State of the World's Newborns, September 2001

Saving Newborn Lives

Save the Children

2000 M Street, NW

Suite 500

Washington, DC 20036

www.savethechildren.org

STATE OF THE WORLD’S NEWBORNS

A Report from Saving Newborn Lives

TABLE OF CONTENTS

“We know what needs to be done.

We have the tools. It is time to

marshal global political will and

to commit unprecedented

resources to saving newborn

lives. We call on the world to give

children a healthy start now.”

Melinda French GatesCo-founder, Bill & Melinda Gates Foundation

Foreword by Melinda French Gates

Introduction by Charles MacCormackand Thomas S. Murphy

Executive Summary

Making the Case

A Slender Thread: The Vulnerable Newborn

Improving Newborn Health

The Way Forward: Saving Newborn Lives

Endnotes

Abbreviations

AppendicesStatistical Overview of Newborn HealthTable I Newborn Health Status Table II Newborn Health ServicesExplanatory Notes on Tables

Call to ActionAcknowledgments

2

3

4

10

18

24

36

42

43

44

48

INTRODUCTION

FOREWORD

On the eve of the United NationsSpecial Summit on Children, Savethe Children is issuing the first-everglobal report on the very youngestmembers of the global community:State of the World’s Newborns. Asinternational leaders sit downtogether to discuss the status ofchildren, we at Save the Childrenbelieve that support must start atthe very beginning. At birth, theodds for a healthy life are first set.What is the fate of the 350,000babies born each day?

It is a tragic irony that in manycountries, the odds are stackedagainst mothers and their babies justwhen both are at their most vulnera-ble and at greatest risk. Throughoutthe developing world, expectantmothers and their newborns run agauntlet of health risks with little orno support or health care. Many ofthem do not survive the ordeal.

Save the Children initiated theEvery Mother/Every Child campaignin 2001 to cast light on the lives ofthe millions of mothers and new-borns worldwide who balance pre-cariously on the brink between lifeand death. These are the 53 millionwomen who give birth at home,without the help of professionalbirth attendants with delivery skills.Over four million newborns suc-cumb to disease or complications ofchildbirth before they have seen amonth of life and a similar numberare stillborn. This situation reflectsan unacceptable state of neglect incontemporary health care.

On Mothers’ Day 2001, Save theChildren released State of the World’sMothers, a country-by-country ratingof the status of women and young

girls according to health, education,and socio-economic indicators. Allthe data point to the following con-clusion: When mothers survive andthrive, children survive and thrive. Andfor mothers to thrive, they musthave access to education; maternaland child health care, including fam-ily planning; and economic opportu-nities. Save the Children iscommitted to making this happen.

In the present report, State of theWorld’s Newborns, we turn to theneeds of newborns and the essentialhealth care required for their futuresurvival and well-being. Despite thedaunting magnitude of newbornmortality each year, we can reversethis trend by initiating key healthsolutions that are proven, affordable,and doable. These include cleandelivery practices, skilled care atbirth, tetanus toxoid immunization,warmth and drying, and immediateand exclusive breastfeeding. Savethe Children has developed a strate-gic program—Saving NewbornLives—to help make that happen.

Thanks to the support of the Bill& Melinda Gates Foundation, theSaving Newborn Lives initiative isundertaking on-the-ground pro-grams in Asia, Africa, and LatinAmerica that will demonstrate howpositive change is possible throughjudiciously supplied health meas-ures. We count on the world’s lead-ers to take stock of how mothersand newborns fare in every country.Investing in this most basic partner-ship of all—between mother andnewborn—is the first and best stepin ensuring healthy children, pros-perous families, and strong communities.

Charles MacCormackPresident, Save the Children

care services—either before, during,or after delivery.

The Bill & Melinda Gates Foun-dation is supporting Save the Chil-dren’s Saving Newborn Livesinitiative as part of a global initiativeto improve the health and survival ofnewborns in the developing world.

To set the stage for this globaleffort, the Saving Newborn Lives ini-tiative is issuing this first-ever report,State of the World’s Newborns, to drawattention and pose solutions that willhelp save lives.

Drawing on the most recent dataavailable from the World HealthOrganization, UNICEF, and otherorganizations, this report providesdata on the situation of mothersand their newborns in 163 coun-tries. It also outlines what can bedone to address this critical, andlargely neglected, health crisis.

Because the health of womenand children go hand in hand, thereport also shares personal storiesof women from around the worldabout their experiences with child-birth and care of their newborns.

Over the next five years, Save the

I believe every child should havethe chance for a healthy start inlife. Yet in many parts of the world,life-saving interventions are oftennot available.

Newborn mortality is one of theworld’s most neglected healthproblems. Worldwide, more thaneight million babies each year arestillborn or die before they reachthe age of one month.

Though these numbers are trag-ic, what’s more devastating is thefact that we have the tools toaddress this situation yet fail toapply them. We can save many new-born lives through existing healthcare interventions that are bothpractical and affordable, even incommunities that lack modernhealth care facilities.

At the heart of the problem is astubborn and widening gap betweenthe health of the world’s rich andpoor. Ninety-eight percent of theseearly deaths occur in developingcountries. Simply put, most preg-nant women and newborns living inimpoverished circumstances do not,or cannot, get access to basic health

Children will work with partners atthe global and national level toimprove health care policies andprograms for mothers and new-borns, with a special emphasis onthose countries in greatest need.The Saving Newborn Lives initiativeis designed to integrate essentialnewborn health care into existingmaternal and infant care programs.Coupled with efforts to improvehousehold and community prac-tices, this strategy can make a last-ing difference in the health ofmothers and their newborns.

We know what needs to be done.We have the tools. It is time to mar-shal global political will and tocommit unprecedented resources tosaving newborn lives. We call onthe world to give all children ahealthy start now.

Melinda French GatesCo-founder, Bill & Melinda Gates Foundation

EVERY MOTHER/EVERY CHILD

CAMPAIGN MAKES NEWBORN AND

MATERNAL HEALTH A PRIORITY

Nearly 70 years of field experiencehave taught Save the Children thatto create real and lasting change inthe quality of children’s lives, weneed to invest in their mothers. On Mothers’ Day 2001, Save theChildren launched a global publicawareness and advocacy cam-paign—Every Mother/Every Child.Its goal is to ensure that mothersin developing countries have thetools they need to raise childrenwho not only survive but thrive.These tools include maternal andchild health care, family planning,education, and economic opportu-nities. Reducing newborn andmaternal deaths are among the toppriorities of the campaign. Whencommunities take measures toensure that mothers are healthy,well nourished, and well educated,their children are more likely to do well and to grow into strong,productive members of society.

STATE OF THE WORLD’S NEWBORNS 3

Thomas S. MurphyChairman, Board of TrusteesSave the Children

EXECUTIVE

SUMMARYPeople in industrialized nations

accustomed to specialized medical

attention and hospital-based care

find it hard to imagine that millions of

babies die every year for the lack of

such simple, low-cost expedients as

regularly giving two doses of tetanus

toxoid vaccine to a mother during

pregnancy, arming a skilled birth

attendant with a simple delivery kit

(a plastic sheet, a bar of soap, string

to tie the umbilical cord, and a razor

to cut it), or encouraging a mother to

exclusively breastfeed and keep her

baby warm. Yet these are examples

of measures we know can help save

countless newborn lives in developing

countries. The challenge now is to

make these and other simple, afford-

able measures more widely available

and used, while working to develop

new and better community-based

measures to treat certain newborn

complications, such as infections

and birth asphyxia.

US$1.00, can provide protection forboth the mother and newborn." Skilled health care at delivery:In many developing countries, mostdeliveries occur at home—and typi-cally in the absence of an attendanttrained in midwifery skills. The lackof knowledge and skills needed tohelp ensure a clean and safe deliv-ery often results in otherwise avoid-able illness, complications, or evendeath. Yet community-based healthworkers and other communitymembers could be trained to bettermanage normal deliveries, to rec-ognize danger signs, and to refermothers in cases of obstetric com-plication. But training in and ofitself is not enough; transport andemergency obstetric care must beavailable for back-up support." Immediate and exclusive breast-feeding: Despite the proven benefitsof immediate and exclusive breast-feeding, these practices are still theexception rather than the rule in

many countries. Over 80 percent ofall newborns in Asia, for example,are not put to the breast at all withinthe first 24 hours.6 While some cul-tures discourage early breastfeedingbecause colostrum (or first milk) isthought to be unclean, nursing thenewborn immediately after birthprovides much-needed immunedefense, nutrients, warmth, andbonding with the mother—thingsevery newborn needs to survive andthrive. Education on breastfeedingshould be regularly included as partof prenatal, delivery, and postnatalcare, emphasized in community-based behavioral change strategies,and supported by advocacy atnational and regional levels.

THE WAY FORWARD: SAVING NEWBORN LIVESPolicymakers, nongovernmentalorganizations (NGOs), health careprofessionals, and community leadersneed to collaborate in strengthening

effective solutions exist to save manyof these young lives. Indeed, newborndeaths now constitute over 40 percentof all deaths to children under agefive. Until recently, policymakers andprogram planners focused relativelylittle attention on this age group, con-centrating instead on interventionsthat primarily benefit infants over onemonth of age. We now recognize,however, that additional gains in childsurvival will depend in large measureon saving newborn lives.

A SLENDER THREAD: THE VULNERABLE NEWBORNAccording to the World Health Organization’s estimates for 2001,infections account for 32 percent ofnewborn deaths (tetanus, sepsis,pneumonia, and diarrhea), complica-tions of prematurity explain a further24 percent, and birth asphyxia andinjuries cause 29 percent.3 Animportant secondary factor in 40 to80 percent of neonatal deaths is lowbirth weight (a weight of less than2,500 grams at birth).4

In addition to inadequate care ofnewborns, another major cause ofneonatal deaths in developing coun-tries is the poor health of mothers,especially during pregnancy, deliv-ery, and the early postpartum peri-od. Many pregnant women areinadequately nourished, overworked,and may still be recovering from aprevious pregnancy. For many moth-ers, health care during this criticalperiod is virtually nonexistent. It isestimated that last year 53 millionwomen in developing countries gavebirth with no professional healthcare whatsoever.5

IMPROVING NEWBORN HEALTHMost of these neonatal deaths canbe prevented with cost-effectivesolutions that do not depend onhighly technical training or sophisti-cated equipment. Proper nutritionand hygiene, for example, are theanswer in many cases, while otherdeaths can be prevented by usingwidely available vaccines and med-ications to prevent and treat infec-tions, by having skilled health careon hand during and after delivery, byrecognizing and promptly treatingobstetric complications, by keepingthe baby warm and the umbilicalcord clean, and by improving breast-feeding and family planning prac-tices. By looking after the health ofexpectant mothers—before, during,and after delivery—many of thecauses of newborn death can beprevented before they occur.

As noted above, there are severalapproaches to reducing newborndeaths that have been proven to beboth feasible and cost-effective,including:" Tetanus toxoid immunization:Over 300,000 newborns die each yearof neonatal tetanus—a highly pre-ventable illness virtually unknown inthe developed world. Two doses oftetanus toxoid, delivered as part ofroutine prenatal care for a little over

MAKING THE CASEEach year, an estimated four millionbabies die before they reach the ageof one month, and four million moreare stillborn (dying between 22 weeksof pregnancy and birth).1 Ninety-eightpercent of these newborn deaths takeplace in developing countries, and,for the most part, these newborns dieat home, in the absence of any skilledhealth care.2 Enormous disparitiesexist between rich and poor coun-tries. A mother in western Africa, forexample, is 30 times as likely as amother in Western Europe or NorthAmerica to lose her newborn in thefirst month of life.

In the State of the World’s New-borns, we review the most recent dataon the newborn, revealing the alarm-ingly poor health and quality of healthcare for mothers and newborns in vir-tually all impoverished countries.While there has been a dramaticreduction in under-five mortality inthe past two decades, there has beenrelatively little change in newbornmortality, even though proven, cost-

FIGURE 1 PERINATAL AND NEONATAL MILESTONES


STILLBIRTH The death of a fetus weighing at least500 grams (or when birth weight is unavailable,after 22 completed weeks of gestation or with acrown-heel length of 25 centimeters or more),before the complete expulsion or extraction fromits mother.

PERINATAL DEATH The death of a fetus weighingat least 500 grams (or when birth weight isunavailable, after 22 completed weeks of gesta-tion or with a crown-heel length of 25 centime-ters or more) or the death of an infant during thefirst week of life.

NEONATAL DEATH The death of a live-born infantduring the period that commences at birth andends 28 completed days after birth.8

PERINATAL

22 WEEKS BIRTH 7 DAYS 28 DAYS

PREGNANCY DELIVERY POSTNATAL

EARLY LATE

TETANUS TOXOID IMMUNIZATION

One success story comes fromBangladesh where death ratesfrom neonatal tetanus have beenreduced by 90 percent in just overa decade. With government com-mitment and support from a rangeof partnerships, a massive immu-nization campaign was launchedin the mid-1980s, increasing cov-erage with tetanus toxoid vaccinefrom 5 percent in 1986 to 86 per-cent in 1998. Thanks to thisincrease, Bangladesh reducedneonatal tetanus death rates from41 for every 1000 live births in1986 to only 4 per 1000 by 1998.7

BANGLADESH

NEONATAL

the newborn. With the support andcollaboration of national decision-makers, community leaders, healthcare professionals, and assistanceagencies, the world’s newborns canreceive the care and resources theyneed to survive and prosper.

breakthroughs, expensive technolo-gy, or the makeover of nationalhealth care systems. Major stridescan be made by putting existingsolutions into general practice, whilethe search continues for the mosteffective way to bring about behav-ioral change and to treat certaincomplications, such as asphyxia, in

likely to space their pregnancies,thereby improving their own healthas well as that of their children. Thisin turn leads to reduced fertilityrates and contributes to the demo-graphic transition from high to lowfertility and mortality.

Reducing newborn and maternalmortality does not require medical

existing health care delivery systemsto provide expectant mothers andtheir newborns healthy alternatives tothe chronic pattern of disease anddeath at the beginning of life.

A key part of this effort will beadvocating for and creating policies atall levels that address the specialneeds of newborns. If newborn careprograms are to receive the supportthey need—the kind of support cur-rently available for reproductivehealth, child health programs, andcommunicable disease prevention, forexample—they will need to become anational priority and figure promi-nently in national health plans andhealth reform programs. When poli-cies are in place, then other neededchanges are more likely to follow; forexample, funding commitments, pro-fessional and technical changes suchas revised national curricula andrecruitment and deployment of staff,and the mobilization of nongovern-mental organizations.

Another front in this effort will beto strengthen and expand provencost-effective services. We can begin,in short, by doing more of what weknow works and, wherever possible,doing it better, such as promotingtetanus immunization and breast-feeding, as noted above. We can alsomake a concerted effort to identifyother feasible, cost-effectiveapproaches to newborn care that canbe easily replicated at the householdand community level. Meanwhile, wecan work on incorporating a newborncare component into existing safemotherhood and child survival pro-grams, ensuring that postnatal carefor mother and baby becomes asroutine as prenatal care. Finally, wecan add a newborn component toother ongoing health initiatives thatalso target mothers, such as familyplanning and prevention programsfor sexually transmitted infections.

Another piece of this effort mustbe to mobilize the resources—finan-

cial, human, and material—that areavailable to improve newborn health.While this can mean supplementingexisting resources, in many casesthis is not realistic or even neces-sary. A first effort should be toensure that the resources presentlyavailable are used as efficiently aspossible. For example, there may bescope to reallocate resources withingovernment health budgets to addthose newborn health componentsthat have been found to be cost-effective. Also, in countries whereseveral NGOs and assistance agen-cies are working in health, betterefforts to coordinate their activitieswill help to integrate these newbornhealth components. Nevertheless, togo to scale with the essential inter-ventions for newborn health, mostcountries will require incrementalresources that need to be providedon a long-term, sustainable basis.

We also need to collaborate withlocal organizations and researchinstitutions to advance the state ofthe art of newborn care, identifyingand testing promising new, low-cost approaches and technologies,and improving our understanding ofcultural factors that affect commu-nity and household practices.

Collaboration must be a com-mon thread in all of these efforts,working together in strategic part-nerships with a wide range of insti-tutions in developed and developingcountries, including universitiesand other NGOs, government min-istries, and international agencies.The potential for impact expandsgreatly whenever resources andexperiences are shared.

