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Progress and some Reversals

Table of Contents Newborns: no longer going unnoticed The Greatest Risks to Life are in its Beginning Progress and some Reversals No Longer Falling Between the Cracks Planning for Universal Access

Neonatal mortality has not been measured for long enough to reach reliable conclusions on trends, but WHO estimates from 1995 to 2000 suggest that most countries in the Region of the Americas, and the South-East Asia, European and Western Pacific Regions have made some progress in reducing the mortality rate among newborns (see Figure 5.3). Improvements may have been less marked in the Eastern Mediterranean Region (but regional averages mask variations between countries), and the African Region may actually have experienced an increase in its neonatal mortality rate.

Consecutive household surveys from 34 developing countries show that most exper-ienced a decrease in neonatal mortality over recent decades. Much of the progress in survival has been made in the late neonatal period, with little improvement in the first week of life ( ⁸ ). This echoes the historical experience of many developed countries, where neonatal mortality (and particularly early neonatal mortality) did not begin to fall substantially until some years after a decline in post-neonatal and childhood mortality had been achieved ( ⁹ ). In many countries, neonatal mortality has fallen at a lower rate than either post-neonatal or early childhood mortality ( ¹⁰ – ¹² ).

Household surveys also suggest that there has been reversal and stagnation in newborn mortality across sub-Saharan Africa since the beginning of the 1990s (see Figure 5.4). Indeed, the actual number of deaths has increased substantially in the African Region. In only five years, the dramatic drop in deaths in South-East Asia has meant that this region no longer has the highest neonatal mortality rate in the world; this place has been taken by Africa, where almost 30% of newborn deaths now occur.

The reversal of progress in neonatal health in sub-Saharan Africa is both concerning and unusual. Historically, declines in child mortality have often reversed when the social context deteriorated. Within Europe, these reversals mostly affected older children, while remaining modest for neonatal mortality ( ¹³ ). The causes of the poor progress in reducing both neonatal and later childhood deaths in sub-Saharan Africa are likely to be many and complex. Economic decline and conflict are likely to have played significant roles through their disruptive effect on access to health services ( ¹⁴ – ¹⁶ ). The impact of the HIV/AIDS epidemic on mortality is less well established for newborns than for the post-neonatal period, but infants born to HIV-positive mothers are more likely to be stillborn or premature; they are also likely to have low APGAR scores1 and very low birth weights ( ¹⁷ , ¹⁸ ).

Reductions in child mortality in many countries are at least partly driven by socioeconomic development: improvements in women’s education and literacy, household income, environmental conditions (safe water supply, sanitation and housing), along with improvements in health services and child nutrition ( ¹⁹ , ²⁰ ). While neonatal mortality is affected by these factors, they may have a greater impact in the post-neonatal and early childhood periods than for newborns (see Box 5.1). Historical data further support this hypothesis. There is little evidence that the often dramatic reductions in infant and child mortality in Europe during the first few decades of the 20th century were fuelled by improvements in health care provision, and most studies argue that they resulted from a number of factors including rising standards of living and nutrition, reduced fertility, safer water, better sanitation, and improved housing ( ²⁶ , ²⁷ ). During this time, progress in reducing neonatal mortality was limited and was confined to the late neonatal period. Progress did not accelerate until around the time of the Second World War ( ²⁸ ), which coincided with greater provision and use of maternal health care, improved quality of professional midwifery and obstetric services, and access to antibiotics. This suggests that, while some limited progress can be made in the late neonatal period as a result of general improvements in standards of living, progress will not accelerate and spread to the early neonatal period until appropriate maternal and neonatal health care is available and widely used.

Footnotes

⁸ Lawn J, Zupan J, Knippenberg R. Newborn survival. In: Jamison D, Measham AR, Alleyne G, Breman J, Claeson M, Evans DB et al, eds. Disease control priorities in developing countries, 2nd ed. Bethesda, MD, National Institutes of Health, 2005.

