The problem of

newborn deaths

Each year, 4 million babies die in the first 28days of life—the neonatal period. Most of

these deaths occur in developing countries fromcauses that are rare in wealthier countries.Approximately 2.5 million newborn deathscould be prevented annually by improving accessto low-cost, low-tech interventions that are notcurrently reaching those most in need.

The greatest risk of death is at the verybeginning of life: Three-quarters of all neonataldeaths (3 million) occur within one week ofbirth, and at least 1 million babies die on theirfirst day of life.Many of the world’s 3 million still-births and 500,000 maternal deaths also occurclose to the time of birth.More than half of new-borns who die were born at home and diedbefore receiving any quality health care services.

The UN’s Millennium Development Goal 4(MDG-4),which aims for a two-thirds reductionin under-5 child mortality from the base year1990 to 2015, will depend on substantiallyreducing newborn deaths, especially in sub-Saharan Africa and South Asia, where two-thirdsof all neonatal deaths occur and the leastprogress has been made in reducing thesedeaths in recent years.

The opportunity to

save newborn lives

The Lancet’s Neonatal Survival Series pub-lished in March 2005 calculated that about $4.1billion per year on top of the $2 billion cur-rently being spent could potentially save thelives of nearly 2.5 million more babies who dieunnecessarily each year from preventable andtreatable causes.i

New information is available that providesmore specific breakdowns regarding the costsand benefits of 16 proven, life-saving interven-tionsii (Table 1) for newborn infants that arerecommended for inclusion in health programsthroughout the world. For example:

■ Additional annual cost of implementing allinterventions proven to save newborn livesin sub-Saharan Africa is $1 billion, saving upto an estimated 740,000 lives each year. InSouth Asia, the cost is $1.2 billion, saving upto 1.1 million lives each year.

■ Simple family and community care practicessuch as breastfeeding, hygiene and warmthfor the baby could save up to 1 millionbabies globally at an annual additional cost of$600 million.

INVESTING TO SAVE NEWBORN LIVES | MAY 2006 1

Investing to Save

Newborn Lives

INVESTING TO SAVE NEWBORN LIVES | MAY 2006 2

Preconception Folic acid supplementation*

Prenatal Tetanus toxoid immunization

Syphilis screening and treatment

Pre-eclampsia and eclampsia: prevention

Intermittent presumptive treatment (IPT) for malaria

Detection and treatment of bacteriuria*

Intrapartum Antibiotics for preterm premature rupture of membranes (PPROM)*

Corticosteroids for preterm labor*

Detection and management of breech, multiple pregnancy

Labor surveillance (including partograph) for early diagnosis of complications

Clean delivery practices

Postnatal Newborn resuscitation

Breastfeeding

Prevention and management of hypothermia

Kangaroo mother care [low birth weight (LBW) infants in health facilities]

Community-based pneumonia case management

Daily intake of 400 µg through supplements or fortification

Two or three injections prior to or during pregnancy Screening and antibiotic treatment effectiveness depends on prevalence; appropriate in areas where syphilis rates are high

Calcium supplementation

Giving a curative treatment dose of an effective antimalarial drug at predefined intervals during pregnancy

Urinalysis during prenatal visits followed by antibiotic treatment for positive diagnoses

Antibiotics (e.g., erythromycin)

Maternal corticosteroid (e.g., betamethasone) injections during premature labor

Caesarian section

Monitoring labor, particularly with the use of a simple chart (partograph) to indicate when intervention is needed, followed by appropriate care

At delivery, clean hands, a clean delivery surface, nothing unclean in the vagina, a clean cord-cutting implement, and proper cord care

Resuscitating asphyxiated newborns using mouth-to-mouth, bag-and-mask, or tube-and-mask ventilation

Immediate (within 1 hour after birth) and exclusive (no prelacteal feeds or other fluids/food) breastfeeding

Maintenance of room warmth, immediate drying and wrapping, prompt recognition of hypothermia, and re-warming of hypothermic infants

Skin-to-skin contact between mothers and newborns

Administration of antibiotics to children with pneumonia by community health workers

Congenital anomalies (neural tube defects)

Tetanus

Infection/Prematurity

Prematurity

Infection

Prematurity

Infection

Prematurity

Asphyxia

Asphyxia

Infection

Asphyxia

Infection

Infection

Infection in preterm/LBW infants

Infection

TIME PERIOD INTERVENTION DESCRIPTION & IMPACT CAUSE OF DEATH ADDRESSED

Table 1: Sixteen interventions that can save newborn livesii

* These interventions are considered “additional” and are for settings in which health systems development and capacity are more advanced.