All of these investments will payoff—and not just in reduced mortal-ity rates. Evidence is growing thathealthy newborns are more likely tobe healthy adults, greatly reducingthe social and economic costs of ill-ness and disability. And when new-borns survive, mothers are more

8 STATE OF THE WORLD’S NEWBORNS

TRAINING IN ESSENTIAL CARE FOR

NEWBORN HEALTH

Another success story comes fromthe Gadchiroli district in Indiawhere the nonprofit organizationSEARCH has trained village healthworkers and traditional birthattendants to provide appropriatehealth care for women duringpregnancy, assistance in cleandeliveries, proper response tocomplications for both mother and baby, as well as support forbreastfeeding, care for low birthweight babies, and family plan-ning. As a result, neonatal mortali-ty has been reduced by approx-imately 60 percent through home-based care among isolated, ruralvillagers.9 INDIA

POLITICAL COMMITMENT

“Africa needs intensive mobiliza-tion of people who have the powerand means to reduce maternaland neonatal mortality on the con-tinent.” This observation byMadame Adame Ba Konare, FirstLady of Mali, represents the kindand level of advocacy needed toadvance the newborn agenda. At ameeting in May 2001, the firstladies of West and Central Africaargued eloquently for “leadershipand commitment from withinAfrica itself.” Conferences such asthese are important for creating apolicy environment favorable tohealth reform and for helping keyagencies and individuals to movefrom rhetoric to action.10 MALI

ESSENTIAL CARE FOR NEWBORN HEALTH

" Ensure early postnatal contact" Promote continued exclusive breastfeeding" Maintain hygiene to prevent infection: ensure

clean cord care and counsel mother on generalhygiene practices, such as hand-washing

" Provide immunizations such as BCG, OPV, andhepatitis B vaccines, as appropriate

SPECIAL ATTENTION" Recognize danger signs in both mother and new-

born, particularly of infections, and avoid delay inseeking care and referral

" Support HIV positive mothers to make appropri-ate, sustainable choices about feeding

" Continue to pay special attention to warmth,feeding, and hygienic practices for LBW babies

" Ensure skilled care at delivery" Provide for clean delivery: clean hands, clean

delivery surface, clean cord cutting, tying andstump care, and clean clothes

" Keep the newborn warm: dry and wrap babyimmediately, including head cover, or put skin-to-skin with mother and cover

" Initiate immediate, exclusive breastfeeding, at least within one hour

" Give prophylactic eye care, as appropriate

SPECIAL ATTENTION" Recognize danger signs in both mother and baby

and avoid delay in seeking care and referral" Recognize and resuscitate asphyxiated babies

immediately" Pay special attention to warmth, feeding, and

hygiene practices for preterm and LBW babies

" Improve the nutrition of pregnant women" Immunize against tetanus" Screen and treat infections, especially syphilis

and malaria" Improve communication and counseling: birth

preparedness, awareness of danger signs, andimmediate and exclusive breastfeeding

SPECIAL ATTENTION" Monitor and treat pregnancy complications, such

as anemia, preeclampsia, and bleeding" Promote voluntary counseling and testing for HIV" Reduce the risk of mother-to-child transmission

(MTCT) of HIV

" Improve the health and status of women " Improve the nutrition of girls" Discourage early marriages and early childbearing

" Promote safer sexual practices" Provide opportunities for female education

CARE AFTER BIRTH

CARE AT TIME OF BIRTH

CARE DURING PREGNANCY

CARE OF FUTURE MOTHERS

Conservative estimates suggest that

each year, at least four million babies

die during the first 28 days of life—

almost two-thirds of whom die within

the first week and in particular

during the first day. In other words,

every minute, eight babies die before

reaching one month of age. An

additional four million are stillborn.11

MAKING

THE CASE

NEWBORN DEATH IS A MAJOR PROBLEMDeaths during the neonatal period(the first 28 days of life) account foralmost two-thirds of all deaths inthe first year of life, and 40 percentof deaths before the age of five (see“Two-Thirds Rule,” p.13). Currentestimates suggest that 34 out ofevery 1,000 babies born in develop-ing countries die before they reachone month of life.12

A disturbing feature of newbornmortality is the marked variation inrates between low-income andhigh-income countries (Table 1,p.14). For example, the neonatalmortality rate (NMR) in Mali is about60 per 1,000 live births, compared toSweden, where the rate is less than3. The disparity between regions iseven wider when we use the lifetimerisk of a mother experiencing aneonatal death as the standard ofcomparison. A mother in westernAfrica, for example, has an approxi-

mately 30 percent risk of one of herbabies dying in the first month,compared to a mother in WesternEurope or North America where thelikelihood is less than one percent.Almost a third of mothers in west-ern Africa have lost at least onenewborn baby—a commonplace butlargely untold tale of grief.

The neonatal mortality rate (42per 1,000) and the perinatal mortali-ty rate (76 per 1,000) are highest inAfrica, and neonatal mortality ishighest of all in western Africa, at54 per 1,000 live births. Asia actual-ly has a lower average neonataldeath rate (34 per 1,000), butbecause of that region’s higher pop-ulation density, it accounts for 60percent of the world’s neonataldeaths (Table 1, p.14). Preliminaryresults from a recent analysis foundthat the loss of healthy life fromnewborn deaths represented 8.2percent and 13.6 percent of the bur-den of disease in sub-Saharan

Africa and South Asia, respectively.13

It should be noted here thatmeasuring newborn mortality hasbeen difficult (see note, Table 1,p.14). Even so, considerably moreinformation is available today thanwas the case even a few years ago.Thus, available estimates such asthose from the World Health Orga-nization (WHO) indicate the magni-tude of the problem rather thanprovide precise figures.14

HEALTHY NEWBORNS HAVE AHEADSTART IN LIFEWhile the alarming number of still-births and neonatal deaths is per-haps the most compelling reason tofocus on newborns, another impor-tant reason is the fact that healthynewborns are likely to enjoy betterhealth in childhood and in later life.Newborns who get off to anunhealthy start, especially low birthweight (LBW) and preterm babies,are particularly vulnerable to illness

and death during their first year.They may also develop disabilitiesand are generally less likely toreach their full potential, withunfortunate consequences forthemselves, their families, andsociety as a whole.

A growing body of literature sug-gests that the intra-uterine envi-ronment “programs” aspects ofchronic disease in adult life.15-18 The“fetal origins hypothesis” has stim-ulated much debate and highlightedthe importance of promoting in-utero health to prevent problems inlater life such as diabetes, hyper-tension and cardiovascular dis-eases. This is particularly importantas people live longer and these dis-

THE “TWO-THIRDS RULE” ON GLOBAL INFANT MORTALITY RATES*

" More than seven million infants

die each year between birth to 12

months

" Almost two-thirds of infant deaths

occur in the first month of life

" Among those who die in the first

month of life, about two-thirds die

in the first week of life

" Among those who die within the

first week, two-thirds die in the

first 24 hours of life


DELAY IN SEEKING CARE

Chan brought her baby, Sopha, to the health center on the baby’sfifth day of life. Chan had noticedthat the baby had redness aroundher umbilical cord from the second day after birth, but shewas not able to seek health carebecause women and newborns are not allowed to leave the homeuntil after the “dropping the stoneceremony”—a ritual symbolizingthat the mother and newborn havesurvived the birthing process. Bythe time Sopha reached the healthcenter, she had a very high feverand was not feeding. She died thenext day, despite treatments withantibiotics.20 CAMBODIA

eases become more common inboth the developed and developingworld. There is also growing evi-dence for and interest in the influ-ence of in-utero health on futurecognitive development: LBW babies,for example, have been found to doless well than normal newborns oneducational and intelligence tests.19

NEWBORN DEATH AND DISABILITY ARE COSTLY

“This birth has cost me 2,000 rupees, and I have lost a grandson.”

These words from a bereavedgrandmother are a harsh reminderthat there are economic and social

* This rule applies only to the world average. Local proportions will depend on progress in addressing newborn rel-ative to post-newborn deaths. Historically, as the number of infant deaths has fallen, the proportion of newbornshas risen. SOURCE Data based on Hill 1999, WHO 2000, and WHO 200121

ABOVE A woman in labor is brought to a localclinic by a bicycle ambulance. MALAWI

TABLE 1 SELECTED NEWBORN AND MATERNAL INDICATORS BY REGION, 1995-2000

costs associated with poor newbornhealth. The family incurs the cost ofhealth care during pregnancy anddelivery, and if the newborn dies, theadditional costs of the funeral andburial. Caring for a disabled or sickchild can consume the family budgetand, in many cases, is an added bur-den on family members who wouldotherwise work and make money.Disabled and sick newborns add tolocal and national health care costs,stretching already scarce resources.The social costs are harder to quan-tify. A newborn death is a distressingemotional experience for the newmother and her family, and it is alsoa social stigma in many cultures.

NEWBORN SURVIVAL CONTRIBUTES TO LOWER BIRTHRATES, THE HEALTH OF THEMOTHER, AND THE HEALTH OF SUBSEQUENT NEWBORNSThere is evidence of a strong associ-ation between newborn and infantmortality and birth interval, withhigher mortality for infants born lessthan 18 months apart.22 And there isrelated evidence that when a new-born dies, many mothers areinclined to enter more quickly intoanother pregnancy in order to pro-vide a “replacement” baby. When anewborn survives, therefore, themother is more apt to space herpregnancies, thus contributing toher own improved health and thehealth of her fetus, and by lengthen-ing the birth interval, increasing thesurvival chances of the next child. Atthe same time she also contributesto the “demographic transition” fromhigh fertility and mortality to low fer-tility and mortality.23

STILLBIRTHS

Behind closed doors in MangochiDistrict Hospital, a woman is wail-ing. Lukia Idrusi has just been toldthat 32 hours ago she gave birth toa stillborn baby girl. AlthoughLukia had been anxiously askingabout her baby ever since shecame round from her operation,neither the nurse in charge nor hergrandmother felt that she was wellenough to accept the news untilnow. Lukia had realized that some-thing was wrong almost immedi-ately following the onset of labor.“The labor went on for hours andhours and then I could feel some-thing bursting inside of me. At thatpoint I stopped feeling laborpains,” she explains. A clinicalexamination confirmed that theuterus had ruptured and the fetalheartbeat had stopped.24 MALAWI


Region

Estimated number of live births per year

(thousands) 1999

Estimated neonatalmortality rate per

1,000 live births circa 1999

Total fertility rate1995-2000

Number of neonataldeaths (thousands)

calculateda

Lifetime risk of a mother

experiencing a neonatal death(%) calculatedb

AFRICA 28,685 42 1,205 5.0 21

EASTERN AFRICA 10,057 41 408 5.8 24

MIDDLE AFRICA 4,107 39 162 6.2 24

NORTHERN AFRICA 4,607 32 147 3.6 12

SOUTHERN AFRICA 1,277 18 23 3.4 6

WESTERN AFRICA 8,636 54 465 5.5 30

ASIA 76,090 34 2,561 2.6 9

EASTERN ASIA 21,106 20 421 1.8 4

SOUTH-CENTRAL ASIA 38,442 46 1,753 3.4 16

SOUTH EASTERN ASIA 11,432 24 277 2.7 6

WESTERN ASIA 5,110 22 110 3.8 8

EUROPE 7,374 6 44 1.4 < 1

EASTERN EUROPE 3,001 9 27 1.4 1

NORTHERN EUROPE 1,074 4 4 1.7 < 1

SOUTHERN EUROPE 1,405 5 8 1.3 < 1

WESTERN EUROPE 1,895 3 5 1.5 < 1

LATIN AMERICA/CARIBBEAN 11,553 17 196 2.7 5

CARIBBEAN 773 19 15 2.6 5

CENTRAL AMERICA 3,427 13 46 3.0 4

SOUTH AMERICA 7,354 18 135 2.6 5

NORTHERN AMERICA 4,098 4 18 1.9 < 1

OCEANIAc 225 34 8 2.4 8

MORE DEVELOPED REGIONS 13,045 5 65 1.6 < 1

LESS DEVELOPED REGIONS 116,550 34 3,970 4.9 17

WORLD 129,596 31 4,035 2.7 8

aDefinitions of the indicators and sources of data are listed in the appendix. NMR is based on WHO estimates for2001 using data collected circa 1999. The number of neonatal deaths was calculated by multiplying the number oflive births (1999 estimates) by the NMR (2001 estimates). TFR is from UNFPA 2000.

bThe lifetime risk of a mother experiencing a neonatal death is calculated by multiplying the neonatal mortality rateby the total fertility rate. This is a simplification of complex statistical interactions between fertility and neonataldeaths, but is used to illustrate the dramatic differences by sub-region.

cJapan, Australia and New Zealand have been excluded from the regional estimate but are included in the total fordeveloped countries.

Very few countries in the developing world have a reliable system for registering births and deaths. While surveys bygovernments and international agencies attempt to estimate the size of the problem, there are many sources ofpotential error, such as the under-reporting of newborn deaths and stillborns, and inaccuracies in fixing the time ofdeaths (i.e., classifying neonatal deaths as stillbirths). Other problems include the reluctance of mothers to talk aboutinfant deaths for cultural reasons and the fact that the populations surveyed are often in easy-to-reach, relativelyadvantaged areas, thus introducing questions of sample bias and a tendency to underestimate the problem.

ABOVE An early postnatal visit provides theopportunity to promote healthy practices andaddress complications. MALAWI

DEMYSTIFYING NEWBORN CARE


baby may be secluded within thehome, contributing to the “invisibility”of the newborn.

There is also the widespread, mis-taken assumption that the problemsof newborns are being addressed bysafe motherhood and child survivalprograms. The reality in many casesis that newborns have benefitted littlefrom the “child survival revolution”and that the neonatal period has forsome time been orphaned betweenthese two programs.

COST-EFFECTIVE SOLUTIONS EXISTIf improving newborn health were amatter of making medical or scien-tific breakthroughs, building expen-sive health care infrastructures, orpurchasing expensive high-tech

ventilators and incubators, then thereluctance to take up the cause ofnewborns might be more under-standable. But it is not. Experiencein developed nations has shown thatneonatal and perinatal mortalityrates fell most dramatically longbefore neonatal intensive care unitscame into existence, thanks to rela-tively simple, low-cost interventionssuch as better maternal and obstet-ric care, better routine newborn care,and the introduction of antibiotics.

Low-cost, proven interventionscan be carried out entirely within theframework of existing maternal andchild health programs. Currentreviews indicate that essential careduring pregnancy, childbirth, and thenewborn period costs an estimated

US$3 a year per capita in low-income countries.26

Improving newborn health is nota matter of developing solutions tothe problems; it is a matter ofapplying existing solutions via exist-ing mechanisms. The real challengeis to spread the awareness of soundnewborn health practices to thosewho need it, especially mothers,other primary caregivers, and healthproviders. But to do that will requiregetting the plight of newborns onnational and international agendasand finding the resources to putproven solutions into practice.

FIGURE 2 INFANT AND NEONATAL MORTALITY RATES IN INDIA (PER 1,000 LIVE BIRTHS), 1960-1996

IMPROVED NEWBORN CARE WILLLEAD TO REDUCED INFANT ANDCHILD MORTALITYInfant and child mortality rates havedropped significantly over the lasttwo decades through reducing post-neonatal deaths due largely to diar-rhea, pneumonia, vaccine-preventableinfections and malaria. As a result,neonatal and especially early neona-tal deaths now represent a muchlarger proportion of the overall totalinfant mortality rate. Further reduc-tions in infant and child mortalitywill now depend on improving thecare of newborns.

In India, for example, infant mor-tality declined by half between 1960and 1990.25 Since then, the infantmortality rate has stagnated (Figure2) and further reductions willdepend largely on national newborncare strategies.

WHY WE HAVEN’T DONE MORE FOR NEWBORNSGiven such a strong case for improv-ing newborn health, why has thestate of newborns not received moreattention? To begin with, there iswidespread under-reporting of still-births and early newborn deaths,which means that policymakers sim-ply do not have the information thatwould make the problem visible tothem. Due to the lack of good data,WHO often uses “models” to esti-mate the numbers of neonatal andfetal deaths, yielding estimates thatmay be less than the actual num-bers. The cry is rising in the field ofneonatal health: Every life counts, socount every birth and death.

In some cultures a birth is notconsidered “complete” until sometime after the first critical days orweeks of life when a ceremony isperformed. Until then, mother and

" Newborn health is a priority

in developing countries

" Newborn care does not

require high-tech hospital

units and specialists

" Newborn care is not just a

mother’s responsibility

" Newborn care is affordable

" Newborn mortality can be reduced

even when socio-economic devel-

opment has not occurred

" Newborn health is essential

for future improvements in

child health

Infant mortality rates have stag-nated in India, largely because newborn deaths continue unabated even though post-neonatal deaths have declined.

SOURCE Ministry of Health, India and 'Trends in Childhood Mortality in the Developing World 1960-1996' UNICEF 1999.

1960 1965 1970 1975 1980 1985 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

160

140

120

100

80

60

40

20

0

IMR

NMR

WOMEN CAN BE

RELUCTANT TO SEEK CARE

Mira’s baby girl was born in thedoorway of her mud-coveredstone house with her sister andsister-in-law supporting her. Theumbilical cord was cut with a newblade, after which mustard oil wasrubbed into the stump. “I didn’t go to the health post for check-ups,” says Mira, “because I wasshy of someone seeing my belly.”Even if there had been complica-tions, the family insists that theywouldn’t have taken her to thehospital. “We’re poor and preferto die in our own houses,” saysMadan, Mira’s husband. NEPAL

We need to do more to improve the

survival rate and general health of the

world’s newborns. The most important

reason, of course, is to save lives and

ensure the well-being of future

generations, but there are other

compelling reasons why the plight of

newborns merits a prominent place

on the international health agenda.

A SLENDER

THREAD: THE

VULNERABLE

NEWBORN

FIGURE 3 DIRECT CAUSES OF NEONATAL DEATHS

birth) and other birth injuries. Pro-longed or obstructed labor, a com-mon phenomenon in such countries,is a leading cause of birth asphyxia.The WHO estimates that betweenfour and nine million newbornsdevelop birth asphyxia each year. Ofthose, an estimated 1.2 million dieand at least the same number devel-op severe consequences, such asepilepsy, cerebral palsy, and devel-opmental delay.31 Prompt detectionand management of obstetric com-plications can prevent many of thesedeaths and disabilities.

Congenital anomalies are thefourth most common cause of newborn deaths, a category thatincludes neural tube defects, cretinism, and congenital rubellasyndrome. Neural tube defects arepreventable if pregnant mothers aregiven folic acid during the first threemonths of pregnancy. Cretinism can be avoided by providing motherswith adequate iodine, and congenitalrubella syndrome can be prevented byimmunizing mothers against rubella.

DIRECT CAUSES OF FETAL DEATHThere are two types of fetal death:fresh stillbirths, which occur withinthe uterus during labor or delivery,and stillbirths, which occur withinthe uterus before the onset of labor.The former are caused almost exclu-sively by a lack of oxygen due toproblems during labor, and the latterare most commonly due to maternalinfections, such as syphilis, and con-genital abnormalities.

