Elsevier

The Lancet

Volume 384, Issue 9938, 12–18 July 2014, Pages 189-205
The Lancet

Series
Every Newborn: progress, priorities, and potential beyond survival

https://doi.org/10.1016/S0140-6736(14)60496-7Get rights and content

Summary

In this Series paper, we review trends since the 2005 Lancet Series on Neonatal Survival to inform acceleration of progress for newborn health post-2015. On the basis of multicountry analyses and multi-stakeholder consultations, we propose national targets for 2035 of no more than 10 stillbirths per 1000 total births, and no more than 10 neonatal deaths per 1000 livebirths, compatible with the under-5 mortality targets of no more than 20 per 1000 livebirths. We also give targets for 2030. Reduction of neonatal mortality has been slower than that for maternal and child (1–59 months) mortality, slowest in the highest burden countries, especially in Africa, and reduction is even slower for stillbirth rates. Birth is the time of highest risk, when more than 40% of maternal deaths (total about 290 000) and stillbirths or neonatal deaths (5·5 million) occur every year. These deaths happen rapidly, needing a rapid response by health-care workers. The 2·9 million annual neonatal deaths worldwide are attributable to three main causes: infections (0·6 million), intrapartum conditions (0·7 million), and preterm birth complications (1·0 million). Boys have a higher biological risk of neonatal death, but girls often have a higher social risk. Small size at birth—due to preterm birth or small-for-gestational-age (SGA), or both—is the biggest risk factor for more than 80% of neonatal deaths and increases risk of post-neonatal mortality, growth failure, and adult-onset non-communicable diseases. South Asia has the highest SGA rates and sub-Saharan Africa has the highest preterm birth rates. Babies who are term SGA low birthweight (10·4 million in these regions) are at risk of stunting and adult-onset metabolic conditions. 15 million preterm births, especially of those younger than 32 weeks' gestation, are at the highest risk of neonatal death, with ongoing post-neonatal mortality risk, and important risk of long-term neurodevelopmental impairment, stunting, and non-communicable conditions. 4 million neonates annually have other life-threatening or disabling conditions including intrapartum-related brain injury, severe bacterial infections, or pathological jaundice. Half of the world's newborn babies do not get a birth certificate, and most neonatal deaths and almost all stillbirths have no death certificate. To count deaths is crucial to change them. Failure to improve birth outcomes by 2035 will result in an estimated 116 million deaths, 99 million survivors with disability or lost development potential, and millions of adults at increased risk of non-communicable diseases after low birthweight. In the post-2015 era, improvements in child survival, development, and human capital depend on ensuring a healthy start for every newborn baby—the citizens and workforce of the future.

Introduction

Unprecedented progress in halving worldwide maternal and child deaths over the past two decades has been called the greatest success story of human development, coinciding with progress in reduction of AIDS, tuberculosis, and malaria.1, 2, 3 During this era, the Millennium Development Goals (MDGs) have driven global health priorities in countries.4 Donor funding for reproductive, maternal, and child health has doubled.5, 6 This recent rapid progress enables us for the first time to envisage a grand convergence, in which health outcomes in the poorest countries converge with those in the richest countries.

However, a major unfinished agenda is the annual toll of 2·9 million neonatal deaths (deaths in the first 28 days after birth), more than half of under-five child deaths in most regions of the world (44% globally).7 Neonatal and congenital conditions account for almost 10% of the global burden of disease. Although deaths account for 95% of this burden, disability is increasingly important in middle-income and high-income settings.8, 9 A closely linked unfinished agenda is that attributable to undernutrition,10 including 800 000 neonatal deaths among babies born small for gestational age (SGA; defined as under 10% birthweight for a particular gestational age and sex-specific reference), plus 800 000 deaths due to suboptimum breastfeeding, dependent on practices commenced in the neonatal period.

Since the Lancet Neonatal Survival Series in 2005,11 some improvements have occurred for the more than 135 million newborn babies entering the world each year. However, the average annual reduction rate (ARR) in neonatal mortality between 1990 and 2012 (2·0%) is much lower than that for children aged 1–59 months (3·4%), and lower than for maternal mortality between 1990 and 2013 (2·6%).7, 12, 13 From a position of near-invisibility, newborn survival, and particularly preterm birth, is now on national agendas,14 having been pulled into the limelight by the policy hook of the MDGs and improved epidemiological estimates. Funding and action, however, are lagging.12, 15 As well as the disappointing worldwide reduction in neonatal mortality, the global average hides huge variations between countries and regions, and also between causes of death. Burden estimates have improved, especially for mortality and major risk factors including preterm birth (<37 weeks completed gestation) and SGA. However, important data gaps remain, such as tracking of progress for programmatic scale-up, especially quality of care at birth.12

Key messages

Progress beyond 2015

  • The Millennium Development Goals (MDGs) have been associated with remarkable progress for maternal and child deaths, but neonatal mortality reduction has progressed about 30% slower, and stillbirth reduction slower still.

  • Every Newborn sets national targets by 2035 for NMR (≤10 per 1000 livebirths) and SBR (≤10 per 1000 total births) in line with the A Promise Renewed under-5 mortality target of less than or equal to 20 per 1000 livebirths by 2035, and maternal mortality ratio (MMR) targets.

  • Adverse birth outcomes are the biggest drain on human capital, especially in the world's poorest countries. By 2035 almost one third of births will be in Africa.

  • Without more action, by 2035 there will be an additional 49 million neonatal deaths and 52 million stillbirths, 5 million maternal deaths, and 99 million children who will not reach their development potential due to disability or stunting after preterm, SGA, or both.

  • Actions must address unmet need for family planning, mortality risk, and size or gestational age risk.

Priorities to accelerate progress

  • Where?

