Textbook of Community and Social Paediatrics SR Banerjee
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Newborn Health around the Globe1

PM Shah
 
INTIMATE INTRINSIC LINK BETWEEN THE HEALTH OF MOTHERS AND NEWBORN INFANTS
The health of newborn is intimately and intrinsically interlinked with that of his/her mother. It strongly influences the health, nutrition, growth and development in subsequent infancy, childhood and adolescence. The health problems of mothers and children have their origin in the inherently vulnerable stages of the human cycle of reproduction, growth and development. At no stage is this vulnerability greater and its life long impact so profound for both mother and infant as it is during pregnancy, delivery, newborn and early infancy period. For the newborn infant we can speak of the critical days, even minutes that establish the individual's quality of life.
 
SOCIAL, CULTURAL, ECONOMIC AND ENVIRONMENTAL INFLUENCES AND NEWBORN HEALTH
The social, cultural, economic and environmental factors have the greatest influence on the fetal, neonatal and childhood periods as compared to any other time of human life. Failure to meet the growth and development needs as these stages of life adversely affects later stages of life. Low birth weight is an appropriate example which demonstrates this close interrelationship between the mother, child and the environment. Low birth weight is the end result of a lifetime of ill health, malnutrition, parasitic infection, overwork, smoking and infections during preconception and pregnancy periods of the mother. Low birth weight baby mostly remains chronically malnourished and stunted during infancy, and grow into a child with low development, remaining prone to repeated infections and infestations. Such a child with severe growth deficiency grows into adulthood with distinct physical and learning disability. The chronically malnourished women deliver low birth weight babies and thus vicious cycle continues in generations.
 
NEWBORN HEALTH: GLOBAL SCENARIO
Child mortality in developing countries fell from 280 to 106 per 1000 in past thirty years. It dropped from 155 to 20 per 1000 in Chile, from 241 to 45 in Tunisia and from 140 to 22 in Sri Lanka.
However, the drop in infant and child mortalities for the least developed countries is unacceptably slow. It is slowest in the perinatal and neonatal periods, even in the developed countries. The perinatal mortality rate in developing countries is four to ten times higher than that in most developed countries.2
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Flow chart 1.1: Mother-newborn child environment and intrinsic links
 
CURRENT LEVEL OF PERINATAL AND NEONATAL MORTALITIES
According to the World Health Organization estimate, there are 7 million perinatal and 4.2 million neonatal deaths every year. That means every eight seconds a newborn dies. Most of these deaths occur in developing world and 70 to 80 percent of the deaths are preventable. Neonatal mortality is under reported as it is not recognized or accepted as a problem in many societies. Individuals, families and societies have adapted by not recognizing the “completion of the birth” until the newborn survives and initial period which may vary from one week to 40 days or even beyond. Incomplete reporting of perinatal and/or neonatal deaths contributes to the lack of priority being accorded to newborn health. Most of these deaths are linked to the mother's poor health and nutrition before and during pregnancy, unsafe child birth practices, inadequate care immediately after birth, untimely pregnancy, low birth weight, preterm births and high fertility (Flow chart 1.1).
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Fig. 1.1: Child mortality in the last 30 years
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Fig. 1.2: Perinatal, neonatal and infant deaths—global estimates
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Fig. 1.3: Infant mortality in rich and poor neighborhoods in urban areas
(Source: Demographic and Health Survey)
Even within developed countries the difference in infant, neonatal and postneonatal mortality rates between most and least socially advantage groups can be two to three times as shown in Figure 1.1.
 
PATTERN OF PERINATAL AND NEONATAL MORTALITY
In most of the countries, about half of the perinatal deaths occurs during the antepartum or intrapartum period; the other half occurs during the first week of life. This ratio may vary more in developing countries. Neonatal and perinatal mortalities decline slowly being less sensitive to general social change and more affected by preventive activities, early diagnosis and treatment of specific medical conditions or by changes in the quality of pregnancy and delivery care as shown in Figure 1.2.
Similar patterns in the decline of early and late neonatal and postneonatal mortality rates are also found in developing countries (Fig. 1.3).
Betweem 40 and 60 percent of infant mortality occurs in the first four weeks of life, the majority occurring during the first week.
In some countries where perinatal mortality has decreased by half over the period from 1965 through the 1980s, improvements in the coverage of prenatal and 4delivery care the appear to be important factors in this decline (Fig. 1.4).
 