INDIRECT CAUSES OF NEONATALMORTALITY: THE INFLUENCE OFLOW BIRTH WEIGHT (LBW)Birth weight strongly influences thechances of the newborn to surviveand thrive. Not surprisingly, LBW (aweight of less than 2,500 grams atbirth) is the most important indirectcause of neonatal mortality andmorbidity. Between 40 percent and

TRADITIONAL BELIEFS AND CLEAN

DELIVERY PRACTICES

In Cochabamba, Bolivia, birthattendants have traditionally useda stone or a piece of clay pot to cutthe newborn’s umbilical cord afterbirth. All attempts to persuadefamilies to use a sterile knife orrazor blade failed. Then a study of traditional birthing practicesrevealed that people living in theregion believe that cutting the cordwith a knife or blade would causethe baby to grow up to be a thief.Since then, families have beeneducated to sterilize stones byboiling them, thereby respectingtradition but preventing infection.27

BOLIVIA

DIRECT CAUSES OF NEONATAL DEATHDetermining why newborns die indeveloping countries is difficultbecause most deaths occur athome, and families are often reluc-tant to seek outside help for a sickchild for a variety of socio-cultural,logistical and economic reasons.The data we have, however, point tofour main causes of neonatal death:infections (tetanus, sepsis, pneumo-nia, diarrhea), complications duringdelivery (leading to birth asphyxiaand birth injuries), congenitalanomalies, and complications ofprematurity (Figure 3). While this isindeed a sad litany of disease, it isnoteworthy—and encouraging—tosee that most of these causes ofdeath are readily preventable viaproven, low-cost solutions.

Every year, an estimated 30 mil-lion newborns acquire a neonatalinfection, and between one and twomillion of those infected die.28 The

most common of these infectionslead to neonatal tetanus, sepsis,pneumonia and diarrhea, whichtogether account for 32 percent ofneonatal deaths. Where hygiene ispoor, newborns may becomeinfected with bacteria leading toserious infections in the skin,umbilical cord, lungs, gastrointesti-nal tract, brain, or blood. Neonataltetanus has been eliminated todayin over 100 countries throughimmunizing mothers with tetanustoxoid, ensuring clean deliverypractices, and maintaining cleancord care.29 Early and exclusivebreastfeeding also contributes toreduced neonatal mortality frominfections.30

Another common cause of highneonatal mortality in developingcountries is complications duringdelivery, which lead to asphyxia (theinadequate supply of oxygen imme-diately before, during, or just after


Infections (tetanus, sepsis, pneumonia, diarrhea) 32%

29%

5%

24%10%

SOURCE WHO 2001 estimates (based on data collected around 1999).

ABOVE Low birth weight babies are vulnerable to a range of life-threatening conditions, including infections such as sepsis, pneumonia, and diarrhea. MALAWI

Birth asphyxia and injuries

Complications of prematurityCongenital anomalies

Other

TABLE 2 LOW BIRTH WEIGHT BY REGION 1995-99

and HIV. Other common causes ofLBW include demanding physicalwork, cigarette use, indoor pollu-tion, and alcohol and drug use.Short spacing between pregnanciesalso seems to be associated withLBW,34 as is adolescent pregnancy.Once again, it should be noted thatmost causes of LBW are treatableor preventable through improvingmaternal health and nutritional sta-tus. Treatment of LBW babiesrequires special attention, particu-larly with regard to warmth, feed-ing, hygiene practices, and prompttreatment of infection.

GENDER BIASGender bias refers to a preferencefor male children in some culturesand a corresponding discriminationagainst and neglect of females. Sur-

veys in some districts of SouthIndia, for example, have shown thatearly newborn mortality among girlsis nearly double the rate for boys.35

Other studies have shown thatreferrals of girl babies for specialcare are fewer than for boys. Inextreme cases, gender bias can belife-threatening: sex-selective abor-tion, female infanticide, and theneglect of the girl-child are respon-sible for an estimated 60 million“missing” girls, mostly in Asia.36

State of the World’s Mothers, a report published by Save the Children in May 2000, presents coun-try-by-country data on indicatorsreflecting the status of womenthrough their access to health care,education, and economic resources.37

80 percent of neonatal deaths occuramong LBW babies,32 and those whodo survive are subject to poorgrowth and increased rates of illnessfrom infectious diseases in infancyand childhood, as well as compro-mised cognitive and behavioraldevelopment. WHO estimates that 17percent of newborns in developingcountries suffer from LBW, com-pared to 6 percent in industrializedcountries (see Appendix, Table I forLBW rates by country).

LBW infants have a much greaterrisk of dying in the newborn period.In a recent study of such infants inBangladesh, the overall LBW new-born mortality rate was 133 per1,000 live births. As birth weightdecreased, the mortality rateincreased: the rate for infantsweighing 2,000–2,499 grams was 52per 1,000; for those weighing1,500–1,999 grams, 204 per 1,000;and for those weighing less than1,500 grams, 780 per 1,000. Pre-term LBW infants were five times aslikely to die as term LBW infants.33

LBW is most commonly causedby short gestation, intra-uterinegrowth retardation (IUGR), or both.However, the causes of LBW arecomplex, often stemming from theeffects of generations of poverty. Ingeneral, the health and nutrition ofthe mother are key factors. Themother’s pre-pregnancy weight, forexample, influenced by her life-longnutritional status and even that ofher mother and grandmother, con-tributes to LBW, as does a fear ofobstructed labor and the relatedpractice of “eating down,” the ideaheld by some mothers that eatingless will result in smaller babies,hence easier, and less risky, labor.

LBW can also result fromuntreated maternal infections—malaria, urinary tract infections,bacterial vaginosis, and sexuallytransmitted infections (STIs), suchas syphilis, gonorrhea, chlamydia,


Region

SUB-SAHARAN AFRICA 15 3,607

MIDDLE EAST/NORTH AFRICA 11 1,024

SOUTH ASIA 31 11,061

EAST ASIA/PACIFIC 8 2,611

LATIN AMERICA/CARIBBEAN 9 1,031

CEE/CIS AND BALTIC STATES* 7 448

LESS DEVELOPED COUNTRIES 17 19,782

INDUSTRIALIZED COUNTRIES 6 586

WORLD 16 20,368

LBW rate (%) 1995-99

Estimated number of LBW babies per year

(thousands)

*CEE: Central and Eastern Europe, CIS: Commonwealth of Independent States Countries grouped by United Nations regionsSOURCE adapted from State of the World’s Children 2001, using UNICEF and WHO data 1995-2001

ABOVE In many developing countries,girls and women face inequality inaccess to education, health care, and employment opportunities. INDIA

Improving the health of newborns

is largely a matter of applying sound

health care practices at the appropri-

ate milestones in the development

of a newborn: that is, during preg-

nancy, at the time of birth, and after

birth up through the first 28 days.

A truly effective approach to newborn

health would start even earlier, of

course, by addressing the health

of future mothers.

IMPROVING

NEWBORN HEALTH

CARE OF FUTURE MOTHERS


A recent study from the Gambia,however, has reopened the debate.Undernourished pregnant womenwere given supplements in the formof a groundnut-based biscuit thatprovided an extra 900 calories perday and added calcium and iron. Thewomen also received prenatal care,including iron and folate supple-ments, tetanus toxoid immunizationif needed, and chloroquine duringthe malaria season. Overall, therewas a 35 percent decrease in LBWbabies and a 49 percent reduction inperinatal deaths among womenreceiving supplements comparedwith those who did not.40

Increasing the intake of vitaminsand micronutrients during pregnan-cy has also produced promisingresults. Recent studies of interven-tions to reduce anemia in pregnancyhave demonstrated the beneficialeffects of iron and folate supple-ments, along with anti-worm treat-ment.41 In one study, adding iodine toa water supply in China reducedneonatal mortality by approximately50 percent.42 Other studies suggest

that zinc supplements during preg-nancy improve infant outcomes, par-ticularly among LBW infants.43,44

Supplementation of women of repro-ductive age in Nepal once weeklywith vitamin A reduced pregnancy-related maternal mortality by 40 per-cent, and modestly reduced maternalmorbidity and anemia.45 In otherstudies, maternal night blindness,indicative of vitamin A deficiency andpresent in 10-20 percent of women insome populations, was associatedwith more severe infections, anemia,increased infant deaths, andincreased risk of maternal mortalityfor up to two years after givingbirth.46 Although maternal vitamin Asupplementation did not impactinfant mortality through 6 months ofage, vitamin A supplementation ofnewborns immediately after birthmay be a promising strategy.47,48

Ideally, the broad use of food andvitamin supplements to improvematernal nutrition should be part ofa wide-scale development effortaimed at alleviating poverty, ensur-ing household food security, pro-

moting healthy diets, and defendinggender equity. In those cases wheresupplements are the only interven-tion, however, the most importantsupplements to include in an ante-natal care package are iron andfolate, and, in some regions, vitaminA, iodine, and zinc. The use of multi-ple micronutrient supplements dur-ing pregnancy, a common practicein the industrial world, is nowundergoing evaluation in severaldeveloping countries.

Adding micronutrients (such asiron, vitamin A, and iodine to fortifyflour and other staples) can be asimpler and quicker means ofimproving nutritional status thanchanging diets. However, for thisstrategy to be effective, fortifiedfoods must be readily available, rel-atively inexpensive, and widely con-sumed by the target population.

Immunize against tetanusAs noted earlier, neonatal tetanus isan important cause of newborn death.Tetanus toxoid vaccination protectswomen against tetanus infection

CARE OF FUTURE MOTHERS:IMPROVING THE STATUS ANDHEALTH OF WOMENSmall girls grow into small women,who develop into underweight moth-ers who have undernourishedbabies, resulting in a cycle of illhealth and high death rates.38 Thecauses of the undernourishment andill health of many women are com-plex. In many societies, girls areuniquely disadvantaged, their optionsin life limited by illiteracy, poor education, and lack of employmentopportunities. They are often bur-dened with heavy workloads, havelesser claims on scarce resources,and may not be free to make theirown decisions regarding access tohealth care or their own fertility.

Improving the status and healthof girls and women is clearly a long-term challenge, one that will requirethe support of and coordinationamong individuals in numerous sec-tors, including health, education,and human rights. Changes in socialand cultural beliefs and practiceswill also be necessary to supportneeded improvements in the statusand health of future mothers.

The ultimate objective is to teachsucceeding new generations of girlsthat their health—and that of theirchildren—will depend on improvingnutrition, delaying marriage andchildbirth beyond the customaryage, and ensuring that they andtheir partners use safer sexualpractices. All of these goals can befurthered by providing educationalopportunities for girls.

CARE DURING PREGNANCYCaring for newborn babies starts withcaring for their pregnant mothers,ensuring that pregnant women areadequately nourished, free frominfections and exposure to harmfulsubstances, and monitored for com-plications during pregnancy. Howev-er, the harsh realities of everyday life

for many pregnant women make itdifficult for them to put these soundrecommendations into practice (seeAppendix, Table II, Percent of preg-nant women with at least one antena-tal visit).

Improve pregnant women’s nutritionA malnourished mother not onlyendangers the health of her fetusbut also her own health, increasingthe likelihood of infection and dis-ease. Short-term options for improv-ing the nutrition of mothers include:" promoting a healthy and varieddiet through an adequate supply andequitable distribution of food;" supplementing pregnant women’s diets through food-basedor manufactured supplements orfortified foods;" reducing work loads;" spacing pregnancies; and" treating conditions such as malaria and worms.

Over the long term, the nutritionof pregnant women can be improvedby studying how these women live.We also need to better understandthe demands on their energy andtime and to take into account theirneeds as they perceive them.39

Providing food supplements hasbeen a common component of pro-grams to improve maternal nutrition.In the 1960s and 1970s, there wereseveral attempts to analyze the effectof such programs on neonatal out-comes, but most studies showed rel-atively small effects on birth weightand perinatal mortality. The cost-effectiveness of these approacheswas also called into question, andfurther troubles arose over claims of“culture clash,” referring to situa-tions where women chose to restricteating in the belief that having asmaller baby would contribute to asafer and easier birth. For these rea-sons, food supplementation pro-grams were largely discredited andnever introduced on a broad scale.

BLAME FOR PROBLEMS

OFTEN FALLS ON MOTHERS

Gopini shows little sympathy forher daughter-in-law who has leftfor a two-month stay at her moth-er’s house following the stillbirthof her first son. There has alwaysbeen friction between Gopini andher daughter-in-law, and thedeath of her grandson only adds toher enmity. She cannot under-stand why the baby died, since sheherself gave birth to a breech baby20 years ago without problems.“My daughter-in-law was verylazy, she was always sleeping,”she says. “Perhaps because of thisthe baby didn’t have enough spaceto move.” NEPAL

DEMANDS OF HARD, PHYSICAL WORK

CONTINUE THROUGH PREGNANCY

Mangala has no idea why she issusceptible to low birth weight,premature babies. If you ask herwhether she took care duringpregnancy, she is nonplussed.“How can I take care?” she says.“I’m always working, picking riceand pulses (lentils), digging pitsand fetching water. I was in thefields until two hours before mybaby was born.” INDIA

" Improve the health and status

of women

" Improve the nutrition of girls

" Discourage early marriages

and early childbearing

" Promote safer sexual practices

" Provide opportunities for

female education

CARE DURING PREGNANCY

during pregnancy and ensures thatmothers pass this immunity to theirunborn children. In this way, babiesare protected against tetanus duringthe first two months of life, up to theage when they themselves can beimmunized against the disease.Where possible, immunization pro-grams should be initiated as earlyas adolescence.

Tetanus toxoid is one of thecheapest, safest, and most effectivevaccines. It costs about US$1.20—asum that includes the purchase anddelivery costs of three doses of vac-cine. Three doses of tetanus toxoidensure 10–15 years protection for awoman and immunity for her new-borns during the critical first twomonths of life. Five doses ensure alifetime of protection for the moth-er.49 Yet only about 52 percent ofpregnant women in developingcountries are now fully immunized(see Appendix, Table II, Percent ofpregnant women with at least twotoxoid immunizations).50 This is oneproven intervention that we need tomore effectively implement.

Screen and treat infectionsInfections during pregnancy are amajor cause of complications, suchas spontaneous abortions, prema-ture rupture of fetal membranes pri-or to labor, preterm birth, andcongenital infection and anomalies.

Prevention and treatment should bepart of antenatal care.

Sexually transmitted infections Gonor-rhea can cause infant blindness, whileactive syphilis is associated withspontaneous abortions, a high rate ofperinatal death, and other conditions,including developmental delay. Test-ing for sexually transmitted infectionsand providing appropriate treatmentshould be included in all antenatalcare. In most developing countries,screening and treatment for syphilisis simple and inexpensive, with signif-icant payoffs for newborn health.

Malaria In regions where it is highlyendemic, malaria may cause up to30 percent of preventable LBW and3–5 percent of neonatal mortality.Malaria is also associated with anincreased risk of spontaneous abor-tions and stillbirths and is linkedwith maternal anemia. These complications can be reduced byproviding intermittent presumptivetreatment during antenatal visits.51

Use of bednets impregnated withinsecticide has also been proven tobe effective in preventing malaria.52

Improve communication and counseling Families and communities can findsolutions to make birth safer andestablish a referral and transportplan if emergencies arise during

labor. Counseling can help thepregnant woman and her familytake steps to:" ensure skilled care at the birth" select a place of birth according toanticipated pregnancy complications" learn danger signs and when andwhere to seek care" highlight the advantages of earlyand exclusive breastfeeding" alert the mother to any obstaclesthat might make it difficult to ensurea safe delivery

SPECIAL ATTENTION

Monitor and treat pregnancy complications Many pregnancy-related complica-tions could be managed appropriatelyif they were detected in time. Anemia,for example, can often be preventedwith iron and folate supplements; urinary tract infections, reproductivetract infections, and maternal hyper-tension/preeclampsia can be treated.However, cases of severe intra-uter-ine growth retardation (IUGR), malpresentation or abnormal lie ofthe fetus, and multiple pregnanciesshould be referred to facilities betterequipped to deal with problematicbirths and LBW newborns. A womanwith a history of serious obstetric ormedical complications should also bemonitored closely.

Obstacles that keep pregnantmothers away from antenatal servic-es need to be identified and over-come. Many factors coulddiscourage women from takingadvantage of maternal health care,such as dissatisfaction with the atti-tude of staff, the time, costs, and dif-ficulties associated with reachingthe service location, and the prefer-ence of many women to be seen onlyby a female health worker.

Problems are often compoundedby some women’s natural shynessand the belief that pain is a naturalpart of pregnancy and birth. “I had

pain, strong stomach pain andcouldn’t sleep,” a mother in ruralIndia noted, speaking of the prema-ture birth of twins who died soonafter delivery. “The next day the painwas still there. I plastered the househoping the pain would go, but I didnot tell anyone. I thought maybe thiswas normal.”

Promote voluntary counseling and testing for HIVCounseling would also be appropri-ate where voluntary testing for HIV isavailable. This would include provid-ing infant-feeding counseling formothers living with HIV/AIDS so thatthey can make informed decisionsabout feeding alternatives.*

Reduce the risk of mother-to-childtransmission (MTCT) of HIV

" Improve the nutrition of pregnant women

" Immunize against tetanus

" Screen and treat infections, especially syphilis and malaria

" Improve communication and counseling: birth

preparedness, awareness of danger signs,

and immediate and exclusive breastfeeding

Special Attention

" Monitor and treat pregnancy complications,

such as anemia, preeclampsia, and bleeding

" Promote voluntary counseling and testing for HIV

" Reduce the risk of mother-to-child transmission (MTCT) of HIV

WOMEN NEED SPECIAL ATTENTION

DURING PREGNANCY AND CHILDBIRTH

Surakha and her husband Vasant,from the Bodli village in Gadchirolidistrict, India, regret not attendingantenatal checkups. Their son diedat birth. Surakha wishes now shehad taken the bus to the clinic 10kilometers away. “If I’d gone forcheckups we would have known thedelivery could be difficult and goneto hospital,” she says. But the factis that when a pregnancy seems tobe entirely normal, most ruralwomen are reluctant to take timeaway from working in the fields.Four months after their son died,Surahka discovered that she waspregnant once again. This time Vas-ant has already accompanied hiswife for an antenatal check at thehospital, and they plan to go again.Putting food on the table is only onething a father can do. A maninvolved with the well-being of hischildren—even before the day theyare born—is making a valuableinvestment in the future. INDIA

Up to one-third of untreated HIV-positive mothers will transmit thevirus to their infant in the perinatalperiod.53 While AZT (an anti-HIVdrug) given during pregnancy hasbeen shown to reduce mother-to-child transmission, families in manydeveloping countries cannot affordthis intervention. Shorter courses oftreatment with AZT or Nevirapinearound the time of delivery might bea more realistic solution,54 providedthat the resources are available.

