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  • 1. Millennium Development Goal 4: reducing perinatal and neonatal mortality in low-resource settings Abi C Smith MBChB,a Wonderful Mutangiri MBChB,b Robert Fox MD MRCOG,c, * Joanna F Crofts MD MRCOG d a Academic Clinical Fellow, Department of Women’s Health, Southmead Hospital, Bristol BS9 5NB, UK b Obstetric and Gynaecology Trainee, Mpilo Central Hospital, Bulawayo, Zimbabwe c Consultant Obstetrician and Gynaecologist, Musgrove Park Hospital, Taunton TA1 5DA, UK d NIHR Clinical Lecturer, School of Social and Community Medicine, University of Bristol, Southmead Hospital, Bristol BS10 5NB, UK *Correspondence: Robert Fox. Email: indigofoxbat@hotmail.com Accepted on 14 October 2013 Key content Millennium Development Goal 4 (MDG4) set targets to reduce by two-thirds the number of deaths of children aged 5 years by 2015 compared with 1990. In 2010, 7.7 million of these children died. Progress is accelerating but many countries will not meet targets. Stillbirths account for 2.65 million deaths but are not addressed in international targets. Possible solutions including ‘kangaroo mother care’, neonatal resuscitation and breastfeeding are identified; a difference can be made with basic training and resources. Political leadership is required to make significant health gains. The evidence for improving peri- and neonatal mortality exists. The challenge is in the implementation. Learning objectives To understand MDG4 and the variation in pregnancy outcomes for neonates globally. To increase knowledge of simple interventions and key barriers to improve peri- and neonatal mortality. To help UK doctors understand the health background of inward migrants. Ethical issues The increasing divide in health outcomes between rich and poor, both within and between countries. Gender inequalities may contribute to poor access to care. Resource limitations are compounded by external factors such as the ‘brain drain’ of health workers. Keywords: Millennium Development Goals / neonatal death / quality improvement / stillbirth Please cite this paper as: Smith AC, Mutangiri W, Fox R, Crofts JF. Millennium Development Goal 4: reducing perinatal and neonatal mortality in low-resource settings. The Obstetrician Gynaecologist 2014;16:1–5. Introduction The Millennium Declaration set out development aims that the world would strive to meet by 2015.1 This included a set of health-related aspirations, known as the Millennium Development Goals (MDGs). They have focused the global community’s attention and funding on specific health-related issues. MDG4 set out to reduce by two-thirds the death rate of children aged 5 years (‘under-five mortality rate’— U5MR), between 1990 and 2015. This article explores the impact of MDG4 on perinatal and infant death in the developing world. As this article is targeted towards those providing maternity care, much of the discussion focuses on neonatal death: babies who die within the first 28 days of life. There has been least progress regarding this element of the U5MR: the proportion of U5MR accounted for in the neonatal period had risen from 37% in 1990 to 42% in 2010.2 It is important to note that there is no mention of stillbirth within the MDGs, and there remains no global target for its reduction. Every year 2.65 million babies are stillborn, with 98% of all stillbirths occurring in low- and middle-income countries. It is estimated that 45% of stillbirths occur during the intrapartum period, a rate much higher than for countries with advanced healthcare systems.3 A reduction in stillbirths in low-resource settings is achievable, and many of the interventions discussed in this article have the potential to reduce the incidence of stillbirth, as well as of neonatal mortality. Any progress towards collecting similar data for stillbirth is hampered by debates around definition of stillbirth, difficulties of registration of stillbirth, and the issues of distinguishing between antepartum and intrapartum deaths. These data challenges compound the lack of political visibility.4 ª 2013 Royal College of Obstetricians and Gynaecologists 1 DOI: 10.1111/tog.12074 The Obstetrician Gynaecologist http://onlinetog.org 2014;16:1–5 Review
  • 2. Progress towards Millennium Development Goal 4 (MDG4) Between 1990 and 2010 the U5MR fell by just 35%,5 but this rate of decline is accelerating. In 2010 approximately 7.7 million children died before their fifth birthday.6 Some regions (such as North Africa) have been successful at reaching their MDG4 targets, but the U5MR in Sub-Saharan Africa and Oceania had only fallen by 30% by 2010.5 Almost all regions have seen slower declines in their neonatal mortality rate than U5MR.5 Annually there are approximately 2.1 million neonatal deaths.6 One million of these deaths occur as a consequence of premature birth.2 Although there has been substantial progress towards MDG4, with 31 countries on target to reach their goals, 23 countries in Sub-Saharan Africa are unlikely to achieve MDG4 targets before 2040.7 Where countries have progressed rapidly, the common theme is a governmental commitment to make the required improvements.8 The model of improvement of U5MR in Nepal clearly demonstrates this point, but also provides a useful short case study for potential cross-sector interventions to improve neonatal health. Progress towards targets in Nepal Between 2001 and 2006 the perinatal mortality rate in Nepal decreased from 47 to 4 per 1000 live births. A sector-wide approach was introduced in 1991, and was subsequently developed