key: cord-0967957-4pb53pkf authors: Lawn, Joy E; Cousens, Simon N; Darmstadt, Gary L; Bhutta, Zulfiqar A; Martines, Jose; Paul, Vinod; Knippenberg, Rudolf; Fogstad, Helga title: 1 year after The Lancet Neonatal Survival Series—was the call for action heard? date: 2006-05-02 journal: Lancet DOI: 10.1016/s0140-6736(06)68587-5 sha: 8c36ce9b9643cfd39660f2e1e49e6fc2cc14b818 doc_id: 967957 cord_uid: 4pb53pkf nan Joy E Lawn, Simon [1] [2] [3] [4] and two Comments, 5, 6 highlighting a huge number of largely neglected deaths-the 4 million newborn babies who die every year, of whom 99% are born in developing countries. 1 4 million is roughly the number of babies born every year in the USA or in the 23 largest countries of western Europe. It is also roughly the number of AIDS and malaria deaths combined in 1 year. Yet deaths in newborn babies are rarely mentioned in global-health priorities. A misconception has been that highly technical care is needed. On the contrary, our estimates suggest that up to three-quarters of these deaths could be prevented with low-technology interventions at an additional cost of less than US$1 per head for the 75 countries with the highest mortality. 2, 4 What is needed is the political will to ensure that these interventions reach the women and babies who need them. 3, 4 1 year on, we ask: what progress has been made over the past year in policy, in funding, and most importantly, in programmes in high-mortality countries? Before discussing the commitments and events aff ecting newborn survival since March, 2005, we have a caveatmeasuring the eff ect on policy and practice is complex, and attributing changes to The Lancet series is not possible and is not our aim. Our purpose is to promote and assess progress in reaching mothers and babies most in need. The series booklets have been widely distributed in English (40 000 printed copies) and translated into French, Spanish, and Portuguese. 7 Indeed, the Mozambican Ministry of Health undertook the Portuguese translation of their own accord. A CD-ROM has been produced to provide the papers, available references, and a toolkit for action with clinical and programmatic implementation guides. 7 After two launches in London, UK, and Washington, DC, USA, several regional events were held in Pakistan, Egypt, and Peru, in April, 2005, all involving Ministers of Health. In Africa, various regional meetings of diff erent audiences have profi led fi ndings from the series. Mass media coverage of the series included articles in the fi ve largest-circulation US newspapers, coverage in about 150 newspapers worldwide, and several radio inter views. We believe that the answer is yes-but much more can still be done. Panel 1 5,8-11 outlines some of the progress we have identifi ed in profi le, policy, programmes, and funding. We think deaths in newborn babies are now mentioned more on the health policy agenda, at least in child survival and maternal health circles-as attested to by the attention received at the Countdown to 2015 conference in London, UK, in December, 2005. 11 However, neither deaths in newborn babies nor in children or mothers appear on the agenda at high-level forums, such as the G8 summit, the Commonwealth Health Ministers meeting, and the World Economic Forum at Davos, Switzerland, in which attention to health tends to focus on HIV/AIDS, malaria, and tuberculosis. The World Health Assembly in 2005 also focused mainly on infectious disease emergencies, such as severe acute respiratory syndrome (SARS). A specifi c change called for was that the neonatal mortality rate be added as an indicator under Millennium Development Goal 4 for child survival. 4 Despite ongoing discussions and recommendations by the Millennium Task Force, this inclusion has yet to happen. However, the neonatal mortality rate was included as an indicator to be tracked as part of the Countdown to 2015 series of meetings planned for the next decade. 11 Increasing eff orts have been made to include newborn health in global guidelines and national strategies, plans, and monitoring for maternal, neonatal, and child health. UNICEF has led the development of draft guidelines for newborn health programming (panel 1). UNICEF has been fast in changing policy, and this has resulted in a high demand from countries for technical support, which requires the strengthening of the capacity of regional and New York headquarters staff to meet this demand. Ongoing progress is being made to adapt several important global strategies and programmes. The Integrated Management of Childhood Illness (IMCI) strategy, which did not previously address children aged less than 7 days, has new guidelines for the care of sick newborn babies, which are nearing completion. The Indian version of IMCI, the IMNCI (N for neonatal), 4 is being adapted by several other countries