CAUSES OF NEONATAL MORTALITY (Table 1.1)
The causes of neonatal and perinatal mortalities are poorly documented in developing countries. As best it can be estimated from the limited community based studies in the developing world; wide variation will be noted in the proportion of neonatal deaths attributed to different causes.
Regional variatios in the causes of perinatal and neonatal mortalities relate to the quality of health services, environmental circumstances, cultural practices and/or genetic predisposition. In Zambia and Ethiopia, syphilis only accounts for 30 to 40 percent of the stillbirths. In some islands in the Pacific, 10 percent of all newborns have hyperbilirubinemia, with five percent of these cases dying and an equal number developing posterior brain damages. In some parts of India, nearly 30 percent of neonatal deaths have been associated with birth asphyxia and another 20 percent are attributed to pulmonary causes (Fig. 1.5).
 
 
Birth Asphyxia
Fetal and natal asphyxia is one of the most common causes of very high perinatal, neonatal and infant mortalities and morbidities. According to most recent estimates nearly 840,000 newborn out of four millions who suffer moderate to severe birth asphyxia die each year in the world (Fig. 1.6). An equal number survives severe or moderate asphyxia but with brain damage.
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Fig. 1.4: Time trends in infant and neonatal mortality—Some selected developing countries
(Source: Institute of Resource Development/DHS 1990)
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Fig. 1.5: Time trends in child infant and perinatal mortality—
A. Finland (1891-1983) and B. Japan (1955-1989)
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Fig. 1.6: Perinatal mortality rates for selected countries, 1965-1984
In the developed world, preventable risk factors are identified and managed in the antenatal period and hence, most of the babies who develop asphyxia have it as the secondary to anomalies of the central nervous system or genetic disorders affecting the brain. In rural areas of developing countries, only a very small proportion of pregnant women are monitored and intervened for risk conditions and most deliveries are domiciliary by traditional birth attendants (TBA).
The other leading causes of neonatal mortality are birth trauma, low birth weight, preterm birth and infections such as tetanus, pneumonia, diarrhea and sepsis (Fig. 1.7).6
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Fig. 1.7: Neonatal deaths (in thousands) by age and cause in developing countries, 1990 estimates
 
Low Birth Weight
The weight of a newborn is closely linked to its chances of survival and subsequent growth and development both during the newborn period and then into infancy and childhood. The low birth weight infant is at much higher risk of mortality and severe morbidity than full term, full-sized infant (Fig. 1.8). Compared to full-term infants, they have three to four times greater risk of dying from diarrheal diseases, acute respiratory infections and, if not immunized, measles. They are more likely to be malnourished at one year of age. Susceptibility of low birth weight infants to increased mortality from cardiovascular diseases and both type I and type II diabetes in adulthood has been recently documented.
Of the 25 million of low birth weight infants born in 1990, about 24 million were in developing countries. The incidence of low birth weight varies widely among different regions of the world.
It is generally recognized that preterm delivery is the predominant cause of low birth weight in industrialized countries and intrauterine growth retardation characterizes much of the low birth weight in many developing countries (Fig. 1.9). The major factors associated with low birth weight in the developing world include mother's low pregnancy weight, short height, low weight gain during pregnancy, pre-eclampsia, arduous work after mid-pregnancy, short birth intervals, teenage pregnancy and infections, particularly malaria (Fig. 1.10).
Table 1.1   Estimates of the percentage of neonatal deaths attributed to different causes
Cause of neonatal death
Percentage of neonatal deaths
Preterm/low birth weight
6.4% to 57.5%
Infections
Tetanus
1.9% to 61.9%
Diarrhea
3.6% to 21.2%
Pneumonia
4.0% to 22.0%
Septicemia
4.8% to 9.7%
Asphyxia
2.9% to 23.6%
Birth injuries
2.9% to 10.0%
 
Hypothermia
A field study carried out on Malawi in hypothermia and breastfeeding confirms that even small departure from the optimal range for neonatal body temperatures are detrimental to health.7
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Fig. 1.8: Birth weight and survival A. USA and Sweden; B. India
(Source: Congress of United States, Office of Technology Assessment 1968) Note: SWF refers to Sweden
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Fig. 1.9: The prevalence of low birth weight in selected countries
Hypothermia can be not only the primary cause of some neonatal deaths but also a contributing factor in many more.
 