⁹ Masuy-Stroobant G. Infant health and child mortality in Europe: lessons from the past and challenges for the future. In: Corsini C, Viazzo PP, eds. The decline of infant and child mortality: the European experience 1750–1990. The Hague, Kluwer Law International/Martinus Nijhoff, 1997.

¹⁰ Hall S. Neonatal mortality in developing countries: what can we learn from DHS data? Southampton, Southampton Statistical Sciences Research Institute, 2005 (Applications & Policy Working Paper, A05/02; http://eprints.soton.ac.uk/14214, accessed 15 February 2005).

¹¹ Hill K, Pande R. The recent evolution of child mortality in the developing world. Arlington, VA, BASICS (Basic Support for Institutionalizing Child Survival), 1997 (Current Issues in Child Survival Series).

¹² Curtis S. An assessment of the quality of data used for direct estimation of infant and child mortality in DHS II surveys. Calverton, MD, Macro International Inc., 1995 (Demographic and Health Surveys Occasional Paper, No. 3).

¹³ Reher D, Perez-Moreda V. Assessing change in historical context: childhood mortality patterns in Spain during demographic transition. In: Corsini C, Viazzo PP, eds. The decline of infant and child mortality: the European experience 1750–1990. The Hague, Kluwer Law International/Martinus Nijhoff, 1997.

¹⁴ Hanmer L, White H. Infant and child mortality in sub-Sarahan Africa. Report to Sida. The Hague, Institute of Social Studies, 1999.

¹⁵ Simms C, Milimo JT, Bloom G. The reasons for the rise in childhood mortality during the 1980s in Zambia. Brighton, University of Sussex, Institute of Development Studies, 1998 (Working Paper 76).

¹⁶ Costello A, White H. Reducing global inequalities in child health. Archives of Disease in Childhood, 2001, 84:98–102.

¹⁷ Ticconi C, Mapfumo M, Dorrucci M, Naha N, Tarira E, Pietropolli A et al. Effect of maternal HIV and malaria infection on pregnancy and perinatal outcome in Zimbabwe. Journal of Acquired Immune Deficiency Syndromes, 2003, 34:289–294.

¹⁸ Brocklehurst P, French R. The association between maternal HIV infection and perinatal outcome: a systematic review of the literature and meta-analysis. British Journal of Obstetricts and Gynaecology, 1998, 105:836–848.

¹⁹ Rutstein SO. Factors associated with trends in infant and child mortality in developing countries during the 1990s. Bulletin of the World Health Organization, 2000, 78:1256–1270.

²⁰ Cornia A, Mwabu G. Health status and health policy in sub-Saharan Africa: a long-term perspective. Helsinki, United Nations University/World Institute for Development Economics Research, 1997.

²¹ Anand S, Bärnighausen T. Human resources and health outcomes: cross country econometric study. Lancet, 2004, 364:1603–1609.

²² Bulatao RA, Ross JA. Which health services reduce maternal mortality? Evidence for ratings of maternal health services. Tropical Medicine & International Health, 2003, 8:710–721.

²³ Shiffman J. Can poor countries surmount high maternal mortality? Studies in Family Planning, 2000, 31:274–289.

²⁴ Filmer D, Pritchett L. The impact of public spending on health: does money matter? Social Science and Medicine, 1999, 49:1309–1323.

²⁵ Matthews Z, Ensor T, Amoako-Johnson F, Van Lerberghe W. socioeconomic and health system determinants of maternal, newborn and child mortality (unpublished IMMPACT/ WHO background paper for The World Health Report).

²⁶ Werner D, Sanders D. Questioning the solution: the politics of health care and child survival. Palo Alto, CA, Heathwrights, 1987.

²⁷ Loudon I. Death in childbirth: an international study of maternal care and maternal mortality, 1800–1950. Oxford, Clarendon Press, 1992.

²⁸ MacFarlane A. Birth counts: statistics of pregnancy and child birth [CD-Rom]. London, The Stationery Office, 2000.

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