[afro-nets] Most Newborn and Maternal Deaths Could Be Prevented, Report Finds

["Claudio Schuftan" <cschuftan@phmovement.org>]

New Review of Evidence Shows Improving Care at Birth Is Key to Saving Lives

Latest Findings from International Team of Experts to be Released at Cape Town Conference Today 

WESTPORT, Conn. (Oct. 6, 2009) — Most of the two million newborn and maternal deaths occurring at birth could be prevented, according to an international team of experts who completed a systematic review of the latest data and evidence on deaths at the time of birth, as well as evidence-based strategies to prevent such deaths.

The new findings appear in a special supplement to the International Journal of Gynecology and Obstetrics (IJGO), the official journal of the International Federation of Gynecology and Obstetrics (FIGO), which will be released today at FIGO's Congress in Cape Town.

Led by Dr. Joy Lawn (Save the Children USA), Dr. Gary L. Darmstadt (Bill & Melinda Gates Foundation) and Dr. Anne C. Lee (Johns Hopkins University), the review identifies some under-used evidence of interventions that could work in resource-constrained, low- and-middle income countries.

Need to Scale Up Effective Practices at Birth 

Each year 904,000 intrapartum (or childbirth-related) neonatal deaths (previously called "birth asphyxia"), 1.02 million intrapartum stillbirths, and around 42 percent of the world's 535,900 maternal deaths occur just when new life is expected. In total, 2.1 million deaths during childbirth or during delivery, occur globally each year. Deaths of babies due to childbirth or delivery outnumber child deaths due to malaria (820,000 a year) and HIV/AIDS (208,000 a year), yet so far have received much less attention and investment. This is partly due to a lack of visibility but also because of a lack of consensus on what works, especially in low-resource healthcare settings and for births that take place at home.

"Birth is the time when the risk of death is at its peak," said Dr. Joy E. Lawn, senior policy and research advisor for Save the Children USA's Saving Newborn Lives program. "These huge numbers of deaths are much more than statistics. Each death is a tragedy to a family — actually, a double tragedy-- since almost all these deaths could be prevented. We must do more to introduce innovations in terms of tools, technology and task-shifting in order to reach the poorest."

Of the world's 136 million births each year, 60 million are outside health facilities, mainly at home. Most deaths at birth (99 percent) take place in low- and middle-income countries, mostly in Africa and South Asia where fewer than half of women deliver with a skilled attendant. In fact, only one out of every five babies born in African hospitals is cared for by staff with the skills and simple equipment to resuscitate them if they do not breathe at birth.

"We provide clear guidance on what practices must be scaled up for effective care at birth and how to achieve this, especially in low resource settings and for the world's 60 million home births." said Dr Gary L. Darmstadt, previously of Johns Hopkins University, Baltimore and now team leader for Maternal, Neonatal and Child Health for The Bill & Melinda Gates Foundation.

Key Strategies Identified in New Report

Five key strategies explained in the supplement include:

Quality of Care: Improving the quality of care in existing facilities could avert 36 percent of intrapartum-related deaths by providing effective emergency obstetric care, especially Caesarean sections and neonatal resuscitation. This would save an estimated 327 200 of the newborns who currently die every year despite being born in health facilities.

Reducing Delays: Delays in receiving care of even a few minutes can result in death or major lifetime disability. Strategies to reduce delays include developing village transportation and communication schemes, providing financial incentives to communities, especially poor families, and building maternity waiting homes near hospitals.

Task Shifting:  Entrusting professional health care services to mid-level cadres of health workers and community health workers, known as task shifting, can increase access to care in hard to reach areas. Some countries (including Ethiopia, Malawi, Mozambique, and Tanzania) have enacted policy that enables alternative cadres of health workers to perform Caesarean deliveries. The outcome has been progress in extending life-saving procedures to rural areas and a reduction in deaths. Similarly, non-physician health care workers and community health workers have been shown to be capable of resuscitating non-breathing babies, resulting in fewer newborn deaths.

Community Mobilization: This has been shown to increase the proportion of women who give birth in health facilities.  A new meta-analysis in this supplement, based on several South Asian studies, showed a 30 percent increase in the number of health facility births where community-led mobilization had occurred.

