternal and newborn care fast enough to put an end to the exclusion of nearly half of the world’s newborns from the life-saving care to which they are entitled.

Footnotes

⁸ Lawn J, Zupan J, Knippenberg R. Newborn survival. In: Jamison D, Measham AR, Alleyne G, Breman J, Claeson M, Evans DB et al, eds. Disease control priorities in developing countries, 2nd ed. Bethesda, MD, National Institutes of Health, 2005.

²⁹ Mahy M. Childhood mortality in the developing world: a review of evidence from the Demographic and Health Surveys. Calverton, MD, Macro International Inc., 2003 (DHS Comparative Reports, No.4).

³⁰ Inter-Agency Group on Safe Motherhood. The safe motherhood action agenda: priorities for the next decade. Report of the Safe Motherhood Technical Consultation, 18–23 October 1997, Colombo, Sri Lanka (http://www.safemotherhood.org/resources/pdf/e_action_agenda.PDF, accessed 16 February 2005).

³¹ MacDonagh S. Creating synergies in maternal and neonatal health services. London, Department for International Development, 2003 (unpublished Options working paper undertaken on behalf of DFID).

³² Harvey SA, Ayabaca P, Bucagu M, Djibrina S, Edson WN, Gbangbade S et al. Skilled birth attendant competence: an initial assessment in four countries, and implications for the Safe Motherhood movement. International Journal of Gynecology and Obstetrics, 2004, 87:203–210.

³³ Bautista LE. Duration of maternal breast-feeding in the Dominican Republic. Revista Panamericana de Salud Pública/Pan American Journal of Public Health, 1997, 1:104–111.

³⁴ Working with individuals, families and communities to improve maternal and newborn health. Geneva, World Health Organization, 2003 (WHO/FCH/RHR/03.11).

³⁵ O’Rourke K, Howard-Grabman L, Seoane G. Impact of community organization of women on perinatal outcomes in rural Bolivia. Revista Panamericana de Salud Pública/Pan American Journal of Public Health, 1998, 3:9–14.

³⁶ Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM et al. and MIRA. Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster randomised controlled trial. Lancet, 2004, 364:970–979.

Planning for Universal Access

Benchmarks for supply-side needs

It would be ill-advised to separate the plan for scaling up access to newborn care from that of care during pregnancy, childbirth and the postpartum. Planning requires benchmarks. The current recommendations suggest that maternal and newborn health facilities should be organized with at least one "comprehensive" and four "basic" essential obstetric care facilities per 500 000 population, that is, one facility for 3000 births per year. These recommendations do not fit the reality of health districts, which are often considerably smaller. In sub-Saharan Africa, where most of the stagnation occurs, the average district has around 120 000 inhabitants; in South-East Asia they are often much smaller units.

Estimating the need for first-level care for mothers and babies is straightforward: eventually all should have access. The problem is to decide on the optimal level of decentralization – the compromise between access and efficiency.

The requirement for back-up care is more difficult to assess, since only some expectant mothers and their babies will eventually need such interventions – but they cannot be identified beforehand. The percentage of mothers and their babies who need such care is the subject of debate. Estimates vary considerably, without a strong empirical basis ( ³⁷ ). According to current guidelines from the United Nations Children’s Fund, the United Nations Population Fund and WHO, the percentage of mothers who develop serious complications is 15% – but this does not mean that all need back-up care: many of these complications can be resolved within the first-level package. On the basis of more recent evidence and ongoing research, this percentage can probably be revised downwards, to a low-end estimate of 7%, including 2–3% who are surgical cases. The proportion of newborns requiring back-up care is often very much underestimated – while the need for sophisticated equipment to save their lives is overestimated. The percentage of newborns for whom back-up care would make the difference between survival and a high risk of dying is probably between 9% and 15%, but the evidence is scarce.

In a district of 120 000 inhabitants, and assuming a birth rate of 30 per 1000 inhabitants, there would be a workload of 3600 mothers and newborns requiring first-level care, of whom some 600–650 would also require back-up. Midwives working in a team can easily assist at least 175 births per year ( ³⁸ ). Such a district would require some 20 midwives, or equivalent skilled attendants, to provide first-level care to all mothers and their newborns in the district, in hospital and in decentralized midwifery-led birthing facilities of 60–80 beds.