into a ‘Safe Motherhood and Neonatal Health long-term Plan for 2006–17’. Nepal’s strategy includes: comprehensive antenatal care, training for birth attendants, increasing attended deliveries through the introduction of Maternity Incentive Schemes (e.g. provision of money for transport costs, payment for giving birth within a healthcare facility) designed to encourage women to deliver in a health institution, postnatal care promoting breastfeeding and immunisation, maternal and perinatal death review reports identifying preventable factors.9 These measures have increased the attended delivery rate in Nepal from 7% in 2001 to 31.6% in 2009, and increase the institutional delivery rate from 9% in 2001 to 19% in 2009. Interventions to improve perinatal and neonatal death The causes of perinatal and neonatal death are multi-factorial and include social factors. The interventions required to reduce mortality are, therefore, not all directly related to healthcare. Improved nutrition, education, sanitation and access to healthcare are all required8 alongside a political will to implement multi-sector solutions. This discussion is limited to interventions directly related to health care. Key healthcare interventions that reduce intrapartum, perinatal and neonatal mortality are detailed below. These interventions perform best as part of a continuum of care in a functioning, integrated healthcare system. However, some could be implemented even in fragile states.10 Community mobilisation Community mobilisation covers interventions ranging from home visits to facilitation of local women’s groups to advocate for the local health resources required. Community mobilisation can strengthen facility-based interventions and contribute to effective healthcare10 and has been shown to be cost-effective.11 When at least one-third of pregnant women in a community participated in such an intervention, neonatal mortality decreased by up to 33%.11 Skilled attendance at birth Skilled attendance at birth has the potential to improve neonatal mortality, especially when coupled with good referral systems.8,12 An attended, clean delivery with access to antibiotics is important for the prevention of infection. Currently 15% of newborn deaths are as a consequence of infection.8 Neonatal resuscitation is lifesaving. Basic skills can enable the 5–10% of babies who require assistance with breathing at birth to survive. The equipment required is of low cost (bag and mask), but training is crucial.4 All birth attendants should be trained in neonatal resuscitation as it is not possible to predict accurately which babies will need intervention.4 Training is simple and feasible.10 A meta-analysis of training for traditional birth attendants demonstrated that neonatal training packages can reduce perinatal and neonatal mortality with a relative risk reduction in both the randomised and non-randomised trials of 24–30% and 21–39% respectively.12 Administration of corticosteroids in prematurity Corticosteroids for promotion of lung maturation in preterm births to reduce respiratory distress syndrome is supported by high-quality evidence.13 This intervention is low cost (for example, a corticosteroid course in India costs just US$0.51), and could save 340 000 newborn lives annually.8 If preterm labour is identified in a timely fashion, the administration of corticosteroids is relatively simple and moderately effective. Kangaroo care of the newborn Kangaroo mother care (KMC) for preterm babies (weighing 2000 g) comprises three components: (i) thermal care; (ii) exclusive breastfeeding; and (iii) early recognition/response to illness.14 In premature babies who are stable, KMC is more 2 ª 2013 Royal College of Obstetricians and Gynaecologists Millennium Development Goal 4
  • 3. effective than nursing in an incubator.8 A meta-analysis of randomised controlled trials of KMC starting in the first week of life demonstrated a reduction in mortality of 50%, together with a reduction in serious morbidity of 60%.14 KMC is low cost and easy to implement. Promotion of breastfeeding Exclusive breastfeeding can prevent sepsis (gastrointestinal diseases and respiratory infection) and offers the opportunity to gain immunity and prevent hypoglycaemia.15 In most regions, fewer than half of newborns are breastfed within an hour of birth.8 Furthermore, exclusive breastfeed- ing contributes to birth spacing through prolonged lactational amenorrhea.16 Birth spacing Birth spacing improves pregnancy outcomes. Preterm birth and low birthweight are associated with either short (18 months) or long (59 months) intervals between pregnancies. Enabling women to optimally space their children can reduce poor perinatal outcomes.17 Education and access to family planning methods is crucial,8 and can reduce up to 40% of unplanned pregnancies. Immunisation programme Immunisation is effective at reducing mortality. For example, offering two doses of an antenatal tetanus vaccine costs approximately US$0.40 and could prevent the death of 58 000 newborns annually.8 Postnatally childhood morbidity and mortality has been reduced with the implementation of a vaccine schedule including measles and haemophilius influenza vaccination.15 Malaria reduction Malaria is a risk factor for low birthweight and contributes to approximately 100 000 deaths annually.18 There are cost-effective proven interventions to prevent malarial infection, which include intermittent preventive treatment (IPT), antimalarial prophylaxis and insecticide-treated bed-nets. These measures could reduce perinatal