The decision of whether and howto address mother-to-child trans-mission of HIV requires carefulthought and discussion. For anyapproach to work, women wouldneed to know their HIV positive sta-tus, in order to be informed abouthow to provide proper care forthemselves and their babies.


CONTROLLING MALARIA AND OTHER INFECTIONS IMPROVES BOTH MATERNAL AND NEWBORN HEALTH

In the past five years, 28-year-old Margaret Edward has lost two chil-dren to malaria before their third birthday. Now, Margaret clutches hernewborn baby girl to her chest, praying that malaria will not take thischild too. But this time she needn’t worry.

Five weeks ago, Margaret herself came down with malaria in thethird trimester of her pregnancy, but fortunately a vigilant traditionalbirth attendant spotted the signs and sent her to the local district hos-pital. Thanks to prompt diagnosis and treatment, Margaret has deliv-ered a healthy baby. MALAWI

*The complex issues of HIV and reproductive health are beyond the scope of this report. For more in-depth informa-tion, see the SARA Project publication: Prevention of mother-to-child transmission of HIV in Africa: practical guid-ance for programs. Washington, DC: AED, May 2001.


head. A naked newborn, for exam-ple, exposed to an environmentaltemperature of 23ºC (73.4ºF) suffersthe same heat loss as a naked adultat 0ºC (32ºF),60 and the loss isgreater still in LBW babies, espe-cially if they are left wet and uncov-ered. Hypothermia in the newbornoccurs in all climates and is due toa lack of knowledge or practice, nota lack of equipment.

Wherever the birth takes place, it is important to maintain a“warm chain” immediately afterbirth and during the following hoursand days. The place where the birthoccurs must be warm (at least25ºC/77ºF) and free of drafts,though ventilated.

At birth, the newborn should beimmediately dried and covered,including the head. While beingdried, the baby should be placed onthe mother’s chest or abdomen to

keep it warm. In some countries,the newborn baby is left uncovereduntil the placenta is delivered, apractice that considerably increasesthe risk of hypothermia. Skin-to-skin or close contact with the mother is the best way to keep thebaby warm. Another advantage ofcontinued close contact betweennewborn and mother is that itencourages breastfeeding ondemand. Breastfeeding within onehour of delivery provides the babywith calories to produce body heatand of necessity keeps the babyclose to the mother and warm.Bathing is generally not necessaryon the first day and should be post-poned until the baby is stable.

Initiate exclusive breastfeedingImmediate breastfeeding is one ofthe most effective interventions; itprovides nutrients, warmth, and

TRAINING FOR TRADITIONAL

BIRTH ATTENDANTS

A TBA who has assisted womenduring birth over four generations,recalls how in the old days shewould pour thick warm gruel overa child immediately after delivery,cut the umbilical cord with a sickle,and check the newborn’s hearingby hitting a steel vessel with metalnear her ear. Then she would mas-sage the head into shape. Thesedays, she washes her hands withsoap and disinfectant before andafter delivery, uses sterilized scis-sors to cut the cord, and cleans themother and child with a cleancloth. She is also trained in resus-citation skills. INDIA

" Ensure skilled care at delivery

" Provide for clean delivery: clean hands, clean delivery surface,

clean cord cutting, tying and stump care, and clean clothes

" Keep the newborn warm: dry and wrap baby immediately,

including head cover, or put skin-to-skin with mother and cover

" Initiate immediate, exclusive breastfeeding, at least within one hour

" Give prophylactic eye care, as appropriate

Special Attention

" Recognize danger signs in both mother and baby and

avoid delay in seeking care and referral

" Recognize and resuscitate asphyxiated babies immediately

" Pay special attention to warmth, feeding, and

hygiene practices for preterm and LBW babies


Decision-makers must also consider the social effects of newpolicies, such as isolation of or violence against women who areidentified to be HIV positive, andthe possibility of increased infantdeaths caused by the high rate ofinfections often associated with theuse of breast milk substitutes.


Ensure skilled care at delivery Historically, skilled care at deliveryhas been associated with lowerneonatal death rates (Figure 4).55

Skilled attendants at birth aredefined as “people with midwiferyskills (e.g., doctors, midwives andnurses) who have been trained toproficiency in the skills to managenormal deliveries, and diagnoseand manage or refer complicatedcases.”56 Skilled care providers maypractice in facility or household set-tings and require a functioningreferral system for the manage-

ment of complications.A primary barrier to delivering

proper obstetric care in developingcountries is that on average 63 per-cent of births occur in the home andonly 53 percent of all births areattended by a health worker skilledin delivery care.57 In other words, 53million women each year give birthwithout the help of a professional.58

In some countries the incidence ofskilled care at deliveries is muchlower; two percent in Somalia, forexample, and nine percent in Nepal.Even in those cases where skilledhealth care is available, ongoingtraining and supervision of personneland quality referral care for obstetricemergencies must be ensured.

Several randomized controlledtrials have shown the value of asupportive companion in reducingthe length of labor, producing fewerinstrumental deliveries, and havinga positive impact on Apgar scores(scores used to evaluate the condi-tion of the newborn baby).59 These

findings emphasize that the attitudeof those attending the birth is animportant factor along with the skillof the professional birth attendant,suggesting that personal supportand skilled assistance in deliveryare important to women in labor.

Provide for clean delivery A clean delivery is crucial to preventinfection of the newborn and of themother. The standard message is tomaintain a "clean chain" by ensur-ing clean hands, clean surfaces,clean cord-cutting and tying, and aclean cloth to wrap the newborn.

The use of a clean delivery kithelps to promote cleanliness at birth.Most clean delivery kits include soap,a plastic sheet for delivery, a cleanblade, and a cord tie.

Keep the newborn warm A newborn baby regulates bodytemperature much less efficientlythan does an adult and loses heatmore easily, particularly from the

FIGURE 4 SKILLED CARE AT DELIVERY AND NEWBORN MORTALITY BY REGION

SOURCE WHO estimates 2001

Africa Asia Latin America More Developedand the Caribbean Regions

100

80

60

40

20

0

Skilled attendance at delivery (%)

Neonatal deaths per 1,000 live births

CARE AFTER BIRTH

the danger signs of infection.One effective approach used in

the care of both preterm and LBWbabies is “kangaroo mother care,”which encourages breastfeedingand provides continuous warmth forthe baby. Based on continuous skin-to-skin contact by laying the babydirectly on the mother, the methodcan be effective, as long as the babyis stable and its signs are moni-tored carefully, and the baby canfeed on demand.66

CARE AFTER BIRTHThe basic, low-cost principles of new-born care are still as relevant today asthey were almost a century ago whenthe French obstetrician Pierre Budinspelled them out in his classic work,The Nursling.68 All newborns requirebreathing, warmth, food, hygiene,

because staff can diagnose the pre-mature rupture of membranes andpremature labor, and various drugsare more readily available, such asthose which suppress labor and cor-ticosteroids (drugs to mature thelungs of the unborn child and pre-vent respiratory distress in babies).When access to a hospital is not pos-sible, simple measures such askeeping the baby warm, preventinginfection by ensuring that caregiversfrequently wash their hands, and fre-quent feeding (breast or expressedmilk given by tube, spoon, or in a cupif the baby is unable to suck) may goa long way to reducing deaths amongbabies born before term.

Like preterm babies, LBW babiesneed special care, particularly withregard to warmth, feeding, hygienepractices, and promptly recognizing

Recognize and resuscitate asphyxiated babies immediately In developing countries, there are anestimated four to nine million casesof birth asphyxia each year, resultingin almost 1.2 million neonataldeaths,63 many of which could beprevented with prompt resuscitation.

There is evidence to suggest thatthe wider use of resuscitation tech-niques for asphyxiated babies, suchas low-tech mouth-to-mouth resus-citation, is possible in developingcountry settings, even during homebirths. A study from Sweden foundthat almost 80 percent of newbornswho needed to be resuscitated couldbe treated with no more than bag-and-mask intervention,64 as opposedto requiring more complex interven-tions, such as intubation, chestcompression, or drugs. Similarly,related research has also demon-strated that in most cases, new-borns can be revived just aseffectively with air as with oxygen,65

a welcome finding for under-resourced district hospitals, healthcenters, and private homes wheresupplemental oxygen is not avail-able. WHO has recently introduced asimple tube-and-mask method foruse in primary care centers and inthe home, but further studies areneeded on its cost-effectiveness andutility during and adaptation for pro-longed resuscitation efforts.

Pay special attention to preterm and low birth weight babies There are a number of ways to helpprevent death from preterm births(those occurring before 37 weeks ofgestation). One is to detect and treaturinary and reproductive tract infec-tions, which can lead to giving birthbefore term.

Another is to ensure that the birthtakes place in a hospital that isequipped to deal with preterm births.Preterm babies have a better chanceof surviving in such hospitals

the mother. Applying antibiotic oint-ment to the baby’s eyes within anhour of birth can prevent this.

SPECIAL ATTENTION

Recognize danger signs and avoid delay in seeking care and referral It is crucial to identify maternal andnewborn complications early andtransport the mother and/or baby toan appropriate facility. There arefour types of delay widely recognizedas contributing to maternal andperinatal mortality:62

" delay in recognizing danger signs;" delay in deciding to seek care;" delay in getting care due to lackof transport or money; and" delay in receiving quality, appro-priate care after arriving at a healthfacility.

ACCESS TO HEALTH CARE FACILITIES

“I’d been in labor for six hourswhen the TBA said I should go tohospital because the baby wasbreech. Luckily a relative had avehicle and as I arrived at the hospital the baby started to be born. Without this vehicle, who knows what would have happened.” MALAWI

CLEAN DELIVERY KITS

Seventeen-year-old Bimala wasassisted in the birth of her son byher sister-in-law who is a trainedbirth attendant. “We used theclean delivery kit, which includeda thread, a knife and a plasticsheet. Usually the baby isn’twrapped up until the placentacomes out, but my sister-in-lawtold me to wrap him up straightaway because it’s so cold up herein the hills.” NEPAL

immunological protection for thebaby; promotes bonding; andreduces postpartum hemorrhage.One of the most important servicesthat can be provided to the mother ispreparation for and support duringbreastfeeding. WHO recommendsthat newborn babies should be put tothe breast within one hour after birthand should not go without breast-feeding for longer than three hours.In May 2001, the World HealthAssembly adopted a resolution whichset the optimal duration of exclusivebreastfeeding at six months.61

Give prophylactic eye care if appropriate Some newborns run the risk ofbecoming blind from gonorrhea orchlamydia infections acquired from

BREASTFEEDING BEHAVIORS CAN BE CHANGED

LINKAGES, a USAID-funded project, works with Ministries of Health,PVOs, NGOs and other partners to promote breastfeeding by encourag-ing individuals to carry out small “doable actions,” by enlisting the sup-port of families and communities, and by building a critical mass ofbreastfeeding advocates at the national and regional levels to lay thegroundwork for community programs.

Before LINKAGES, baseline data painted a bleak picture. In Mada-gascar, for example, one in two infants were given water, fluids, or oth-er foods before the age of six months instead of only breastmilk. InGhana, only 25 percent of women initiated breastfeeding within the firsthour after birth, and only 31 percent exclusively breastfed their babies.In the Indian states of Bihar and Uttar Pradesh, most mothers delayedthe start of breastfeeding for more than 24 hours, and many mothersintroduced liquids too early and soft foods too late—feeding practiceswhich lead to increases in infant morbidity and mortality.

With the right intervention, breastfeeding behaviors can changequickly and dramatically. Within six to nine months, the LINKAGES pro-gram doubled early initiation of breastfeeding in Madagascar (from 34percent to 73 percent) and Ghana (from 25 percent to 50 percent). Theprogram also increased the rates in Bolivia from 39 percent to 64 per-cent and in India from less than 1 percent to 22 percent (in the WorldVision/LINKAGES project sites). Equally dramatic were the increases inexclusive breastfeeding, which went from 46 percent to 68 percent inMadagascar, from 31percent to 68 percent in Ghana, and from 12 per-cent to 28 percent in CARE/LINKAGES project sites in India.67

" Ensure early postnatal contact

" Promote continued exclusive breastfeeding

" Maintain hygiene to prevent infection: ensure clean cord care and

counsel mother on general hygiene practices, such as hand-washing

" Provide immunizations such as BCG, OPV, and hepatitis B vaccines,

as appropriate

Special Attention

" Recognize danger signs in both mother and newborn, particularly

of infections, and avoid delay in seeking care and referral

" Support HIV positive mothers to make appropriate,

sustainable choices about feeding

" Continue to pay special attention to warmth, feeding,

and hygienic practices for LBW babies


TABLE 3 SELECTED NEWBORN AND MATERNAL HEALTH SERVICE AND PRACTICE INDICATORS BY REGION, 1995-2000


love, and prompt treatment of illness.

Ensure early postnatal contactSince so many deaths occur withinthe first hours or days after birth,early postnatal contact is key to new-born health and survival. Thisincludes counseling on newborn carepractices and recognizing, managing,and referring problems that needspecial attention. Appropriate follow-up must also be ensured.

Promote continued exclusive breastfeedingA recent review has demonstratedthe substantial benefits of exclusivebreastfeeding over substitute feed-ing or partial breastfeeding, show-ing, among other things, that earlyand exclusive breastfeeding reducesneonatal mortality from infections.69,70

But exclusive breastfeeding is stillthe exception rather than the rule inmany countries. Over 80 percent ofall newborn infants in South Asia, forexample, are not put to the breast at

Region

Antenatal care (at least one visit)

(%) 1995-99

Tetanus toxoid coverage in pregnant

women (%) 1997-99

Exclusive breastfeeding aged 0- 4 months

(%) 1995-2000Skilled attendance

at delivery (%) 1995-2000

Definitions of the indicators and sources of data are listed in the Explanatory Notes of Table II in the Appendix. A dash (“-”) indicates that an average could not be calculated for that region as more than 25% of countries hadmissing data.

SUB-SAHARAN AFRICA 65 42 37 34

MIDDLE EAST/NORTH AFRICA 65 55 69 42

SOUTH ASIA 51 69 29 46

EAST ASIA/PACIFIC 81 34 66 57

LATIN AMERICA/CARIBBEAN 84 51 83 37

CEE/CIS AND BALTIC STATES - - 94 _

INDUSTRIALIZED COUNTRIES 99 - 99 _

WORLD 69 51 56 44

all in the first 24 hours, and colostrum(the “first milk” from the mother withpotent immune defense properties) iswidely discarded.71 Rates for earlybreastfeeding are much lower insome countries, 10 percent or less,and rates for exclusive breastfeedingfor the first three months are lowerstill (see Appendix, Table II for coun-try-specific data).

Evidence clearly shows that the rates of early and continuedexclusive breastfeeding can both be increased. In one study of home-based support for mothers in Mexico, exclusive breastfeedingincreased among mothers whoreceived counseling in the hospitaland during follow-up home visits.72

In a similar study of peer counselorsin Bangladesh, early and extendedbreastfeeding increased after expec-tant and new mothers receivedcounseling in the home.73 Recent evi-dence from the LINKAGES Project inGhana, Madagascar, and India hasalso shown that well-designed com-

munity-based behavior changeinterventions can produce dramaticincreases in immediate and exclu-sive breastfeeding.74 The UNICEFBaby-Friendly Hospital Initiative hasalso succeeded in increasing ratesof breastfeeding in hospitals.

Maintain hygiene to prevent infection Neonatal infections account forabout one-third of neonatal deathsin developing countries. Early andexclusive breastfeeding, cleanhands, and proper cord care are thebasic principles for preventinginfections, but they are still notpracticed on a large scale.

Provide ImmunizationsWHO recommends birth doses ofBCG and oral polio vaccines (OPV).Hepatitis B vaccine should also begiven where perinatal transmissionof hepatitis B is frequent, as inSouth Asia.75

SPECIAL ATTENTION

Recognize danger signs and avoiddelay in seeking care and referral Caregivers are in a position toobserve danger signs in the new-born. Many of these danger signsare difficult to recognize, however,so caregivers need to be alert to avariety of abnormal infant behaviorsand physical signs, such as changesin levels of activity or alertness,breathing and feeding difficulties,floppy limbs, convulsions, abnormaltemperature, jaundice, pale skin,bleeding, vomiting, or a swollenabdomen.

Support HIV positive mothers to make appropriate, sustainable choices about feeding In recent years, the advice of exclu-sive breastfeeding has come upagainst the reality of the risk of HIVtransmission through breast milk.While the risk is real, so is the risk

associated with the alternative,mixed feeding. A study in develop-ing countries with 25 percentprevalence of HIV estimates therisk of transmission of HIV throughbreastfeeding at less than four percent.76 A study in Durban, SouthAfrica, meanwhile, suggests thatexclusive breastfeeding has areduced risk of transmission com-pared with mixed feeding, i.e.,breastfeeding supplemented withbreast milk substitutes.77

The best approach in these areasis to provide voluntary counselingand testing (VCT) where possible.Only when replacement feeding issafe, acceptable, feasible, affordable,and sustainable should alternativesto breastfeeding by HIV-infectedmothers be recommended. Other-wise, exclusive breastfeeding shouldbe considered during the first sixmonths of life.

