Abstract
Progress in newborn survival has been slow, and even more so for reductions in stillbirths. To meet Every Newborn targets of ten or fewer neonatal deaths and ten or fewer stillbirths per 1000 births in every country by 2035 will necessitate accelerated scale-up of the most effective care targeting major causes of newborn deaths. We have systematically reviewed interventions across the continuum of care and various delivery platforms, and then modelled the effect and cost of scale-up in the 75 high-burden Countdown countries. Closure of the quality gap through the provision of effective care for all women and newborn babies delivering in facilities could prevent an estimated 113 000 maternal deaths, 531 000 stillbirths, and 1.325 million neonatal deaths annually by 2020 at an estimated running cost of US$4.5 billion per year (US$0.9 per person). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1.9 million [range 1.6-2.1 million]), 33% of stillbirths (0.82 million [0.60-0.93 million]), and 54% of maternal deaths (0.16 million [0.14-0.17 million]) per year. These reductions can be achieved at an annual incremental running cost of US$5.65 billion (US$1.15 per person), which amounts to US$1928 for each life saved, including stillbirths, neonatal, and maternal deaths. Most (82%) of this effect is attributable to facility-based care which, although more expensive than community-based strategies, improves the likelihood of survival. Most of the running costs are also for facility-based care (US$3.66 billion or 64%), even without the cost of new hospitals and country-specific capital inputs being factored in. The maximum effect on neonatal deaths is through interventions delivered during labour and birth, including for obstetric complications (41%), followed by care of small and ill newborn babies (30%). To meet the unmet need for family planning with modern contraceptives would be synergistic, and would contribute to around a halving of births and therefore deaths. Our analysis also indicates that available interventions can reduce the three most common cause of neonatal mortality-preterm, intrapartum, and infection-related deaths-by 58%, 79%, and 84%, respectively.
| Original language | English |
|---|---|
| Pages (from-to) | 347-370 |
| Number of pages | 24 |
| Journal | The Lancet |
| Volume | 384 |
| Issue number | 9940 |
| DOIs | |
| Publication status | Published - 2014 |
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In: The Lancet, Vol. 384, No. 9940, 2014, p. 347-370.
Research output: Contribution to journal › Review article › peer-review
TY - JOUR
T1 - Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?
AU - Bhutta, Zulfiqar A.
AU - Das, Jai K.
AU - Bahl, Rajiv
AU - Lawn, Joy E.
AU - Salam, Rehana A.
AU - Paul, Vinod K.
AU - Sankar, M. Jeeva
AU - Blencowe, Hannah
AU - Rizvi, Arjumand
AU - Chou, Victoria B.
AU - Walker, Neff
N1 - Funding Information: Our review is the first comprehensive analysis of the evidence base and strategies to address global newborn health and survival and delivery strategies since our analyses in 2005, and has the additional strength of considering maternal and stillbirth outcomes. 5,136 During the past decade, notable advances have been made in the breadth and depth of the evidence base for newborn interventions, 1 especially in the context of essential interventions and packages of care. 137 Some highlights include new interventions such as cord cleaning with chlorhexidine, additional evidence of the potential benefits of known interventions such as kangaroo mother care and antenatal steroids, expansion of access to treatment of neonatal infections, and the improved feasibility of more advanced care such as neonatal resuscitation and continuous positive airway pressure devices because of adaptation and innovation of equipment and training methods. We now have more experience with large-scale community-based projects to scale-up care in Asia and Africa 98 and strategies to improve access to universal care. Despite this enhanced evidence, overall coverage of interventions remains low, reductions in neonatal mortality very poor, and progress for stillbirths even more inadequate. 3,138 High coverage of available interventions by 2025 could prevent almost three-quarters of neonatal deaths, saving around 2 million lives per year, at a running cost of $1·15 per person, and would put countries on track to achieve the “Every Newborn” and “A Promise Renewed” targets for neonatal mortality reduction by 2030 and 2035, respectively. Packages for care during labour and childbirth (including complications and immediate care of the neonate) and for the care of small and ill neonates have the potential to save 1·9 million newborn infants (almost 92% of all newborn deaths averted). These two packages are the main focus of the call for action in the Every Newborn Action Plan. 139 Indeed, even if by 2020 every woman delivering a newborn in a facility received recommended care, our estimates suggest that 1·325 million newborn infants, 0·531 million stillbirths, and 0·112 million women could be saved every year at annual running costs of US$4·5 billion, or less than a dollar per person in the 75 highest burden countries. This closure of the quality gap for facility births must become imperative for every country and is surely one of the best investments in health and also human rights. According to the Lancet Global Investment Framework, 127 an even greater effect is possible