From evidence to action to deliver a healthy start for the next generation

Summary

Remarkable progress has been made towards halving of maternal deaths and deaths of children aged 1–59 months, although the task is incomplete. Newborn deaths and stillbirths were largely invisible in the Millennium Development Goals, and have continued to fall between maternal and child health efforts, with much slower reduction. This Series and the Every Newborn Action Plan outline mortality goals for newborn babies (ten or fewer per 1000 livebirths) and stillbirths (ten or fewer per 1000 total births) by 2035, aligning with A Promise Renewed target for children and the vision of Every Woman Every Child. To focus political attention and improve performance, goals for newborn babies and stillbirths must be recognised in the post-2015 framework, with corresponding accountability mechanisms. The four previous papers in this Every Newborn Series show the potential for a triple return on investment around the time of birth: averting maternal and newborn deaths and preventing stillbirths. Beyond survival, being counted and optimum nutrition and development is a human right for all children, including those with disabilities. Improved human capital brings economic productivity. Efforts to reach every woman and every newborn baby, close gaps in coverage, and improve equity and quality for antenatal, intrapartum, and postnatal care, especially in the poorest countries and for underserved populations, need urgent attention. We have prioritised what needs to be done differently on the basis of learning from the past decade about what has worked, and what has not. Needed now are four most important shifts: (1) intensification of political attention and leadership; (2) promotion of parent voice, supporting women, families, and communities to speak up for their newborn babies and to challenge social norms that accept these deaths as inevitable; (3) investment for effect on mortality outcome as well as harmonisation of funding; (4) implementation at scale, with particular attention to increasing of health worker numbers and skills with attention to high-quality childbirth care for newborn babies as well as mothers and children; and (5) evaluation, tracking coverage of priority interventions and packages of care with clear accountability to accelerate progress and reach the poorest groups. The Every Newborn Action Plan provides an evidence-based roadmap towards care for every woman, and a healthy start for every newborn baby, with a right to be counted, survive, and thrive wherever they are born.

Introduction

The Millennium Development Goals (MDGs) showed that a few outcome-focused targets with accountability can unify many players around a common agenda to deliver results. The average annual rate of reduction in child mortality, for example, has more than doubled in the past 10 years compared with the previous decade, and both child and maternal mortality have halved since the 1990 baseline¹ associated with increased intervention coverage of care and technical advances supported by political commitment and investment.² By contrast, newborn mortality and stillbirth reduction did not feature in the MDGs, and had slower progress compared with overall under-5 mortality and maternal mortality during the same period. The collective action behind successful postneonatal interventions, such as high immunisation coverage and malaria prevention and care, is one explanation for the increasing proportion of newborn mortality in the under-5 age group. This success illustrates that it is both realistic and timely for the same attention to also be channelled to newborn survival and stillbirth prevention. For example, Africa now has more newborn deaths than at the MDG baseline in 1990, in view of slow progress in reducing mortality risk and in closing the gap in unmet need for contraception.1, 3 Fertility reduction contributes to improved newborn survival, and vice versa. As the chance of newborn survival becomes more certain, families are more likely to decide on fewer children by using contraception.2, 4

As the MDG era ends, about 2·9 million newborn babies (ie, babies in their first 4 weeks after birth) die every year, mostly from preventable causes.1, 5 These deaths account for 44% of under-5 child deaths globally. In most regions of the world, more than half of all deaths in children younger than 5 years occur in the newborn period. Additionally, more than 2·6 million third trimester stillbirths occur globally each year,⁶ with 45% taking place during childbirth.⁷ A key principle guiding the development of the post-2015 framework is “no-one left behind”.⁸ The data show that newborn babies were left behind—invisible in the MDG framework, and receiving scant policy attention and investment.9, 10 Stillbirths were entirely missed and still do not appear in UN reporting for women's and children's health.⁷ Also missing in the current health goals is the clear link beyond survival to development outcomes, increasingly affected by insults around the time of birth and care of the baby, especially early nutrition.¹

Key messages

• Ending of preventable deaths: Accelerated change for child survival, health, and development needs increased focus on a healthy start. With nearly 3 million newborn babies dying annually, accounting for 44% of deaths in children younger than 5 years, progress has been slow and is now impeding change for child survival worldwide. Closely linked are 2·6 million babies stillborn each year, almost half occurring during labour. More than 15 000 babies die every day—ten every minute.

• Prioritisation of birth day risk: The day of birth is the most dangerous for mothers and their babies, resulting in nearly half of maternal and newborn deaths and stillbirths. The cost of inaction devastates families and societies, causing a substantial drain on human capital, through death, disability, poor growth, and lost potential for development and economic productivity.

• Counting of every newborn baby: Most newborn babies and nearly all stillborn babies are born and die without ever being recorded. One in three babies does not receive a birth certificate before their first birthday. This reflects fatalism around newborn deaths and stillbirths despite the fact that most of these deaths are preventable. Preterm birth, intrapartum complications, and infections are the leading causes of neonatal death.

• Investment for a triple return: Care around the time of birth saves mothers and their newborn babies and prevents stillbirths and disability. By 2025, high coverage of care would save 3 million lives (women, stillbirths, and newborn babies) every year at an additional running cost of US$1·15 per head. Interventions delivered around the time of birth have the greatest potential (41% of the deaths averted), followed by care of small and ill newborn babies (30% of the deaths averted). By improving the quality of care for every birth now in facilities, we could reduce deaths by 2 million each year; and for the poorest still at home, deaths could be prevented by nearly a quarter through community-based strategies.

• Targeting of specific health-systems bottlenecks: Important impediments to scale-up of facility-based care with the highest effect on mortality outcome include finance and workforce, especially skilled midwives and nurses. Some low-income and middle-income countries are making remarkable progress, innovating to reach the poorest families with higher quality care at birth and care for small and ill newborn babies.

• Unprecedented opportunity for progress: the Every Newborn Action Plan is based on epidemiology, evidence, and global and country learning, setting a framework to end preventable newborn deaths and stillbirths by 2035. The action plan will also advance standards for quality of care, measurement of births, and deaths, and programmatic coverage with accountability for results.

Yet newborn deaths and stillbirths matter not only to the families and communities that lose them, but to societies and economies, which fail to benefit from their contributions to labour and intellectual capital. Birth is the moment in the human lifecycle with the greatest risk of death, disability, and lost development potential and the most crucial moment to invest. The generation born today is the workforce of 2030—a time when many countries, particularly those in Africa, hope to reap the so-called demographic dividend that comes from having an employed, healthy, and optimally productive working-age population caring for a smaller dependent population. This dividend, and the potential for accelerated economic growth, cannot be fully realised without addressing of newborn survival and health.¹ This is why a healthy start to life must be at the heart of the post-2015 agenda.

In this the final paper in The Lancet Every Newborn Series, we summarise findings from the first four papers leading to an action plan to reduce newborn and maternal deaths and prevent stillbirths.