mortality due to malaria by 27% in affected areas.18 Emergency obstetric care Access to emergency obstetric care is necessary.10 Whereas many interventions can be carried out in the community there still needs to be a strong link to facility-based care.11 Caesarean section is indicated in 5–15% of births and could go some way to preventing the 30% of intrapartum stillbirths.4 Moreover, if a mother dies as a result of childbirth, the risk of her children dying before they reach the age of 5 years more than doubles.8,19 Improving antenatal, intrapartum and postnatal care is vital for the health of the mother, baby and wider family. Continuum of care The continuum of care is crucial; effective care for mothers must have a pregnancy-course approach. Antenatal care must run seamlessly into intrapartum and postnatal care. Postnatal care should facilitate the integration of community and outreach interventions with facility-based care where necessary.20 It can enable promotion of healthy practices such as breastfeeding, nutrition and immunisation while facilitating the early identification of illnesses and access to curative care.10,20 Barriers to the implementation of evidence into practice Much of the evidence on mortality reduction has now existed for well over a decade but implementation is patchy; the challenge remains how to implement evidence into practice consistently. The overarching barrier to achieving MDG4 is that of political will. If the government of a country does not commit to improving perinatal and neonatal mortality, then very few gains will be made. Some of the other main barriers to success include paucity of health workers and training, cultural issues, and inability to access services. These are discussed below. Lack of healthcare workers Lack of healthcare workers to deliver services leads to increased challenges.19 Skilled care at birth can decrease intrapartum death and birth asphyxia, but worldwide there remains a shortage of 5 million health workers with 350 000 more midwives required alone.8 A lack of update training of existing health workers further compounds this problem; it is estimated that 50% of health workers in low-resource settings have not received enough training to be able to adequately perform basic neonatal resuscitation.4 Various methods have been considered to combat this problem. Many countries are moving to develop a new cadre of health professionals with shorter training who are now undertaking roles which were previously only performed by qualified staff. There have been successful examples of this in Mozambique and the Democratic Republic of Congo. Existing cultural practices Existing cultural practices can contribute to poor neonatal outcomes. For example, in rural India women give birth on to a dirt floor and breastfeeding is discouraged for several days. In Bangladesh and Ethiopia the mother and baby may be isolated to fend off evil spirits.8,21 Other traditional practices, such as not feeding the baby colostrum, are prevalent.21 There may also be erroneous perceptions of some interventions being inferior despite evidence to the contrary; kangaroo care being viewed as a poor man’s alternative to an incubator, or breastfeeding less good than ª 2013 Royal College of Obstetricians and Gynaecologists 3 Smith et al.
  • 4. the more modern formula feeding.4 Furthermore, issues of gender roles can lead to men hindering access to care, resulting in critical delays in receiving treatment.8,19 Access to services Access to services is central to improving perinatal health. In addition to the gender disparity, financial, geographical and poor quality services affect the ability of women to access healthcare services. The most obvious financial barrier is the requirement to pay user fees (direct payment made by the patient’s family for the care required); however, the cost implications of seeking care are much broader.19 These include time off work and costs of transport and accommodation.19 All of these factors can make the out-of-pocket costs catastrophic for families. Solutions are being sought, including investigation of conditional cash transfers to improve care-seeking,9 and the abolition of user fees.19 Geographical variations are numerous, with a rural/urban divide in access to care, with health facilities being concentrated in urban, easy-to-reach areas. This is compounded by poor infrastructure making it difficult for the rural population to reach the health facility.19 Quality of services The quality of services patients receive at a healthcare facility affects health-seeking behaviour. Fewer women access poor-quality services.4 Multiple problems can be responsible for lack of quality of care, including absenteeism of staff and lack of good management, training and equipment.4,21 Addressing health inequities The MDGs were designed to address inequalities between countries. We are quickly approaching their end, but Sub-Saharan Africa and South Asia still continue to bear the majority of the burden of disease. Sub-Saharan Africa has just 11% of the world’s population, but accounts for nearly half of all newborn and child deaths.10 Eighty per cent of the babies who die in their first day of life, live and die in Sub-Saharan Africa and South Asia,8 illustrating the inequalities that have continued despite the MDGs. Each country’s target does not demand equity of services within the country. This has often led to improvement in outcomes for those parts of the population that are easy to reach, and with no improvement or even worsening outcomes in the harder-to-reach