Summary In this Series paper, we review trends since the 2005 Lancet Series on Neonatal Survival to inform acceleration of progress for newborn health post-2015. On the basis of multicountry analyses ...and multi-stakeholder consultations, we propose national targets for 2035 of no more than 10 stillbirths per 1000 total births, and no more than 10 neonatal deaths per 1000 livebirths, compatible with the under-5 mortality targets of no more than 20 per 1000 livebirths. We also give targets for 2030. Reduction of neonatal mortality has been slower than that for maternal and child (1–59 months) mortality, slowest in the highest burden countries, especially in Africa, and reduction is even slower for stillbirth rates. Birth is the time of highest risk, when more than 40% of maternal deaths (total about 290 000) and stillbirths or neonatal deaths (5·5 million) occur every year. These deaths happen rapidly, needing a rapid response by health-care workers. The 2·9 million annual neonatal deaths worldwide are attributable to three main causes: infections (0·6 million), intrapartum conditions (0·7 million), and preterm birth complications (1·0 million). Boys have a higher biological risk of neonatal death, but girls often have a higher social risk. Small size at birth—due to preterm birth or small-for-gestational-age (SGA), or both—is the biggest risk factor for more than 80% of neonatal deaths and increases risk of post-neonatal mortality, growth failure, and adult-onset non-communicable diseases. South Asia has the highest SGA rates and sub-Saharan Africa has the highest preterm birth rates. Babies who are term SGA low birthweight (10·4 million in these regions) are at risk of stunting and adult-onset metabolic conditions. 15 million preterm births, especially of those younger than 32 weeks' gestation, are at the highest risk of neonatal death, with ongoing post-neonatal mortality risk, and important risk of long-term neurodevelopmental impairment, stunting, and non-communicable conditions. 4 million neonates annually have other life-threatening or disabling conditions including intrapartum-related brain injury, severe bacterial infections, or pathological jaundice. Half of the world's newborn babies do not get a birth certificate, and most neonatal deaths and almost all stillbirths have no death certificate. To count deaths is crucial to change them. Failure to improve birth outcomes by 2035 will result in an estimated 116 million deaths, 99 million survivors with disability or lost development potential, and millions of adults at increased risk of non-communicable diseases after low birthweight. In the post-2015 era, improvements in child survival, development, and human capital depend on ensuring a healthy start for every newborn baby—the citizens and workforce of the future.
Nepal is on target to meet the Millennium Development Goals for maternal and child health despite high levels of poverty, poor infrastructure, difficult terrain and recent conflict. Each year, nearly ...35 000 Nepali children die before their fifth birthday, with almost two-thirds of these deaths occurring in the first month of life, the neonatal period. As part of a multi-country analysis, we examined changes for newborn survival between 2000 and 2010 in terms of mortality, coverage and health system indicators as well as national and donor funding. Over the decade, Nepal's neonatal mortality rate reduced by 3.6% per year, which is faster than the regional average (2.0%) but slower than national annual progress for mortality of children aged 1-59 months (7.7%) and maternal mortality (7.5%). A dramatic reduction in the total fertility rate, improvements in female education and increasing change in skilled birth attendance, as well as increased coverage of community-based child health interventions, are likely to have contributed to these mortality declines. Political commitment and support for newborn survival has been generated through strategic use of global and national data and effective partnerships using primarily a selective newborn-focused approach for advocacy and planning. Nepal was the first low-income country to have a national newborn strategy, influencing similar strategies in other countries. The Community-Based Newborn Care Package is delivered through the nationally available Female Community Health Volunteers and was piloted in 10 of 75 districts, with plans to increase to 35 districts in mid-2013. Innovation and scale up, especially of community-based packages, and public health interventions and commodities appear to move relatively rapidly in Nepal compared with some other countries. Much remains to be done to achieve high rates of effective coverage of community care, and especially to improve the quality of facility-based care given the rapid shift to births in facilities.
Who has been caring for the baby? Darmstadt, Gary L, Dr; Kinney, Mary V, MSc; Chopra, Mickey, MD ...
