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Neonatal health: Foundation for the future
Globally, 4 million babies die in the first month of life.
Neonatal deaths (defined as those occurring between
0-28 days in live-born infants) represent almost 40% of
all deaths in childhood and this proportion will increase
over time.
The Millennium Development Goal of reducing child
mortality by two thirds by 2015 will only be met if there
is a significant improvement in newborn survival.
Effective, low-cost interventions to reduce neonatal
deaths can be implemented at family, community and
health-facility levels.
Most maternal and neonatal deaths occur during
childbirth and the immediate post-natal period.
Interventions before and during pregnancy and during
and after delivery can save the lives of mothers and
babies.
Interventions in the first month of life can also reduce
long-term disability and promote behaviours such as
breastfeeding, with benefits for the health of children
and of the nation.
Countries with limited resources have shown that it is
possible to reduce neonatal and maternal deaths. The
running costs of providing a set of comprehensive
interventions to reduce neonatal deaths at 90%
coverage is around US$ 1.42 per capita.
Newborn health needs to be addressed by national
poverty reduction and health sector plans and
interventions integrated into maternal and child health
services. Reaching poor and under-served populations
will require special attention.
PURPOSE
The aim of the Newborn Health Policy and Planning Framework is to
assist countries with a high burden of neonatal mortality and morbidity to
develop strategies for improving newborn health that are integrated with
maternal and child health plans and set within broader health and
development frameworks.
The Framework outlines a structured approach to developing the newborn
health component of a strategy. The approach is consultative and
participatory, takes account of national needs and resources, and builds on
existing programmes and services. More specifically, the Framework
provides guidance on the main steps involved in strategy development:
Situation analysis – Conducting a situation analysis to assess the extent
and causes of newborn mortality and morbidity and the existing capacity
of maternal and child health services to address newborn health.
Prioritizing and choosing interventions - Reviewing and prioritizing
evidence-based interventions, and selecting those that are most
appropriate to national needs and available human, financial and
institutional resources.
Intervention delivery - Deciding how best to deliver interventions,
including ways to strengthen and create synergies between maternal
and child health services and between the health system and the
community
Monitoring and evaluation - Planning for monitoring and evaluation,
including identifying indicators and tools.
The Framework is divided into two parts:
Part 1 provides an overview of the process of developing the newborn
health component of a health strategy. It is intended primarily for those
who are responsible for policy-making, strategic planning and decisions
about allocation of resources.
Part 2, still to be completed, will provide more detailed guidance on the
steps involved in developing the newborn health components of a
strategy. It will refer to tools available to support these steps, which will
be included on an accompanying CD-Rom. It will be intended primarily
for those who are directly responsible for managing and implementing
programmes and services at national, provincial and district levels. The
need for and content of Part 2 will be confirmed as part of the country
experience with Part 1.
Introduction
No country can afford to ignore newborn health. Globally, 4 million babies
die in the first month of life and neonatal deaths account for almost 4 in
every 10 deaths in childhood.
Newborn survival can be improved by implementing available cost-effective
interventions and by strengthening existing maternal and child health
services. However, for this to happen, countries need a strategy to improve
newborn health.
This part of the Framework outlines:
The importance of incorporating newborn health into health policy
and planning.
The rationale for including newborn health into broader strategies.
The process of developing the newborn health components of a
strategy.
Incorporating newborn health into health policy
and planning
Addressing newborn health requires a supportive policy environment.
Development of newborn health approaches should take place within
existing national policy formulation and planning processes and consultation
mechanisms. Many opportunities exist to ensure that national policies and
plans support improvements in neonatal health. For example:
Integrating newborn health with maternal and child health, rather than
creating a vertical neonatal health programme, with an emphasis on
strengthening or creating synergies between maternal and child health
services and between the health system and the community.
Integrating newborn health interventions into wider development and
health sector policy and planning processes. Poverty Reduction Strategy
Papers (PRSPs) and Sector-Wide Approaches (SWAps) are vehicles for
developing comprehensive approaches to newborn health that are linked
to safe motherhood and child survival efforts.
Advancing efforts through human rights approaches and the fulfilment
of obligations enshrined in the 1948 Universal Declaration of Human
Rights and the 1990 United Nations Convention on the Rights of the
Child.
