4 million neonatal deaths: When? Where? Why?

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The proportion of child deaths that occurs in the neonatal period (38% in 2000) is increasing, and the Millennium Development Goal for child survival cannot be met without substantial reductions in neonatal mortality. Every year an estimated 4 million babies die in the first 4 weeks of life (the neonatal period). A similar number are stillborn, and 0·5 million mothers die from pregnancy-related causes. Three-quarters of neonatal deaths happen in the first week—the highest risk of death is on the first day of life. Almost all (99%) neonatal deaths arise in low-income and middle-income countries, yet most epidemiological and other research focuses on the 1% of deaths in rich countries. The highest numbers of neonatal deaths are in south-central Asian countries and the highest rates are generally in sub-Saharan Africa. The countries in these regions (with some exceptions) have made little progress in reducing such deaths in the past 10—15 years. Globally, the main direct causes of neonatal death are estimated to be preterm birth (28%), severe infections (26%), and asphyxia (23%). Neonatal tetanus accounts for a smaller proportion of deaths (7%), but is easily preventable. Low birthweight is an important indirect cause of death. Maternal complications in labour carry a high risk of neonatal death, and poverty is strongly associated with an increased risk. Preventing deaths in newborn babies has not been a focus of child survival or safe motherhood programmes. While we neglect these challenges, 450 newborn children die every hour, mainly from preventable causes, which is unconscionable in the 21st century.

Of the 130 million babies born every year, about 4 million die in the first 4 weeks of life—the neonatal period.1 A similar number of babies are stillborn—dying in utero during the last 3 months of pregnancy. Most neonatal deaths (99%) arise in low-income and middle-income countries, and about half occur at home. In poor communities, many babies who die are unnamed and unrecorded, indicating the perceived inevitability of their deaths. By contrast, the 1% of neonatal deaths that arise in rich countries are the subject of confidential inquiries and public outcry if services are judged substandard. Most trials of neonatal interventions focus on these few deaths in rich countries. The inverse care law, first described in the UK in the 1960s, remains valid: “The availability of good medical care tends to vary inversely with the need for it in the population served.”2 For newborn babies, this law could appropriately be renamed the inverse information and care law: the communities with the most neonatal deaths have the least information on these deaths and the least access to cost-effective interventions to prevent them.

In this report, the first in a series of four on neonatal survival, we present epidemiological data to help guide efforts to reduce deaths of newborn children in countries where most of these deaths take place. This series follows the Bellagio child survival series,3 which emphasised the need for further work into neonatal deaths. It will also focus on strengthening of health systems (including community level) to provide care for newborn children in the highest mortality settings, and the costs of doing so. Our emphasis on neonatal survival is deliberate.4 We believe stillbirths, maternal morbidity and mortality, and neonatal morbidity are of great public-health importance. However, doing justice to all of these topics is not possible in one series. We believe that increased attention to improving health systems around the time of childbirth will also reduce maternal deaths and stillbirths.

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