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The Lancet Neonatal Survival Series
Full text versions of the articles are available on the Lancet web site, but registration is required. (Registration is free).
On March 3, 2005, the leading international medical journal The Lancet released a series of four research papers on the survival of newborn babies worldwide. The series finds that 4 million newborns die each year, and nearly 3 million of these infants could be saved if they and their mothers had access to low-cost care such as tetanus immunizations during pregnancy, exclusive breastfeeding, clean delivery and antibiotics to treat illness. The series of papers analyzes the status of newborn health around the world and calls for immediate and sustained action to save newborn lives.
The newborn series follows the Bellagio Child Survival series, also published in The Lancet in July 2003, which focused on providing affordable, effective measures that could prevent two-thirds of the nearly 10 million deaths to children under age five each year. The series on newborn survival is possible because of new analysis detailing the causes of these deaths and the interventions that are available to prevent them.
"Eight million children are either stillborn or die each year within the first month of life. This figure never makes news," said Richard Horton, Lancet editor-in-chief, in his series editorial. "The aim of the present Lancet series is to erase the excuse of ignorance for public and political inaction once and for all."
Lancet Neonatal Survival Series: Papers and Abstracts
- Lancet Neonatal Survival Series: Executive Summary
- Lancet Series Launch Press Release (March 3, 2005)
- Paper 1: Four million neonatal deaths: When? Where? Why?
Joy E Lawn et al.
The proportion of child deaths that occurs in the neonatal period (38% in
2000) is increasing, and the Millennium Development Goal for child
survival cannot be met without substantial reductions in neonatal
mortality. Every year an estimated 4million babies die in the first 4
weeks of life (the neonatal period). A similar number are stillborn, and
0·5 million mothers die from pregnancy-related causes. Three-quarters of
neonatal deaths happen in the first week-the highest risk of death is
onthe first day of life.
Almost all (99%) neonatal deaths arise in low-income
and middle-income countries, yet most epidemiological and other research
focuses on the 1% of deaths in rich countries. The highest numbers of
neonatal deaths are in south-central Asian countries and the highest rates
are generally in sub-Saharan Africa. The countries in these regions (with
some exceptions) have made little progress in reducing such deaths in the
past 10-15 years. Globally, the main direct causes of neonatal death are
estimated to be preterm birth (28%), severe infections (26%), and asphyxia
(23%). Neonatal tetanus accounts for a smaller proportion of deaths (7%),
but is easily preventable. Low birthweight is an important indirect cause
of death. Maternal complications in labour carry a high risk of neonatal
death, and poverty is strongly associated with an increased risk.
Preventing deaths in newborn babies has not been a focus of child survival
or safe motherhood programmes. While we neglect these challenges, 450
newborn children die every hour, mainly from preventable causes, which is
unconscionable in the 21st century.
- Paper 2: Evidence-based, cost-effective interventions: How many newborn babies can we save?
Gary L. Darmstadt et al.
In this second article of the neonatal survival series, we identify 16
interventions with proven efficacy (implementation under ideal conditions)
for neonatal survival and combine them into packages for scaling up in
health systems, according to three service delivery modes (outreach,
family-community, and facility-based clinical care). All the packages of
care are cost effective compared with single interventions. Universal
(99%) coverage of these interventions could avert an estimated 41-72% of
neonatal deaths worldwide. At 90% coverage, intrapartum and postnatal
packages have similar effects on neonatal mortality-two-fold to three-fold
greater than that of antenatal care. However, running costs are two-fold
higher for intrapartum than for postnatal care. A combination of
universal-ie, for all settings-outreach and family-community care at 90%
coverage averts 18-37% of neonatal deaths. Most of this benefit is derived
from family-community care, and greater effect is seen in settings with
very high neonatal mortality. Reductions in neonatal mortality that exceed
50% can be achieved with an integrated, highcoverage programme of
universal outreach and family-community care, consisting of 12% and 26%,
respectively, of total running costs, plus universal facility-based
clinical services, which make up 62% of the total cost. Early success in
averting neonatal deaths is possible in settings with high mortality and
weak health systems through outreach and family-community care, including
health education to improve home-care practices, to create demand for
skilled care, and to improve care seeking. Simultaneous expansion of
clinical care for babies and mothers is essential to achieve the reduction
in neonatal deaths needed to meet the Millennium Development Goal for
child survival.
- Paper 3: Systematic scaling up of neonatal care in countries
Rudolf Knippenberg et al.
Every year about 70% of neonatal deaths (almost 3 million) happen because
effective yet simple interventions do not reach those most in need.
Coverage of interventions is low, progress in scaling up is slow, and
inequity is high, especially for skilled clinical interventions.
Situations vary between and within countries, and there is no single
solution to saving lives of newborn babies. To scale up neonatal care, two
interlinked processes are required: a systematic, data-driven
decision-making process, and a participatory, rights-based policy process.
The first step is to assess the situation and create a policy environment
conducive to neonatal health. The next step is to achieve optimum care of
newborn infants within health system constraints; in the absence of strong
clinical services, programmes can start with family and community care and
outreach services. Addressing missed opportunities within the limitations
of health systems, and integrating care of newborn children into existing
programmes-eg, safe motherhood and integrated management of child survival
initiatives-reduces deaths at a low marginal cost. Scaling up of clinical
care is a challenge but necessary if maximum effect and equity are to be
achieved in neonatal health, and maternal deaths are to be reduced. This
step involves systematically strengthening supply of, and demand for,
services. Such a phased programmatic implementation builds momentum by
reaching achievable targets early on, while building stronger health
systems over the longer term. Purposeful orientation towards the poor is
vital. Monitoring progress and effect is essential to refining strategies.
National aims to reduce neonatal deaths should be set, and interventions
incorporated into national plans and existing programmes.
- Paper 4: Neonatal health: A call for action
Jose Martines et al.
To achieve the Millennium Development Goal for child survival (MDG-4),
neonatal deaths need to be prevented. Previous papers in this series have
presented the size of the problem, discussed cost-effective interventions,
and outlined a systematic approach to overcoming health-system constraints
to scaling up. We address issues related to improving neonatal survival.
Countries should not wait to initiate action. Success is possible in
low-income countries and without highly developed technology. Effective,
low-cost interventions exist, but are not present in programmes. Specific
efforts are needed by safe motherhood and child survival programmes.
Improved availability of skilled care during childbirth and
family/community-based care through postnatal home visits will benefit
mothers and their newborn babies. Incorporation of management of neonatal
illness into the integrated management of childhood illness initiative
(IMCI) will improve child survival. Engagement of the community and
promotion of demand for care are crucial. To halve neonatal mortality
between 2000 and 2015 should be one of the targets of MDG-4. Development,
implementation, and monitoring of national action plans for neonatal
survival is a priority.
We estimate the running costs of the selected
packages at 90% coverage in the 75 countries with the highest mortality
rates to be US$4·1 billion a year, in addition to current expenditures of
$2·0 billion. About 30% of this money would be for interventions that have
specific benefit for the newborn child; the remaining 70% will also
benefit mothers and older children, and substantially reduce rates of
stillbirths. The cost per neonatal death averted is estimated at $2100
(range $1700-3100). Maternal, neonatal, and child health receive little
funding relative to the large numbers of deaths. International donors and
leaders of developing countries should be held accountable for meeting
their commitments and increasing resources.
Select Press Coverage of March 3 Lancet Series Launch
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