JPediatr(RioJ).2016;92(6):543---545
www.jped.com.br
EDITORIAL
Maternal
and
neonatal
mortality:
time
to
act
夽
,
夽夽
Mortalidade
materna
e
neonatal:
hora
de
agir
Waldemar
A.
Carlo
∗,
Colm
P.
Travers
UniversityofAlabamaatBirmingham,DivisionofNeonatology,Birmingham,UnitedStates
Maternal, infant, and neonatal mortality rate are bench-marksformaternal/infantcareandthehealthofasociety in general.Global effortstoreduce these mortalityrates have been led by the World Health Organization (WHO) andtheUnitedNations;therateshavedecreased substan-tiallyworldwide,buttheambitiousreductionssetforthby theMillenniumDevelopmentGoalshavenotbeenachieved. Maternal mortality has decreased by approximately 45% from the Millennium Development Goals baseline rate in 1990.1 One in four babies worldwide are delivered with-out the presence of a skilled birth attendant. Every day, hundredsofpreventablematernaldeathsoccurdueto preg-nancyorchildbirth-relatedcomplications.Infantmortality rates have decreased in developing countries, but these reductions have been largely due to decreases in deaths frompneumonia and diarrheal diseaseafter the neonatal period,while earlier deathsrelatingto prematurity,birth asphyxia,andinfectionhaveexperiencedalowerdecrease.2 As a consequence, neonatal deaths now account for 44% ofthechildhoodmortality,thehighestrateever.2 Approxi-mately2.8millionbabiesworldwidedieeachyearduringthe firstmonthafterbirth;mostofthesedeathsoccurin devel-opingcountries.2Scalingupinterventionsproventobevery effectivecouldsubstantiallyreducetheregrettablelossof younglives.
夽
Pleasecitethisarticleas:CarloWA,TraversCP.Maternaland neonatalmortality:timetoact.JPediatr(RioJ).2016;92:543---5.
夽夽
SeepaperbyRodriguesetal.inpages567---73.
∗Correspondingauthor.
E-mail:[email protected](W.A.Carlo).
The article ‘‘Temporal and spatial evolution of mater-nalandneonatalmortalityratesinBrazil,1997---2012,’’by Rodriguesetal.3 reports thetrends inmaternal mortality ratioand neonatal mortality rate in a large geographical areawithsignificantdisparitiesinsocioeconomicstatus.The studyhighlightsthatthematernalmortalityrateremained relatively constant during the study period in spite of decreases in the neonatal mortality rate. Furthermore, important geospatial differences in mortality were docu-mented;thelargestreductionsinneonatalmortalityrates wereobserved in regions with the highest socioeconomic status, when compared toregions withthe lowest socio-economicstatusinBrazil.Internationalcomparisonsofthe neonatal mortality rate are difficult to interpret due to majordifferencesinreporting,asinfantsatthelowestbirth weightsandgestationagesmaybecountedasfetaldeaths regardlessofsignsoflifeafterbirth.4,5
Efforts related to the Millennium Development Goals have been associated with a reduction of approximately 45% in maternal mortality and over 50% in neonatal and child mortality.The reductionin neonatal and child mor-talityhasresultedinalmostsixmillionlivessavedperyear. However,similartotheresultsfromBrazilinthestudyby Rodriguesetal.3thesereductionsinmaternalandneonatal mortalityhavenotbeenhomogeneous,withsmaller reduc-tionsorevenincreasesinthemostvulnerablepopulations. Mostmaternal,neonatal,andchilddeathsarepreventable withimplementationof well-proven andeffective health-careinterventions.
