REDUCING PERINATAL

AND NEONATAL
MORTALITY
Dr R Soerjo Hadijono SpOG(K), DTRM&B(Ch)
Jaringan Nasional Pelatihan Klinik Kesehatan Reproduksi
Sub Bagian Obginsos Bagian Obgin FK Undip RSUP Dr Kariadi
Semarang

 Over 9 million deaths occur each

year in the perinatal and neonatal

periods;
98% of these deaths take place in the
developing world;
Most of these deaths are caused by
infectious diseases; pregnancyrelated complications; or deliveryrelated complications.

In most of the world, under-5

year and infant (under-1 year)
mortality rates have declined
substantially in the past three
decades.

 Neonatal mortality has declined

less rapidly than other child

mortality;
Neonatal deaths now account
for 40 -70% of all infant
mortality;

Comparison of Infant and

Neonatal Mortality Decline in
Nepal 1975-1995

Infant Mortality
Neonatal Mortality

Comparison of Infant and

Neonatal Mortality Decline in
Turkey 1975-1995

Infant Mortality
Neonatal Mortality

Comparison of Infant and

Neonatal Mortality Decline in
Egypt 1975-1995

Infant Mortality

Neonatal Mortality

Comparison of Infant and

Neonatal Mortality Decline in
Ghana 1975-1995

Infant Mortality
Neonatal Mortality

Comparison of Infant and

Neonatal Mortality Decline in
Peru 1975-1995

Infant Mortality
Neonatal Mortality

To further reduce child

mortality, a new focus of
programs will have to be on
reducing neonatal deaths,
particularly those in the first
week of life.

Medium-Term Trends in
Neonatal Mortality in Asia

Medium-Term Trends in
Neonatal Mortality in Latin
America

Medium-Term Trends in Neonatal

Mortality
in the Middle East and North Africa
Neonatal Mortality Rate

75

50
Yemen
Tunisia

25

Morocco
Egypt
Jordan

0
1975

1980

1985
Year

1990

1995

Medium-Term Trends in Neonatal

Mortality
in Sub-Saharan Africa
N
eonatal M
ortalityR
ate

75

Nigeria

50

Ghana

Senegal
Cameroon

25

Kenya

0
1975

1980

1985
Year

1990

1995

E arly N eonatal D eath/N eon atal M o rtality

Early Neonatal Deaths as a Proportion

of Neonatal Mortality in Developing
Countries
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Direct Causes of Perinatal

Mortality
in Tygerberg, South Africa

Fetal
Abnormality

Intrauterine
Growth
Retardation

6%
8%

Infection

34%

7%
12%

Preterm Birth

14%
Other

Antepartum
Hemorrhage

Causes of Perinatal
Mortality
Unsafe
Abortion
13%

Obstructed
Labor
7%

Other Direct
8%

Other Indirect
20%

Hypertension
13%

Sepsis
14%
Joint WHO-UNICEF-UNFPA-WB statement

Hemorrhage
25%

Direct Causes of Neonatal

Mortality
Neonatal
Tetanus
14%

Pneumonia
19%
Diarrhea
2%
Other
5%

Asphyxia
21%

Prematurity
10%
Injuries
11%
WHO Mother and Baby Package, 1993

Congential
abnormalities
11%

Sepsis
7%

Estimated Global Burden of

Disease of
Major Neonatal Infections
Infection
Acute Respiratory
Infections
Neonatal Tetanus
Sepsis
Diarrhea
Meningitis

Number of
Cases
2,500,000

Case Fatality Rate (%)

30

Number of
Deaths
750,000

438,000
750,000
25,000,000
126,000

85
40
.6
40

372,000
300,000
150,000
50,400

Stoll, BJ. The global impact of infection, in Clin Perinatol 1997; 24:1-21.(14)

Estimated Global Burden of

Disease of Major Neonatal
Infections
Infection
Acute Respiratory
Infection
Neonatal Tetanus
Sepsis
Diarrhea
Meningitis

Number of
cases

Case Fatality Number

Rate (%)
of Deaths

2,500,000

30

750,000

438,000
750,000
25,000,000
126,000

85
40
0.6
40

372,000
300,000
150,000
50,400

Interventions
Prior to or During Pregnancy
During Delivery
After Delivery

Interventions Prior to or
During Pregnancy
Nutritional Interventions
Malaria Prophylaxis
Maternal Immunization