The need to address newborn health
Deaths in the first month of life account for 37% of all child deaths. Of
the 4 million neonatal deaths annually, 2.8 million occur in the first week of
life (the early neonatal period) and 1.2 million between 8 and 28 days of life
(the late neonatal period).
The main causes of neonatal death are complications related to delivery or
pre-term birth and infections. Most deaths in the early neonatal period are
due to causes and risk factors related to pregnancy and delivery. Safe delivery
and immediate postnatal care are critical since approximately 40% of
neonatal deaths occur in the first day of life. Most deaths in the late neonatal
period are due to infections.
Causes of death in the neonatal period
The vast majority - 98% - of neonatal deaths occur in developing countries.
An analysis of 193 countries shows that neonatal mortality accounts for
between 31% and 98% of infant deaths. In settings where child deaths
from common illnesses such as pneumonia and diarrhoea have been reduced,
the contribution of neonatal mortality to under-five mortality has increased.
Even in countries with the highest under-five mortality, a significant
proportion of deaths occur in the neonatal period. For example, in Ethiopia,
neonatal deaths represent nearly a third of childhood deaths.
In addition to neonatal deaths, 500,000 maternal deaths and at least 3 million
stillbirths occur each year, and neonatal morbidity and disability - caused
by birth asphyxia, congenital malformations, severe jaundice and infections
-represent a significant burden for health services and communities. The
neonatal period is also critical for establishing exclusive breastfeeding and
bonding with the mother, which are essential for a child's future growth
and development.
Pre-pregnancy - Neonatal survival and health are influenced by factors
that are present before conception. Maternal educational and social
status, nutrition and health, age, and the time between pregnancies, are
important predictors of neonatal outcome. Comprehensive strategies
need to emphasize integration with a range of other services such as
family planning, and sectors such as poverty reduction and education,
as well as synergies between maternal and child health programmes.
Pregnancy – Appropriate antenatal care is critical to reduce maternal
mortality, stillbirths and neonatal deaths. Interventions during pregnancy
can reduce premature birth, low birth weight, congenital malformations,
congenital infections and neonatal tetanus.
Labour, delivery and the first 1-2 hours of life – Skilled care at birth to
ensure safe and clean delivery benefits mothers and babies. This period
is critical for preventing birth asphyxia, birth injuries and infections in
the newborn, and provision of supportive care for pre-term babies.
Newborns also have special care needs immediately after birth, including
establishment of breathing, providing warmth, initiating breastfeeding
and preventing and managing life-threatening complications.
Early neonatal period (week 1) - Provision of basic care for all mothers
and newborns, and identifying and managing those in need of special
care is critical in the first week of life, when over two thirds of neonatal
deaths, and many maternal deaths, occur. This period is critical for
prevention and management of infections in all newborns and for
provision of extra care for low-birth-weight babies and those with
complications following delivery. Mortality can be reduced in most
moderately low-birth-weight babies through low-tech approaches that
include keeping babies warm, providing breastfeeding support and
ensuring early management of complications. Extra care may also
require a functional referral system and access to a referral centre where
complications can be properly addressed.
Late neonatal period (weeks 2-4) - Prevention and treatment of
infections is the highest priority during this period. The one third of
neonatal deaths that occur in this period can be reduced through
interventions to ensure that families recognize the signs of infection
and seek care promptly, and that antibiotics are available, accessible
and used correctly
The process of developing the
newborn components of a
health strategy
Before establishing a process, it is important to assess
what steps have already been taken to address
maternal, newborn and child health. For example,
there may be an existing strategy that needs updating
or further developing to incorporate a neonatal
component.
One way to start is for the Ministry of Health to
establish a core group of key stakeholders in newborn
health with multidisciplinary expertise to guide the
process. Again it is important to assess what
mechanisms already exist to bring together relevant
stakeholders before deciding to set up a new group.
For example, there may be an existing technical
advisory committee or working group that could
oversee or carry out the work.
Key stakeholders who need to be involved in the
process include policy-makers and programme
managers from maternal and child health and other
relevant areas such as nutrition, immunization, HIV/
AIDS, malaria control, human resources and essential
drugs. It may be necessary to bring in additional
expertise in areas such as neonatology, behaviour
change communication, community development and
health systems. Inputs from maternal and child health
professionals, social scientists and health economists,
as well as from key multilateral, bilateral and NGO
partners, may also be needed