New data released today (September 16) by the United Nations Organisation show that under-five mortality rates have dropped by 49 per cent between 1990 and 2013. There has been accelerated average annual reduction during this period but overall progress is still short of meeting the global target of two-thirds decrease in under-five mortality by 2015.
New estimates in Levels and Trends in Child Mortality 2014 show that in 2013, globally, 6.3 million children under five years of age died from mostly preventable causes. Compared with 2012, the 2013 numbers show a reduction of 200,000 deaths. The reduction is only marginal as there are still 17,000 child deaths every day in the world.
The neonatal period (0-27 days) is the most vulnerable period for a newborn. It is therefore not surprising that in 2013, 2.8 million babies across the world died during this period. The 2.8 million neonatal deaths account for 44 per cent of all under-five deaths in children.
India has the highest number of neonatal deaths in the world. Of the three million neonatal deaths globally in 2012, 779,000 took place in India.
If the neonatal period is vulnerable, the first day of life (24 hours) is even more critical. Of the 2.8 million babies dying across the world during the first 27 days, death during the first day of birth alone accounts for one million. What is poignant is that over 300,000 newborn deaths in India are on the very first day of birth. Thus, India accounts for about one-third of all babies dying globally on the first day of birth.
What is shocking is that many of the neonatal deaths can be easily prevented with simple, cost-effective interventions before, during and immediately after birth. Of the three periods, the time close to delivery is most critical and any failures in the healthcare system during this short window period lead to more newborn deaths.
In June this year, WHO, UNICEF and partners issued the first-ever global plan to end preventable newborn deaths and stillbirths by 2035. The Every Newborn Action Plan requires all countries to take the necessary steps to provide basic, cost-effective health services — in particular around the time of childbirth, as well as for small and sick babies — and to improve the quality of care.
“The global community is poised to end preventable maternal, newborn and child deaths within a generation,” Dr. Flavia Bustreo, Assistant Director General at WHO said in a release. “We know what to do and we know how to do it. The challenge now is to move from plan to action — we are pleased to see countries like India beginning to lead the way.”
“Fifty-six per cent of under-five child mortality in India is from neonatal mortality. Neonatal mortality had remained stable [in India] for a long time,” said Dr. Ajay Khera, Deputy Commissioner and Public Health Expert, Child Health Programme, Ministry of Health and Family Affairs, India. “Neonatal mortality rate was 37 per 1,000 live births in 2003 and by 2009 it dropped to 34. But from 2009 to 2012 the rate dropped from 34 to 29.”
“There was a decline of five points in three years [from 2009 to 2012], while it dropped only three points in six years [from 2003 to 2009],” he said.
There was a global stagnation in neonatal mortality for a long period and India’s stable condition was a reflection of the global trend. The reason: the Millennium Development Goal (MDG) targeted only under-five mortality reduction and as a result the reduction in child mortality more than doubled in the last ten years compared with previous decades.
“By contrast, newborn mortality and stillbirth reduction did not feature in the MDG and had slower progress compared with overall under-five mortality and maternal mortality during the same period,” notes a paper published on August 2 in The Lancet .
“India has shown significant reduction in neonatal mortality in the last two years. Every year [since 2009 when the rate was 34] we have reduced the rate,” Dr. Khera said. “In 2010 the [neonatal mortality] rate was 33, in 2011 it was 31 and in 2012 it dropped two points to 29.”
“The government has accorded highest priority to improving newborn health and it has come out with special interventions to improve newborn survival,” he said.
Four major interventions
The first of the four major interventions to reduce neonatal mortality has been the promotion of institutional deliveries by providing conditional cash transfer to pregnant women. In addition to cash transfer incentive, women delivering in government institutions are guaranteed free drugs, diagnostic tests, diet and free transport to the healthcare centre.
Getting pregnant women to healthcare facilities where trained healthcare workers are present greatly improves the chances of survival of the newborn babies.
“Institutional deliveries five years back were 40 per cent but are now 70 per cent,” Dr. Khera said.
While institutional deliveries have reduced neonatal mortality, the rate of reduction fails to reflect the increase in institutional deliveries. For instance, in the three States of Madhya Pradesh, Uttar Pradesh and Odisha, the mortality during the period 0-7 days is still high despite institutional deliveries being 63 per cent, 46 per cent and 53 per cent respectively.
“There are several reasons for this,” said Dr. Khera. “The first is to do with the quality of skill training of healthcare workers. Multi-deliveries by women at short intervals is one of other reasons for newborn deaths. So family planning has to be given importance and pregnant mothers need to be educated on spacing between births, having fewer children and the need for rest during pregnancy. These are happening simultaneously but changes will take time to show up.”
He also said that the proportion of women wanting to deliver at home despite the conditional cash transfer and other incentives is only 10-20 per cent. “The proportion of women wanting to deliver at home has reduced drastically,” he said.
The second major government intervention has been the establishment of newborn care corners. “The newborn care corners have been started all over the country. There are currently 14,000 such care corners, roughly three or four per district,” Dr. Khera said. The newborn care corners provide immediate care for newborns to further improve their chances of survival.
The third major initiative of the government is the establishment of special newborn care units. Currently, there are 548 such units across the country. “The special newborn units care for babies that have very serious conditions. Every year six lakh newborn babies get admitted. But for these units they would have died,” he said.
The last major initiative has been the home visits of newborns by nine lakh ASHA workers. “During home visits, the ASHA workers educate the mothers on breastfeeding, the importance of keeping the babies warm and also identify sick newborns and refer them to units where they can get admitted,” Dr. Khera said.
Greater attention should be focussed on improving breastfeeding within an hour of birth as it can save 44 per cent of newborns. “The first breast milk is colostrum which is thicker and nutritious. It is important on several counts -- it provides early nutrition, has vitamin A, decreases jaundice, has antibodies from the mother which decreases infections, improves newborn development. Early breastfeeding also provides the baby with warmth and provides bonding with the mother," Dr. Shyama Kuruvilla, Senior Technical Officer, Knowledge for Policy, Partnership for Maternal, Newborn & Child Health (PMNCH) hosted by WHO said in an email to this Correspondent.
Areas of concern
There are still some critical areas where more action has to be taken to further reduce newborn and neonatal mortality. For instance, of the 2.6 million stillbirths in the world, 600,000 are in India. Stillbirths take place quite close to the time of delivery and hence there are chances of preventing such deaths.
Another area that needs focus is the reduction in preterm births. According to a 2012 WHO report, there were 100,000 to 250,000 preterm births in India. Premature birth is one that takes place more than three weeks before the baby (after less than 37 weeks of pregnancy) is due for normal delivery. Preterm births cause about 50 per cent of neonatal mortality and the precise reasons are not known. But surely, increasing the spacing between two births, preventing adolescent pregnancy and providing medical care will go a long way in reducing the number of preterm births.