in Africa and south Asia. There is wider recognition that midwifery training should include training in simple care and resuscitation of newborn babies, although challenges remain in health-system roll-out, including a shortage of competency-based training, a lack of supervision, few resuscitation dummies for training, and insuffi cient supplies of bags and masks. A companion volume on neonatal deaths and stillbirths is being added to WHO's maternal audit guide, Beyond the numbers. Work continues to improve the ability of verbal autopsy instruments in capturing deaths in newborn babies and identifying the causes of death. However, many issues remain unresolved in postnatal care-there is no international consensus on the where, who, and what of care provided to mothers and babies in the fi rst week after birth, when the risk of death for both is the highest. In view of the size of the problem, newborn, child, and maternal deaths receive relatively little funding, Financial support q World Bank funding for health-sector reform and strengthening now promotes an emphasis on health for newborn babies as well as mothers and children (eg, in a recent $250 million grant for health-system strengthening to Democratic Republic of the Congo) q The Bill & Melinda Gates Foundation has provided grants of $60 million to Saving Newborn Lives/Save the Children-USA and $24 million to the Program for Appropriate Technology and Health (PATH), to advance survival of newborn babies in highmortality countries q The Global Alliance for Vaccines Initiative (GAVI Alliance) has earmarked $60 million for elimination of neonatal tetanus Programme monitoring q Inclusion of neonatal mortality rate as a Millennium Development Goal target has been recommended by The Lancet series steering team, and by task force on goals 4 and 5 q Tracking Child Survival Report, presented at Countdown to 2015 conference in London, included neonatal health indicators that were proposed in The Lancet series, 4 and will be monitored by existing population-based surveys in high-mortality countries 11 1 The GAVI Alliance has allocated $60 million to the elimination of maternal and neonatal tetanus (panel 1), and has recently announced a commitment to wider health-systems strengthening with a "pot" of $500 million. Since interventions for maternal, newborn, and child health are a well-recognised marker of an eff ective health system, the Alliance grants will hopefully contribute to scaling-up of MNCH interventions. The Bill & Melinda Gates Foundation has allocated $84 million to newborn health through two initiatives-Saving Newborn Lives/Save the Children-USA and Sure Start (PATH, Program for Appropriate Technology and Health; panel 1). For the next 6 years, Saving Newborn Lives will work with countries and partners to increase the coverage of eff ective interventions and to expand operations research relating to scaling-up of newborn care. Special emphasis will be on action in Africa. Because of the need to integrate newborn-health interventions with maternal and child-health programmes, the separate tracking of resource fl ows for newborn health at the macro-level is diffi cult, and makes little sense to attempt. At the Countdown to 2015 conference in London, new work to develop a tracking method for resource fl ows for maternal and child health was presented. Improved tracking during the next few years is aimed to improve accountability of donor and local governments for their investments in maternal, newborn, and child health. 11 Reductions in the global burden of neonatal deaths depend on eff ective action in individual countries, especially in those with the highest burden of deaths in newborn babies. In several large Asian countries, groups have been actively working to improve newborn health; for example, the highly infl uential National Neonatalogy Forum in India has more than 2000 members. In many African countries, newborn health (and maternal, neonatal, and child health in general) has received little attention or leadership so far, with public-health action focused on HIV/AIDS, malaria, and immunisation. This emphasis is changing (panel 2). In the past year, at least 20 African countries have requested technical assistance from WHO to integrate and scale up newborn health care. The Kenyan Paediatric Society has called for a national newborn-survival group and is planning specifi c actions. 