The Lancet (British edition),
07/2014, Letnik:
384, Številka:
9938
Journal Article
Recenzirano
Summary Nearly a decade ago, The Lancet published the Neonatal Survival Series, with an ambitious call for integration of newborn care across the continuum of reproductive, maternal, newborn, and ...child health and nutrition (RMNCH). In this first of five papers in the Every Newborn Series, we consider what has changed during this decade, assessing progress on the basis of a systematic policy heuristic including agenda-setting, policy formulation and adoption, leadership and partnership, implementation, and evaluation of effect. Substantial progress has been made in agenda setting and policy formulation for newborn health, as witnessed by the shift from maternal and child health to maternal, newborn, and child health as a standard. However, investment and large-scale implementation have been disappointingly small, especially in view of the size of the burden and potential for rapid change and synergies throughout the RMNCH continuum. Moreover, stillbirths remain invisible on the global health agenda. Hence that progress in improvement of newborn survival and reduction of stillbirths lags behind that of maternal mortality and deaths for children aged 1–59 months is not surprising. Faster progress is possible, but with several requirements: clear communication of the interventions with the greatest effect and how to overcome bottlenecks for scale-up; national leadership, and technical capacity to integrate and implement these interventions; global coordination of partners, especially within countries, in provision of technical assistance and increased funding; increased domestic investment in newborn health, and access to specific commodities and equipment where needed; better data to monitor progress, with local data used for programme improvement; and accountability for results at all levels, including demand from communities and mortality targets in the post-2015 framework. Who will step up during the next decade to ensure decision making in countries leads to implementation of stillbirth and newborn health interventions within RMNCH programmes?
Neonatal deaths account for 40% of global under-five mortality and are ever more important if we are to achieve the Millennium Development Goal 4 (MDG 4) on child survival. We applied a results ...framework to evaluate global and national changes for neonatal mortality rates (NMR), healthy behaviours, intervention coverage, health system change, and inputs including funding, while considering contextual changes. The average annual rate of reduction of NMR globally accelerated between 2000 and 2010 (2.1% per year) compared with the 1990s, but was slower than the reduction in mortality of children aged 1-59 months (2.9% per year) and maternal mortality (4.2% per year). Regional variation of NMR change ranged from 3.0% per year in developed countries to 1.5% per year in sub-Saharan Africa. Some countries have made remarkable progress despite major challenges. Our statistical analysis identifies inter-country predictors of NMR reduction including high baseline NMR, and changes in income or fertility. Changes in intervention or package coverage did not appear to be important predictors in any region, but coverage data are lacking for several neonatal-specific interventions. Mortality due to neonatal infection deaths, notably tetanus, decreased, and deaths from complications of preterm birth are increasingly important. Official development assistance for maternal, newborn and child health doubled from 2003 to 2008, yet by 2008 only 6% of this aid mentioned newboms, and a mere 0.1% (US$4.56m) exclusively targeted newborn care. The amount of newborn survival data and the evidence based increased, as did recognition in donor funding. Over this decade, NMR reduction seems more related to change in context, such as socio-economic factors, than to increasing intervention coverage. High impact cost-effective interventions hold great potential to save newborn lives especially in the highest burden countries. Accelerating progress requires data-driven investments and addressing context-specific implementation realities.
Elimination communication, also known as natural infant hygiene, is the practice of using the infant's natural timing and cues to recognize when they need to defecate or urinate. By identifying these ...cues, caregivers can coordinate elimination in the toilet rather than in a diaper. Avoiding soiled diapers and promoting more complete bladder emptying at a younger age may reduce the risk of urinary tract infections.
Background
Kangaroo mother care (KMC), originally defined as skin‐to‐skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from ...hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants.
Objectives
To determine whether evidence is available to support the use of KMC in LBW infants as an alternative to conventional neonatal care before or after the initial period of stabilization with conventional care, and to assess beneficial and adverse effects.
Search methods
We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches in CENTRAL (Cochrane Central Register of Controlled Trials; 2016, Issue 6), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILACS (Latin American and Caribbean Health Science Information database), and POPLINE (Population Information Online) databases (all from inception to June 30, 2016), as well as the WHO (World Health Organization) Trial Registration Data Set (up to June 30, 2016). In addition, we searched the web page of the Kangaroo Foundation, conference and symposia proceedings on KMC, and Google Scholar.
Selection criteria
Randomized controlled trials comparing KMC versus conventional neonatal care, or early‐onset KMC versus late‐onset KMC, in LBW infants.
Data collection and analysis
Data collection and analysis were performed according to the methods of the Cochrane Neonatal Review Group.
Main results
Twenty‐one studies, including 3042 infants, fulfilled inclusion criteria. Nineteen studies evaluated KMC in LBW infants after stabilization, one evaluated KMC in LBW infants before stabilization, and one compared early‐onset KMC with late‐onset KMC in relatively stable LBW infants. Sixteen studies evaluated intermittent KMC, and five evaluated continuous KMC.