Saving newborn lives

around the world

The additional annual cost of implementingall interventions proven to save newborn livesin the two highest mortality regions—Asia andAfrica—would be $3.2 billion, saving up to anestimated 2.3 million lives. South Asia and sub-Saharan Africa have the highest risks and num-bers of newborn deaths, and are the prioritysub-regions where the greatest numbers of livescould be saved. If life-saving interventionsreached 90 percent of pregnant women andtheir babies, up to an estimated 1.5 millionbabies could be saved in Asia each year (Table2). Almost 80 percent of the deaths averted inAsia would be in the populous South Asia sub-region, principally India, Bangladesh, Pakistan andNepal (Figure 1). Up to an estimated 800,000newborn lives could be saved in Africa eachyear, primarily in 10 countries of sub-SaharanAfrica. Achieving this impact would require anextra $1.2 billion in South Asia and $1 billion insub-Saharan Africa per year. This comes to$1.39 per capita in extra costs in sub-SaharanAfrica and $0.86 per capita in South Asia.

Packaging interventions

to save lives

Delivering interventions in “packages” dur-ing specific time periods and through commonmodes of service delivery (e.g., outreach, fami-ly-community care, clinical care) is more cost-effective than delivering interventions individu-ally. Table 3 details the annual additional costsrequired and the numbers of newborn deathsthat could be averted by sets of interventions.When care is available across the continuum oftime periods from prenatal (also called antena-tal) to postnatal, and through a variety of deliv-ery modes from the community to health facil-ities, mothers and their newborn infants seethe greatest benefits.This is the approach thatwill achieve the most progress toward meetingMDG-4.

Prenatal care

Providing good prenatal services such astetanus toxoid immunization and screening forinfections and other pregnancy related compli-cations can be critical in ensuring that otherservices are used during and after delivery.

INVESTING TO SAVE NEWBORN LIVES | MAY 2006 3

Table 2: Annual additional costs and newborn deaths averted globally and by region

Region Current costs (US$)

Additional costs(US$)

Current deaths (in 2000)

Deaths averteda Deaths averteda

Globalb $1.97 billion $4.11 billion 3.69 million 1.33-2.45 million 36-66%

Africa $480 million $1.18 billion 1.19 million 460,000-810,000 38-68%

Sub-Saharan Africa $400 million $1.00 billion 1.08 million 420,000-740,000 39-68%

North Africa $80 million $170 million 110,000 40,000-70,000 36-66%

Asiac $910 million $2.06 billion 2.19 million 780,000-1.47 million 36-67%

South Asia $360 million $1.23 billion 1.63 million 610,000-1.13 million 37-69%

East Asia $530 million $810 million 560,000 170,000-330,000 30-60%

aRange based on low to high effectivenessiii b75 high-mortality countriescAsia also includes Azerbaijan, Kyrgyzstan, Tajikistan and Kazakhstan, however, these do not fit into either sub-region

INVESTING TO SAVE NEWBORN LIVES | MAY 2006 4

Although the data indicates that the impact ofexpanding coverage of prenatal care is morelimited than other types of care, particularly inSouth Asia (five percent to 10 percent ofdeaths averted), the cost of prenatal care is rel-atively low, so its cost-effectiveness is high. Upto 440,000 newborn lives (12 percent) couldbe saved per year through global expandedcoveragev of all prenatal care interventions atan additional annual cost of $400 million.

Delivery/intrapartum care

Intrapartum care is the care received dur-ing labor and delivery. Effective intrapartumcare includes services that are provided bybirth attendants who are trained and skilledand have links to emergency obstetric careshould it be needed. It also includes immediate

care for the newborn.While the investment inintrapartum care is relatively high, this type ofcare is an essential long-term goal for any effec-tive and integrated health program for womenand children. Up to 1.2 million newborn lives(34 percent) could be saved each year throughglobal expanded coverage of all proven intra-partum interventions at an additional annualcost of $2.1 billion.

Postnatal care

Postnatal care is highly cost-effective andbrings lasting benefits to the mother and new-born. Despite this, it is one of the most neglect-ed components of health care programs inmany of the poorest developing countries.During this time period, simple family and com-munity care practices such as breastfeeding,

NMR (per 1000 livebirths)< 15

15–2930–45

> 45

Figure 1: The majority of newborn deaths occur in sub-Saharan Africa and South Asia. This map highlights the variation between countries in Neonatal Mortality Rates (NMRs)

iv

INVESTING TO SAVE NEWBORN LIVES | MAY 2006 5

Table 3: Annual additional costs and newborn deaths averted by package of interventions

$380 $2.08 billion $590 million $1.03 $3.68 billion $4.11

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All postnatal

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Continuum of care (including

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Additional costs (US$)

Deaths averted

Deaths averted

Additional costs (US$)

Deaths averted

Deaths averted

Additional costs (US$)