Thus,whatcanbedone toreduceneonataland mater-nalmortality?Thefirsttwodaysafterbirthaccountforover 50%ofneonataldeaths,whilethefirstweekoflifeaccounts for over 75% of all neonatal deaths. Neonatal deaths are
http://dx.doi.org/10.1016/j.jped.2016.08.001
544 CarloWA,TraversCP
mostfrequentlyduetobirthasphyxia,prematurity,sepsis, andcongenitalmalformation,indicatingthatinterventions shouldfocusonduringlaborandtheearlypost-natalperiod, based on the timing of the causes of death, with some efforts to reduce neonatal deaths extended beyond the first week after birth. Therefore, the WHO has made a strongrecommendation for postnatalcare in facilities for atleast 24h after birthand postnatalcontactwithin 24h afterbirth for infants born at home.6 Training in resusci-tationandinessentialnewborncarereducesperinataland neonatalmortality.5,7Ithasbeenestimatedthatthese pro-gramshave thepotentialtoreduceuptoamilliondeaths per year if implemented worldwide.8 The HelpingBabies BreatheandtheEssentialCareforEveryBabytraining pro-gramsareavailable,buthavenotbeenscaledupasneeded. Thenewprogram EssentialCarefor SmallBabiesalsohas thepotentialtoreducedeathsduetoprematurity,the cur-rent main cause of infant mortality. These programs can be implemented in such a way to be one of the most cost-effectiveinterventionstoreduceneonatalmortality.9 In addition, postnatal contacts are recommended on the third day (48---72h), between the seventh and 14th day, and six weeks after birth. Public health initiatives that aimtoimprove accesstohealth care andtarget thoseat highestriskofadverseoutcomescanreducematernaland neonatalmortality.Suchinterventionsincludehome visits bycommunity health workers, especiallyin selected high mortalitysettings.Homevisitsforneonatalcareby commu-nityhealth workers areassociated withreduced neonatal mortalityin resource-limitedsettingswith poorly accessi-ble facility-based healthcare. Trained healthcare workers can identifyseriously illchildren. Data fromseveral con-trolledstudies in settingsof poor accesstofacility-based healthcareinSouthAsiaindicatethathome-basedneonatal carethroughcommunityhealthcareworkersreduced neona-tal and perinatal mortality, particularly in those settings withthe highest baseline neonatalmortality rates.10 The adoptionofthispolicyisjustifiedinsuchsettings.
There is alarge bodyof evidence oneffective health-carepackagesofselectivelow-costeffectiveinterventions to reduce neonatal mortality in resource-limited settings inlow-andmiddle-incomesettings,whichareparticularly appropriateforscalingup.11Largescaletrialshave demon-strated the feasibility and effectiveness of packages of interventionstoreduceneonatalmortality.5,11Intherecent EveryNewbornseriesbyLancet,ithasbeenestimatedthat very large neonatal survival benefits would accrue from scalingupinterventionsconsisting of healthcarepackages particularlyfocusedonsmallandsickneonates.5,11 Inthat light,theWHO recommendations6 basedonthesereviews provideanopportunepolicyimpetustoward achievingthe post-2015neonatalmortalitytargets.
Neonatal hypothermia occurs in as many as 50% of infantsinlow-andmiddle-incomesettings;theseverityof hypothermia is associated with a higher risk of mortality duringthefirstsevendaysafterbirth.12Toreduceneonatal hypothermia,theWHOrecommendsasetofinterlinked pro-cedurescalledthe‘‘warmchain’’tobefollowedafterbirth. Interventionsincludewarmdeliveryrooms,immediate dry-ing,skin-to-skincontactascontinuouslyaspossible,early breastfeeding,delayed bathingand weighing,appropriate bundlingofmotherandbabytogether,warmtransportation,