A practical and cost-effective arrangement would be for one team of 9–10 midwives (or equivalent staff) to be stationed in the hospital ( ³⁸ ). The others would be stationed in other birthing facilities in the district. In a more dispersed population, smaller birthing facilities, with perhaps five midwives each, would be an option that would still provide round-the-clock service, but with higher quality control and emergency evacuation costs. In large, sparsely populated districts, the only solution may be to station individual midwives in villages – as has been the policy in Indonesia. This greatly improves access, but poses problems of quality assurance, 24-hour availability and the effectiveness and cost of emergency referral links.

A district like this would require the services of one full-time equivalent doctor and his or her supporting team to provide back-up care for the 600 or more mothers and babies with problems that go beyond the competence of the first-level staff. Given the imperative of 24-hour availability and the range of skills required for back-up care, a single gynaecologist-obstetrician per district is not a viable option. Alternatives, such as improving the skills of all-round medical staff or specialized technicians, have successfully been tried out in a large number of resource-poor countries, with considerable success. Such upgrading of skills has to cover both obstetric and neonatal care, a consideration that has received too little attention so far.

Room for optimism, reasons for caution

Where credible services are offered, uptake can increase dramatically. For example in Dakar, Senegal, the opening of a surgical theatre in an urban maternity unit immediately led to an 80% increase in the number of births in the unit. There is obviously a huge demand waiting to be tapped.

Globally the availability of nationally representative data for skilled attendants at birth is high and data are available for 93.5% of all live births. >From this we know that 61.1% of births worldwide are attended by a professional who, at least in principle, has the skills to do so. Extrapolating from data available on 58 countries representing 76% of births in the developing world, the use of a skilled attendant at delivery – the key feature of first-level care – increased significantly, from 41% in 1990 to 57% in 2003, a 38% increase between 1990 and 2003. The greatest improvements occurred in South-East Asia (from 34% in 1990 to 64% in 2003) and northern Africa (from 41% in 1990 to 76% in 2003). These trends represent an increase of more than 85% in both regions. Hardly any change was observed, however, in sub-Saharan Africa, where rates remained at around 40% – among the lowest in the world. Within these regional averages there are significant differences between countries and between urban and rural areas. Almost all of the increases in births with a skilled attendant are driven by increases in the presence of medical doctors at birth. In fact, most regions, with the exception of sub-Saharan Africa, show decreasing use of other types of professional assistance. There is a marked increase in the proportion of deliveries that take place in health facilities, both in rural and urban areas (see Figure 5.6).

This tendency towards increased use of professional maternal and newborn care services should not give rise to excessive optimism. There are many places where hospitals with trained professional staff exist, and yet mortality remains staggeringly high. In 1996, for example, Brazzaville, Congo, had a maternal mortality ratio of 645 per 100 000, university hospital and health care facilities notwithstanding ( ³⁹ ). Delivery care is not merely a matter having a hospital with trained clinicians, it is also a question of how professional staff perform and behave ( ⁴⁰ ).

Two tendencies are particularly worrying. First, there is the difference between what the qualification of midwife, nurse-midwife or doctor guarantees and the actual level of skills and competence. In a seminal study of their capacities in four countries, there was little correspondence between knowledge and skills, and all types of providers showed large differences between their actual skill levels and international reference standards. This was also the case for crucial life-saving skills, for newborns, and also for their mothers ( ⁴¹ ).

Second, maternal and newborn care is an area where commercialization of health care delivery – overt or covert – finds a readily exploitable public. Payments for a spontaneous vaginal delivery amount to at least 2% of annual household cash expendi-ture in Benin and Ghana; in cases of interventions for complications, costs reached a high of 34% of annual household cash expenditure ( ⁴² ). With an ample potential clientele, supply-induced overuse of medical technology is rife, with consequent risk of iatrogenesis and financial exploitation of clients. The worldwide epidemic of caesarean section is a typical example, but not the only one (see Box 5.3)

Closing the human resource and infrastructure gap

Information is now becoming available on the infrastructure and personnel available to provide this kind of care, but it is still very fragmentary. In Bangladesh, Benin, Bhutan, Chad, Morocco, Nicaragua, Niger, Senegal and Sri Lanka, for example, five years of monitoring the adequacy of emergency care shows a mixed picture, but with a consistent lack of first-level care in most settings and an inappropriate spread of facilities ( ⁵⁴ – ⁵⁶ ). The situation is very different from country to country, but appears to be worse in the countries whose outcomes were stagnating or in reversal between 1990 and 2002.

