Research Article: Improving Newborn Survival in Low-Income Countries: Community-Based Approaches and Lessons from South Asia

Date Published: April 6, 2010

Publisher: Public Library of Science

Author(s): Nirmala Nair, Prasanta Tripathy, Audrey Prost, Anthony Costello, David Osrin

Abstract: David Osrin and colleagues discuss the critical importance of reducing global neonatal mortality in developing countries and how community-based approaches can help.

Partial Text: Until about twenty years ago, child survival meant the survival of children rather than newborn infants. With a steady worldwide decline in under-5 deaths—most of the lives saved being those of infants and children over the age of a month—the newborn period has come into focus as a relatively intransigent source of mortality. The “child survival revolution” increased child survival [1], but newborn infants went largely unnoticed. Neonatal mortality (0–28 d) now accounts for about two-thirds of global infant (0–1 y) mortality and about 3.8 million of the 8.8 million annual deaths of children under 5 [2]. Most of these deaths (98%) occur in low- and middle-income countries [3].

The main obstacles to improving newborn survival are that many babies are born at home without skilled attendance, care-seeking for maternal and newborn ailments is limited, health workers are often not skilled and confident in caring for newborn infants, and inequalities in all these factors are felt by those most in need.

Figure 1 summarises both the components of health care that have been recommended to improve newborn survival and the range of delivery strategies that have been proposed, tested, or introduced. More detail can be found in a recent set of systematic reviews on intrapartum-related deaths [16]–[20]. Pregnancy is just one stage of a woman’s life, and the figure reminds us that it may occur on a background of gender inequality. Inadequate education, nutrition, and care for childhood illness have short- and long-term effects that are not limited to women (although the burdens often fall on them, as do young age at marriage and conception, short birth intervals, and undesirably large families).

There is little doubt that community interventions for newborn survival work in principle. In our opinion, the key questions are now more about the medium than the message: how effective simplified program designs might be, whether they are relevant in African contexts, whether they will be as effective as they appear, and how they could be rolled out and sustained. Research now needs to move from components to the operational realities of systems [60],[64]. Some major questions remain: the optimal population coverage of community-based workers, since coverage, we think, is crucial for success, and does require investment in community mobilization [65],[66], the requirements for selection of workers and their remuneration or compensation [41], and the right mix of existing and new cadres [12]. A particular challenge is how to integrate newborn and maternal survival interventions [67]. For governments the choice of approach should almost certainly focus on defining the roles and responsibilities of existing cadres in reaching out to women who deliver at home with an essential newborn care package. This is not simply a matter of training health workers, since it is the marginalised and hard to reach who are most at risk. Women’s groups represent a valuable community resource that already exists in many areas and may have inbuilt sustainability. We see active involvement of individuals and communities as the key to achieving targeted coverage of poor and marginalized families to bring down neonatal mortality, and this is an opportunity for governments to facilitate community mobilization in partnership with civil society organisations.



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