warm resuscitation,alongwithtrainingandraising aware-ness of the risks of hypothermia. Kangaroo mother care, amethodofskin-to-skincontact,promotesbreastfeeding, reduceshypothermia,neonatalmortality,sepsis,andlength ofhospitalstayatdischargeorat40weeksinpretermand lowbirthweigh infantscomparedtoconventionalhospital care.13 Multiple applications(daily for seven toten days) ofchlorhexidinetotheumbilicalcordcanreducetheriskof neonatalmortalityandomphalitisininfantsbornathomein highneonatalmortalitysettings(30ormoreneonataldeaths per1000livebirths),14 andisrecommendedbyWHO. How-ever, thereis insufficientevidence for recommendingthis interventionininfantsborninhealthfacilitiesand/orlower neonatal mortalitysettings. Observationalstudies suggest thathospitalmortalityinpreterminfantscouldbereduced withimplementationofcontinuouspositiveairwaypressure, which is consistentwithdata fromrandomizedcontrolled trialsconductedinhigh-resourcesettings.15 Evidencefrom randomized and observational studies indicates that rou-tine intramuscular administrationof 1mg of vitamin Kat birthreducesvitaminKdeficiencybleedingduringinfancy.16 Extensiveevidencefromhighincomesettingsindicatethat surfactant replacementtherapy reduces mortalityand air leaks;17 surfactant therapy has the potential to reduce neonatal mortalityand air leaksin low-resource settings. Somestudiesinlow-resourcesettingsthattestedtherapies withprovenefficacyinhigh-resourcesettingshavehad dis-appointingresults.Forexample,alargecluster-randomized controlled trial of antenatal corticosteroid administration in resource-limited countries did not observe a survival benefit amongpreterm infants exposed to antenatal cor-ticosteroids;exposurewasassociatedwithanincreasedrisk ofmaternalinfection.18
Maternalmortalitytargetsarenotdecliningattherate set in the Millennium Development Goals. The maternal morality ratiodeclined from 385deaths per100,000 live-births in 1990---216 in 2015, worldwide,having decreased inallWHO regions.1The majorcausesofmaternal deaths are post-partum hemorrhage, pre-eclampsia/pregnancy-induced hypertension and eclampsia, and infections, all of which are largely preventable with proven and effec-tiveinterventions.Todate,successfulstrategiesthathave reduced maternal mortality in low-resource settingshave includedinvestmentintransportationandaccesstocare,19 aswellasinvestmentinantiretroviraltherapyincountries with high prevalence of human immunodeficiency virus infection.20 Access to maternal and child health services has been improved by opening health centers 24h per day and by adding maternity waiting houses anddelivery roomsathealthcenters.21Increasingthenumberofskilled birth attendantshasalsobeen linkedtoreductionsin the maternalmortalityratio.21Nationaltrainingprogramshave increasedthenumberofmidwivesandtrainedcommunity healthcare workers available, particularly in underserved areas through targeted deployment and incentivization.21 Continued researcheffortsandimproved dataareneeded to determine cost-effective ways to implement interven-tions that can reduce maternal mortality in low-resource settings.
Maternalandneonatalmortality 545
have notbeen achieved,particularlyfor themost vulner-ablepopulationsworldwide.Geospatialandtemporaldata canhelpidentifythemostvulnerableareasthatarein par-ticular need of improved maternal andneonatal care. As statedbyNobellaurateGabrielaMistral,‘‘weareguiltyof manyerrorsandmanyfaults,butourworstcrimeis aban-doningthechildren,neglectingthefountain oflife.’’Itis timetoacttoscaleupinterventionsproventobeefficient andcost-effective.
Conflicts
of
interest
Dr.WaldemarA.CarloisontheBoardofDirectorsofMednax. Dr.ColmP.Traversdeclaresnoconflictsofinterest.
References
1.Alkema L, Chou D, Hogan D, Zhang S, Moller AB, Gemmill A, etal. Global, regional,and national levelsand trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis bythe UN Maternal Mortality Estimation Inter-Agency Group. Lancet. 2016;387:462---74.
2.LiuL,OzaS,HoganD,PerinJ,RudanI,LawnJE,etal.Global, regional,andnationalcausesofchildmortalityin2000---13,with projectionstoinformpost-2015priorities:anupdated system-aticanalysis.Lancet.2015;385:430---40.
3.Rodrigues NC, MonteiroDL, Almeida AS, BarrosMB,Neto A, O’DwyerG,etal.Temporalandspatialevolutionofmaternal andneonatalmortalityratesinBrazil,1997---2012.JPediatr(Rio J).2016;92:567---73.
4.MacDormanMF,MathewsTJ.Behindinternationalrankingsof infantmortality:howtheUnitedStatescompareswithEurope. IntJHealthServ.2010;40:577---88.