The number of beds available in the maternity wards of health facilities of many countries is well below their needs and unevenly distributed. The main constraint, however, is the shortage of skilled professionals. Examples of the extent of the shortage in human resources can be seen in Figure 5.7, which compares the benchmarks set out above with an exhaustive on-the-spot inventory of staff in both public and private facilities. The gaps are most pronounced, in all countries, for the personnel typically entrusted with first-level maternal and newborn care.

It will take time and money to make up for these shortages: midwives are in short supply, especially outside the capital cities, and in many countries the scarcity is becoming more pronounced. It will also take time and money to establish the health care network infrastructure, both for first-level and back-up care. This is particularly true for countries in sub-Saharan Africa and others in stagnation or reversal.

Scenarios for scaling up

WHO has established scenarios to make up for these shortages in 75 countries, and move towards universal access to both first-level and back-up maternal and newborn care (details on the scenarios and associated costs are available at: http/www.who.int/whr). Together, these countries account for more than 75% of the world’s population, almost 90% of all births worldwide, and approximately 95% of all maternal and neonatal deaths. At present, some 43% of births in these countries take place in health facilities, with skilled attendants, though the level of skills is highly variable, and only a fraction of these mothers and their babies have access to the full range of maternal and newborn health interventions. There is thus a double agenda of reaching all mothers and newborns, and of improving the quality and range of interventions made available.

The pace of scaling up depends on the specific circumstances and difficulties each country is facing. It is likely to be slowest in the countries that currently face the greatest challenges: the lowest levels of coverage, poorly developed and fragile health systems, and unfavourable circumstances. Taking into account the specific situation of the 75 countries, it seems realistic, in 12 countries, to provide access to the full set of first-level and back-up care for 95% of mothers and newborns by 2010, and to do the same in 18 other countries by 2015. For 25 countries, however, it is unlikely that coverage could be scaled up beyond 65% by 2015, and to universal access before 2025; in a fourth group of 20 countries, where current coverage is lowest, the supply gap most pronounced, health systems weakest and the environment most unfavourable, it seems possible to reach 50% by 2015, but full coverage may well require a further 15 years.

According to these scenarios, coverage with maternal and newborn care in the 75 countries taken together would grow from its present 43% (with a limited package of care) to around 73% (with a full package of care) in 2015. Table 5.1 shows some of the implications this has for the stock of health professionals and for the infrastructure for first-level and back-up maternal and newborn care. A first estimate of the potential impact of this scaling up suggests a reduction of maternal mortality, in these 75 countries, from a 2000 aggregate level of 485 to 242 per 100 000 births by 2015, and of neonatal mortality from 35 per thousand live births to 29 by the same date.

Costing the scale up

The cost of implementing these scenarios up to 2015 is estimated at US$ 39 billion (US$ 1 billion in 2006 increasing, as coverage expands, to US$ 6 billion in 2015), additional to current expenditure on maternal and newborn health. This corresponds to around US$ 0.22 per inhabitant per year initially, expanding to US$ 1.18 in 2015 (see Figure 5.8; a breakdown of the estimated costs is given in Box 5.4).

Of this investment, 18% would be to scale up access to 50% in the 20 countries facing the greatest challenge (the equivalent of US$ 1.25 per inhabitant per year); 17% for the 25 countries that would reach 65% coverage (US$ 0.87 per inhabitant per year); 9% for the 18 countries that can reach 95% coverage by 2015 (US$ 0.74 per inhabitant per year); and 56% for the 12 countries that can reach full coverage as of 2010 (US$ 0.61 per inhabitant per year). This outlay corresponds to a growth in the level of public expenditure on health, compared with current levels, of respectively 30%, 5%, 7% and 3% per year.

The largest effort is needed in the poorest and most aid-dependent countries, despite the fact that cost estimates in these countries may be biased downwards because they reflect the current prices of labour and commodities, which are much lower than elsewhere. National authorities and the international community have to be aware that, if the scenarios are implemented, the results obtained will be slowest in the countries where the largest effort is made. In a superficial analysis this may appear an inefficient way of allocating the world’s resources to maternal and newborn health – but it is necessary in order to reduce the growing gaps between countries and to move towards the MDGs in all countries of the world.

Footnotes

³⁷ Maine D, McCarthy J, Ward V. Guidelines for monitoring progress in reduction of maternal mortality. New York, NY, United Nations Children’s Fund, 1992.