LBW babiesLBW and preterm babies continue to

EFFORTS TO PREVENT MOTHER-TO-CHILD

TRANSMISSION OF HIV IN MALAWI

On average 16 percent of pregnantwomen in Malawi who have beentested in the antenatal period areinfected with HIV. Consequently,there is an urgent need to counselwomen in relation to reproductivehealth and feeding practices. CHAPS(Community Health Partnerships)has designed a voluntary counselingand testing (VCT) program that will be available through the Baby-Friendly Hospital Initiative (BFHI).The government of Malawi has giventhe go-ahead to the drug Nevirapinewhich prevents replication of thevirus causing infection in the moth-er’s blood and breastmilk. At a costof US$4 per woman and requiringjust two doses (one for the motherwhen she goes into labor and one forthe baby 72 hours after birth), it hasbeen shown to reduce the transmis-sion rate by half. However, the cost-effective use of Nevirapine still depends on an effective VCTprogram, since only mothers knownto be HIV positive will be given thedrug. Unfortunately, most poorAfrican women are out of reach of facilities that can provide testingand treatment. MALAWI

require special attention during thepostnatal period as described on p. 33.

MONITORING PROGRESS IN NEWBORN HEALTHA number of health status andprocess indicators have been pro-posed for monitoring progress inimproving newborn health and sur-vival. Commonly used indicatorsinclude neonatal mortality rate, ante-natal care coverage, the percentageof all births attended by skilledhealth workers, tetanus toxoid vacci-nation coverage, and the proportionof mothers who exclusively breast-feed their babies (see Table 3; forcountry-specific data, see Appendix,Table II). However, information onpostnatal care is rarely collected.Measuring the proportion of mothersand newborns who have early post-natal contact will go a long way tohelp ensure that healthy practicesare promoted and complications rec-ognized and addressed.

The plight of the world’s newborns is

real; the case for addressing it is

strong; and the solutions are within our

grasp. All that is needed is to mobilize

the will and the resources to put the

necessary interventions into practice.

THE WAY FORWARD:

SAVING NEWBORN

LIVES

Begin care for newborns with care formothers. A newborn’s chance of sur-vival and well-being begins wellbefore birth, with the health andnutritional status of the mother andpreparation for a safe delivery. Acontinuum of care, beginning beforebirth, should include antenatal careand safe delivery, followed by healthvisits for both mother and baby toensure good newborn care practices,and the identification and appropri-ate management of complications. A healthy start requires nutritionalsupport to pregnant women, treat-ment of infections such as malariaand syphilis, birth preparedness,skilled care at delivery, recognitionof danger signs, and prompt treat-ment of obstetric complications.

Programs also need to addressthe cultural, social, and economicbarriers that may inhibit women’saccess to information and services,emphasizing community and home-based approaches and the involve-ment of husbands and other familydecision-makers. Improving educa-tion and employment opportunitieswill have the greatest long-termimpact on the status of women.

Integrate newborn care into existingsafe motherhood, child survival, andother programs. Newborn care effortsdo not have to be started fromscratch. Rather than being initiatedindependently, interventions toimprove newborn health (before,during, and after birth) should befolded into already established pro-grams, and can be linked particular-ly effectively with safe motherhoodand child survival. Those interven-tions with demonstrated effective-ness include tetanus toxoidimmunization, skilled care at deliv-ery, breastfeeding support, hygienicpractices, and thermal control.

Most countries also have a varietyof other programs that could easilyaccommodate an added emphasis

on health care for newborns. Pro-grams that encourage improvedmaternal nutrition, screen for sexu-ally transmitted infections (STIs),expand immunization coverage, pro-vide family planning services, or pro-mote improved reproductive healthare all candidates for the integrationof a newborn health component.

For the most part, this integra-tion does not have to be complicat-ed. An early postnatal visit can beadded to safe motherhood programsto benefit both the new mother andher baby; child health programs canbegin to address the newborn aswell as the older child; STI andmalaria control programs can do abetter job of reaching expectantmothers; and family planning serv-ices offer a natural platform forencouraging adolescent women todelay childbearing and new mothersto space their pregnancies at leasttwo years apart.

Develop and replicate promising pro-gram innovations. In addition tostrengthening and expanding thenewborn component of existing pro-grams, promising new programs toimprove newborn health and sur-vival need to be further refined,tested, and replicated. The programinnovation may be a new cadre ofhealth worker, an approach (such asthe positive deviance method usedby SC in Vietnam), a new technology,or a new model of collaboration.Meanwhile, existing projects in new-born health should be closely evalu-ated and replicated whereappropriate. Innovative and cost-effective projects—such as theSEARCH project in India, the Warmiproject in Bolivia, or the Bidan diDesa (Village Midwife) project inIndonesia—have shown such prom-ising initial results that they shouldbe tested, adapted, and evaluatedfurther. Indeed, Save the Children’sSaving Newborn Lives initiative is

THE WAY FORWARD:SAVING NEWBORN LIVESThe plight of the world’s newborns isreal; the case for addressing it isstrong; and the solutions are withinour grasp. In recent years, childhooddeaths have been reduced throughmajor public health interventions;now it’s time to focus on expectantmothers and their newborns. Ahealthy start in life leads to healthierand more productive children andadults. It is key to meeting the globaldevelopment goal, agreed upon bythe international development com-munity, to reduce by two-thirds thedeath rates of infants and childrenunder the age of five years in devel-oping countries. Because neonataldeath rates have been stagnant andnewborn deaths now account fortwo-thirds of infant deaths, substan-

tial progress towards this goal willclearly depend on improving new-born health.

Change is possible. In closing, weoffer several recommendations tohelp guide international and nation-al strategies for improving newbornsurvival and well-being.

Increase commitment to newbornhealth. Improving newborn health isequally a matter of practice and poli-cy, and in most cases the latter mustbe in place to drive the former. Ifnewborn care programs are toreceive the support they need—thekind of support currently availablefor reproductive health, child health,and communicable disease preven-tion, for example—they will need toreceive more commitment andresources and to figure more promi-

nently in national health plans andhealth reform programs. To create afavorable policy environment con-ducive to and supportive of newbornhealth, advocacy will be needed atprofessional, local, national, andinternational levels.

To translate policy into practice,a commitment must be made toprovide adequate financialresources as well as to increase thequantity and quality of staff with rel-evant skills. In addition to the needfor incremental national budgetallocations, the international donorand NGO community should beencouraged to support efforts totake to scale both established andinnovative interventions proven to becost-effective on a small scale.


TRAINING AND PLACING VILLAGE MIDWIVES

In 1993, Indonesia embarked on an ambitious village midwifeprogram, Bidan di Desa (BDD), that trained and placed morethan 54,000 midwives with the aim of making family planningand maternity care accessible to all women. These village mid-wives complete a four-year training program, which includesthree years of nursing school plus one year of a midwifery pro-gram. They are expected to have midwifery skills for managingnormal pregnancies and deliveries; identifying, stabilizing andreferring complications; and providing basic care of newborns.Given that so many women remain at home for labor and deliv-ery, the village midwives are encouraged to visit them in thehome throughout the pregnancy and postpartum time and toattend home deliveries.

Village midwives are hired on three-year renewable con-tracts in almost every village in the country. They are frequent-ly the only source of maternal, child, and basic health care.Between 1994 and 1997, the proportion of births attended by avillage midwife increased from 34 percent to 40 percent nation-ally and to almost 65 percent in parts of Java and Bali. More-over, 80 percent of women now consider village midwives to bean appropriate source of family planning information. Thisdemonstrates a rising level of acceptance of the village midwifeas a provider of reproductive health services.78,79 INDONESIA

SAVE THE CHILDREN’S WARMI PROJECT

The objective of the Warmi Projectis to improve maternal and new-born health in rural areas ofBolivia with limited access to mod-ern medical facilities. During thedemonstration phase (1990–1993),the program focused on initiatingand strengthening women’s organi-zations, developing women’s skillsin identifying problems, and train-ing community members in safebirthing techniques. As a result ofthe intervention, perinatal mortali-ty decreased from 117 deaths per1,000 births before the interventionto 44 deaths per 1,000 births after.There was a significant increase inthe number of women participatingin women’s organizations followingthe intervention, as well as in thenumber of functioning women’sorganizations. The proportion ofwomen receiving prenatal care andinitiating breastfeeding on the firstday after birth also increased sig-nificantly. The study demonstratedthat community organization canimprove maternal and child healthin remote areas.80 BOLIVIA

point contributing factors to new-born deaths.

It is time to move from efficacytrials of single interventions toeffectiveness trials with communi-ties. Furthermore, interventionsmust be evaluated quickly so sus-tainable packages of care can bescaled up without delay, even in themost remote and impoverishedareas. Finally, communicationsamong researchers, program man-agers, and policymakers must beestablished at the outset of eachresearch project to make sure studyresults are translated into effectiveprograms.

Keep the focus on the home and thecommunity. At the present time andfor the foreseeable future in devel-oping countries, the vast majority ofbirths—and therefore of newborndeaths—will take place in the home.Accordingly, effective newborn careefforts must focus on this crucialsetting and what transpires there.

Thus, programs must target birthattendants and other communityhealth workers, whether it is to pro-vide training, strengthen supervisionand referral linkages, or provide sup-plies such as clean home deliverykits. Enhancing the capacity of thesecaregivers will help to ensure propercounseling of women and their fami-lies, a clean, well-managed delivery(or timely referral where necessary),and effective postnatal care for moth-er and child—the cornerstones of asuccessful newborn health program.

Programs must also target fami-lies with maternal and newbornhealth messages through non-health channels, such as communi-ty organizations and the media. Theultimate goal, of course, is chang-ing behavior, of mothers and allfamily members, from practiceswhich put mothers and newborns atrisk to those which enhance theirhealth and well-being.

THE CHALLENGE AHEADThe familiar call to “think globallyand act locally” is as relevant tosaving newborn lives as it is to otherdevelopment efforts. The challengeis to transfer knowledge and fundsfrom “high places” of learning andpolicy-making to the home andcommunity. Donors and internation-al agencies need to coordinate theiractivities and form partnerships toprovide leadership at all levels andhelp lay the foundation of efforts tosave newborns.

We have a great deal of knowl-edge about effective neonatal careand low-cost approaches such astetanus toxoid immunization, skilledcare at delivery, breastfeeding, andthermal control that can save manynewborn lives. One challenge,therefore, is simply improving whatwe already do and applying what wealready know. Another challenge isto identify cost-effective interven-tions to address newborn problemscurrently lacking ready solutions,such as managing asphyxia at thecommunity level.

Saving newborn lives requires aparadigm shift. We need to changeour focus to the time when mostinfants die—the first 28 days of life.We need to shift the focus of ourresearch from hospitals to the com-munity, where most babies die. Weneed to concentrate our efforts onthose who are best placed to makethe greatest contribution: familycaregivers and those working at thecommunity level. And we need tomove quickly to ensure that proven,effective interventions are imple-mented on the widest possible scale.

Communities in developing countries will discover that ensuringa healthy beginning for every new-born will make a significant returnon the investment, as each child hasan opportunity to survive and thrivefrom the moment of birth.

already engaged in expanding theSEARCH project to seven differentsites in India.

Monitor and evaluate what we do. Policymakers and program plannersneed good data in order to betterunderstand how to use existingresources, monitor program per-formance, and make necessarychanges in health care programs. Itis critical to develop, validate, anduse better process and outcome

indicators to carefully monitor anddocument progress in newbornhealth and services. To this end, pro-gram managers and researcherswill need to shift their focus fromhospitals to the community, wheremost babies die.

Enhance our knowledge base.While information on the status ofthe newborn is increasingly avail-able, less is known about how toprevent the causes of newborn

death. Three types of research wouldbe particularly helpful in addressingthis need:

" Formative research to betterunderstand current local beliefs andpractices, and the reasons for these,so that effective behavior changestrategies can be developed;" Operations research to betterunderstand how to deliver afford-able, life-saving preventive and cura-tive care; and" Epidemiological research to pin-

QUALITATIVE RESEARCH CAN

PROVIDE VALUABLE INSIGHTS

MIRA (Mother and Infant ResearchActivities), a community-basedproject in the Makwanpur districtof Nepal, spent nearly one yearcollecting ethnographic informa-tion during the first phase of theprogram. The facilitation teamexplored the issues around child-birth in the communities in whichthey were to initiate the interven-tion. This exploration served as aprolonged induction and trainingperiod for the facilitators, and gen-erated a body of ethnographicinformation on pregnancy andchildbirth. This included an under-standing of how decisions aremade within households, the roleof mothers-in-law, pollution ritu-als, and spiritual beliefs aboutpregnancy-related problems. Thegroup also discovered that mostbabies were being given cold bathswithin three hours of birth, expos-ing them to the risk of hypother-mia. This understanding provides astarting point for the facilitators todiscuss alternatives with commu-nity groups.82 NEPAL


A MODEL OF NEONATAL CARE IN THE GADCHIROLI DISTRICT IN INDIA

In the Gadchiroli district of India, about 1,000 kilome-ters from the state capital, Mumbai, a remarkablemodel of home-based neonatal care has managed tosignificantly reduce neonatal and infant mortalityamong malnourished, illiterate, rural villagers in theSEARCH project area.

Recognizing that hospital-based care for sick new-borns was not possible in their community, Drs Raniand Abhay Bang and colleagues at SEARCH (Society forEducation, Action & Research in Community Health)conceived the innovative idea of a home-based new-born health care program. It had to be home-based,they concluded, because 83 percent of births in ruralIndia occur at home; more than 90 percent of parentsare unwilling to go to hospital for treatment of a sicknewborn; local doctors are not trained to manage sickneonates; and hospital care is inaccessible and costly.

The SEARCH study collected baseline data for two years(1993–1995) from 39 intervention villages and 47 controlvillages. SEARCH then introduced neonatal care in theintervention villages (1995–1998) and monitored mortalityrates in both the control and intervention villages.

The key promoters of neonatal health in this programare village health workers (VHWs) and TBAs. The VHWsvisit each woman three times during her pregnancy, pro-vide health education, and look after the neonate duringthe first month of life. They are trained to resuscitateasphyxiated babies, support breastfeeding and mainte-nance of body temperature, and to recognize and treatsepsis. They also provide hand-made portable incubators(a cloth bag insulated with foam) for LBW babies.

TBAs receive training and are supplied with cleandelivery kits as well as iron, folic acid and calciumtablets, ointment for neonatal conjunctivitis, antisepticointment for cracked nipples, cotrimoxazole syrup forpneumonia, paracetamol tablets, vitamin A capsules fornight blindness, and glycerin for mouth infections. Theyalso provide condoms.

By the third year, 93 percent of newborns in the inter-vention areas were receiving home-based care. SEARCHwas able to record 98 percent of births and child deaths inthe area. While the NMR in the control area remained ataround 50 to 65 per 1,000 over the course of the study, inthe action area it dropped to 25 per 1,000 by the third yearof intervention, a 62 percent reduction compared to thebaseline period. The infant mortality rate was also nearlycut in half. About 75 percent of the reduction in NMR wasattributed to fewer deaths with signs of infection. Thispackage of care also significantly reduced the incidence ofvarious neonatal morbidities as well as maternal morbidi-ties, thus establishing the feasibility of combining post-partum care of the mother with neonatal care.

The package costs an estimated US$5.30 per new-born, and one death was avoided for every 18 babieswho received care. The cost per life saved was an esti-mated US$95.40, which is less than the cost per lifesaved with measles vaccination. Abhay and Rani Banghope that SEARCH will provide a creative initiative forsimilar organizations throughout the developing world.

Save the Children, through the Saving NewbornLives initiative, is testing the impact of this approach inother settings, and is evaluating the sustainability ofthis strategy in a larger setting through the expansionof SEARCH’s program to seven additional sites through-out Maharashtra state.81 INDIA

ENDNOTES

1 World Health Organization2001 estimates. Based on datacollected around 1999.

2 World Health Organization.Perinatal mortality: a listing of available information. FRH/MSM.96.7. Geneva: WHO, 1996.


4 Kramer, MS. Intrauterinegrowth and gestational durationdeterminants. Pediatrics 1987;80(4):502–11.

5 United Nations PopulationFund. The State of the World’sPopulation 2000:Lives Togeth-er, Worlds Apart. New York:UNFPA, 2001.

6 World Health Organization pres-entation. Neonatal survivalintervention research work-shop. Kathmandu, Nepal: WHO,April 29-May 3, 2001.

7 World Health Organization.Success stories in developingcountries. Geneva: WHO, 2001.Available at: http://who.int/inf-new/mate3.thm

8 World Health Organization.Mother-baby package: imple-menting safe motherhood incountries. FHE/MSM/94.11.Geneva: WHO, 1994.

9 Bang AT, Bang RA, BaituleSB, Reddy MH, Deshmukh MD.Effect of home-based neonatalcare and management of sep-sis on neonatal mortality: fieldtrial in rural India. Lancet1999;354:1955–61.

10 Madame Adame Ba Konare.Speech at the regional forum onmaternal and neonatal mortalityreduction. Vision 2010. Bamako,Mali: UNICEF, May 2001.



13 Hyder AA, Morrow RH, WaliS, McGuckin J. Burden of dis-ease for neonatal mortality inSouth Asia and Sub-SaharanAfrica. Preliminary report sub-mitted to Save the Children,USA. Baltimore, MD: JohnsHopkins University, 2001.


15 Barker DJ, Martyn CN,Osmond C, Hales CN, Fall CH.Growth in utero and serumcholesterol concentrations inadult life. BMJ 1993;307:1524–1527.

