Nearly 750,000 newborns lives could be saved every year with specific interventions for small and sick newborns.

In order to achieve SDG 3 (to ensure healthy lives and promote well-being for all at all ages) focus is needed in improving care for every newborn, mainly in those who are born small (from prematurity or intrauterine growth restriction) or become ill. These babies are at high risk of dying or becoming disabled; an estimated 1 million of survivors in this group survive with a long-term disability.

Approximately 80% of the 2.4 million newborn deaths globally every year, are in low-birth-weight (LBW); two thirds of deaths happen in those born prematurely. Care in facilities for newborns is needed for the most common conditions, such as complications from prematurity, intrapartum brain injury, severe bacterial infection, pathological jaundice, and congenital conditions. (1)

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deaths every year happen in low birth weight babies

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deaths happen in premature babies (less than 37 completed weeks of gestation) every year globally

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newborns require care in facilities every year around the world

What can be done?

Where is the improvement in care most needed?

Ninety-eight percent of neonatal deaths occur in low and middle-income countries, with 75% occurring in Southern Asia and sub-Saharan Africa (2). Of the 10 countries with the highest NMRs, eight are in Africa, where the majority have experienced a recent humanitarian crisis. In humanitarian settings, pregnant and post-partum women face enormous challenges to access care for themselves and for their newborns. These women are also at risk for malnutrition, sexual violence, poor mental health and unplanned pregnancies, as well as those related to births with no skilled attendants. (3)

In high-income countries (HICs), the neonatal mortality rate is usually low, and most small newborns survive and thrive. In middle-income countries (MICs), the risk of disability for infants born between 28 and 32 weeks of gestation is nearly double that of HICs, due to deficiencies in the quality of care. In low-income countries (LICs), disability is uncommon since the smallest and sickest newborns, usually die due to lack of access to essential care or more advanced care when needed. (4)

What is the care needed?

Most newborns can survive and thrive when good quality health care, including appropriate inpatient care, is available. In order to provide appropriate care for small and sick newborns, LMICs require improvements in inpatient care to reduce mortality and avoid long-term complications. High-quality inpatient care requires an adequate space, competent professionals in all areas, and equipment and supplies to deliver the care. All newborns require essential care, particularly at the time of birth and during the first days of life, whether in a health facility or at home. Most small and sick newborns require special inpatient care, which can only be provided in a health facility. Intensive care in a high-level referral facility is only required by a third of sick newborns. In addition, the linkages between obstetric and neonatal services need to be protected and strengthened. The Survive and Thrive report provides a list of in-patient interventions proven effective in preventing newborn mortality and disability, by each level of care; and WHO’s standards for quality care of small and sick newborns in facilities specify the various aspects of the health systems that need to be improved. Core interventions that should be available to all small or sick newborns beyond basic essential care for all newborns include:

  1. Kangaroo Mother Care started as soon as possible after birth for small newborns, provided as continuously as possible for at least 20 hours per day during the time the newborn is transitioning and receiving neonatal special care;
  2. Immediate and exclusive breastfeeding, including colostrum,  provided by cup, spoon, or NG tube if baby is unable to breastfeed;
  3. Respiratory support when needed, guaranteeing safe oxygen use through blended air-oxygen and with oxygen saturation monitoring;
  4. CPAP for respiratory distress requiring positive airway pressure with guarantees of safe oxygen use and oxygen saturation monitoring;
  5. Appropriate and timely management of suspected serious infections (eg, sepsis, pneumonia, meningitis) with antibiotics and supportive care as needed;
  6. Family-centered care with families having continuous access to their babies in special care or neonatal intensive care, and participating in providing appropriate care of their baby;
  7. Developmentally supportive care for newborns and support for families to provide nurturing care in facilities and after discharge home;
  8. Discharge planning with parents to ensure their competence and confidence to provide essential nurturing care at home; and
  9. Follow up care after discharge from appropriate trained health care workers to monitor the baby’s condition, support the family for KMC and nurturing care, and referral for any new danger signs or complications (including Retinopathy of Prematurity follow up for small babies receiving oxygen therapy).

(1,5)

The Nurturing Care Framework for ECD

The Nurturing Care Framework for Early Childhood Development, launched by WHO, UNICEF and the World Bank Group in 2018, demonstrates that focusing on ECD is one of the wisest investments a country can make to boost economic growth. Nurturing care is the provision of a stable environment that promotes children’s health and nutrition and interactions that are responsive, emotionally supportive, and developmentally stimulating, while providing protection from threats.

Neurosensory development begins in-utero and is responsive to positive and negative influences in the external environment from the time of birth. Hence early life exposure to hostile environment, including stress is linked to decreased brain density, with longer-term effects on learning outcomes. Newborns who are small — preterm, low birth weight, and/or small for their gestational age — and/or are sick — from infections, intrapartum related complications and pathological jaundice — are at heightened risk of neurodevelopmental delays and disabilities.