Fertility Patterns and Newborn Health
Births that are too closely placed, increase the infant and child mortalities and pose a substantial risk to infant health.8
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Fig. 1.10: Relative importance of established factors with direct casual impacts on IUGR (developed country)
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Fig. 1.11: Fertility pattern and child mortality
(Source: Hobcraft 1991)
In Kenya, the infants born within 18 months of birth of previous child are more than twice likely to die as those born a longer interval. In Egypt the risks are more than triple (Fig. 1.11).
 
AIDS in Newborns and Infants
The HIV infection casts a dark shadow over the prospects for major gains in infant and child mortalities. Babies born to women infected with HIV have about a 30 percent chance on contracting the virus in perinatal and neonatal periods from their mothers. During 1990s as many as five to ten millions newborn infants will be HIV infected through perinatal transmission of the infection (Fig. 1.12).
Much of this mother-to-infant transmission occurs during pregnancy and delivery. Recent data confirm that some of this occur through breasfeeding.9
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Fig. 1.12: Global incidence of HIV AIDS in men, women and children
However, the benefits of breastfeeding are multiple. It helps protect infant from dying of diarrhea, pneumonia and other infections. The babies’ risk of HIV infection through breastfeeding must be weighed from its risk of dying of other cause, if he/she is denied breastfeeding (Table 1.2).
 
Other Factors Contributing to Perinatal and Neonatal Mortalities
Half a million women die each year as a consequence of pregnancy or child birth. The infants they are carrying usually are either stillborn or subsequently die. Large number of perinatal or neonatal deaths are a consequence of poorly managed pregnancies and deliveries.
Large number of studies including most recently the Demographic Health Survey demonstrate the increased relative risk of neonatal and infant mortalities in association with adolescent pregnancy, low level of maternal education and high birth order. In developing countries better educated women start their families later, thus diminishing the risk to child health associated with early pregnancy. Educated women tend to make greater use of prenatal care and trained assistance. Well-educated mothers often manage to reduce the damage the poverty does to health. Data from 13 African countries between 1975 and 1985 show that a 10 percent increase in female literacy rate reduced child mortality by 10 percent whereas changes in male literacy had little influence (Table 1.3).
Table 1.2   AIDS and breastfeeding Breastfeeding and HIV transmission
  • Roughtly one-third of babies of HIV + women become infected
  • Much of mother-infant transmission in pregnancy delivery
  • Transmission can occur through breastfeeding
  • Breastfeeding saves lives. It protects from dying of diarrhea, pneumonia, other infections
  • Baby's risk of HIV infection through breastfeeding must be weighted against its risk of dying of other causes
10
Table 1.3   Complications of pregnancy affecting mothers and newborn infants
Problem complication
Mother
Baby
Severe anemia
Risk of hemorrhage
LBW: Asphyxia; SB
Hemorrhage
CCF; Puerperal sepsis
Asphyxia; SB
HDP
Eclampsia
LBW: Asphyxia; SB
Unclean delivery
Puerperal sepsis; tetanus
Teanus; Sepsis
Obstructed labor
Fistula; uterine rupture; amnionitis; sepsis
Asphyxia; Sepsis SB; Handicap
Infection
Premature labor; pelvic inflammatory disease; cerebral malaria; severe anesing infertility; ectopic pregnancy;
Premature delivery; ophthalmia; SB; congenital syphilis; LBW
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Fig. 1.13: Percentage reduction in child mortality by age two in relation to parents’ schooling, late 1980s
(Source: Hobcraft 1993)
Poverty leads to less access to health care and lower utility of health services. In China, despite remarkable overall progress in health as measured by a fall in infant mortality rate from 200 in 1949 to 27 per 1000 livebirths in 1992, there are still wide variations between regions and groups which are strongly related to income. The newborn in poor families is less healthy.
The status of women in a society influences the health of newborn, their growth and development (Fig. 1.13). Violence against women increases risk of miscarriage by two folds and having a baby below average weight by four times.
The health consequence of substance abuse during pregnancy such as tobacco, alcohol and drugs on newborn infants is well known. The babies of mothers who smoke weigh, on an average, 200 g less at birth than those of non-smokers. In industrialized countries cigarette smoking accounts for one-third of the low birth weight. Passive inhalation of smoke in the households of smokers greatly increases the risk of respiratory infections and growth retardation. Alcohol and drug use during pregnancy causes serious health problems in their newborns resulting in brain damage, growth retardation and behavioral problems.11
 