Nutritional
Interventions I
Ceesay et al supplemented pregnant
women in The Gambia with 900
additional calories per day, and
reduced:

Low birthweight by 35%

Stillbirths by 55%
Perinatal deaths by 49%
Neonatal deaths by 40%
BMJ 1997 Sept 27;315(7111):786-90

Nutritional
Interventions II
In Sri Lanka, iron
supplementation along with
antihelminthic therapy reduced:
Low birthweight by 50%
Perinatal deaths by 45%

Atukorala TM et al AJCN 1995 Aug;60(2):286-92

Malaria - Effects on
Perinatal and Neonatal
Mortality
In 1994, 45 million pregnant women

were living in malarious areas, with over

23 million in Sub-Saharan Africa;
Malaria may cause up to 30% of
preventable low birth weight, and 3-5%
of neonatal mortality in highly endemic
areas, and
Malaria is also associated with an
increased risk of spontaneous abortions
and stillbirths

Malaria Prophylaxis
In Kilifi District, Kenya, an area of high
malaria transmission, Shulman et al
presumptively treated pregnant women
with Fansidar which reduced:
Perinatal deaths by 22%
Neonatal deaths by 38%

Shulman CE et al, Lancet 1999 Feb 20; 353(9153):632-6

Maternal Immunization
Maternal immunization with tetanus

toxoid reduced neonatal mortality

(from days 4 to 14) from 30/1000 to
10/1000, and reduced deaths for
three years after vaccination.
Maternal immunization with
pneumococcus produced antibody
levels in infants twice that of infants
of unimmunized mothers.
Black RE et al Bull WHO 1980 58:927-930 & Shahid et al, Lancet 1995;346(8985):1252-7.

Interventions During
Delivery
Prevention and Management of

Delivery Complications
Resuscitation of the newborn

Prevention and
Management of Delivery
Complications
A study in Shunyi, China reduced perinatal
mortality by 34% and early neonatal mortality by
25% by implementing the following interventions:
Training a community member to recognize early

warning signs of pregnancy problems, and refer

the woman to a township doctor;
Improvements in transportation services for
referral;
Education campaigns specifically targeted at
newly married couples and their families, and the
general public through television and radio
messages
Yan et al. Int J Gynaecol Obstet 1989 Sep;30(1):23-6

Resuscitation of the
newborn
Asphyxia due to prolonged labor or small

infant size continues to claim the lives of

nearly 1 million neonates each year.
Infants born at home are those at greatest
risk.
Midwives and community health workers
must be authorized and trained to give bag
and mask resuscitation to newborns.
Complex interventions such as intubation,
chest compression and drugs are rarely
needed.

Interventions After
Delivery
Kangaroo Care Method
Breastfeeding and Nutritional

Support
Prevention and Management of
Infections

Kangaroo Care Method

In Zimbabwe, Kangaroo Care babies
had:
Improved survival
Faster growth;
A higher median weight and hospital
discharge weight;
A lower frequency of illness, and
A lower median duration of hospital
stay.
Bergman & Jurisoo Trop Doct 1994;24(2):57-60 & Kambarami et al. Ann Trop Paediatr 1998 Jun;18(2):81-6.

Breastfeeding and
Nutritional Support
Breastfeeding protects against

late neonatal deaths (from 8 - 28

days) which are primarily due to
infections, such as sepsis, ARI,
meningitis, umbilical infection
(omphalitis), and diarrhea.

Relative Risk for Mortality (0-1

Month) by Breastfeeding,
Pelotas, Brazil

Victora et al Lancet 1987;Aug;8:319-21

Prevention and
Management of Infections
To protect immature epithelial barriers from

infection, a topical emollient such a Aquaphor

may be applied to the skin of pre-term infants.
In clinical trials, Aquaphor reduced positive
blood and cerebrospinal fluid cultures to 3.3%
(controls = 26.7%).
Studies are currently in progress to examine
the safety and efficacy of inexpensive and
locally available vegetable oil substitutes for
use in the developing world.

Primary Causes of
Neonatal Deaths in the
Community
Other
13%

Prematurity
15%
Sepsis
52%

Asphyxia
20%
A Bang, Personal Communication

Primary Causes of Death in

Hospital-Borne Neonates
Congenital
abnormality
9%
Other
12%

Prematurity
31%
Report on the Neonatal-Perinatal Database, 1995. New Delhi

Sepsis
22%

Asphyxia
26%

Implications for Research

and Programs
Community and Health System

Barriers
Adapting IMCI to the Neonatal
Period
Community-Based Neonatal
Care in India

Community and Health

System Barriers
A study in Guatemala of perinatal and

neonatal deaths by McDermott and

colleagues showed that 83% of
mothers sought care, but most
received care only from TBAs.
In neonatal deaths, hypothermia was
noted in 89%, the umbilical cord was
cut with scissors in 86%, and nothing
was applied to the cord wound in
53%.