Traditional inpatient care facilities expose vulnerable newborns to excess sound and light conditions in the units, potential harm from unsafe oxygen use, separation of the mother-infant dyad, leading to parental stress and negative psychological effects in addition to delayed feeding and difficulties breastfeeding which can persist after discharge. Of the 13 million preterm newborns who survive globally each year, an estimated 2.7% have moderate to severe impairments and 4.4% have mild neurodevelopmental impairments.

Nurturing care for small and sick newborns is possible. Several evidence-based interventions can create a healing physical and sensory environment. These include Family Centered Care that allows for non-separation of the mother from her newborn; Kangaroo Care, including immediate initiation even when the newborn is receiving special care in the SCU/NICU; the Baby-Friendly Hospital Initiative that supports the mother for breastmilk feeding; safety and security through infection prevention and control; judicious use of antibiotics; and safe oxygen use when needed.

Use of data for action

Countries are required to improve the measurement of the care of small and sick newborns, and their later development and health in order to achieve the goal of ending all preventable deaths by 2030.

It is of utmost importance to collect and analyze data on coverage and quality of care, including long-term outcomes in the most at-risk. In order to guide programs and investments, the continuous monitoring of data on quality of care is a key element for better results for newborns’ survival and thriving.

It is also important to establish good measurement for innovations implemented in LMICs for the care of high-risk newborns. Some examples are simpler and affordable technologies, such as bubble CPAP (continuous positive airway pressure), or innovative implementation approaches, such as task-shifting roles for various cadres of health workers.

 

Cost of care and return on investment

The Survive and Thrive report mentions that the increased investment by LMICs to improve access to inpatient quality care for small and sick newborns is currently at US$ 0.20 per person and US$ 1,700 per newborn death averted. The investment in health and development of all newborns, providing a good start in the life cycle, and in particular for the most at-risk, will potentially increase economic development in such countries.

Every Newborn Tracking Progress toward SDG Targets

The Every Newborn Action Plan set concrete goals regarding newborn mortality and stillbirths in general and the care for small and sick newborns specifically. Interim goals and targets for 2025 were developed in 2020 through a multi-partnered consultative process by global and country leaders and experts. The four goals are to 1)eliminate preventable newborn and stillbirth deaths by 2025, 2) that 90% of mothers have four or more antenatal visits, 3) 90% of births are attended by trained health personnel, and that 4) 80% of mothers receive routine postnatal care within two days of birth, and 80% of districts in all countries have at least 1 inpatient newborn care unit (level 2) care to provide small and sick/or newborns.

Care of the Small and Sick Newborn Community of Practice (SSNB CoP)

The Care of the Small and Sick Newborn Community of Practice (SSNB CoP), is an interactive platform that allows practitioners and experts to exchange ideas, share lessons learned, disseminate and discuss implementation research results and evidence in the area of newborn health.

The Care of SSNB provides a space for dissemination of the standards and the implementation toolkit, including country experiences shared in webinars.

REQUEST to join the SSNB CoP email list serve by emailing SSNB+subscribe@groups.ibpnetwork.org

REQUEST to join the SSNB CoP Online IBP Exchange Group here.

Key Resources
  • WHO Standards for improving the quality of care for small and sick newborns in health facilities — Theses standards for the care of small and sick newborns in health facilities define, standardize and mainstream inpatient care of small and sick newborns, building on essential newborn care and ensuring consistency with the WHO quality of care framework.
  • Survive and Thrive: transforming care for every small and sick newborn — This report maps out a pathway towards 2030. It is built upon epidemiology, historical trends, lessons learnt and evidence-based interventions.
  • Every Preemie Do No Harm Technical Briefs — This series of briefs was developed between 2017-2019 and highlights the safe and effective use of specific inpatient newborn care interventions, with the guiding principle of “Do No Harm.”
  • Nurturing Care for Every Newborn — This brief summarizes why nurturing care is essential for every newborn to survive and thrive. It outlines the five components of nurturing care and contains examples of practical actions to create and strengthen nurturing environments for newborns, including those who are born too soon, small or sick.
  • The Nurturing Care Framework for Early Childhood Development — This framework draws on state-of-the-art evidence on how ECD unfolds to set out the most effective policies and services that will help parents and caregivers provide nurturing care for babies.
  • Implementation Toolkit for Small and Sick Newborn Care —Released on World Prematurity Day 2021, this Implementation Toolkit brings together readings, tools and learnings to provide a one-stop shop for implementers to act, use, share and learn. Information in support of WHO norms and standards from more than 300 implementers around the world is systematically organised to enable implementation and reach every newborn.
Guidelines and Statements
Educational Materials for Professionals
Parent Education and Integrated Family Delivered Neonatal Care