SIGNS OF PROGRESS IN THE HEALTH STATUS OF NEWBORN
Despite many of these persisting problems, the trend in perinatal, neonatal and infant mortalities as well as in the health care coverage of mothers and children shows some signs of progress and hope. In some developed countries and few developing countries perinatal mortality has decreased by half over the period from 1965 to 1980. To a considerable extent, this decline is due to application of the concept of risk approach as a management tool for policy and program development, resource allocation, evaluation as well as the use of simplified, appropriate but scientifically sound technologies.
In 1974 when the Expanded Program on Immunization was established by World Health Organization, less than 5 percent of the infants in developing world were fully immunized. In 1990, a global average of 80 percent coverage of immunization of all infants was achieved.
In Haiti, improvements in the training of TBA helped to reduce the neonatal tetanus deaths by as much as half. The subsequent introduction of immunization of pregnant women and later of all women in an outreach program eliminated disease as public health problem.
 
Family Planning Programs
In early 1960s, there were only a few countries in which family planning programs had been initiated. Currently 120 Governments support such programs.
 
Code of Marketing of Breast milk Substitutes and Baby-friendly Hospital Initiative
To answer the threat of decline in breastfeeding in both developed and developing countries, the World Health Assembly in 1991 adopted the International Code of Marketing of Breastmilk Substitutes. Subsequently in 1991, recognizing the role of maternity facilities in addressing the problem of decline in breastfeeding, WHO and UNICEF issued a joint statement and launched the Baby-friendly Hospital Initiative (BFHI) which aims at changing mother care and breastfeeding practices so as to ensure that hospitals and health workers recognize and support parents specially mothers in the care of their infants.
 
Three International Events in 1990
In 1990, three international events have given new visibility to the health and well-being of the children. These were: Ratification of the Convention on the Rights of the Child, the World Summit for Children and World Conference of Education-for-all.
The plan of action based on World Declaration on Survival, Protection and Development includes goals to reduce infant mortality rate by one-third or to 50 percent per 1000 live births and maternal mortality by half between 1990 and the year 2000. These goals also include elimination of neonatal tetanus by 1995 and empowerment of women of breastfeed, reduction adult illiteracy and universal access to basic education. Subsequent to the Summit, the countries have developed their National Plans of Action for the 1990s.
 
STRATEGIES FOR THE ORGANIZATION AND DELIVERY OF NEWBORN HEALTH CARE
Major contributory factors to high perinatal and neonatal mortality rates in babies are failure to detect high risk conditions during pregnancy, labor and newborn period, and failure of timely referral to the nearest referral center or hospital. In case of hospital deliveries timely detection of the morbidity and its management is important. It is estimated from the World Health Statistics 12that of some 140 live births each year, about 123 million take place in developing world, between 50-80 percent of all deliveries take place at home rather than at maternity facilities. For instance in rural India about 90 percent (some 20 million every year) and in Bangladesh almost all babies born in rural areas are delivered at home by TBA, relatives and neighbours. The majority of birth attendants are illiterate and about 63 million babies are delivered by untrained birth attendants. The use of health services is restricted because of distance, difficult terrain and lack of transport, roads and communication (Table 1.4).
 