14 Other countries, such as Uganda, have incorporated newborn care into their 5-year health-sector plan (panel 2). Major challenges still remain in Asia and Africa. To seize opportunities and respond to country demand, there is a need for more people to be funded to provide technical support, increase capacity, and work with ministries of health to institutionalise newborn care in existing country programmes-developing, imple menting, and monitoring integrated, strategic plans, especially in Africa. Many countries have teams for HIV, malaria, and vaccines, but have no one in the ministries of health specifi cally to integrate newborn care into existing programmes. Strong management and negotiation skills are needed, since there are multiple programmes to link with: ante natal care, midwifery, emergency obstetric care, postnatal care, IMCI, nutrition and breastfeeding programmes, malaria, prevention of mother-to-child transmission/HIV, immunisation programmes, and com munity health-worker programmes. Several countries are implementing community health-worker programmes. The human resources are staggering; In Ethiopia, 30 000 new health extension workers will be graduating this year. By 2010, India plans to deploy 300 000 village-based workers, with newborn and child care as a prime responsibility. Pakistan has expanded its successful Lady Health Workers programme from 70 000 to 100 000. In the enthusiasm to implement these ambitious programmes, the need to monitor their eff ect on the coverage of essential interventions and on mortality should not be forgotten. Although 99% of deaths in newborn babies occur in developing countries, less than 1% of published neonatal research during the past decade is relevant to deaths in low-resource settings. 1 It is therefore unfortunate that an unintended negative consequence of The Lancet series has been to foster, in some quarters, the misconception that since we have identifi ed simple interventions that could prevent up to three-quarters of deaths in newborn babies, there is no need for research in low-resource settings. Although we know what we should be aiming for-high coverage of several simple cost-eff ective interventionsmajor questions remain about how to get there. The research agenda identifi ed in every article in the series remains pertinent 1 year on, especially the need for eff ectiveness research to inform scaling-up of interventions in currently underserved communities, and how to implement eff ective maternal and newborn postnatal care. There have been some positive developments. A study in Ghana 15 advances our understanding of the benefi ts of early breastfeeding on neonatal survival. A trial of community mobilisation and behaviour-change communications to promote simple essential practices for newborn care in the home and community has shown a 50% reduction in neonatal mortality in rural Uttar Pradesh, India. 16 Benefi ts from chlorhexidine cleaning of the newborn umbilical cord 17 and sunfl ower oil 18, 19 for preterm babies have shown promise for potential scalability. Several trials funded by Saving Newborn Sub-Saharan Africa has 46 countries with great variation, together accounting for more than 1 million neonatal deaths and including 16 of the 20 countries with the highest neonatal mortality rates. The third article in The Lancet series called for action in countries and led by countries. q Within 1 month of publication of the series, at least eight African countries requested technical assistance from WHO to integrate and scale up health in newborn babies, and another 12 have since requested support q Policy and programme changes have already begun in countries, which include: In July, 2005, the Ugandan Government added a newborn health team to their cluster for maternal and child health in the next 5-year Health Sector Reform Plan, attaching specifi c interventions, a dedicated budget line, and a yearly review process Tanzania has seen a 25% reduction in mortality in children younger than 5 years during past 5 years; however, the reduction in neonatal mortality has been less striking, with the government and the maternal, newborn, and child national partnership reviewing strategies to address deaths in newborn babies In Ethiopia, scaling-up of community-based care, including newborn care, 3 is in progress, with almost 10 000 health-extension workers graduating in 2005 and another 30 000 in training q The Road Map for Accelerating the Reduction of Maternal Deaths is a continent-wide policy process approved by the African Union, and now includes survival of newborn babies. The Road Map uses a systematic, stepwise approach to develop, accept, fund, and implement a national plan. Since its launch in 2004, at least 32 African countries have begun the process, and plans have been adopted in 12 countries, overseen by a regional task force. In some countries, health components for newborn babies could need review and strengthening, but the recognition and inclusion of care for newborn babies is an essential fi rst step q A large group of partners are working together to develop programme and policy guides, adapting approaches, and building capacity in organisations and countries. A publication, Opportunities for Africa's Newborns, is in preparation. This