16 Hales CN, Barker DJ, ClarkPM et al. Foetal and Infantgrowth and impaired glucosetolerance at age 64. BMJ 1991;303:1018–1022.

17 Barker D. Intrauterine pro-gramming of coronary heartdisease and stroke. Acta Paedi-atr Suppl 1997; 423:178–182.

18 Leon DA. Foetal growth andadult disease. Eur J Clin Nutr1998; 52 (Suppl.1):S72-S82.

19 Grantham McGregor SM, LiraPI, Ashworth A, Morris SS,Assuncao AM. The developmentof low birth weight term infantsand the effects of the environ-ment in northeast Brazil. J Pedi-atr 1998; 132:661–6.

20 Lawn J, McCarthy BJ, RossS. The Healthy Newborn: a ref-erence manual for programmanagers. Atlanta, GA: CDC,CARE, CCHI, 2001. More infor-mation from www.cdc.gov/nccdphp/drh.

21 Lawn J, McCarthy BJ, RossS. The Healthy Newborn: a ref-erence manual for programmanagers. Atlanta, GA: CDC,CARE, CCHI, 2001. More infor-mation from www.cdc.gov/nccdphp/drh.

22 Zhu BP, Rolfes RT, NangleBE, Horan JM. Effect of theinterval between pregnancieson perinatal outcomes. N Engl JMed 1999; 340:589–94.

23 Caldwell JC, Reddy PH,Caldwell P. The causes ofdemographic change—experi-mental research in South India.1989: ISBN 0299116107.

24 de Graft Johnson J. Save theChildren, Malawi. Personalcommunication. June 2001.

25 Ministry of Health, India andTrends in childhood mortality inthe developing world 1960–1996.New York: UNICEF, 1999: ISBN92–806–3441–0.

26 Safe Motherhood Inter-Agency Group. Skilled Care Dur-ing Childbirth: A Review of theEvidence. New York: FamilyCare International (in press).For more information, see RHat a Glance fact sheet atwww.worldbank.org/hnp

27 Sejas, C. Save the Children,Bolivia. Personal communica-tion. June 2001.

28 Stoll, B. The global impact ofneonatal infection. Clin Perina-tol 1997; 24 (1): 1–21.

29 UNICEF/WHO/UNFPA.Maternal and neonatal tetanuselimination by 2005. New York:UNICEF, 2000.

30 Victora CG, Smith PG,Vaughan JP, Nobre LC, Lombardi C, Teixeira AM, FuchsSC, Moreira LB, Gigante LP,Barros R. Evidence for protection by breastfeedingagainst infant deaths frominfectious diseases in Brazil.Lancet 1987; Aug, 8:319–321.

31. World Health Organization.World Health Report, 1998: Lifein the 21st century—a vision forall. Geneva: WHO, 1998.

32. Kramer, MS. Intrauterinegrowth and gestational durationdeterminants. Pediatrics 1987;80(4):502–11.

33. Yasmin S, Osrin D, Paul E,Costello AM de L. Neonatalmortality of low birth weightinfants in Bangladesh. BullWHO (in press).

34. Kramer, MS. Intrauterinegrowth and gestational durationdeterminants. Pediatrics 1987;80(4):502–11.

35. Nielsen B, Liljestrand J,Hedegaard M, Thilsted S,Joseph A. Reproductive pattern,perinatal mortality, and sexpreference in rural Tamil Nadu,South India: community based,cross sectional study. BMJ1997; 314(7093):1521–4.

36. United Nations PopulationFund. The State of the World’sPopulation 2000:Lives Together,Worlds Apart. New York: UNF-PA, 2001.

37. Save the Children. The Stateof the World’s Mothers 2001.Available from http://www.savethechildren.org/mothers/learn/sowm2001/.htm

38. Murray C, Lopez A. Genderand nutrition in the global bur-den of disease, 1990–2020. In:Nutrition US-Co (ed.) Chal-lenges for the 21st century: agender perspective on nutritionthrough the life cycle. Geneva:ACC/SCN, 1998: 67–77.

39 Panter-Brick C. Women’swork and maternal-child

health: anthropological viewson intervention. In: Costello AMde L, Manandhar DS, editors.Improving newborn infanthealth in developing countries.London: Imperial College Press2000 distributed by World Sci-entific Publishing Co. P.O. Box128, Farrer Road, Singapore,912805.

40 Ceesay SM, Prentice AM,Cole TJ, Foord F, Weaver LT,Poskitt EM, Whitehead RG.Effects on birthweight and peri-natal mortality of maternaldietary supplements in ruralGambia; five year randomisedcontrolled trial. BMJ 1997;315(7111):786–90.

41 Atukorala TM, de Silva LD,Dechering WH, DassenaeikeTS, Perera RS. Evaluation ofeffectiveness of iron-folate sup-plementation and antihelminth-ic therapy against anemia inpregnancy–a study in the plan-tation sector of Sri Lanka. Am JClin Nutr 1994; 60(2):286–92.

42 De Lon GR, Leslie PW, WangSH, Jiang XM, Zhang ML, Rake-man M, Jiang JY, Ma T, Cao XY.Effect on infant mortality of iod-ination of irrigation water inseverely iodine deficient area inChina, Lancet 1997 Sep 13; 350(9080):771–3.

43 Merialdi M, Caulfield LE,Zavaleta N, Figueroa A, DiPietroJA. Adding zinc to prenatal ironand folate tablets improvesfoetal neurobehavioural devel-opment. Am J Obstet Gynecol1999 Feb; 180(2 Pt 1):483–90.

44 Osendarp SJM, van RaaijJMA, Darmstadt GL, Baqui AH,Hautvast GAJ, Fuchs GJ. Zincsupplementation during preg-nancy and effects on growthand morbidity in low birth-weight infants. Lancet 2001;357:1080–85.

45 West KP Jr, Katz J, KhatrySK, LeClerq SC, Pradhan EK,Shrestha SR, Connor PB, DaliSM, Christian P, Pokhrel RP,Sommer A, the NNIPS-2 StudyGroup. Double-blind, clusterrandomized trial of low dosesupplementation with vitamin Aor ß-carotene on mortalityrelated to pregnancy in Nepal.BMJ 1999; 318:570–575.

46 Christian P, West KP Jr,Katry SK, LeClerq SC, Kim-brough-Pradhan, Katz J,Shrestha SR. Maternal nightblindness increases risk ofmortality in the first 6 monthsof life among infants in Nepal. J

Nutr 2001; 131;1510–1521.

47 Humphrey JH, Agoestina T,Wue L, et al. Impact of neonatalvitamin A supplementation oninfant morbidity and mortality. JPediatr 1999; 128:489–496.

48 Tielsch JM, Rahmathullah L,Thulasiraj RD, Katz J, Coles C.Impact of vitamin A supplemen-tation to newborns on earlyinfant mortality: a community-based, randomized trial in SouthIndia. Proc XX IVACG Meeting,Hanoi, Vietnam, 2001; p 70.

49 http://www.who.int/vaccines-diseases/services/immschedule.htm

50 Bellamy C. State of theWorld’s Children. UNICEF 1999.

51 Steketee, RW Wirima JJ,Slutsker WL, Khoromana CO,Reman JG, Heymann DL. Objec-tives and methodology in astudy of malaria treatment andprevention in pregnancy in ruralMalawi: the Mangochi MalariaResearch Project. Am J TropMed Hyg 1996;55(Suppl 1):8–16.

52 Shulman CE. Malaria inpregnancy: its relevance tosafe-motherhood programmes.Ann Trop Med Parasitol 1999;93(Suppl 1):S59-S66.

53 Coovadia HM and Rollins N.Current controversies in theprenatal transmission of HIV indeveloping countries. Seminarsin Neonatology 1999; 4:192–200.

54 Vuthipongse P, BhadrakomC and Chaisilwattana P. Admin-istration of zidovudine duringlate pregnancy and delivery to prevent perinatal HIV transmis-sion–Thailand. Morbidity andMortality Weekly Report 1998;47:151–154.

55 World Health Organization.Making pregnancy safer.RHR00.6. Geneva: WHO, 2000.

56 MotherCare Policy brief #3.Washington DC: MotherCare,May 2000.

57 World Health Organization.Coverage of maternity care. Alisting of available information.WHO/RHT/MSM/96.28. Geneva:WHO, 1996.

58 United Nations PopulationFund. State of World Population2000: Lives together, Worldsapart. New York: UNFPA, 2000.

59 Hofmeyer GJ, Nikodem VC,Wolman WL, Chalmers BE,

Kramer TR. Companionship tomodify the clinical birth envi-ronment: effect on progressand perceptions of labour andbreastfeeding. Br J Obs Gynae1991; 98:756–764.

60 World Health Organization.Thermal protection of the new-born: a practical guide.WHO/RHT/MSM/97.2. Geneva:WHO, 1997.

61 World Health Assembly.Resolution on infant and youngchild nutrition. Geneva: WHO,May 2001. Available fromhttp://www.who.int/inf-pr-2001en/pr2001wha-6.html

62 Thaddeus S, Maine D. Toofar to walk: maternal mortalityin context. New York: ColumbiaUniversity, 1990.

63 World Health Organization.World Health Report, 1998: Lifein the 21st century—a vision forall. Geneva: WHO, 1998.

64 Palme-Kilander. Methods ofresuscitation in low-Apgarscore newborn infants—anational survey. Acta Paediatr1992; 81:739–44.

65 Saugstad OS, Rootwell T,

Aalen O. Resuscitation ofasphyxiated newborn infantswith room air or oxygen; aninternational controlled trial;the Resair 2 Study. Pediatrics1998; 102:1.

66 Bergman JJ, Jurisoo LA. The“kangaroo” method for treatinglow birth weight babies in adeveloping country. Trop Doc1994; 24(2):57–60.

67 Academy for EducationalDevelopment LINKAGES Pro-ject. LINKAGES results. Pre-sentation at USAID stakeholdermeeting. Washington DC: AED,December 14, 2000.

68 Budin P. The Nursling. English translation by MaloneyWJ. London: The Caxton Publishing Co, 1907.

69 World Health OrganizationEffect of breastfeeding oninfant and child mortality dueto infectious diseases in lessdeveloped countries: a pooledanalysis. Lancet 2000;355451–455.

70 Victora CG, Smith PG,Vaughan JP, Nobre LC, Lom-bardi C, Teixeira AM, Fuchs SC,Moreira LB, Gigante LP, Barros

R. Evidence for protection bybreastfeeding against infantdeaths from infectious diseasesin Brazil. Lancet 1987;2(8554):319–321.

71 World Health Organizationpresentation. Neonatal survivalintervention research work-shop. Kathmandu, Nepal: WHO,April 29-May 3, 2001.

72 Morrow AL, Lourdes Guer-rero M, Shults J, Calva JJ, Lut-ter C, Bravo J, Ruiz-Palacios G,Morrow RC, Butterfoss FD. Effi-cacy of home-based peer coun-selling to promote exclusivebreastfeeding. Lancet 1999;353:1226–1231.

73 Haider R, Ashworth A, KabirK, Huttly SRA. Effect of com-munity-based peer counsellorson exclusive breastfeedingpractices in Dhakar,Bangladesh: a randomised con-trolled trial. Lancet 2000;356(9242).

74 Academy for EducationalDevelopment LINKAGES Pro-ject. LINKAGES results. Pre-sentation at USAID stakeholdermeeting. Washington DC: AED,December 14, 2000.

75 http://www.who.int/vaccines-diseases/services/immschedule.htm

76 Academy for EducationalDevelopment LINKAGES Pro-ject. Breastfeeding andHIV/AIDS. FAQ sheet 1. Washing-ton DC: AED, May 2001. http://www.linkagesproject.org

77 Coutsoudis A, Pillay P,Spooner E, Kuhn L, CoovadiaHM. Influence of infant feedingpatterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: aprospective cohort study.Lancet 1999; 354:471–76.

78 Daly, P and Fadia S. Repro-ductive Health in Indonesia:Lessons from the Past andOpportunities for the Future,Washington DC: World Bank,2000. Unpublished paper.

79 Indonesia Central Bureau ofStatistics, State Ministry ofPopulation/National FamilyPlanning Coordinating Board,Ministry of Health and MacroInternational. Indonesia Demo-graphic Health Survey. Calver-ton, MD: Central Bureau ofStatistics and Macro Interna-tional, 1997.

80 O’Rourke K, Howard-Grab-man L, Seoane G. Impact ofcommunity organization ofwomen on perinatal outcomesin rural Bolivia. Rev PanamSalud Publica/Pan Am/PublicHealth 1998; 3(1).

81 Bang AT, Bang RA, BaituleSB, Reddy MH, Deshmukh MD.Effect of home-based neonatalcare and management of sep-sis on neonatal mortality: fieldtrial in rural India. Lancet 1999;354:1955–61.

82 Manandhar, D. Mother andInfant Research Activities(MIRA). Nepal. Personal com-munication. June 2001.

83 Onis M de, Lossner M, VillarJ. Levels and patterns ofintrauterine growth retardationin developing countries. Eur JClin Nutr 1998; 52:S5-S15.

84 Aarts C, Kylberg E, HornellA, Hofvander Y, Grebe-MedhinM, Greiner T. How exclusive isbreastfeeding? A comparison ofdata since birth with the cur-rent status data. Int J Epi 2000;29:1041–1046.

AIDS Acquired ImmunodeficiencySyndrome

ANC Antenatal care

BCC Behavior change communications

BFHI Baby-Friendly Hospital Initiative

CDC Centers for Disease Control and Prevention

CEE Central and Eastern Europe

CHAPS Community Health Partnerships, Malawi

CIS Commonwealth of Independent States

DHS Demographic and Health Surveys

HDI Human development index

HIV Human Immunodeficiency Virus

IMCH Integrated Maternal and Child Health

IMR Infant mortality rate

IUGR Intra-uterine growth retardation

LBW Low birth weight

MIRA Mother and Infant Research Activities, Nepal

MMR Maternal mortality rate

MTCT Mother-to-child transmission

NGO Nongovernmental organization

NMR Neonatal mortality rate

OPV Oral Polio Vaccine

SEARCH Society for Education,Action and Research in Community Health

SNL Saving Newborn Lives

STI Sexually transmitted infection

TBA Traditional birth attendant

TFR Total fertility rate

TT Tetanus toxoid

UN United Nations

UNDP United Nations Development Programme

UNFPA United Nations Population Fund

UNICEF United Nations International Children’s Fund

USAID United States Agency for International Development

VCT Voluntary counseling and testing program

VHW Village health worker

WHO World Health Organization

ABBREVIATIONS

and Health Surveys (DHS) and theCenters for Disease Control andPrevention (CDC); nationally report-ed data from countries with vitalregistration coverage over 90 per-cent; a few population-basedresearch trials (references footnot-ed); WHO estimates for eight coun-tries, using the best available data.Data quality and limitations of the indi-cator The statistics included forNMR are likely to be underesti-mates, especially in countries withlimited national reporting systems.Even in industrialized countries,neonatal deaths may be under-reported, especially among babieswho are very small or die very soonafter birth. The data used here arebased on national reporting or onpopulation-based surveys such asDHS. The nationally reported dataare mainly from industrialized coun-tries, where data quality is deter-mined by the efficiency of thereporting system. Different coun-tries may have different definitionsof livebirths and neonatal deaths;for example, some countries do notinclude a baby dying in the first 24hours as a livebirth, which mayreduce the neonatal mortality rateby as much as 40 percent. The sur-vey data is collected by askingmothers to report neonatal death,and so may underestimate reality aswomen may not give this informa-tion to the interviewer. Global esti-mates of neonatal (and fetal andperinatal) mortality are generatedby the WHO using mortality ratesthat are adjusted for estimatedunder-reporting of fetal and neona-tal deaths. The first global esti-mates were produced in 1996, andthe 2001 estimates (based on datacollected circa 1999) are shown inTable 1, p.14.

Estimated births per yearThe expected number of births per

year for each country, estimated byUnited Nations Population Division(1999) using data on current popula-tion size and expected births anddeaths. The estimated number ofbirths worldwide each year is 129million.

Low birth weight rate (%)Definition The low birth weight rateis the number of babies weighingless than 2,500 grams at birth per100 live births. Justification for inclusion Birth weightis a strong predictor of the baby’soutcome and also a good measure ofthe health status of the mother. TheLBW rate allows calculation of thenumber of LBW babies per countryand gives an estimated global totalof 20 million LBW babies.Sources Data were obtained from anumber of sources, mainly fromWHO/UNICEF (1995-99), WHOreview,83 and specific sources for afew countries.Data quality and limitations of the indi-cator It is estimated that approxi-mately 50 percent of babies areweighed at birth. In some countriesbirth weight is recorded for themajority and the nationally reportedLBW rate is representative. In othercountries the reported LBW rate isbased on survey data or on hospitaldata. Hospital data may overesti-mate the LBW rate if more compli-cate deliveries, such as pretermbirth, are occurring in hospital. Con-versely hospital data may underesti-mate the LBW rate if hospitaldeliveries are mainly women ofhigher socio-economic standing.Even if babies are weighed, weightsmay be mis-read or mis-recorded.

Maternal mortality ratioDefinition Maternal mortality ratio isdefined as the number of womenwho die from conditions related topregnancy, delivery, or related com-


WHAT THE TABLES WILL AND WILL NOT TELL YOUThese tables provide information for163 countries regarding 12 indica-tors relevant to newborn health andsurvival. The countries in thesetables represent over 99 percent ofthe world’s births. Most of the coun-tries not included have less than10,000 births per year.

