Elsevier

The Lancet

Volume 365, Issue 9463, 12–18 March 2005, Pages 977-988
The Lancet

Series
Evidence-based, cost-effective interventions: how many newborn babies can we save?

https://doi.org/10.1016/S0140-6736(05)71088-6Get rights and content

Summary

In this second article of the neonatal survival series, we identify 16 interventions with proven efficacy (implementation under ideal conditions) for neonatal survival and combine them into packages for scaling up in health systems, according to three service delivery modes (outreach, family-community, and facility-based clinical care). All the packages of care are cost effective compared with single interventions. Universal (99%) coverage of these interventions could avert an estimated 41–72% of neonatal deaths worldwide. At 90% coverage, intrapartum and postnatal packages have similar effects on neonatal mortality—two-fold to three-fold greater than that of antenatal care. However, running costs are two-fold higher for intrapartum than for postnatal care. A combination of universal—ie, for all settings—outreach and family-community care at 90% coverage averts 18–37% of neonatal deaths. Most of this benefit is derived from family-community care, and greater effect is seen in settings with very high neonatal mortality. Reductions in neonatal mortality that exceed 50% can be achieved with an integrated, high-coverage programme of universal outreach and family-community care, consisting of 12% and 26%, respectively, of total running costs, plus universal facility-based clinical services, which make up 62% of the total cost. Early success in averting neonatal deaths is possible in settings with high mortality and weak health systems through outreach and family-community care, including health education to improve home-care practices, to create demand for skilled care, and to improve care seeking. Simultaneous expansion of clinical care for babies and mothers is essential to achieve the reduction in neonatal deaths needed to meet the Millennium Development Goal for child survival.

Published online March 3, 2005 http://image.thelancet.com/extras/05art1217web.pdf

Section snippets

Identification of effective interventions

The Bellagio child survival series7, 8, 9, 10, 11 has been important in drawing attention to the unfinished child survival agenda. Writing for the series, Jones and colleagues8 estimated that implementing existing evidence-based interventions at high coverage (99%) could avert 63% of all child deaths and 35–55% of neonatal deaths. These estimates have limitations, however, especially in terms of putting the interventions into a health systems context.1, 12 Several potential interventions,

Cost-effective delivery of interventions

In a health-systems context, to package interventions according to their target populations and service delivery modes is logical (panel 3).27, 28, 29 We therefore considered how to deliver these interventions for home births and neonatal care in settings where access to health services is poor, as well as how to integrate them into facility-based maternal and child health care. We packaged interventions according to common service delivery mode and time of implementation (table 2). Moreover,

How many lives can be saved?

Although cost-effective interventions to prevent neonatal mortality are available, coverage of many of these interventions is low (figure 2), especially in resource-poor settings. The number of neonatal deaths that could be prevented through wider implementation of evidence-based interventions in the 75 countries included in the WHO 2005 world health report25 was estimated as described in panel 1. These 75 countries include the 42 analysed by the Bellagio child survival study group, plus

Cost of saving newborn babies

We estimated annual running costs for current degrees of coverage (US$1·97 billion) with evidence-based interventions, and the additional costs for expansion of coverage (excluding initial investments for scaling up coverage, such as building new facilities) from current levels to 90% ($4·11 billion) for the 75 countries included in our analyses (panel 1, webtable 4 [http://image.thelancet.com/extras/05art1217webtable4.pdf]). Of the additional expenditures needed to maintain expanded coverage

Discussion

Analyses of the evidence base for efficacy and effectiveness of interventions, cost-effectiveness, and the potential to avert neonatal deaths if implemented at increased coverage indicate that feasible, highly cost-effective interventions are available that could avert up to 72% of neonatal deaths. These interventions can be packaged according to service delivery modes and provided to populations in need in a complementary way within health systems.

Our data further suggest that emphasis on

References (42)

  • JE Lawn et al.

    4 million neonatal deaths: When? Where? Why? Published online

  • A Costello et al.

    Reducing maternal and neonatal mortality in the poorest communities

    BMJ

    (2004)
  • Z Bhutta et al.

    Perinatal and newborn care in Pakistan: seeing the unseen

  • T McKeown et al.

    An interpretation of the decline in mortality in England and Wales during the twentieth century

    Pop Stud

    (1975)
  • A MacFarlane et al.

    Epidemiology

  • M Claeson et al.

    Knowledge into action for child survival

    Lancet

    (2003)
  • Z Bhutta

    Beyond Bellagio: addressing the challenge of sustainable child health in developing countries

    Arch Dis Child

    (2004)
  • Z Bhutta et al.

    Community-based interventions for improving perinatal and neonatal outcomes in developing countries: a review of the evidence

    Pediatrics

    (2005)
  • R Baltussen et al.

    Methods for generalized cost-effectiveness analysis

  • T Adam et al.

    Cost-effectiveness analysis: can we reduce variability in costing methods?

    Int J Technol Assess Health Care

    (2003)
  • Cited by (1197)

    View all citing articles on Scopus

    Lancet Neonatal Survival Steering Team listed at end of article

    View full text