populations.8 There are many examples of health inequity. Babies born to the poorest fifth of the population are 40% more likely to die than those born to the richest fifth.8 Estimates from low- and middle-income countries suggest a caesarean section rate of approximately 12%; however, in 42 countries the caesarean section rate is only 1% for the poorest fifth of the population,4 and in Sub-Saharan Africa the coverage for skilled birth attendance is five-times lower for the least poor compared with most of the poor.10 Sophisticated solutions are still required to ensure that the needs of the poorest, most vulnerable members of society are not simply overlooked. It is beyond the scope of this article to address many of the important non-health sector interventions that could lead to improved neonatal outcomes. Female education can lead to later marriage and childbearing and it decreases chances of dying in childbirth, in turn reducing child mortality.8,19 Poverty is associated with poor housing, undernutrition and poor sanitation, which all impact on the ability of families to make healthy choices.19 Addressing these issues concurrently could result in significant health gains. Conclusion MDG4 has served to highlight the issue of child health globally, and, despite a slow start, progress towards achieving the goal has recently accelerated. Much evidence for effective, affordable interventions that prevent neonatal and childhood deaths already exists. The task now is to ensure that these are implemented consistently and evenly, within and between countries. It remains a role of individual countries to identify and address local priorities, supported by the wider global community. Looking beyond 2015, the development agenda is unclear. However, the energy created through the MDGs would be wasted if momentum for reducing neonatal deaths were not maintained. Obstetricians have a vital role in advocating for improvements in reproductive health— improvements that can save the lives of mothers, their babies and their children. Acknowledgements North Bristol NHS Trust and Mpilo Central Hospital are Health Partners. The Health Partnership Scheme is funded by the UK Department for International Development (DFID) and managed by the Tropical Health Education Trust (THET). Disclosure of interests Dr Joanna Crofts is a member of the PROMPT Maternity Foundation, a Registered Charity that enables maternity units to run their own multi-professional obstetric emergencies training. AS, WM and RF have no interests to disclose. References 1 United Nations. United Nations Millennium Declaration; 18 September 2000. p. 1–9. 2 Lawn JE, Gravett MG, Nunes TM, Rubens CE, Stanton C. GAPPS Review Group. Global report on preterm birth and stillbirth (1 of 7): definitions, description of the burden and opportunities to improve data. BMC Pregnancy Childbirth 2010;10(Suppl 1):S1. 3 Lawn JE, Blencowe H, Pattinson R, Cousens S, Kumar R, Ibiebele I, et al. Stillbirths: Where? When? Why? How to make the data count? Lancet 2011;377:1448–63. 4 ª 2013 Royal College of Obstetricians and Gynaecologists Millennium Development Goal 4
  • 5. 4 Victora CG, Rubens CE. Global report on preterm birth and stillbirth (4 of 7): delivery of interventions. BMC Pregn Childbirth 2010; 10(Suppl 1):S4. 5 United Nations. The Millennium Development Goals Report; June 2012. p. 1–72. 6 Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L, et al. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet 2010;375:1988–2008. 7 Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet 2011;378:1139–65. 8 Save the Children. Surviving the First Day. London: Save The Children; 2013. p. 1–88. 9 Malla DS, Giri K, Karki C, Chaudhary P. Achieving Millennium Development Goals 4 and 5 in Nepal. BJOG 2011; 118:60–8. 10 Friberg IK, Kinney MV, Lawn JE, Kerber KJ, Odubanjo MO, Bergh A-M, et al. Sub-Saharan Africa’s mothers, newborns, and children: how many lives could be saved with targeted health interventions? PLoS Med 2010;7: e1000295. 11 Prost A, Colbourn T, Seward N, Azad K, Coomarasamy A, Copas A, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 2013;381:1736–46. 12 Wilson A, Gallos ID, Plana N, Lissauer D, Khan KS, Zamora J, et al. Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: meta-analysis. BMJ 2011;343:d7102–2. 13 Roberts D, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2006;(3):CD004454. 14 Lawn JE, Mwansa-Kambafwile J, Horta BL, Barros FC, Cousens S. “Kangaroo mother care” to prevent neonatal deaths due to preterm birth complications. Int J Epidemiol 2010;39(Suppl 1):i144–54. 15 Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362:65–71. 16 Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev 2012;(8):CD003517. 17 Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes. JAMA 2006;295:1809–23. 18 Desai M, ter Kuile FO, Nosten F, McGready R, Asamoa K, Brabin B, et al. Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis 2007;7:93–104. 19 Kinney MV, Kerber KJ, Black RE, Cohen B, Nkrumah F, Coovadia H, et al. Sub-Saharan Africa’s mothers, newborns, and children: where and why do they die? PLoS Med 2010;7:e1000294. 20 Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet 2007;370:1358–69. 21 Sayem AM, Nury ATMS, Hossain MD. Achieving the millennium development goal for under-five mortality in Bangladesh: current status and lessons for issues and challenges for further improvements. J Health Popul Nutr 2011;29:92–102. ª 2013 Royal College of Obstetricians and Gynaecologists 5 Smith et al.

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