Addressing Critical Knowledge Gaps in Newborn Health

Systematic scaling up of neonatal care in countries

Systematic scaling up of neonatal care in countries
By Knippenberg R, Lawn JE, Darmstadt GL, Begkoyian G, Fogstad H, Walelign N, Paul VK,
The Lancet


Every year about 70% of neonatal deaths (almost 3 million) happen because effective yet simple interventions do not reach those most in need. Coverage of interventions is low, progress in scaling up is slow, and inequity is high, especially for skilled clinical interventions. Situations vary between and within countries, and there is no single solution to saving lives of newborn babies. To scale up neonatal care, two interlinked processes are required: a systematic, data-driven decision-making process, and a participatory, rights-based policy process. The first step is to assess the situation and create a policy environment conducive to neonatal health. The next step is to achieve optimum care of newborn infants within health system constraints; in the absence of strong clinical services, programmes can start with family and community care and outreach services. Addressing missed opportunities within the limitations of health systems, and integrating care of newborn children into existing programmes—eg, safe motherhood and integrated management of child survival initiatives—reduces deaths at a low marginal cost. Scaling up of clinical care is a challenge but necessary if maximum effect and equity are to be achieved in neonatal health, and maternal deaths are to be reduced. This step involves systematically strengthening supply of, and demand for, services. Such a phased programmatic implementation builds momentum by reaching achievable targets early on, while building stronger health systems over the longer term. Purposeful orientation towards the poor is vital. Monitoring progress and effect is essential to refining strategies. National aims to reduce neonatal deaths should be set, and interventions incorporated into national plans and existing programmes.

Every year, 4 million newborn babies die in the first month of life, 99% in low-income and middle-income countries.1 Babies born in the poorest countries have the highest risk of death, and within these countries the neonatal mortality rate (NMR) among the poorest families is 19—44% higher than among the richest (regional averages based on 48 demographic and health surveys [DHS], 1995—2002). Up to 70% of deaths could be prevented if proven interventions were implemented effectively with high coverage where they are needed most2—a modern-day example of the inverse care law (figure 1).3 Although universal recommendations can be given for evidence-based interventions, the delivery strategy for a particular intervention varies across settings4 and should be adapted to local reality.5 Health care can be delivered through population-oriented outreach services, family-oriented and community-oriented services, and individual-oriented clinical services.

Interventions that have the greatest effect on neonatal deaths are less dependent on technology and commodities than on people with skills. Ideally, every woman should be able to choose to deliver with a skilled attendant present, and if either the mother or her newborn baby have complications, both have the right to access safe professional care. In high-income countries, this ideal exists. In south Asia and sub-Saharan Africa, however, where two-thirds of neonatal (and maternal) deaths happen, only about a third of women deliver in the presence of a skilled attendant. Coverage of postnatal care is lower still, although comparable DHS data are available for only a handful of countries. The average number of mothers giving birth with a skilled attendant in Africa has risen by 0·2% per year for the past decade ( At this rate, by the year 2015 the average skilled attendant coverage in Africa will still be less than 50%. Rates of caesarean sections are low in the highest mortality countries in Africa.7 Clinical care is even less equitable than antenatal care: within poor countries the richest women have two-times to three-times higher antenatal care coverage than the poorest, but about six-times higher skilled attendance (figure 1). Thus, coverage is low, progress is slow, and inequity is high.

In countries with low coverage of skilled clinical care for maternal and child health, the staff, infrastructure, and support needed to achieve universal coverage are attainable with major investments, but not in the short term.8 Increasing coverage depends on new commitment to a massive increase in the numbers of midwives and doctors as well as innovative approaches to retaining staff, especially in poor rural communities. Even with many new resources, there are no shortcuts: achieving universal coverage of skilled care will take decades. Meanwhile, most neonatal deaths continue to arise in underserved and poor communities—the same communities that will wait the longest for access to skilled care.

In this third paper of the neonatal survival series, we use an adaptation of the four-step management cycle as a guide for scaling up care for newborn babies in different settings (panel 1).9 Two parallel, interdependent processes are needed: a systematic prioritisation and management process, and a rights-based political process, including identification and engagement of key stakeholders. A rights-based approach is necessary to focus attention on tailoring services to the needs of the poor and empowering mothers and communities to adopt good health practices and demand quality care.5, 6, 10 This notion involves a major shift from neonatal care as charity, to a view that holds politicians and providers accountable for the health of babies. We describe the processes with case studies from two countries (Ethiopia and Madagascar) and one large Indian State (Gujarat), and include estimates of the effect and cost of the strategies selected by the governments in these settings.