³⁸ Van Lerberghe W, Lafort Y. The role of the hospital in the district; delivering or supporting primary health care? Current Concerns SHS Papers, 1990:1–36.

³⁹ Le Coeur S, Pictet G, M’Pelé P, Lallemant M. Direct estimation of maternal mortality in Africa. Lancet, 1998, 352:1525–1526.

⁴⁰ Buekens P. Over-medicalisation of maternal care in developing countries. Studies in Health Services Organisation and Policy, 2001, 17, 195–206.

⁴¹ Harvey SA, Ayabaca P, Bucagu M, Djibrina S, Edson WN, Gbangbade S et al. Skilled birth attendant competence: an initial assessment in four countries, and implications for the Safe Motherhood movement. International Journal of Gynaecolology and Obstetrics, 2004, 87:203–210.

⁴² Borghi J, Hanson K, Acquah CA, Ekanmian G, Filippi V, Ronsmans C et al. Costs of near-miss obstetric complications for women and their families in Benin and Ghana. Health Policy and Planning, 2003, 18:383–390.

⁴³ Buekens P, Curtis S, Alayon S. Demographic and Health Surveys: caesarean section rates in sub-Saharan Africa. BMJ, 2003, 326:136.

⁴⁴ Kristensen MO, Hedegaard M, Secher NJ. Can the use of cesarean section be regulated? A review of methods and results. Acta Obstetricia Gynecologica Scandinavica, 1998, 77:951–960.

⁴⁵ Walker R, Turnbull D, Wilkinson C. Strategies to address global cesarean section rates: a review of the evidence. Birth, 2002, 29:28–39.

⁴⁶ Carroli G, Belizan J. Episiotomy for vaginal birth (Cochrane Review). Cochrane Database of Systematic Reviews, 1999, 3:CD000081.

⁴⁷ Fraser WD, Turcot L, Krauss I, Brisson-Carrol G. Amniotomy for shortening spontaneous labour (Cochrane Review). Cochrane Database of Systematic Reviews, 1999, 4:CD000015.

⁴⁸ Elbourne DR, Prendiville WJ, Carroli G, Wood J, McDonald S. Prophylactic use of oxytocin in the third stage of labour. Cochrane Database of Systematic Reviews, 2001, 4:CD001808.

⁴⁹ Jeffery P, Jeffery R, Lyon A. Labour pains and labour power, London, Zed Books, 1989.

⁵⁰ Van Hollen C. Invoking vali: painful technologies of modern birth in south India. Medical Anthropology Quarterly, 2003, 17:49–77.

⁵¹ Bouvier-Colle MH, Prual A, de Bernis L et le groupe MOMA. Morbidité maternelle en Afrique de l’Ouest. Resultats d’une enquete en population a Abidjan, Bamako, Niamey, Nouakchott, Ougadougou, Saint-louis et Kaolack [Maternal mortality in West Africa. Results from a population-based survey in Abidjan, Bamako, Niamey, Nouakchott, Ougadougou, Saint-louis et Kaolack]. Paris, Ministère des Affaires Etrangères – Cooperation et Francophonie, 1998.

⁵² Ellis M, Manandhar N, Manandhar DS, Costello AM. Risk factors for neonatal encephalopathy in Kathmandu, Nepal, a developing country: unmatched case-control study. BMJ, 2000, 320:1229–1236.

⁵³ Dujardin B, Boutsen M, De S, I, Kulker R, Manshande JP, Bailey J et al. Oxytocics in developing countries. International Journal of Gynecology and Obstetrics, 1995, 50:243–251.

⁵⁴ AMDD Working Group on Indicators. Program note. Using UN process indicators to assess needs in emergency obstetric services in Morocco, Nicaragua and Sri Lanka. International Journal of Gynecology and Obstetrics, 2003, 80:222–230.

⁵⁵ AMDD Working Group on Indicators. Program note. Using UN process indicators to assess needs in emergency obstetric services: Bhutan, Cameroon and Rajasthan, India. International Journal of Gynecology and Obstetrics, 2002, 77: 277–284.

⁵⁶ Goodburn EA, Hussein J, Lema V, Damisoni H, Graham W. Monitoring obstetric services: putting the UN guidelines into practice in Malawi. I: developing the system. International Journal of Gynecology and Obstetrics, 2001, 74:105–117.