Deaths averted

1All antenatal care includes: medical history and physical examination, including assessment of blood pressure, weight gain and fundal height; screening for anemia, proteinuria, pre-eclampsia and other pregnancy complications; syphilis screening and treatment; intermittent presumptive treatment (IPT) for malaria; tetanus toxoid (TT) immunization; and detection and treatment of bacteriuria.2All delivery/intrapartum care includes the promotion and practice of clean delivery and clean cord care for home births, skilled maternal and immediate neonatal care, antibiotics for preterm premature rupture of membranes (PPROM), emergency obstetric care, and corticosteroids for preterm labor.3Postnatal family and community care includes promotion of birth preparedness, emergency readiness, care-seeking for obstetric and newborn complications, and demand for quality clinical care; counseling and preparation for newborn care; community mobilization and engagement; promotion of thermal care, clean cord care, and early and exclusive breastfeeding; community-based care of low birth weight infants; and community-based pneumonia case management.4All postnatal care includes postnatal family and community care (see above) plus emergency neonatal care: facility-based care for ill newborns, especially sepsis management, birth asphyxia, and complications of prematurity.5Includes antenatal, intrapartum and postnatal interventions. Universal interventions are appropriate for all settings. Situational interventions are recommended for certain settings where a condition targeted by the intervention is problematic from a public health standpoint. Other interventions are referred to as “additional” and are for settings in which health systems development and capacity are more advanced.

Deaths averted

INTERVENTIONPACKAGE

million

260,000-440,000

660,000-1.25 million

590,000-1.4 million

1.18-2.25 million 1.33-2.45million

330,000-960,000

120,000-180,000

190,000-370,000

170,000-400,000

380,000-680,000 420,000-730,000

100,000-280,000

$140million

$530 million $200 million $860 million $1.00billion

$100 million

$130million

$680 million $280million

$1.08 billion $1.20billion

$110 million

80,000-160,000

290,000-570,000

290,000-680,000

540,000-1.03 million 600,000-1.03 million

160,000-470,000

7-12% 18-34% 16-38% 32-61% 36-66%9-26%

11-17% 18-34% 16-37% 35-63% 39-68%9-26%

5-10% 18-35% 18-42% 33-63% 37-69%10-29%

billion billion

hygiene and warmth for the baby could save upto 1 million newborn lives globally at an annualadditional cost of $600 million. Global expand-ed coverage of all postnatal interventions at anadditional annual cost of $1 billion would saveup to 1.4 million (38 percent) newborn livesannually.

Continuum of care

Up to 2.5 million newborn lives (66 percent)could be saved each year through global expand-ed coverage of all packages of interventions list-ed above, at an extra cost of $4.1 billion.

Conclusion

Every year, an estimated 2.5 million newbornlives are lost unnecessarily.Additional resourcesare urgently needed today to deliver the inter-ventions and improve the health systems thatcan save their lives. These costing breakdownsare intended to demonstrate the impact thatcan be achieved with additional resources.

It is likely that increases in funding for new-born health will occur incrementally and there-fore programs will expand in an incrementalmanner as well. Policy and program decisionsmust be made as to how best to use addition-

al resources as they become available. Theselection of interventions, the order of intro-duction and the level of expansion of coveragewill need to be decided on a country-by-coun-try basis.

Funding for maternal, neonatal and childhealth is shamefully low given the burden ofdeaths, the human rights imperative and thefact that extremely cost-effective interventionsare available. Significant reductions in newborndeaths, particularly in South Asia and sub-Saharan Africa, can be achieved with every newcommitment to newborn health.

INVESTING TO SAVE NEWBORN LIVES | MAY 2006 6

Courtesy of Saksham Shivgarh, Uttar Pradesh, India.

Written by Gary L. Darmstadt (Johns Hopkins Bloomberg School of Public Health and Save the Children-US), Simon Cousens (LondonSchool of Hygiene and Tropical Medicine), Neff Walker (UNICEF), Joy Lawn (Save the Children-US; International Perinatal Care Unit,Institute of Child Health, London; and Health Systems Research Unit, Medical Research Council, South Africa), Zulfiqar Bhutta (Aga KhanUniversity), and Rachel Haws (Johns Hopkins Bloomberg School of Public Health). Edited and designed by GMMB.iNewborn health: a key to child survival, The Lancet Series on Neonatal Survival http://www.thelancet.com/collections/neonatal_survival.

ii The methods used to estimate the cost and impact of these 16 interventions are the same as those utilized in The Lancet Neonatal Survival Series analyses.They are basedon achieving 90 percent coverage in the same 75 countries.

iii The impact range of effectiveness is provided to demonstrate that while the figures presented are based on a thorough literature review, existing evidence and expert opinion,these figures serve as estimates only, and therefore imply a level of uncertainty. Effectiveness refers to the impact of interventions when implemented under existing conditionswithin health systems, as opposed to the idealized conditions of a research study.The estimated range of effectiveness (i.e., deaths averted) was derived by applying the low andhigh end of the estimated range of intervention effect reported in the published literature (Darmstadt et al, Lancet 2005; 365; 977-988).

ivFigure courtesy of The Lancet, March 2005.

vExpanded global coverage assumes 90 percent coverage level.