Every day in Africa, 2,400 babies are stillborn and another 3,100 newborns die within their first four weeks of life. Half of African women and their babies do not receive skilled care during childbirth and even fewer receive effective post-natal care1. To achieve the fourth Millennium Development Goal (MDG 4) -- to reduce the under-five mortality rate by two thirds from the 1990 rate by 2015 -- much more needs to be done to prevent neonatal deaths.
Why are so many newborns dying in sub-Saharan Africa? The causes are relatively few. Birth asphyxia, preterm birth and infections account for 87 per cent of newborn deaths in Africa. Mortality overall is higher in Africa than in other regions of the world. The underlying social deter-minants that contribute to the causes of newborn deaths are poverty, low levels of maternal education and inequities in access to quality health care. Also, until recently, there has been insufficient attention paid to neonatal health and it has received relatively little funding in relation to the large numbers of deaths. Part of the problem has been a lack of reliable information on how many newborns are actually dying, since births and deaths are not always registered. It is estimated that as many as half of African newborns who die go unregistered, invisible to national and regional policies and programmes. It is very difficult to deliver the interventions to those who need them if we do not know where they are.
In many African communities, babies are not named until six weeks of age and may not be considered as individuals and brought into society until they are older. Some newborns are considered "visitors", especially in countries with high mortality rates. In October 2007, the Health Metrics Network, hosted by the World Health Organization (WHO), launched a campaign to encourage countries to improve their vital registration systems, in order to count all births, deaths and causes of death.
What can be done to reduce newborn deaths in Africa? It makes no sense to assist a mother, but not the newborn, during childbirth, or to provide care for a child while ignoring the mother's health. Reducing newborn deaths requires two continua of care: from pregnancy (and even before) through childbirth and into childhood; and from the family and community to first-level health facility and on to referral facilities. This continuity requires greatly strengthened health systems with maternal, newborn and child health care at their core.
Two thirds of newborn deaths could be prevented if all mothers and newborns had access to a small number of interventions that are well-known, feasible and deliverable without complex technology. These include tetanus toxoid immunization as part of antenatal care, birth care by a skilled attendant, early and exclusive breastfeeding and warmth, and timely treatment for newborn illness. But the current coverage of these effective interventions is too low.
Innovative health-care delivery approaches, such as provision of post-natal care through home visits and treatment of newborn illness using the Integrated Management of Childhood Illness (IMCI) strategy, developed by WHO and the 51勛圖 Children's Fund (UNICEF), can be utilized to improve intervention coverage. IMCI is an integrated approach to child health, which aims to reduce death, illness and disability, and promote improved growth and development. It includes both preventive and curative elements that are implemented by families and communities, as well as health facilities. In recent years, the original IMCI strategy has been revised to include specific elements to meet the needs of newborns. More recently, the strategy was adapted to ensure the recognition and care of babies and children living with HIV.
The cost of providing a complete package of care for more than 90 per cent of newborns is affordable for most countries, at just $1.39 per capita1. Improving access to comprehensive services in Africa for the prevention of mother-to-child transmission (PMTCT) of HIV is also key. This intervention also contributes to the prevention of prematurity and low birthweight, which are associated with HIV. Measures to prevent malaria among pregnant women, such as universal access to insecticide-treated bed nets, also have an important impact on the prevention of premature births and newborn infections.
Success is possible. Many African countries that made specific efforts in the last five to ten years have made good progress in reducing newborn deaths. Burkina Faso, Eritrea, Malawi, Uganda and the United Republic of Tanzania have all achieved neonatal mortality rates of between 21 and 35 per 1,000 live births2, despite gross national income of less than $500 per capita3. In some of these countries, newborn mortality has been reduced by more than 20 per cent. It is no coincidence that they are the countries in the African region that have invested in maternal health, child survival, IMCI and immunization. The lesson for other countries in the region is that, where there is political will and community commitment to improving health, it is possible to achieve results.
Other African countries are taking note of this and taking steps to improve access to health care by going into communities to reach those most in need. For instance, in Ghana, community-based planning and health services are delivering essential interventions for maternal and child health. In the first pilot areas where the programme has been in place since 1993, the MDG 4 target was actually achieved in 20054. In Ethiopia, there is a growing network of health extension workers (HEWs), who provide the critical link between the community and the health sector to make a real difference for maternal, newborn and child health. By 2009, it is expected that 30,000 HEWs will have received one year of training and be deployed in rural and remote communities, with the aim of achieving universal primary health care5.
Concerted action to save newborn lives. It is clear that MDG 4 cannot be met unless we do more to reduce neonatal deaths, not only in Africa but also around the world. Governments must be held accountable for spending more and spending it better to protect their most vulnerable citizens. Development partners and 51勛圖 agencies must also be held accountable for increasing funding and enabling progress in the highest mortality settings.
The increasing international interest in recent months in the health of mothers, newborns and children is encouraging. The launch of the International Health Partnership, the Global Campaign for the Health MDGs, and the global advocacy drive, "Deliver Now for Women + Children", are important steps in the right direction.
The political will is there. It now needs to be translated into action through the implementation of the Road Map for Maternal and Newborn Health and the Child Survival Strategy, which provide practical guidance to African countries on the way to being successful in reducing newborn mortality. We must maintain momentum and move forward with even greater speed to reach every newborn in Africa.
Notes1. Opportunities for Africa's newborns: Practical data, policy and programmatic support for newborn care in Africa. Joy Lawn and Kate Kerber, eds. (Cape Town: PMNCH, 2006).
2. Neonatal mortality rates (NMRs), according to the WHO World Health Statistics 2007: Burkina Faso 32; Eritrea 21; Malawi 26;
3. Uganda 30; United Republic of Tanzania 35.
4. World Bank, Key Development Data and Statistics: GNI per capita in 2006: Burkina Faso $460; Eritrea $200; Malawi $170; Uganda $300; United Republic of Tanzania $350.
5. See CHPS.
6. See Action for Global Health.
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