Strategies to reduce perinatal mortality
Authors: Peter Cooper
Journal: The Lancet Global Health (2015)

In the past few decades, there has been an impressive decline in the mortality of children younger than 5 years worldwide. Child mortality was given impetus by Millennium Development Goal (MDG) 4, which aimed to reduce the under-5 mortality rate by two-thirds, between 1990 and 2015. Although this figure will not be reached globally, child mortality has nevertheless been reduced by 53% over this period.1UNICEFWHOCountdown to 2015: a decade of tracking progress for maternal, newborn and child survival—the 2015 report. UNICEF and World Health Organization, Geneva2015Google Scholar However, the reduction in neonatal mortality has been much slower, with the result that, by 2012, neonatal mortality constituted 44% of all deaths in children younger than 5 years.2UNICEFWHOEvery Newborn: an action plan to end preventable deaths. UNICEF and World Health Organization, South Africa2014Google Scholar To reduce child mortality further, a focus on preventable neonatal deaths is essential. In The Lancet Global Health, Catherine Pitt and colleagues3Pitt C Tawiah T Soremekun S et al.Cost and cost-effectiveness of newborn home visits: findings from the Newhints cluster-randomised controlled trial in rural Ghana.Lancet Glob Health. 2015; (published online Nov 27.)http://dx.doi.org/10.1016/S2214-109X(15)00207-7Google Scholar report findings from their cluster-randomised controlled trial of the cost and cost-effectiveness of the Newhints newborn home-visit strategy in rural Ghana. Similar studies have been done in south Asia,4Bacqi AH Arifeen SE Darmstadt GL et al.Effect of community based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster randomised controlled trial.Lancet. 2008; 371: 1936-1944Summary Full Text Full Text PDF PubMed Scopus (460) Google Scholar but this was the first to be done in sub-Saharan Africa. The Newhints intervention consisted of home visits to pregnant women and their newborn babies by community-based surveillance volunteers. One of the primary objectives of the study was to assess the effect of the intervention on neonatal mortality. In the paper presenting the results of the Newhints trial,5Kirkwood BR Manu A Ten Asbroek AHA et al.Effects of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial.Lancet. 2013; 381: 2184-2192Summary Full Text Full Text PDF PubMed Scopus (140) Google Scholar Betty Kirkwood and colleagues reported that, although there was a reduction in neonatal mortality of 8% in the intervention group, this did not reach statistical significance. However, the investigators did a meta-analysis by combining their results with three studies from south Asia, which then showed a significant reduction in neonatal mortality of 12%. Using the finding of a 12% reduction in neonatal mortality, Pitt and colleagues show that, even though the reduction in neonatal mortality was relatively modest, the intervention would still be cost-effective.3Pitt C Tawiah T Soremekun S et al.Cost and cost-effectiveness of newborn home visits: findings from the Newhints cluster-randomised controlled trial in rural Ghana.Lancet Glob Health. 2015; (published online Nov 27.)http://dx.doi.org/10.1016/S2214-109X(15)00207-7Google Scholar With further statistical modelling they calculate that such an intervention is likely to be cost-effective across a wide range of neonatal mortality rates—namely, 20–60 deaths per 1000 livebirths. The conclusions of the study support the WHO recommendation that a newborn home-visiting programme should be implemented in low-income and middle-income countries.6WHOWHO recommendations on postnatal care of the mother and newborn. World Health Organization, Geneva2014Google Scholar Despite these findings, the study should be viewed in its context. The region in which the study was done already had an existing cadre of community-based surveillance volunteers who assisted with, for example, registration of births and national immunisation days. These volunteers received further training from the study team to undertake home visits during pregnancy and during the first week of life of the neonate. The volunteers received monthly incentives of US$3·49 to do these visits, and similar bonus payments for good performance. In the absence of such an existing cadre in the community, it might be necessary to pay a modest salary to establish such workers, which would substantially increase the cost of the intervention. As Pitt and colleagues rightly point out, their findings would be expected to be relevant to other rural areas of Ghana and rural areas of other similar countries. However, such a system would not easily be transferable to an urban setting. With the increasing urbanisation that is taking place in most low-income and middle-income, different strategies might need to be developed to ensure effective early follow-up of newborn babies. The Newhints trial was not expected to have more than a small effect on the mortality rate in the first 24 h after birth, which is mainly attributable to birth asphyxia and complications of prematurity.5Kirkwood BR Manu A Ten Asbroek AHA et al.Effects of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial.Lancet. 2013; 381: 2184-2192Summary Full Text Full Text PDF PubMed Scopus (140) Google Scholar However, 36% of all neonatal deaths happen in the first 24 h after birth.6WHOWHO recommendations on postnatal care of the mother and newborn. World Health Organization, Geneva2014Google Scholar Prevention of these deaths requires appropriately trained health-care professionals, adequately equipped facilities, and the necessary life-saving commodities for women and newborns. The same requirements are needed for the management of serious illness later in the neonatal period that might be detected by community health workers and referred for treatment. The quality of maternal and newborn care in health facilities in many countries with a high burden of maternal and neonatal deaths is often suboptimum, resulting in many preventable deaths, and this situation needs to be addressed. In addition to the focus on neonatal mortality, stillbirths were not part of the MDG agenda, despite having a major effect on pregnancy outcomes. Estimates show that 2·9 million neonatal deaths occur globally each year, and an additional 2·6 million babies are stillborn.7Askeer N Lawn JE Keenan W Ending preventable newborn deaths in a generation.Int J Gynecol Obstet. 2015; 131: S43-S48Summary Full Text Full Text PDF PubMed Scopus (44) Google Scholar It is therefore encouraging that the most recent Cochrane review on community-based intervention packages not only confirmed the findings of the Newhints meta-analysis with regard to a reduction in neonatal mortality, but also showed a significant reduction in stillbirths.8Lassi ZS Bhutta ZA Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes.Cochrane Database Syst Rev. 2015; 3 (CD007754.)PubMed Google Scholar Thus, although community health workers should be an important component of strategies to reduce perinatal mortality, a continuum of quality care during pregnancy, labour, delivery, and throughout the neonatal period will be key to achievement of the reduction, and ultimately the elimination, of avoidable perinatal deaths. I declare no competing interests. Cost and cost-effectiveness of newborn home visits: findings from the Newhints cluster-randomised controlled trial in rural GhanaOur findings show that the seemingly modest mortality reductions achieved by a newborn home-visit strategy might in fact be cost effective. In Ghana, such strategies are also likely to be affordable. Our findings support recommendations from WHO and UNICEF that low-income and middle-income countries implement newborn home visits. Full-Text PDF Open Access