Every attempt has been made toobtain the most recent and the bestquality data available and, whereverpossible, nationally reported data orpopulation-based survey data havebeen used. But the information inthese tables also comes from a widevariety of other sources, and thequality varies accordingly. In general,data quality is likely to be worse forcountries that have suffered recentdisruptions in infrastructure, due towar or natural disasters. Neonatalmortality data were especially diffi-cult to access, and are likely to beunderestimated, as discussed underthe notes for this indicator. We havenot adjusted the figures here despiteexpected inaccuracies, but have useddata from national or internationalagencies and population-based sur-

veys, and stated the likely sources oferror and the limitations for eachindicator. WHO has produced esti-mates for neonatal mortality, whichare adjusted to allow for underesti-mation (Table 1, p.14). Partly becausefocus on newborn health is a recentphenomenon, information is lackingfor many of the indicators that wewould like to have included, espe-cially late fetal deaths and postpar-tum/newborn care.

Explanation of the tablesThe indicators are described indetail in the explanatory notes onpage 45, which include a definition,justification for use, details ofsources, and comments on the qual-ity of the data. Data that were col-lected outside the time periodspecified in the column heading aremarked with “x.” If data were notavailable, the cell is marked “-.”

Using a country’s name in thesetables does not imply recognition ofany country or territory on the partof the compilers.Table I Newborn Health Statusincludes the following indicators:" Ranking by Human

Development Index;" Neonatal mortality rate;" Estimated number of

births annually;" Calculated number of

neonatal deaths annually;" Percent of babies born with LBW;" Estimated number of LBW babies

per year; and" Estimates of maternal death.Table II Newborn Health Servicesand Practices includes the followingindicators:" Antenatal care contact;" Tetanus toxoid immunization

(2 vaccinations) coverage in pregnant women;

" Skilled attendant at delivery;" Early breastfeeding; and" Exclusive breastfeeding 0-4

months (based on 24 hour recall).

EXPLANATORY NOTES

TABLE I NEWBORN HEALTH STATUS

Human Development Index rank Definition A composite indicator ofdevelopment status developed byUNDP, including: Life expectancy atbirth; Educational achievement(composed of adult literacy andcombined gross primary, secondaryand tertiary enrollment); and RealGDP per capita.Justification for inclusion This is abroad, well-recognized indicator ofdevelopment status. Some countrieshave a low rank for HDI, and yet haverelatively low NMR, such as Cuba.Sources From The World Develop-ment report 1999, UNDP, for 176countries. Available on the web atwww.undp.org/hdro/index.htmlData quality and limitations of the indi-cator This composite index involvessix indicators, and the quality ofdata varies by country and by indica-tor, which may affect ranking.

Neonatal mortality rateDefinition The neonatal mortalityrate is the number of livebornbabies who die in the first 28 daysafter birth, per 1,000 live births.Justification for inclusion Neonatalmortality rate (NMR) is the key new-born survival indicator. Deaths ofbabies in late pregnancy (fetaldeaths or stillbirths) are closelyrelated to early neonatal deaths asthe causes are similar. Very limitedinformation is available about thenumbers of fetal deaths. The lack ofuseable data on late fetal deathsalso means that we cannot reportperinatal mortality, which is thesum of late fetal and early neonatal(first week of life) deaths. The num-ber of neonatal deaths per countrywas calculated using the estimatedbirths per country from UnitedNations Population Division 1999.Sources Obtained from a number ofsources including: Demographic

STATISTICAL

OVERVIEW

OF NEWBORN

HEALTH

This statistical overview reveals great variation in the health status of newborns around the world and in the services, practices andpolicies that affect their survival. Our hope is that these statistics,despite their limitations, will providea tool to improve the health of tomorrow’s newborns, and hence the future for all.

46 STATE OF THE WORLD’S NEWBORNS STATE OF THE WORLD’S NEWBORNS 47

plications, per 100,000 live births.Justification for inclusion Maternaloutcomes are strongly linked tonewborn outcomes, and a newbornwhose mother dies has a markedlyincreased chance of dying.Sources All data was from theWHO/UNICEF estimates based on1995 data. Hill K, AbouZahr C,Wardlaw T. Estimates of maternalmortality for 1995. Bull WHO, 200179(3) 182-193. Available on the webat: www.childinfo.org/eddb/mat_mortal/whobulletin79.pdfData quality and limitations of the indi-cator In the countries where MMR ishighest, the precise estimates arethe most difficult. Even in industri-alized countries maternal deathsmay be unrecorded. The methodsand limitations of the MMR esti-mates are discussed in detail in thesource document.

TABLE II NEWBORN HEALTH SERVICES AND PRACTICES

Antenatal contact with a skilled provider (%)Definition The number of pregnant

women seen at least once by skilledhealth personnel because of preg-nancy, per 100 live births. A skilledprovider includes a doctor, midwife,or nurse with midwifery training.Justification for inclusion Skilled careduring pregnancy benefits bothmothers and newborns.Sources UN Statistics Division (TheWorld’s Women 2000), DHS and CDCsurveys and UNICEF. The latter isavailable on the web at www.childin-fo.org/eddb/antenatal/database.htmData quality and limitations of the indi-cator The main limitation in thequality of this data is the variabilityin measurement of “skilled” healthcare provider, as discussed in moredetail under the skilled attendanceat delivery. This indicator includesonly one antenatal visit, and the rec-ommended number is four. If theindicator were changed to four visitsthis may be a better predictor ofnewborn and maternal survival, butdata are not available on a widescale to measure this at present.The content of antenatal care is alsoimportant, but is not reflected inthis indicator. Even if the attendant

is skilled, if there are no standardsfor care and no supporting system,for example to test and treatsyphilis, the care may have littleeffect on outcome.

Tetanus toxoid coverage in pregnant women (%) Definition The number of pregnantwomen with appropriate tetanustoxoid immunization, per 100 livebirths. Appropriate tetanus toxoidimmunization is considered to betwo vaccinations (TT2) that are atleast four weeks apart with the sec-ond dose a month or more beforedelivery, or a lifetime total of five ormore tetanus immunizations.Justification for inclusion Neonataltetanus is a leading cause of neona-tal deaths. Prevention is highly cost-effective, yet in many countries withhigh death rates from neonataltetanus, coverage of pregnantwomen with TT2 remains low, espe-cially in rural areas where the riskis often higher.Sources Data is based on UNICEF/WHO data (1997-99) as listed in theState of the World’s Children 2001.Data quality and limitations of the indi-cator The data is collected throughsurveys and national reporting.Women may be unsure of theirimmunization status or unable toproduce records to verify this. Thedata is adjusted by UNICEF/WHO toallow for reporting issues.

Skilled attendant at delivery coverage (%)Definition The number of womenwith skilled attendance at delivery,per 100 live births. A skilled atten-dant includes a doctor, midwife, ornurse with midwifery training. Justification for inclusion Skilledattendance at delivery is one of thekeys to improving the survival of babies and mothers.Sources Based on UNICEF/WHO1995 – 2000 and DHS data as listed

in the State of the World’s Children2001 available on the web atwww.unicef.org/sowc01/ and addi-tional data from The State of WorldPopulation at www.unfpa.org/swp/2000/english/indicators/indica-tors2.htmlData quality and limitations of the indi-cator The major issues for the quali-ty of this indicator are defining the“skill” of the attendant and reflect-ing whether the attendant is part ofa functioning system. The skill ofthe attendant is more than a qualifi-cation, as a high level of qualifica-tion may not correlate withcompetency. In addition, even ahighly skilled attendant will havelimited effect in saving the lives ofmothers and babies if there is not afunctioning system for comprehen-sive care of complications for themother or baby, including caesare-an section, blood transfusion etc.

Breastfeeding inthe first hour of life (%)Definition The percentage of womenwith an infant less than one year oldwho recall breastfeeding within thefirst hour after delivery.Justification for inclusion Breastfeed-ing is important for the survival ofnewborns, but also provides bene-fits that last a lifetime. If all babieswere exclusively breastfed for sixmonths, it is estimated that 1.5 mil-lion infant lives would be saved eachyear. Early breastfeeding ensuresthat the baby benefits by receivingcolostrum, which is rich in VitaminA and K and in antibodies. Themother also benefits in many ways,including a reduced risk of postpar-tum hemorrhage.Sources Mainly based on DHS, butalso including individual countrycontacts. Data was especially lack-ing from Europe. Data quality and limitations of the indi-cator Information regarding breast-feeding is lacking, particularly fromindustrialized countries. The data

available are mainly based on sur-veys relying on the mother’s recallof the time she fed her baby in thelast delivery, which may be affectedby recall bias.

Exclusive breastfeeding at 0–4 monthsof age (% based on 24 hour recall bythe mother)Definition The percentage of womenwith infants aged 0-4 months whoreport feeding their infant breast-milk alone during the last 24 hours.Exclusive breastfeeding is the prac-tice of feeding breastmilk alone to ababy, with no water, formula milk,or cereals. A baby who is givenmedicines but otherwise onlybreastmilk is still considered to beexclusively breastfed. Justification for inclusion A baby whois ever breastfed has advantagesover the baby who receives nobreastmilk. However, the advan-tages, especially in protectionagainst infections, are much greaterif the baby is exclusively breastfed.WHO recommends exclusive breast-feeding to six months of age.Sources Based on UNICEF, DHS,MICS and WHO data as well as indi-vidual country contacts.Data quality and limitations of the indi-cator Indicators assessing exclusivebreastfeeding are compromised bythe difficulty of measuring “exclu-sive” breastfeeding. The most com-mon method of assessment is toask the mother about the infant’sintake during the last 24 hours. Astudy in Sweden compared 24-hourrecall of exclusive feeding to arecord of babies’ intake since birth.The 24 hour recall was found to beabout 40 percent higher at 2 and 4months of age than the "alwaysexclusively breastfed" category fromthe record of intake.

84Many industri-

alized countries do not collect com-parable data regarding exclusivebreastfeeding.

ACKNOWLEDGMENTS

Writer/EditorAnthony Costello, Women & Children First, United KingdomVictoria FrancisAli ByrneClaire Puddephatt

Contributing Editors, Save the ChildrenAnne Tinker, Director, Saving Newborn LivesPatricia DalyGary DarmstadtJoy Lawn, ConsultantDavid MarshJudith MooreDavid OotRon ParlatoCcoya Sejas, BoliviaDianne Sherman

Editorial StaffRobin Bell, Save the ChildrenCharlotte StortiRebecca Lowery

ReviewersCarla AbouZahr, WHO, SwitzerlandAbhay Bang, SEARCH, IndiaPetra ten Hoope-Bender,International Confederation of Midwives, The NetherlandsZulfiqar Bhutta, Aga Khan University, PakistanRose Kambarami, University of Zimbabwe, ZimbabweJerker Liljestrand, World Bank, United StatesJosé Martines, WHO, SwitzerlandDharma Manandhar, MIRA, NepalClaudia McConnell, Women & Children First, United KingdomNatasha Mesko, International Perinatal Care Unit, Institute of ChildHealth, United KingdomDavid Osrin, International Perinatal Care Unit, Institute of Child Health, United Kingdom

SAVING

NEWBORN

LIVES

CALL TO

ACTION

Vinod Paul, All India Institute of Medical Sciences, IndiaImogen Sharp, Women & Children First,United KingdomTomris Türmen, WHO, SwitzerlandDavid Woods, University of Capetown,South AfricaJelka Zupan, WHO, Switzerland

Institutions Providing DataBaby-Friendly Hospital Initiative,SwitzerlandCenters for Disease Control and Preven-tion, United StatesMacro International, United StatesMedical Research Council, University ofCapetown, South AfricaPan Arab Program for Child Survival, League of Arab States, EgyptUnited Nations Development Fund, Unit-ed StatesUnited Nations International Children’s Fund, United States

World Health Organization,European Office, DenmarkWorld Health Organization, Family andCommunity Health, Switzerland

JournalistMarina Cantacuzino

Design & ProductionKINETIK Communication Graphics Inc., Washington, DC

Photography CreditsPatricia Daly, Indonesia page 38Rebecca James, Haiti page 17Thomas L. Kelly, India pages 1, 6, 9, 13,22, 25, 27, 32 Thomas L. Kelly, Nepal back cover,pages 4, 10, 11, 35, 36, 37, 41, 44, 46Brian Moody, Malawi front cover, pages 3,9, 12, 15, 18, 19, 21, 24, 29, 31, 47, 48Anne Tinker, Bolivia pages 2, 39

Photos in this publication may not represent Save the Children programs.

This report was printed by S+S Graphicsutilizing soy-based inks on Sappi StrobeGloss, a recycled paper containing 10percent post-consumer waste.

ISBN 1-888393-05-X

© Save the Children, 2001

SAVING NEWBORN LIVES INITIATIVESave the Children has launched anew effort called Saving NewbornLives. Supported by the Bill &Melinda Gates Foundation, SavingNewborn Lives is a 10 to 15 yearglobal initiative to improve thehealth and survival of newborns in the developing world. The initia-tive works with governments, localcommunities, and partner agenciesat a national level to make progresstoward real and lasting change innewborn health.

SAVE THE CHILDREN is a leadinginternational nonprofit child-assis-tance organization working in nearly50 countries worldwide, includingthe United States. Our mission is tomake lasting, positive change in thelives of children in need. Save theChildren is a member of the inter-national Save the Children Alliance,a worldwide network of 30 inde-pendent Save the Children organiza-tions working in more than 100countries to ensure the well-beingand protect the rights of childreneverywhere.


tion and immediate, exclusivebreastfeeding, ensuring the pres-ence of skilled care at birth, andappropriate and early postnatal carefor the newborn can help savecountless newborn lives. These suc-cessful maternal and newborn carepractices should be integrated intoexisting safe motherhood, child sur-vival, and other community healthcare services." Conduct appropriate research.Additional research is required to:identify and test promising new,low-cost approaches and technolo-gies; enhance the understanding ofthose socio-cultural and economicfactors that limit the adoption ofimproved newborn care practices inlocal communities; and derive prac-tical lessons from the most suc-cessful programs of infant andmaternal health and apply them tonewborn care." Foster and promote strategicpartnerships. Adequate financial,human, and material resources willbe needed to improve newbornhealth, through the reallocation ofexisting resources, increased

With the support and collaborationof national decision-makers, com-munity leaders, health care profes-sionals, the private sector, andinternational donors, the world’snewborns can receive the care andresources they need to survive andthrive. Specifically, we call on policymakers to:

" Establish newborn care as a pri-ority in national health plans andhealth reform programs. Four mil-lion newborns die within the firstmonth of life; and four million moreare stillborn. While death rates ofchildren under the age of five havefallen dramatically in the past twodecades, there has been relativelylittle change in newborn mortality,even though proven, cost-effectivesolutions exist to save most of theseyoung lives. For further gains inchild survival, reducing the newbornmortality rate must become anational and international priority." Strengthen and expand provencost-effective services. Promotingservices such as tetanus immuniza-

efficiency, or additional funding.Collaboration among a wide rangeof institutions in developed anddeveloping countries—governmentministries, international agencies,professional organizations, universi-ties, and private sector organiza-tions—can provide a foundation onwhich to build newborn care pro-grams. Such collaboration can alsoprovide important opportunities forsharing experiences and knowledgeas well as coordinating programefforts." Support programs that promotewomen’s health. Newborn survivalbegins with ensuring the health andnutritional status of the mother andpreparation for a safe delivery. Pro-grams need to address barriers thatinhibit women’s access to informa-tion and services, emphasizingcommunity and home-basedapproaches and the involvement ofhusbands and other family decision-makers. Expanding access to familyplanning and improving educationand economic opportunities willalso contribute substantially towomen’s health.

