Elsevier

The Lancet

Volume 384, Issue 9938, 12–18 July 2014, Pages 174-188
The Lancet

Series
Who has been caring for the baby?

https://doi.org/10.1016/S0140-6736(14)60458-XGet rights and content

Summary

Nearly a decade ago, The Lancet published the Neonatal Survival Series, with an ambitious call for integration of newborn care across the continuum of reproductive, maternal, newborn, and child health and nutrition (RMNCH). In this first of five papers in the Every Newborn Series, we consider what has changed during this decade, assessing progress on the basis of a systematic policy heuristic including agenda-setting, policy formulation and adoption, leadership and partnership, implementation, and evaluation of effect. Substantial progress has been made in agenda setting and policy formulation for newborn health, as witnessed by the shift from maternal and child health to maternal, newborn, and child health as a standard. However, investment and large-scale implementation have been disappointingly small, especially in view of the size of the burden and potential for rapid change and synergies throughout the RMNCH continuum. Moreover, stillbirths remain invisible on the global health agenda. Hence that progress in improvement of newborn survival and reduction of stillbirths lags behind that of maternal mortality and deaths for children aged 1–59 months is not surprising. Faster progress is possible, but with several requirements: clear communication of the interventions with the greatest effect and how to overcome bottlenecks for scale-up; national leadership, and technical capacity to integrate and implement these interventions; global coordination of partners, especially within countries, in provision of technical assistance and increased funding; increased domestic investment in newborn health, and access to specific commodities and equipment where needed; better data to monitor progress, with local data used for programme improvement; and accountability for results at all levels, including demand from communities and mortality targets in the post-2015 framework. Who will step up during the next decade to ensure decision making in countries leads to implementation of stillbirth and newborn health interventions within RMNCH programmes?

Introduction

During the 1990s, more than 4 million neonatal deaths worldwide each year were hardly mentioned in global health circles, and newborn care was perceived as technical, expensive, and deficient in cost-effective solutions feasible for low-income countries.1, 2, 3 It was widely assumed that investment in newborn health should wait until countries had greater wealth and more functional health systems. These myths were challenged in 1999, when Abhay Bang published results4 from rural India showing that a home-based package of maternal and newborn health interventions delivered by community health workers (CHWs) could reduce neonatal mortality by 62%. In 2000, the Bill & Melinda Gates Foundation funded Save the Children's Saving Newborn Lives initiative to develop evidence, policy, and programmes to improve global newborn survival. The Lancet Child Survival Series in 20035 catalysed rethinking of the global child-health agenda, and noted the important burden of newborn deaths, but at the time details were insufficient on neonatal causes of death, interventions (especially at community level), and how to deliver newborn care at scale in low-resource settings.5, 6, 7

In 2005, the Lancet Neonatal Survival Series sought to accelerate action by describing the timing, causes, and location of neonatal deaths;8, 9 identifying highly cost-effective interventions that could avert more than two-thirds of neonatal deaths, including about a third through community care;10 and outlining how these solutions can be delivered by integration and scaling up at both facility and community levels11 for an estimated additional cost of US$1 per person, of which about 70% would also benefit mothers and older children.1 A “new category of vulnerable persons that did not exist in the minds of many global health actors”12 received widespread attention for the first time, driven especially by the recognition that Millennium Development Goal (MDG) 4 for child survival could not be achieved without increased attention to newborn health.1 An ambitious call was made for ownership of newborn health outcomes across the continuum of care for reproductive, maternal, newborn, and child health and nutrition (RMNCH) for women and children, and linking community, outreach, and facility care. 1 year later progress seemed promising,2 but in 2013, the independent Expert Review Group of the UN Secretary General's Every Woman Every Child movement highlighted that neonatal deaths still need more attention, and they account for an increasing proportion (now 44%) of deaths of children younger than 5 years.13, 14

This paper is the first in a five-part Series on newborn health and survival and stillbirths15, 16, 17, 18 in which we analyse the extent to which the 2005 call to action in the Lancet was acted on, in the broader context of changes in global health (panel 1). We acknowledge that measurement of effects on policy and practice is complex,19, 20 and do not seek to attribute changes to the Lancet Neonatal Survival Series; rather, we aim to assess what has changed and, if something has not, then why not, as a basis for accelerating progress for every newborn baby (figure 1).

Section snippets

Agenda setting

We rate agenda setting for newborn health (figure 1) overall as “green”, indicating major advances (figure 2, appendix). This shows the rapidity with which evidence has been generated and disseminated. As noted by Shiffman,12 “Researchers produced reviews of evidence that summarised successful strategies for newborn care and made this information widely available in forms accessible to policy makers and programme managers.” Although the evidence base is incomplete, especially for prevention of

Conclusion

During the past decade, progress has been made in each category of the heuristic policy process (figure 2). Remarkably, rapid progress occurred in agenda setting, and newborn babies have shifted from being almost invisible on the global health agenda in the 1990s to being a central element in the RMNCH continuum of care in several countries. However, in view of the size of the burden (almost 10% of the Global Burden of Disease 2010, without including 2·6 million stillbirths),112 the potential

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