monograph will detail eight opportunities to integrate newborn care in existing programmes and provide profi les of 46 countries, plus a CD-ROM of relevant information The focus of The Lancet series on newborn survival was deliberate. However, as mortality reduces, non-fatal outcomes, especially in children surviving with disabilities, become increasingly important. Stillbirths, issues of maternal and fetal malnutrition aff ecting intrauterine growth, and long-term disability outcomes are still largely ignored in low-resource settings, and we still know little about how to address these problems. New systematic estimates for stillbirth rates in 190 countries will increase visibly for these neglected deaths, which are closely linked to newborn survival. 20 Nevertheless, we hesitate to expand the newborn research agenda too soon, in view of the very small number of relevant eff ectiveness trials. 21 A major need is to increase and strengthen the capacity for newborn research in Africa, and it is to be hoped that Asian researchers will contribute to this. A year has passed since a call to action for neonatal survival was made through The Lancet series. What has been achieved is encouraging, but certainly nowhere near what must be done to reduce neonatal deaths and achieve Millennium Development Goal 4. Much of our This plan should be based on situation analyses, include a defi ned baseline neonatal mortality rate, be evidence-based, and specify strategies to reach the poorest families q Finance implementation of the plan by identifi cation and mobilisation of internal resources, and by seeking of external support when necessary q Implement plan with defi ned targets and timelines q Monitor progress and publish results regularly Action at international level q Include neonatal mortality rate as an indicator for Millennium Development Goal 4, with a target of 50% reduction between 2000 and 2015 q Find the resources to meet additional needs identifi ed ($0·96 per person in the 75 high-mortality countries), to achieve high coverage of interventions q Promote partner and donor convergence at country level, as promoted by the Partnership for Maternal, Newborn, and Child Health, to increase effi ciency and reduce reporting load on national governments* q Invest in health-systems research advancing how to reach the poor, as well as new research into postnatal care, stillbirths, and non-fatal outcomes around time of birth* Challenges q Perceived competition between newborn survival and maternal or child survival-a false dichotomy, since if one loses, then all lose q Potential confl icts between interventions at community and facility levels-another false dichotomy since both are needed q Maternal, newborn, and child health is still a quiet ongoing stream of 11 million deaths a year, in a world of emergencies with higher profi les such as avian infl uenza and HIV/AIDscurrent attention and funding remain inadequate for task q Not enough people are available to follow through on country requests for support, and countries will not go on asking indefi nitely *Items not originally in the call for action for newborn survival. 4 original call holds true (panel 3), but we emphasise the following points. First, we repeat the call for country plans by the end of 2007. These do not need to be stand-alone plans for newborn health, but an overall strategy for how governments plan to reduce deaths in newborn babies, in safe motherhood, child health, and other related programmes. Because a high percentage of deaths at ages less than 5 years old are neonatal, no government that is serious about Millennium Development Goal 4 can aff ord to omit newborn health interventions. The RoadMap process in Africa provides an opportunity for all African countries to develop such plans in a public forum with accountability for results (panel 2). Second, we call specifi cally for improved integration of newborn health with other relevant programmes, especially maternal health and child survival, and for enhanced integration between programmes-eg, HIV, malaria, sexually transmitted diseases, and the UN's Expanded Programme of Immunisation. This integration would benefi t not only newborn babies but also mothers and children by increasing the rate of increase of essential interventions. Indeed, in the countries that have undertaken strategic planning, examination of newborn health can clearly serve as a catalyst to bring maternal and child health groups together and to link maternal, neonatal, and child care, with benefi ts for mothers, babies, and children. The Partnership for Maternal, Newborn, and Child Health's call for every country to have one plan for maternal, neonatal, and child health; one fi nancing mechanism; and one monitoring and assessment plan is highly compatible. Third, we call again for governmental commitment and leadership, with international partners' support to ensure that plans are translated into actions. Programme implementation does not just need increased funding, although current levels are clearly not commensurate with the number of deaths and the cost-eff ectiveness of the solutions. 