Country Human Develop-ment Index rank

Neonatal mortality

rate per 1,000 live births1995-2000

Estimated births per

year in thousands

1999

Estimated number

of neonatal deaths

per yearcalculated

Percent of babies born withlow birth

weight1995-99

Estimated number of

low birth weight babies

per year

Estimated number

of maternaldeaths per

100,000 live births 1995 Country

Human Develop-ment Index rank

Neonatal mortality



year in thousands

1999

Estimated number

of neonatal deaths

per yearcalculated


weight1995-99

Estimated number of


per year

Estimated number


100,000 live births 1995 Country

Human Develop-ment Index rank

Neonatal mortality



year in thousands

1999

Estimated number

of neonatal deaths

per yearcalculated


weight1995-99

Estimated number of


per year

Estimated number


100,000 live births 1995

NIGER 173 44 497 21,967 15 74,550 923

NIGERIA 151 37 4,176 154,512 16 668,160 1,129

NORWAY 2 3 57 164 4 2,280 9

OMAN 86 - 87 - 8 6,960 115

PAKISTAN 135 49x 5,349 261,566 25 1,337,250 201

PANAMA 59 - 61 - 10 6,100 98

PAPUA NEW GUINEA 133 - 149 - 23 34,270 387

PARAGUAY 81 20 165 3,300 5 8,250 172

PERU 80 24 610 14,640 11 67,100 235

PHILIPPINES 77 18 2,064 36,739 9 185,760 238

POLAND 44 9 417 3,808 8.6 35,862 12

PORTUGAL 28 4 102 421 5 5,100 12

QATAR 42 - 11 - 5 550 41

ROMANIA 64 18 201 3,698 7 14,070 62

RUSSIAN FEDERATION 62 9 1,434 1,233 7 100,380 74

RWANDA 164 39x 295 11,387 - - 2,318

SAUDI ARABIA 75 10a 696 6,960 7 48,720 23

SENEGAL 155 37 364 13,614 4 14,560 1,198

SIERRA LEONE 174 - 214 - 11 23,540 2,065

SINGAPORE 24 26 49 105 7 3,430 9

SLOVAKIA 40 - 56 - - - 14

SLOVENIA 29 4 18 69 6 1,080 17

SOLOMON ISLANDS 121 - 15 - 20 3,000 59

SOMALIA - 48c 500 24,000 16 80,000 1,582

SOUTH AFRICA 103 11d 1,055 116,050 14d 147,700 341

SPAIN 21 4 358 1,285 4 14,320 8

SRI LANKA 84 20 328 6,560 25 82,000 62

SUDAN 143 44x 944 41,347 15 141,600 1,452

SWAZILAND 112 - 37 - 10 3,700 374

SWEDEN 6 3 86 227 5 4,300 8

SWITZERLAND 13 3 79 237 5 3,950 8

SYRIAN ARAB REPUBLIC 111 18 472 8,496 7 33,040 195

TAJIKISTAN 110 - 189 - 6 12,285 123

TANZANIA, REP 156 40 1,332 53,280 14 186,480 1,059

THAILAND 76 20 997 20,139 6 59,820 44

TOGO 145 41 185 7,640 20 37,000 983

TRINIDAD AND TOBAGO 50 10 18 180 10 1,800 67

TUNISIA 101 30 190 5,700 8 15,200 69

TURKEY 85 26 1,415 36,507 8 113,200 56

TURKMENISTAN 100 - 121 - 5 6,050 63

UGANDA 158 27 1,081 29,187 13 140,530 1,056

UKRAINE 78 10 482 4,627 5 24,100 45

UNITED ARAB EMIRATES 45 - 44 - 6 2,640 30

UNITED KINGDOM 10 4 680 2,808 7 47,600 10

UNITED STATES 3 5 3,754 18,524 7 262,780 12

URUGUAY 39 - 58 - 8 4,640 51

UZBEKISTAN 106 23 653 14,888 6 39,130 59

VENEZUELA 65 10a 574 5,740 9 51,660 43

VIET NAM 108 18 1,654 30,434 17 281,180 96

YEMEN 148 34 821 27,586 19 155,990 850

YUGOSLAVIA - 15a 136 2,040 6 8,160 15

ZAMBIA 153 36 377 13,346 13 49,010 867

ZIMBABWE 130 29 354 10,266 10 35,400 609

GERMANY 14 3 736 2,350 5 36,800 12

GHANA 129 30 724 21,502 8 57,920 586

GREECE 25 5 97 503 6 5,820 2

GUATEMALA 120 23 399 9,296 15 59,850 267

GUINEA 162 48 312 15,100 13 40,560 1,224

GUINEA BISSAU 169 - 49 - 20 9,800 914

GUYANA 96 - 18 - 15 2,700 151

HAITI 150 31 255 7,956 15 38,250 1,122

HONDURAS 113 20 205 4,100 9 18,450 221

HUNGARY 43 6 96 613 9 8,640 23

ICELAND 5 5 4 19 4 160 -

INDIA 128 43 24,489 1,053,027 33 8,081,370 437

INDONESIA 109 22 4,608 100,454 8 368,640 472

IRAN, ISLAMIC REP. OF 97 30a 1,392 41,760 10 139,200 130

IRAQ 126 30a 804 24,120 15 120,600 367

IRELAND 18 4 53 209 4 2,120 9

ISRAEL 23 4 118 493 7 1,260 8

ITALY 19 5 506 2,410 5 25,300 11

JAMAICA 83 8 54 432 11 5,940 115

JAPAN 9 2 1,271 2,307 7 88,970 12

JORDAN 92 19 223 4,237 10 26,280 41

KAZAKHSTAN 73 20 292 5,694 9 158,720 78

KENYA 138 28 992 28,173 16 158,720 1,339

KOREA, DEM. PEOPLE'S REP. - - 472 - 4 18,880 35

KOREA REP. 31 5a 681 3,405 9 61,290 20

KUWAIT 36 - 40 - 7 2,800 25

KYRGYZSTAN 98 32 116 3,666 6 6,960 79

LAO PEOPLE’ DEM. REP. 140 - 205 - 18 36,900 653

LATVIA 63 8 20 160 - - 68

LEBANON 82 - 73 - 10 7,300 127

LESOTHO 127 - 73 - 11 8,030 529

LIBERIA - 68x 129 8,760 - - 1,016

LIBYAN ARAB JAMAHIRIYA 72 - 160 - 7 11,200 117

LITHUANIA 52 6 36 225 4 1,440 27

LUXEMBOURG 17 2 5 11 6 300 0

MACEDONIA, TFYR 69 10 31 322 - - 17

MADAGASCAR 141 40 604 24,402 5 30,200 583

MALAWI 163 41x 497 20,476 20 99,400 576

MALAYSIA 61 12 520 6,344 9 46,800 39

MALDIVES 89 - 10 - 13 1,300 385

MALI 165 60 507 30,623 16 81,120 630

MALTA 27 5 5 24 4 200 0

MAURITANIA 147 41x 104 4,264 11 11,440 874

MAURITIUS 71 17 18 314 13 2,320 45

MEXICO 55 25 2,324 58,100 7 162,680 67

MOLDOVA, REP. 102 9 56 527 5 2,240 63

MONGOLIA 117 - 58 - 7 4,060 63

MOROCCO 124 20 703 14,060 9 63,270 390

MOZAMBIQUE 168 54 826 44,521 12 99,120 975

MYANMAR 125 - 942 - 24 226,080 165

NAMIBIA 115 32 60 1,890 16 9,600 368

NEPAL 144 50 82 4,092 27 22,140 826

NETHERLANDS 8 3 176 528 5 8,800 10

NEW ZEALAND 20 4 57 223 6 3,420 15

NICARAGUA 116 17 174 2,976 9 15,660 246

AFGHANISTAN - - 1,139 - 20 27,800 819

ALBANIA 94 - 62 - 7 4,340 31

ALGERIA 107 22x 881 19,382 9 79,290 148

ANGOLA 160 - 595 - 19 113,050 1,308

ARGENTINA 35 12 718 8,631 7 50,260 84

ARMENIA 93 - 46 - 9 4,140 29

AUSTRALIA 4 4 245 949 6 14,700 6

AUSTRIA 16 3 81 261 6 4,860 11

AZERBAIJAN 90 - 121 - 6 7,260 37

BAHRAIN 41 - 11 - 6 660 38

BANGLADESH 146 48 3,504 169,594 30 1,051,200 596

BELARUS 57 - 99 - - - 33

BELGIUM 7 4 105 420 6 6,300 8

BENIN 157 38 242 9,244 8 19,360 884

BHUTAN 142 - 76 - - - 502

BOLIVIA 114 34 264 8,923 5 13,200 550

BOSNIA AND HERZEGOVINA - 9 39 351 3 1,170 15

BOTSWANA 122 22x 53 1,192 11 5,830 1,379

BRAZIL 74 19 3,344 63,536 8 267,520 262

BULGARIA 60 8 71 537 6 4,260 23

BURKINA FASO 172 41 530 21,624 21 111,300 1,379

BURUNDI 170 35x 273 9,610 - - 1,881

CAMBODIA 136 45a 360 16,200 18 64,800 590

CAMEROON 134 37 573 21,201 13 74,490 720

CANADA 1 4 343 1,357 6 20,580 6

CAPE VERDE 105 - 13 - 9 1,170 188

CENTRAL AFRICAN REPUBLIC 166 42 132 5,557 15 19,800 1,205

CHAD 167 44 323 14,179 - - 1,497

CHILE 38 5a 290 1,450 5 14,500 33

CHINA 99 23x 19,821 455,883 6 1,189,260 62

COLOMBIA 68 19 988 18,475 9 89,820 119

COMOROS 137 38 24 917 8 1,920 573

CONGO 139 - 123 - 16 19,680 1,108

CONGO, DEM. REP. 152 - 2,293 - 15 343,950 939

COSTA RICA 48 8 90 684 7 6,300 35

CÔTE D’IVOIRE 154 42 540 22,680 12 64,800 1,188

CROATIA 49 7 47 321 5 2,350 18

CUBA 56 5 141 706 7 9,870 24

CZECH REPUBLIC 34 3 88 289 6 5,280 14

DENMARK 15 4 63 264 6 3,780 15

DJIBOUTI 149 - 23 - 11 2,530 520

DOMINICAN REPUBLIC 87 27 195 5,187 13 25,350 110

ECUADOR 91 19 309 5,871 13 40,170 207

EGYPT 119 30 1,720 52,288 10 172,000 174

EL SALVADOR 104 23 167 3,841 13 21,710 183

EQUATORIAL GUINEA 131 - 18 - - - 1,404

ERITREA 159 25 148 3,700 13 19,240 1,131

ESTONIA 46 6 12 68 78

ETHIOPIA 171 49 2,699 131,441 16 431,840 1,841

FIJI 66 - 17 - 12 2,040 20

FINLAND 11 3 57 171 4 2,280 6

FRANCE 12 3 711 2,214 5 35,550 20

GABON 123 - 44 - 8 3,520 617

GAMBIA 161 40b 50 2,000 14 7,000 1,071

GEORGIA 70 23 69 1,580 5 3,450 22

KEY

x Indicates that the datawere collected outsidethe time period specifiedin the column heading.

- Indicates that the datawere not available.

a WHO estimates made in2001 based on the bestavailable data.

b Ceesay SM et al. BMJ1997; 315: 786-790.

c Ibrahim MM et al. BullWHO, 1996; 74(5): 547-552.

d R Pattinson. Unpublisheddata based on 27 hospital-based sentinelsites during 2000.

TABLE I NEWBORN HEALTH STATUS


Percent of pregnant

women with at least one

antenatal visit1995-99

Percent of pregnant

women with at least two

tetanus toxoidimmunizations

1997-99

Percent of births

attended by skilled

personnel 1995-2000

Percent of babies

breastfed in the first

hour of life 1995-99

Percent of babies aged 0-4 months exclusively

breastfed (24 hour recall)

1995-99

AFGHANISTAN 8 19 8 - 25

ALBANIA 94 58 77 99 - 9

ALGERIA 107 - 52 77 22 48

ANGOLA 160 52 16 17 - 12

ARGENTINA 35 95 - 98 - -

ARMENIA 93 82 36 97 - 21

AUSTRALIA 4 100 - 100 - -

AUSTRIA 16 100 - 100 - -

AZERBAIJAN 90 98 - 100 - 26

BAHRAIN 41 96 80 98 40 36

BANGLADESH 146 33 85 13 13 53

BELARUS 57 - - 100 - -

BELGIUM 7 - - 100 - -

BENIN 157 80 90 60 24 15

BHUTAN 142 51 73 15 - -

BOLIVIA 114 69 27 59 39 61

BOSNIA AND HERZEGOVINA 99 - 97 - 8

BOTSWANA 122 92 56 87 - 39

BRAZIL 74 82 30 92 32 42

BULGARIA 60 - - 100 - -

BURKINA FASO 172 61 30 27 30 5

BURUNDI 170 88 9 24 - 89

CAMBODIA 136 34 33 34 - 16

CAMEROON 134 78 44 55 38 16

CANADA 1 100 - 100 - -

CAPE VERDE 105 99 52 54 57

CENTRAL AFRICAN REP 166 67 25 46 34 23

CHAD 167 23 27 15 24 2

CHILE 38 98 - 100 - 74

CHINA 99 79 13 67 - 64

COLOMBIA 68 91 57 85 49 16

COMOROS 137 84 22 52 25 5

CONGO 139 55 33 50 - 43

CONGO, DEM.REP. 152 66 - - 32

COSTA RICA 48 95 - 98 - 35

CÔTE D’IVOIRE 154 83 44 47 44 4

CROATIA 49 - - 100 - 24

CUBA 56 100 70 100 - 76

CZECH REPUBLIC 34 100 - 99 - -

DENMARK 15 100 - 100 - -

DJIBOUTI 149 76 14 79 - -

DOMINICAN REP 87 98 86 99 63 25

ECUADOR 91 75 34 71 38 29

EGYPT 119 53 66 61 41 60

EL SALVADOR 104 69 70 90 15 21

EQUATORIAL GUINEA 131 37 - 5 - -

ERITREA 159 49 28 21 48 66

ESTONIA 46 98 - 95 - -

ETHIOPIA 171 26 35 10 - 84

FIJI 66 100 - - - -

FINLAND 11 100 - 100 77 26

FRANCE 12 99 83 99 - -

GABON 123 86 25 80 - 32

GAMBIA 161 86 96 44 - 35

GEORGIA 70 95 - 96 - 18


Percent of pregnant



Percent of pregnant



1997-99

Percent of births

attended by skilled

personnel 1995-2000

Percent of babies





1995-99 Country Human Develop-ment Index rank

Percent of pregnant



Percent of pregnant



1997-99

Percent of births

attended by skilled

personnel 1995-2000

Percent of babies





1995-99

NIGER 173 38 19 18 28 1

NIGERIA 151 60 29 33 33 22

NORWAY 2 - - 100 71 -

OMAN 86 98 97 91 83 31

PAKISTAN 135 27 51 19 9 16

PANAMA 59 72 - 90 - 32

PAPUA NEW GUINEA 133 78 14 53 - 75

PARAGUAY 81 89 32 71 30 7

PERU 80 67 57 56 44 63

PHILIPPINES 77 86 38 56 42 47

POLAND 44 98 - 99 65 60

PORTUGAL 28 99 - 98 - 41

QATAR 42 100 - 98 - -

ROMANIA 64 - - 99 - -

RUSSIAN FED 62 - - 99 - -

RWANDA 164 94 83 26 20 61

SAUDI ARABIA 75 90 66 91 31

SENEGAL 155 82 45 47 16 16

SIERRA LEONE 174 68 25 42 - 2

SINGAPORE 24 100 - 100 - -

SLOVAKIA 40 - - 95 - -

SLOVENIA 29 98 - 100 - -

SOLOMON ISLANDS 121 71 55 85 - -

SOMALIA 40 16 2 - 1

SOUTH AFRICA 103 94 26 84 - 10

SPAIN 21 - - 96 - -

SRI LANKA 84 80 91 94 - 24

SUDAN 143 54 62 86 60 14

SWAZILAND 112 70 96 56 - 37

SWEDEN 6 100 - 100 - -

SWITZERLAND 13 99 99 67 48

SYRIAN ARAB REPUBLIC 111 33 94 76 22 -

TAJIKISTAN 110 71 - 71 - 19

TANZANIA, U. REP. OF 156 82 77 35 59 41

THAILAND 76 86 90 71 - 4

TOGO 145 82 48 51 19 15

TRINIDAD & TOBAGO 50 98 - 98 - 10

TUNISIA 101 79 80 81 38 12

TURKEY 85 68 36 81 21 9

TURKMENISTAN 100 90 - 96 - 54

UGANDA 158 91 49 38 49 7

UKRAINE 78 100 - 100 - 82

UNITED ARAB EMIRATES 45 97 - 99 25 -

UNITED KINGDOM 10 99 - 98 46 <16

UNITED STATES 3 99 - 99 - 19 +

URUGUAY 39 94 - 100 - -

UZBEKISTAN 106 97 - 96 19 22

VENEZUELA 65 74 88 95 - 7

VIET NAM 108 71 85 77 - 29

YEMEN 148 33 26 22 47 25

YUGOSLAVIA - - 93 - 11

ZAMBIA 153 96 55 47 58 11

ZIMBABWE 130 93 58 84 40 16

GERMANY 14 99 80 100 - 33

GHANA 129 88 52 44 16 36

GREECE 25 - - 99 - -

GUATEMALA 120 53 38 41 55 47

GUINEA 162 71 48 35 - 13

GUINEA BISSAU 169 62 13 35 - 42

GUYANA 96 95 82 95 - -

HAITI 150 79 38 21 36 3

HONDURAS 113 84 100 55 43 42

HUNGARY 43 - - 99 - -

ICELAND 5 100 - 100 - 50

INDIA 128 60 73 34 16 37

INDONESIA 109 90 81 56 8 52

IRAN, ISLAMIC REP. 97 77 48 86 - 66

IRAQ 126 78 51 54 - -

IRELAND 18 - - 100 -

ISRAEL 23 90 - 99 - -

ITALY 19 99 - 100 - -

JAMAICA 83 99 52 95 - -

JAPAN 9 - - 100 - -

JORDAN 92 91 18 97 32 15

KAZAKHSTAN 73 92 - 98 10 59

KENYA 138 92 44 44 58 17

KOREA, DEM. PEOPLE'S REP. 100 5 100 - 97

KOREA, REP. OF 31 96 71 98 - -

KUWAIT 36 95 70 98 - -

KYRGYZSTAN 98 97 98 53 31

LAO PEOPLE DEM. REP. 140 25 36 14 - 39

LATVIA 63 - - 100 - -

LEBANON 82 87 89 15 41

LESOTHO 127 89 - 50 - 54

LIBERIA 83 14 58 - -

LIBYAN ARAB JAMAHIRIYA 72 81 - 94 22 -

LITHUANIA 52 - - 95 - -

LUXEMBOURG 17 99 - 100 - -

MACEDONIA, TFYR 69 100 - 97 45

MADAGASCAR 141 58 35 47 34 61

MALAWI 163 90 97 55 59 11

MALAYSIA 61 90 81 96 - -

MALDIVES 89 95 95 90 - 8

MALI 165 46 62 24 10 13

MALTA 27 - - 98 - -

MAURITANIA 147 49 13 40 5 60

MAURITIUS 71 99 75 97 20 16

MEXICO 55 86 67 86 - 38

MOLDOVA, REP. 102 99 - - 8 -

MONGOLIA 117 89 - 93 - 64

MOROCCO 124 45 36 40 43 31

MOZAMBIQUE 168 70 53 44 81 38

MYANMAR 125 80 64 56 - -

NAMIBIA 115 88 81 68 55 22

NEPAL 144 25 65 9 18 83

NETHERLANDS 8 95 80 100 - -

NEW ZEALAND 20 95 - 95 - -

NICARAGUA 116 82 100 65 80 29

KEY

- Indicates that the datawere not available.

+ The US data regarding exclusive breastfeeding are based on babies exclusively breastfed frombirth using NSFG survey data.

TABLE II NEWBORN HEALTHSERVICES

Documents

State of the World's Newborns, September 2001