Every newborn, every mother, every adolescent girl

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This article was originally published in The Lancet

With the launch of a new report by Save the Children this week, the momentum to achieve substantial reductions in neonatal mortality is accelerating. Ending Newborn DeathsEnsuring Every Baby Survives is a continuation of Save the Children’s No Child Born to Die campaign. The report presents a powerful reminder of the reasons for neonatal deaths, identifies eight essential areas for intervention, and proposes a five-point Newborn Promise plan to end all preventable newborn deaths, which governments and others should commit to this year. It argues that the focus on universal health coverage and the Every Newborn Action Plan, which is part of the United Nations Secretary General’s Every Woman, Every Child movement and will be presented to the World Health Assembly in May, provides an unprecedented opportunity not only to reduce but also to end preventable child and maternal mortality.

Although the number of children younger than 5 years who die has been almost halved since 1990, the progress in the reduction of neonatal deaths has been much slower than that of children older than 4 weeks (average annual reduction of 2.1% vs 3.4%). The proportion of neonatal deaths among children younger than 5 years is now 44%, whereas in 2005 it was 38%. In 2012, 2.9 million newborn babies died within 28 days after birth—1 million on the first and only day of life—and there were an additional 1.2 million stillbirths shortly before or during labour. The most common reasons for deaths include complications of prematurity (34%); intrapartum-related complications (24%); sepsis, meningitis, or pneumonia (22%); and congenital abnormalities (9%). And while some countries have made substantial progress, most notably China and Egypt (both 60% reduction in newborn deaths) and Cambodia (51%), progress in sub-Saharan Africa has been slowest (28%). Inequalities within countries can be stark, for example in India, where 26 per 1000 livebirths die in the wealthiest quintile compared with 56 per 1000 in the poorest.

The solutions and suggested interventions are obvious; their implementation needs concerted and integrated action plans, political will, and dedicated funding. The “N” in the reproductive, maternal, neonatal, and child health (RMNCH) agenda needs to be more than just a letter. The eight areas of interventions suggested in the report, drawn from the first Lancet Neonatal Suvival Series published in 2005 and the Every Newborn Bottleneck Analysis Toolare skilled care at birth and emergency obstetric care; management of preterm births, including antenatal corticosteroids for lung maturation; basic neonatal care, such as general cleanliness, cord care, warmth, immediate breastfeeding, and recognition of danger signs; neonatal resuscitation; kangaroo mother care; early identification and antibiotic treatment of serious infections; inpatient care for small and sick newborns; and prevention of mother-to-child transmission of HIV.

One area of dedicated and targeted intervention, although mentioned in passing in the report, deserves more attention. Those called “young mothers” in the report, but who are in fact children bearing children—16 million girls aged 15—19 years and 2 million younger than 15 years—have a higher risk of adverse maternal and birth outcomes, including stillbirths, neonatal deaths, preterm births, small-for-gestational-age babies, and complications during birth than do those older than 19 years. The interventions for this age group need to include prevention of child marriage and unwanted births, comprehensive access to sexual and reproductive education (including contraception), keeping girls in secondary education and therefore delaying age at the birth of the first child, and empowerment to make the right choices for health and wellbeing. The dividend will be not only an acceleration of progress towards ending maternal, neonatal, and child mortality, but also a better educated future generation of women who will contribute to the skilled workforce and so the economic development of their countries. In turn, their children will have a better start in life. The continuum of care needs to become a lifecycle of care.

The second report of the independent Expert Review Group on Information and Accountability for Women’s and Children’s Health, published in 2013, included as one of its six recommendations: “Take adolescents seriously: Include an adolescent indicator in all monitoring mechanisms for women’s and children’s health, and meaningfully involve young people on all policymaking bodies affecting women and children.” Prevention of stillbirths and neonatal mortality and morbidity must include greater attention to adolescent girls in particular. It is time to add the letter “A” to RMNCH. 

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