5.CarloWA,GoudarSS,JehanI,ChombaE,TshefuA,GarcesA, etal.Newborn-caretrainingandperinatalmortalityin devel-opingcountries.NEnglJMed.2010;362:614---23.
6.WorldHealth Organization(WHO). WHOrecommendations on postnatalcareofthemotherandnewborn.Geneva:WHO;2013. 7.CarloWA,McClureEM,ChombaE,ChakrabortyH,HartwellT, HarrisH,etal.Newborncaretrainingofmidwivesandneonatal and perinatalmortality rates in a developing country. Pedi-atrics.2010;126:e1064---71.
8.LittleG,NiermeyerS, SinghalN,LawnJ,KeenanW. Neona-tal resuscitation: a global challenge. Pediatrics. 2010;126: e1259---60.
9.Manasyan A, Chomba E, McClure EM, Wright LL, Krzywanski S, Carlo WA, et al. Cost-effectiveness of essential newborn
caretraininginurbanfirst-levelfacilities.Pediatrics.2011;127: e1176---81.
10.DasJK,RizviA,BhattiZ,PaulV,BahlR,ShahidullahM,etal. StateofneonatalhealthcareineightcountriesoftheSAARC region.SouthAsia:howcanwemakeadifference?PaediatrInt ChildHealth.2015;35:174---86.
11.BhuttaZA,DasJK,BahlR,LawnJE,SalamRA,PaulVK,etal. Canavailable interventionsendpreventabledeathsin moth-ers,newbornbabies,andstillbirths,andatwhatcost?Lancet. 2014;384:347---70.
12.MullanyLC,KatzJ,KhatrySK,LeClerqSC,DarmstadtGL,Tielsch JM.Riskofmortalityassociatedwithneonatalhypothermiain southernNepal.ArchPediatrAdolescMed.2010;164:650---6. 13.Conde-Agudelo A,Díaz-RosselloJL. Kangaroomothercare to
reduce morbidity and mortality in low birthweight infants. CochraneDatabaseSystRev.2014:CD002771.
14.SankarMJ,ChandrasekaranA,RavindranathA,AgarwalR,Paul VK.Umbilicalcordcleansingwithchlorhexidineinneonates:a systematicreview.JPerinatol.2016;36:S12---20.
15.JensenEA,ChaudharyA,BhuttaZA,KirpalaniH.Non-invasive respiratory support for infants in low- and middle-income countries.SeminFetalNeonatalMed.2016;21:181---8. 16.Sankar MJ,Chandrasekaran A, Kumar P, Thukral A, Agarwal
R, Paul VK. Vitamin K prophylaxis for prevention of vita-min Kdeficiency bleeding: a systematic review.J Perinatol. 2016;36:S29---35.
17.SegerN,SollR.Animalderivedsurfactantextractfortreatment ofrespiratorydistresssyndrome.CochraneDatabaseSystRev. 2009:CD007836.
18.Althabe F, Belizán JM, McClure EM, Hemingway-Foday J, BerruetaM,MazzoniA,etal.Apopulation-based,multifaceted strategy to implement antenatal corticosteroid treatment versus standard care for the reduction of neonatal mortal-ity due to preterm birth in low-income and middle-income countries:theACTcluster-randomisedtrial.Lancet.2015;385: 629---39.
19.Hanson C,CoxJ, MbarukuG, Manzi F,Gabrysch S, Schellen-bergD,etal.Maternalmortalityanddistancetofacility-based obstetriccareinruralsouthernTanzania:a secondary analy-sisofcross-sectionalcensusdatain226,000households.Lancet GlobHealth.2015;3:e387---95.
20.KassebaumNJ,Bertozzi-VillaA,CoggeshallMS,ShackelfordKA, Steiner C, Heuton KR, et al. Global, regional, and national levelsand causesofmaternalmortalityduring1990---2013:a systematicanalysisfortheGlobalBurdenofDiseaseStudy2013. Lancet.2014;384:980---1004.
