Elsevier

The Lancet

Volume 384, Issue 9940, 26 July–1 August 2014, Pages 347-370
The Lancet

Series
Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?

https://doi.org/10.1016/S0140-6736(14)60792-3Get rights and content

Summary

Progress in newborn survival has been slow, and even more so for reductions in stillbirths. To meet Every Newborn targets of ten or fewer neonatal deaths and ten or fewer stillbirths per 1000 births in every country by 2035 will necessitate accelerated scale-up of the most effective care targeting major causes of newborn deaths. We have systematically reviewed interventions across the continuum of care and various delivery platforms, and then modelled the effect and cost of scale-up in the 75 high-burden Countdown countries. Closure of the quality gap through the provision of effective care for all women and newborn babies delivering in facilities could prevent an estimated 113 000 maternal deaths, 531 000 stillbirths, and 1·325 million neonatal deaths annually by 2020 at an estimated running cost of US$4·5 billion per year (US$0·9 per person). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1·9 million [range 1·6–2·1 million]), 33% of stillbirths (0·82 million [0·60–0·93 million]), and 54% of maternal deaths (0·16 million [0·14–0·17 million]) per year. These reductions can be achieved at an annual incremental running cost of US$5·65 billion (US$1·15 per person), which amounts to US$1928 for each life saved, including stillbirths, neonatal, and maternal deaths. Most (82%) of this effect is attributable to facility-based care which, although more expensive than community-based strategies, improves the likelihood of survival. Most of the running costs are also for facility-based care (US$3·66 billion or 64%), even without the cost of new hospitals and country-specific capital inputs being factored in. The maximum effect on neonatal deaths is through interventions delivered during labour and birth, including for obstetric complications (41%), followed by care of small and ill newborn babies (30%). To meet the unmet need for family planning with modern contraceptives would be synergistic, and would contribute to around a halving of births and therefore deaths. Our analysis also indicates that available interventions can reduce the three most common cause of neonatal mortality—preterm, intrapartum, and infection-related deaths—by 58%, 79%, and 84%, respectively.

Introduction

This Lancet Every Newborn Series shows that despite a halving of under-5 child deaths in the past two decades, progress in reducing newborn deaths has been slower, with about 3 million neonates still dying every year.1 Reductions in neonatal mortality have averaged 2·0% annually since the Millennium Development Goals (MDG) baseline in 1990, which is much slower than corresponding reductions in maternal mortality (2·6%) or mortality in children 1–59 months of age (3·4%). Additionally, 2·6 million stillbirths (≥28 weeks or ≥1000 g) occur every year, including 1·2 million during labour.2 These stillbirths were not counted in the MDGs and progress has been substantially slower than even that for reductions in newborn mortality.1 Achievement of the proposed Every Newborn targets of ten or fewer neonatal deaths and stillbirths per 1000 births in every country1, 2 would need a doubling of present rates of change at a global average, and more in some high-burden countries. Such progress needs focus on the most effective interventions and intentional investment and implementation, which has been insufficient so far.3 In this third paper of the Series, we provide an update of the evidence base for interventions since the Lancet 2005 Neonatal Series and 2011 Stillbirth Series, and other relevant reviews.4, 5, 6, 7 We estimate the potential lives saved and the running costs of implementation, and make recommendations for prioritisation linked to the Every Newborn Action Plan.

Section snippets

Review of interventions and delivery platforms

We identified specific interventions across the continuum of care (preconception, antenatal, intrapartum, immediate postnatal period, and thereafter), building on previous evidence reviews4, 5, 6, 7, 8 (appendix pp 3–4), which could affect stillbirths and newborn outcomes (figure 1). We also reviewed delivery platforms that could augment the uptake of these interventions and methods to improve quality of care. We searched all major databases to identify available quality systematic reviews in

Methods

We selected interventions from those reviewed, based on evidence of benefits as described here and extensively in previous publications. The cause-specific effects of these interventions on stillbirths and neonatal mortality are presented in table 2 and appendix pp 50–64. We used the Lives Saved Tool (LiST) to model the effect of these interventions within the health systems of 75 Countdown countries that together account for more than 95% of maternal, neonatal, and child deaths worldwide. LiST

Discussion

Our review is the first comprehensive analysis of the evidence base and strategies to address global newborn health and survival and delivery strategies since our analyses in 2005, and has the additional strength of considering maternal and stillbirth outcomes.5, 136 During the past decade, notable advances have been made in the breadth and depth of the evidence base for newborn interventions,1 especially in the context of essential interventions and packages of care.137 Some highlights include

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