with universal coverage in 2035. Especially important is to address unmet need for family planning, which would reduce births, further reduce deaths and also reduce the load on the health-care system. This framework suggests that an investment of US$5 per person per year up to 2035 in 74 high-burden countries could yield up to nine-times that value in economic and social benefits, and would prevent the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. The analysis also suggested that scaling up of family planning could lead to a 47% reduction in child deaths and a 64% reduction in stillbirths. Their estimate for running costs—excluding those for health system strengthening, new human resources, programme management, and conditional cash transfers—was US$2·1 per person, which suggests that our estimated running costs of US$1·15 per person for maternal and newborn interventions are plausible. The high proportionate reduction in neonatal mortality suggests that the major killers of newborn babies in low-income and middle-income countries can be addressed—a notion supported by the dramatic reduction in these deaths in high-income countries. New trend data suggest that in some low-income and middle-income countries, deaths caused by neonatal infections have fallen during the past decade at a rate faster than have deaths due to intrapartum complications and substantially more than preterm deaths. 1 This finding might be indicative of inadequate attention to care of small babies in facilities in low-income and middle-income countries. Importantly, since many of these interventions are delivered in the antenatal period and around childbirth, they have the potential to reduce stillbirths by a third and reduce maternal deaths by 50%—a triple return on investment with additional benefits on later child survival, improved growth, reduced disability, and non-communicable diseases. The effect on stillbirths is smaller and more work is needed to increase the scope and scaleability of interventions, especially for antepartum stillbirths. The effect on maternal mortality would be higher with the inclusion of some other postnatal interventions to address maternal mortality, such as the prevention and management of maternal haemorrhage and infections. Our scale-up scenarios for the care of the small and ill neonates are deliberately ambitious but not unrealistic. Our analysis also challenges the view that newborn care is prohibitively expensive once intensive care is added. 140 With the scaling up of secondary and tertiary care for 90% of newborn infants in need by 2025, the model suggests that although the costs are substantial, the effect is huge. These benefits do not yet take into account potential long-term gains for human capital by lower disability. 3 The rapid increase in facility births in many settings in recent years gives credence to opportunities for impact with more focus on facility care ). We continue to support the importance of community-based strategies, including women's groups and the key role that community health workers have in preventive and promotive care and in delivering basic care in primary care settings. 110 but also emphasises the crucial need to match the supply-side interventions to provide quality maternal and newborn care in health systems with ongoing promotion of demand for care. Our analysis here, consistent with the 2005 Lancet Neonatal Series, estimated that community and primary care approaches will save about a third of newborn lives over the next 5–6 years. Even when facility-based care coverage exceeds 90%, community interventions will still continue to contribute to reducing a fifth of all newborn deaths. The maximum benefits would be accrued through a focus on integrated delivery and scale-up of both community-based and primary care strategies while clinical care in facilities and transport systems are strengthened ( figure 6 98 However, in view of the effect at community level, especially for intrapartum-associated complications and preterm infants, improvement of the quality of care in referral facilities through evidence-based interventions should also be prioritised. A key programme challenge is to reduce the equity gap, to reach those women and newborn infants in the greatest need. Although classic equity analysis relies largely on tracking differentials using income or asset quintiles, 141 many of these differentials relate to issues of ethnicity, geography, and other forms of social marginalisation. We limited our repertoire of interventions to those that address the distal pathways within the health sector while fully recognising the importance of social determinants. We should emphasise that these technological advancements and interventions have to be layered on approaches to address social determinants, education and empowerment of women in society, and human rights, especially the health and wellbeing of girls. Strategies to overcome these obstacles include addressing of financial barriers 105 and deliberate targeting of patient groups through community outreach programmes. 