 
Principles of Newborn Healthcare
Generally, the health and well-being of the newborn infant is based on the following principles of care, whether at home or in health facilities: (1) Atraumatic and clean delivery, (2) maintenance of body temperature, (3) initiation of spontaneous respiration, (4) breastfeeding beginning shortly after birth, and (5) prevention and management of illness.
The model of MCH/FP care that has been advocated over the last several decades has been described as a pyramid with the level of care corresponding to the level of need. The elements include a district hospital, health center and community level activities. The constraints often found include inadequate skills and materials, inaccessibility and cultural obstacles. Major improvement in maternal and neonatal health requires the placement of essential obstetric functions, including cesarean section, blood replacement, anesthesia, neonatal resuscitation, the treatment of infections at the level of the district hospital. Many of the functions could be performed only at the well equipped health center. However, only a small proportion of population live within the distance of immediate access. Hence, the obvious strategy would be to maintain and strengthen the capacity of the health center to provide essential maternal and newborn care. By introducing a risk approach and raising the skill levels at the health center and district hospital, a 50 percent reduction in perinatal mortality and stillbirth rates was accomplished among plantation workers in South India.
Table 1.4   The world summit goals with reference to newborns
Between 1990 and the year 2000*
  • Reduction of:
    • Infant mortality rate by one third or 50 per 1000 live births
    • Maternal mortality rate by half
    • Low birth weight to less than 10%
  • Reduction by 50% in diarrheal deaths by 1995
  • Elimination of neonatal tetanus by 1995
  • Immunization of 90% children under-one by 2000
  • Empowerment of women to exclusive breastfeeding for 4-6 months
  • Institutionalization of growth promotion and monitoring
  • Special attention to health and nutrition of the female child
  • Access to all couples to information and services for family planning
  • Access to prenatal care, trained attendants during child birth and referral facilities achieve
*Many developing countries could not achieve the targets
Even when care is accessible in many settings, cultural and social economic preference may play a greater role.
 
Articulation of TBA
TBAs are intimately involved with women's reproductive health care, and they have respect and authority in the community. Because of the current shortage of midwives and institutional facilities to provide prenatal care and clean safe delivery as well as a variety of primary health care functions, various agencies and organizations have promoted 13the training of TBA in order to bridge the gap until there is access to acceptable professionals of modern healthcare services for all women and children. The effectiveness of TBA is dependent upon supplies made available to her and to referral center, the ongoing supervision and support for realistic and effective referral system.
 
Appropriate Technologies
Many domiciliary deliveries are attended by family member. A simple, clean disposable delivery kit containing a piece of soap, a sterilized, blade, cord ties and dressing materials, can be kept by the mother and used to ensure clean delivery. Prevention of puerperal sepsis and neonatal infection including tetanus have been reduced through the training and use of clean delivery techniques and procedures.
Positive pressure insufflation of the lungs is the most effective method for resuscitation of the asphyxiated newborn infant. Mouth-to-mouth and mouth-to-mask and bag-and-mask ventilation are the methods which can be employed at home by the birth attendants. The disadvantages of mouth-to-mouth ventilation are the risk of cross infection including HIV and the fact that it is tiring when continued for a long time. It is easier to maintain stable pressure in mouth-to-mask ventilation. The technology of bag and mask has been found to be effective for 96 percent of asphyxiated babies in an hospital in Sweden.
 
Training
Recent research has revealed a general lack of knowledge in newborn care at all levels of health care. Training of all health personnel needs to be reconsidered. The training should be task oriented. For deliveries occurring in the homes, family members can be taught certain principles, for example, recognizing prolonged labor and referring women, securing a clean delivery and using techniques for thermal control e.g., immediate drying and wrapping of the newborn, early feeding and skin-to-skin contact. In the presence of accessible and adequate referral facilities the use of Home-Based Maternal Record (HBMR) can help with the task of risk screening.
 
Levels of Care
A senior experienced midwife at the level of health center maternity facility should be able to make clinical judgement and provide resuscitation of asphyxiated infants, arrange thermal control and warming of hypothermic infants, give antibiotic treatment and control neonatal hypoglycemia. The families should have means of communication and access to transport for referral at higher level for those problems for which continuing care is not possible at this level.
The district or regional hospital would provide 24-hour coverage by physician with training and experience in essential obstetric funcitons and neonatal care. This level of institution should include a nursery unit that is well insulated, able to control infections and equipped with running water, phototherapy and exchange transfusion.
The advent of primary health care has not significantly changed the health problem of newborn babies and their mothers. The CHWs, nurse-midwives and physicians continue to focus their efforts on specialized and targeted vertical programs. In the least developed countries the situation is worsening due to limited resources and adverse economic circumstances. This is a crucial moment for pediatricians, neonatologists, obstetricians, health planners and managers to pause and rethink how neonatal and maternal health care can be delivered to all even under constraint of scarce resources.