    • More than half of neonatal deaths occur in the five highest burden countries: India (779 000 deaths), Nigeria (276 000), Pakistan (202 400), China (157 400), Democratic Republic of Congo (118 100).

    • The countries with the highest stillbirth and neonatal mortality risk are in Africa, emergency contexts, or both.

  • When? Focus around the time of birth (triple return for women, stillbirths, neonatal deaths, and also to prevent disability).

  • What? The three leading causes of neonatal deaths are severe infections, intrapartum and preterm birth complications.

  • Who? Targeting preterm and small babies is crucial for effect (>80% of neonatal deaths, of which two-thirds are preterm). Boys have higher biological risk, but girls often have higher risk associated with social practices.

  • Rapid change for newborn and child survival is associated with accelerated fertility transition.

  • There is urgency in addressing of delays, since babies can die within minutes, making stillbirths and newborn deaths a sensitive marker of effective health system.

Post-MDGs and new frontiers beyond survival

  • Disability following neonatal conditions (especially preterm birth) occurs mostly in middle-income countries with variable quality of neonatal intensive care, and is double that in high-income countries.

  • Preventing preterm and SGA, as well as caring for 20 million small babies is crucial to future progress for reduction of deaths, disability, stunting, and long-term risk of NCDs.

  • Strategic investment in birth outcomes and care of small and ill babies would transform human capital and economic development, especially in low-income and middle-income countries.

Counting Every Newborn

  • About a third of babies do not have a birth certificate by their first birthday, and worldwide nearly all of the 6 million stillbirths and neonatal deaths each year are never recorded.

  • Data collection platforms vary in coverage and quality, but by 2035 every country can advance birth and death counting through vital registration, improvement of facility-based data systems, and inclusion of more neonatal and stillbirth-relevant metrics in household survey modules.

  • Development of a minimum perinatal dataset with standard metrics for counting births, stillbirths, neonatal deaths, birthweight, and gestational age, plus maternal outcomes and key programme coverage data is needed.

  • Standardised and simplified disability assessments are few and are especially important for routine use in countries that are scaling up neonatal intensive care.

  • The Every Newborn Action Plan will depend on data being collected, used, and linked to accountability—we commit ourselves to improvement of the data definitions and methods.

The estimated 2·6 million annual stillbirths (WHO definition: fetal death at ≥1000 g or ≥28 weeks' gestation) were not included in the MDGs and remain invisible.16 1·2 million of these stillborns die during labour (intrapartum stillbirths), with similar causes and interventions as early neonatal deaths.17 However, these stillborn babies are not included in global tracking mechanisms such as the Global Burden of Disease study, routinely reported to the UN from vital registration, or routinely measured in Demographic and Health Surveys or UNICEF's Multiple Indicator Cluster Surveys.17 Failure to count stillbirths ignores their effect on women and families, and leads to underestimation of the benefits of investments in maternity care.18 Despite the large numbers of neonatal deaths and stillbirths, global attention is inadequate, and analyses of official development assistance underline low investment.14, 15

As the MDG era comes to an end, the health policy focus beyond 2015 (the so-called post-2015 era) is widening beyond survival to include wellbeing and human capital, the increasing importance of disability, non-communicable diseases (NCDs) and mental health, and the links between environment and health. Astonishingly, neither stillbirths nor neonatal deaths are mentioned in post-2015 documents.19 With this broader agenda, the new momentum for newborn babies risks being lost with stillbirths still invisible. Where do newborn babies and a healthy start in life fit in the post-2015 era?

Section snippets

Objectives

Recognising these challenges, countries have requested attention from the global community, leading to the Every Newborn Action Plan—a multi-partner movement that aims to end preventable newborn deaths and stillbirths, intimately linked with maternal mortality reduction.20 In this Series paper, we review the status of newborn health and progress since the 2005 Lancet Neonatal Survival Series to inform action in countries and globally.

Neonatal mortality trends

Since 1990, the global neonatal mortality rate (NMR) has decreased by 37%, from 33 to 21 deaths per 1000 livebirths, compared with greater than 50% reduction for mortality rates among children aged 1–59 months.7 Substantial regional variations in NMR reductions (from 1990–2012) have been achieved, from 65% in eastern Asia to only 28% in sub-Saharan Africa, and 17% in Oceania. Generally, sub-Saharan African and southern Asian regions had the highest NMRs in 1990, and have made the slowest

Priorities to accelerate progress towards newborn survival

To ensure that national targets for mortality reduction are achieved, we examine which countries need the most attention, when deaths occur, and which causes of death and major risk factors should have priority.

Beyond survival: shifting to include child development and human capital

The first worldwide burden estimates of neonatal morbidities have drawn attention to 19 million neonates with life-threatening conditions (including intrapartum-related brain injury, severe bacterial infection, pathological jaundice, and preterm birth) who need specific and special care, many of whom do not receive even basic warmth and feeding support.32, 40, 42, 79, 80

Among 15 million preterm babies born each year, an estimated 1 million die of direct preterm birth complications, 1 million of

Counting every newborn baby

Child mortality estimates have improved and are converging; however, neonatal and maternal mortality are not yet converging.7, 12, 92, 93 Improvements in the frequency and visibility of neonatal mortality and cause-of-death estimates have helped to attract attention, but data gaps in morbidity, and in coverage and quality of care are major constraints to planning of programmes and tracking of progress. Strengthening of national data systems is urgently needed, and requires phased strategies for

Conclusion

In view of the delayed attention to neonatal survival and poor investment, especially for care of small and sick newborn babies, and in the highest mortality countries, that progress has been slow is unsurprising. Inputs, including donor funding, have increased since 2005, but not commensurate with a burden of almost 10% of disability-adjusted life-years worldwide, or with the potential for major (71%) effect with highly cost-effective interventions. We emphasise the importance of counting of

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