98 The evidence from the role of women's groups from various settings also underscores the need for continued community engagement, demand creation, and empowerment of communities—especially women—as a continued adjunct to interventions within the health sector. The transition from home deliveries to facility births can be accelerated through incentives that increase coverage of skilled care in facility settings. The latter also necessitates consideration of strategies to move beyond community care and task shifting to appropriate quality care in district and referral health facilities. So far, this approach has not received sufficient attention and is crucially important, especially in view of the longer time frame post-MDGs to 2035. Given the burden of preterm births in low-income and middle-income countries, low-cost strategies to manage preterm infants with respiratory distress syndrome as an adjunct to preventive strategies, such as the use of antenatal steroids and management of complications in pregnancy, could potentially save many lives. The mortality reduction targets of the Every Newborn strategy would not be achievable without the rational development of high-quality facility-based newborn care. An urgent need therefore exists to develop acceptable standards, norms, and protocols for facility-based newborn care, and enhance capacity in this crucial area of newborn health care. The vital role of health care professionals, especially well-trained midwives, in achieving these goals must be recognised. 142 Our findings have several limitations that should be recognised. We still struggle with the level and quality of evidence for many of the interventions considered here, with relatively few effectiveness assessments of packages of care. We have used LiST to estimate effect and have provided uncertainty ranges that do draw attention to the wide uncertainty, more so for partial estimates. Our cost estimates are also consistent with those in several recent studies ( table 3 and appendix pp 68–80 ) and are based on estimated annual running costs. Contextual factors and assessment of specific health systems gaps are essential for planning, and further analysis of the full costs should be based on actual country-specific planning for human resources and infrastructure gaps. The incremental running cost approach is also more comparable across countries and does provide a basis for more detailed national and subnational planning for additional specific investments. Integration and further scale-up of these interventions in health systems will benefit women, babies, development outcomes, and economic capital—a quadruple return on investment. The key is to prioritise implementation to overcome context-specific bottlenecks. 143 Universal health coverage, which entitles every citizen and every family to a package of health care services guaranteed by the state is the lens through which equitable provision of maternal and newborn care should be viewed. No country can afford to ignore this investment case to change survival and health for every newborn baby and future generations. This online publication has been corrected. The corrected version first appeared at thelancet.com on June 23, 2014 Contributors ZAB was responsible for overall coordination and oversight of the review and writing process; JKD for coordination of reviews and substantial contribution to the writing process; RAS for reviews of maternal vaccination, emollient and massage therapy, adolescent interventions, and quality of care reviews; ZL for community delivery platforms, management of gestational diabetes mellitus; VKP, RA, and JMS for respiratory distress syndrome, meconium aspiration syndrome, and continuous positive airway pressure reviews; HB and JEL for folate supplementation or fortification, syphilis, tetanus vaccine, hypothermia management, kangaroo mother care, obstetric care, and neonatal resusciation; AI for maternal calcium and balanced energy protein supplementation, cord care and intrauterine growth restriction; SA and AL for contributing the section on mHealth; JEL, VBC, and AR for working on the LiST and cost analysis; and NW for overseeing the modelling and costing process. All named authors contributed to the conceptualisation, writing, and finalisation of the paper. ZAB is the overall guarantor. The Lancet Every Newborn Interventions Review Group Rehana A Salam, Zohra Lassi, Jai K Das (Aga Khan University, Karachi, Pakistan); Zulfiqar A Bhutta (Aga Khan University, Karachi, Pakistan, and Sick Kids Centre for Global Child Health, Toronto, Canada); Hannah Blencowe, Joy Lawn (London School of Hygiene & Tropical Medicine, London, UK); Vinod K Paul, Jeeva M Sankar, Ramesh Agarwal (All India Institute of Medical Sciences, New Dehli, India); Venkatnarayan Kannan (Command Hospital Eastern Command, Kolkata, India); Rajiv Bahl (World Health Organization, Geneva, Switzerland). The Lancet Every Newborn Study Group Joy E Lawn, Zulfiqar Bhutta, Gary Darmstadt, Kim Dickson, Mary Kinney, Liz Mason, and Lori McDougall. Declaration of interests We declare no competing interests. Acknowledgments RB's views are his own and do not represent the official position of WHO. The systematic reviews and the consultative meetings were supported by unrestricted support to various review group members from the Aga Khan University, WHO, Mother and Child Care Trust, Save the Children (USA), and grants from Bill & Melinda Gates Foundation to the US Fund for UNICEF. None of the funding bodies had any influence on the content and scope of the paper. We thank Smisha Agarwal and Alain Labrique (USAID) for information about mHealth interventions for newborn survival and Ingrid Friberg (JHU) for her support towards the LiST analyses. We thank Akber Ali for his assistance in the logistics around communications and the preparation of this report.