KMC versus conventional neonatal care: At discharge or 40 to 41 weeks' postmenstrual age, KMC was associated with a statistically significant reduction in the risk of mortality (risk ratio RR 0.60, 95% confidence interval CI 0.39 to 0.92; eight trials, 1736 infants), nosocomial infection/sepsis (RR 0.35, 95% CI 0.22 to 0.54; five trials, 1239 infants), and hypothermia (RR 0.28, 95% CI 0.16 to 0.49; nine trials, 989 infants; moderate‐quality evidence). At latest follow‐up, KMC was associated with a significantly decreased risk of mortality (RR 0.67, 95% CI 0.48 to 0.95; 12 trials, 2293 infants; moderate‐quality evidence) and severe infection/sepsis (RR 0.50, 95% CI 0.36 to 0.69; eight trials, 1463 infants; moderate‐quality evidence). Moreover, KMC was found to increase weight gain (mean difference MD 4.1 g/d, 95% CI 2.3 to 5.9; 11 trials, 1198 infants; moderate‐quality evidence), length gain (MD 0.21 cm/week, 95% CI 0.03 to 0.38; three trials, 377 infants) and head circumference gain (MD 0.14 cm/week, 95% CI 0.06 to 0.22; four trials, 495 infants) at latest follow‐up, exclusive breastfeeding at discharge or 40 to 41 weeks' postmenstrual age (RR 1.16, 95% CI 1.07 to 1.25; six studies, 1453 mothers) and at one to three months' follow‐up (RR 1.20, 95% CI 1.01 to 1.43; five studies, 600 mothers), any (exclusive or partial) breastfeeding at discharge or at 40 to 41 weeks' postmenstrual age (RR 1.20, 95% CI 1.07 to 1.34; 10 studies, 1696 mothers; moderate‐quality evidence) and at one to three months' follow‐up (RR 1.17, 95% CI 1.05 to 1.31; nine studies, 1394 mothers; low‐quality evidence), and some measures of mother‐infant attachment and home environment. No statistically significant differences were found between KMC infants and controls in Griffith quotients for psychomotor development at 12 months’ corrected age (low‐quality evidence). Sensitivity analysis suggested that inclusion of studies with high risk of bias did not affect the general direction of findings nor the size of the treatment effect for main outcomes.
Early‐onset KMC versus late‐onset KMC in relatively stable infants: One trial compared early‐onset continuous KMC (within 24 hours post birth) versus late‐onset continuous KMC (after 24 hours post birth) in 73 relatively stable LBW infants. Investigators reported no significant differences between the two study groups in mortality, morbidity, severe infection, hypothermia, breastfeeding, and nutritional indicators. Early‐onset KMC was associated with a statistically significant reduction in length of hospital stay (MD 0.9 days, 95% CI 0.6 to 1.2).
Authors' conclusions
Evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care, mainly in resource‐limited settings. Further information is required concerning the effectiveness and safety of early‐onset continuous KMC in unstabilized or relatively stabilized LBW infants, as well as long‐term neurodevelopmental outcomes and costs of care.
Nearly every European country has experienced some increase in nonmarital childbearing, largely due to increasing births within cohabitation. Relatively few studies in Europe, however, investigate ...the educational gradient of childbearing within cohabitation or how it changed over time. Using retrospective union and fertility histories, we employ competing risk hazard models to examine the educational gradient of childbearing in cohabitation in eight countries across Europe. In all countries studied, birth risks within cohabitation demonstrated a negative educational gradient. When directly comparing cohabiting fertility with marital fertility, the negative educational gradient persists in all countries except Italy, although differences were not significant in Austria, France, and West Germany. To explain these findings, we present an alternative explanation for the increase in childbearing within cohabitation that goes beyond the explanation of the Second Demographic Transition and provides a new interpretation of the underlying mechanisms that may influence childbearing within cohabitation.
Sweden has a long tradition of being at the forefront of the management of extremely preterm infants. In this article, we explore the historical background, ethical discussions, and evidence from ...national surveys combined with data from quality registers that form the background of the current Swedish guidelines for the care of extremely preterm infants. The current Swedish national guidelines suggest providing active care for preterm infants from 23 weeks' gestation and considering active care from 22 weeks' gestation. The survival of infants in gestational weeks 22 and 23 has increased and now exceed 50% and 60%, respectively; importantly, the Swedish proactive approach to care at the border of viability has not resulted in an increased proportion of functional impairment among survivors.
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