2 Funding should be spent strategically, including investment in human resources. Increased personnel are needed to provide technical support; to work in ministries of health to link essential programmes for maternal, neonatal, and child health with each other; and to deliver services to mothers and babies, especially those in under-served populations. The World Health Report 2005 21 estimated that an additional 700 000 skilled birth attendants are needed to provide universal coverage of maternal and newborn services in 75 countries, where maternal and neonatal mortality is high. 22 However, a great deal can be achieved for maternal, neonatal, and child care through community-based interventions that can be delivered by community health workers. The current wave of new community health workers will be most eff ective in saving lives if highly eff ective interventions for maternal, neonatal, and child care are the core set of tasks, and if the lessons of the fi rst revolution in primary health care are applied-ie, the need for supervision, close links with the rest of the health system, and remuneration. Finally, we call for donors and national governments to invest strategically in programmes for maternal, neonatal, and child care as a cornerstone for development and poverty alleviation and for achievement of the Millennium Development Goals. Increased commitment has been galvanised and changes have occurred over the past year, with real progress in some countries and organisations. The Lancet Neonatal Survival Series contributed to some of these changes, but which and how much is diffi cult to tell and really does not matter. There is still much to do and high demand from countries for help to do it. The launch of The Partnership for Maternal, Newborn, and Child Health provides new opportunities for maternal, neonatal, and child care. The real challenge ahead remains the provision of essential interventions to all mothers and babies, the integration and institutionalisation of interventions for newborn babies in programmes for maternal, neonatal, and child care, and the scaling-up of these programmes. We have much to learn about what works in diff erent settings. This goal will need ongoing investment from countries and donors and should be seen for what it is: an investment in the health of the next generation. However, money is not all that is needed. Currently, too few people are involved and too little research is underway, in view of the size of the problem. We need more champions and researchers committed to asking and answering questions that can save many lives. We declare that we have no confl ict of interest. 4 million neonatal deaths: When? Where? Why? Evidence-based, cost-eff ective interventions: how many newborn babies can we save? Systematic scaling up of neonatal care in countries Neonatal survival: a call for action A continuum of care to save newborn lives Newborn survival: putting children at the centre WHO. The Lancet Neonatal Survival Series Rosenfi eld A. Transforming health systems to improve the lives of women and children Newborn survival The Partnership for Maternal The coming decade for global action on child health The case for a new Global Fund for maternal, neonatal, and child survival Maternal and child health in Pakistan: challenges and opportunities Newborn survival revolution Delayed breastfeeding initiation increases risk of neonatal mortality Community mobilization and behavior change communications promote evidence-based essential newborn care practices and reduce neonatal mortality in Uttar Pradesh Countdown to 2015: tracking progress in child survival Topical applications of chlorhexidine to the umbilical cord for prevention of omphalitis and neonatal mortality in southern Nepal: a community-based, cluster-randomised trial Topically applied sunfl ower seed oil prevents invasive bacterial infections in preterm infants in Egypt: a randomized, controlled clinical trial Eff ect of topical treatment with skin barrier-enhancing emollients on nosocomial infections in preterm infants in Bangladesh: a randomised controlled trial Stillbirth rates: delivering estimates in 190 countries Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence The World Health Report: make every mother and child count JL and GD are supported by the Bill & Melinda Gates Foundation through a grant to Save the Children Federation for the Saving Newborn Lives Initiative. We thank Anne Tinker from Saving Newborn Lives/Save the Children-USA for comments on the draft.