PY - 2014
Y1 - 2014
N2 - Progress in newborn survival has been slow, and even more so for reductions in stillbirths. To meet Every Newborn targets of ten or fewer neonatal deaths and ten or fewer stillbirths per 1000 births in every country by 2035 will necessitate accelerated scale-up of the most effective care targeting major causes of newborn deaths. We have systematically reviewed interventions across the continuum of care and various delivery platforms, and then modelled the effect and cost of scale-up in the 75 high-burden Countdown countries. Closure of the quality gap through the provision of effective care for all women and newborn babies delivering in facilities could prevent an estimated 113 000 maternal deaths, 531 000 stillbirths, and 1.325 million neonatal deaths annually by 2020 at an estimated running cost of US$4.5 billion per year (US$0.9 per person). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1.9 million [range 1.6-2.1 million]), 33% of stillbirths (0.82 million [0.60-0.93 million]), and 54% of maternal deaths (0.16 million [0.14-0.17 million]) per year. These reductions can be achieved at an annual incremental running cost of US$5.65 billion (US$1.15 per person), which amounts to US$1928 for each life saved, including stillbirths, neonatal, and maternal deaths. Most (82%) of this effect is attributable to facility-based care which, although more expensive than community-based strategies, improves the likelihood of survival. Most of the running costs are also for facility-based care (US$3.66 billion or 64%), even without the cost of new hospitals and country-specific capital inputs being factored in. The maximum effect on neonatal deaths is through interventions delivered during labour and birth, including for obstetric complications (41%), followed by care of small and ill newborn babies (30%). To meet the unmet need for family planning with modern contraceptives would be synergistic, and would contribute to around a halving of births and therefore deaths. Our analysis also indicates that available interventions can reduce the three most common cause of neonatal mortality-preterm, intrapartum, and infection-related deaths-by 58%, 79%, and 84%, respectively.
AB - Progress in newborn survival has been slow, and even more so for reductions in stillbirths. To meet Every Newborn targets of ten or fewer neonatal deaths and ten or fewer stillbirths per 1000 births in every country by 2035 will necessitate accelerated scale-up of the most effective care targeting major causes of newborn deaths. We have systematically reviewed interventions across the continuum of care and various delivery platforms, and then modelled the effect and cost of scale-up in the 75 high-burden Countdown countries. Closure of the quality gap through the provision of effective care for all women and newborn babies delivering in facilities could prevent an estimated 113 000 maternal deaths, 531 000 stillbirths, and 1.325 million neonatal deaths annually by 2020 at an estimated running cost of US$4.5 billion per year (US$0.9 per person). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1.9 million [range 1.6-2.1 million]), 33% of stillbirths (0.82 million [0.60-0.93 million]), and 54% of maternal deaths (0.16 million [0.14-0.17 million]) per year. These reductions can be achieved at an annual incremental running cost of US$5.65 billion (US$1.15 per person), which amounts to US$1928 for each life saved, including stillbirths, neonatal, and maternal deaths. Most (82%) of this effect is attributable to facility-based care which, although more expensive than community-based strategies, improves the likelihood of survival. Most of the running costs are also for facility-based care (US$3.66 billion or 64%), even without the cost of new hospitals and country-specific capital inputs being factored in. The maximum effect on neonatal deaths is through interventions delivered during labour and birth, including for obstetric complications (41%), followed by care of small and ill newborn babies (30%). To meet the unmet need for family planning with modern contraceptives would be synergistic, and would contribute to around a halving of births and therefore deaths. Our analysis also indicates that available interventions can reduce the three most common cause of neonatal mortality-preterm, intrapartum, and infection-related deaths-by 58%, 79%, and 84%, respectively.
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U2 - 10.1016/S0140-6736(14)60792-3
DO - 10.1016/S0140-6736(14)60792-3
M3 - Review article
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SN - 0140-6736
VL - 384
SP - 347
EP - 370
JO - The Lancet
JF - The Lancet
IS - 9940
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