Technology: Even basic, low-cost equipment and tools, such as a bag-and-mask device for neonatal resuscitation, are often unavailable, not only for home deliveries but also for hospital births.  Many of these technologies are produced and used on a small scale and do not reach the poor.

The authors conclude that many of these interventions are feasible right now — and indeed are being implemented in a number of countries — but unless more priority is given, the world will continue to miss the unheard cry of the 230 babies who die every hour from childbirth complications.

The supplement was funded by the Bill & Melinda Gates Foundation through Saving Newborn Lives/Save the Children USA.

Background: The Papers

   1. Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, Pattinson R, Darmstadt GL. Two million intrapartum stillbirths and neonatal deaths: where, why, and what can we do? Int J Gynecol Obstet 2009:107;
S5–S19. This paper presents a new overview of these 2 million deaths – where, when and why do they occur- as well as introducing the scope of the systematic review of interventions and strategies to address these deaths in varying health system contexts.
   2. Hofmeyr GJ, Haws RA, Bergström S, Lee AC, Okong P, Darmstadt GL, Mullany LC, Oo EKS, Lawn JE. Obstetric care in low-resource settings: What, who, and how to overcome challenges to scale up? Int J Gynecol Obstet 2009:107; S21–S45. This paper presents evidence for obstetric care interventions in low income settings, which is weak as most research focuses in high- income settings. The paper also outlines approaches to improve quality of care to reach the underserved.
   3. Wall SN, Lee AC, Niermeyer S, English M, Keenan WJ, Carlo W, Bhutta ZA, Bang A, Narayanan I, Ariawan I, Lawn JE. Neonatal resuscitation in low resource settings: What, who, and how to overcome challenges to scale up? Int J Gynecol Obstet 2009;107: S47–S64. This paper examines neonatal resuscitation - Who can do what?  What are the tools and technologies we have and what development needs are there for tools? Providing neonatal resuscitation could save almost 300,000 neonatal lives a year.
   4. Lee AC, Lawn JE, Cousens S, Kumar V, Osrin D, Bhutta ZA, Wall S, Nandakumar AK, Syed U, Darmstadt GL. Linking families and facilities for care at birth: what works to avert intrapartum-related deaths? Int J Gynecol Obstet 2009;107: S65–S88. This paper presents a systematic review and meta-analysis of strategies to link home- and hospital-based care, with cases studies of what has worked in African and Asian countries.
   5. Darmstadt GL, Lee AC, Cousens S, Sibley L, Bhutta ZA, Donnay F, Osrin D, Bang A, Kumar V, Wall SN, Baqui A, Lawn JE. 60 million nonfacility births: Who can deliver in community settings to reduce intrapartum-related deaths? Int J Gynecol Obstet 2009: 107; S89–S112. This paper presents a systematic review and meta-analyses of strategies for community-based care to reduce intrapartum-related burden for the 60 million births that occur outside facilities each year.
   6. Pattinson R, Kerber K, Waiswa P, Day LT, Mussell F, Asiruddin S, Blencowe H, Lawn JE. Perinatal mortality audit: Counting, accountability, and overcoming challenges in scaling up. Int J Gynecol Obstet 2009:107; S113–23. Perinatal audit could reduce stillbirths and neonatal deaths by 31% if audit links to action according to a new meta analysis in this paper. The authors use case studies from South Africa and Bangladesh to examine what more could be done to reach scale and to result in effective change.
   7. Lawn JE, Kinney M, Lee AC, Chopra M, Donnay F, Paul VK, Bhutta ZA, Bateman M, Darmstadt GL. Reducing intrapartum-related deaths and disability: can the health system deliver? Int J Gynecol Obstet 2009;107: S123–S142. In the final paper, the authors present estimates of lives saved if various interventions were applied, as well as who can do what and key gaps in action and knowledge. Some 613 000 newborns could be saved each year with obstetric care, neonatal resuscitation, and management of neonatal encephalopathy.

Save the Children <http://www.savethechildren.org/> is the leading independent organization

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Claudio Schuftan 
mailto:cschuftan@phmovement.org