Implementation of IMCI (June 1999)*

Discussions had started in at least
another 8 countries
Dominican
Rep.
El Salvador
Haiti
Honduras
Nicaragua

Argentina
Brazil
Bolivia
Colombia
Ecuador
Paraguay
Peru
Venezuela

*Based on information
available in June 1999

Egypt
Iran
Morocco
Pakistan
Sudan
Syria
Turkey
Yemen

Benin
Botswana
Cote d'Ivoire
Eritrea
Ethiopia
Ghana
Kenya
Madagascar
Malawi
Mali
Mozambique

Armenia
Azerbaijan
Belarus
Georgia
Kazakhstan

Namibia
Niger
Nigeria
Senegal
South Africa
Tanzania, U.R.
Togo
Uganda
Zambia
Zimbabwe

Kyrgyzstan
Moldova
Tadjikistan
Turkmenistan
Uzbekistan
Bangladesh
Bhutan
Cambodia
China
India
Indonesia
Laos
Myanmar
Nepal
Philippines
Viet Nam

Status of implementation
Introduction (20 countries)
Early implementation (31 countries)
Expansion (12 countries)

Neonatal Health
Interventions I
During Pregnancy
Preparedness and counselling on

safe childbirth;
Treatment of maternal complications;
Infection control in endemic areas
(malaria, syphilis and hookworm);
Control of nutritional deficiencies
Immunizing the mother with tetanus
toxoid;
Avoiding harmful substances.

Neonatal Health
Interventions II During
Childbirth
Safe and clean delivery;
Effectively managed pregnancy
complications, and
referral for essential obstetric
care;

Neonatal Health
Interventions III For the
Newborn
Routine care and vigilance for all newborns,

during from 6-12 hours after birth;

Special care for preterm and/or low birth
weight infants, including Kangaroo Care;
Identification and treatment of infections;
Support for mothers on providing newborn
care, and on recognizing danger signs and
taking appropriate action;
Immunization, and
Prevention of vertical HIV/AIDS
transmission

Community-Based
Neonatal Care in India
A study in India which trained community
health workers to treat or refer women with
pregnancy complications; identify sick or
high-risk newborns, treat infections and
administer injections, reduced:
Case fatality from sepsis from 18.5% to

2.8%
Perinatal mortality by 71%
Neonatal mortality by 62%
Bang et al

RESEARCH AND PROGRAM

PRIORITIES

Program Priorities
Before Birth
During Labor and Delivery
The Early Weeks of Life

Perinatal and Neonatal

Program Priorities Before
Birth
Increasing the quality and scope of

syphilis screening;
Improving the diagnosis and
treatment of ascending, reproductive
tract infections in pregnant women;
Expanding maternal immunization
with tetanus toxoid and
pneumococcus;

Perinatal and Neonatal

Program Priorities Before
Birth
Presumptive malaria prophylaxis in

routine antenatal care visits, and

Nutritional support for pregnant
women to improve birth outcomes.

Perinatal and Neonatal

Program Priorities During
Labor and Delivery
Regular re-education of health

workers and birth attendants and the

use of economic incentives to
improve the identification and
management of malpresentation and
prolonged labor;
Referral of complicated cases to
health center or hospital;

Perinatal and Neonatal

Program Priorities During
Labor and Delivery
Combating the barriers to referral

compliance, including transportation

of mothers and care of other children,
and
Institution of perinatal and neonatal
audits at hospitals and health centers

Perinatal and Neonatal Program

Priorities In the Early Weeks of
Life
Wider use of resuscitation techniques

for asphyxiated infants;

Proper management of neonatal
sepsis and other infections;
Skin-to-skin Kangaroo Care for
preterm infants, and
Immediate and exclusive
breastfeeding for all newborns.

Crucial to the success

of programs is:
national ownership, and
public-private partnerships to

ensure long-term funding

A cost-effective, and efficient

way
to introduce interventions
would be to make additions
to already existing programs.

Research Priorities
Neonatal Infections
IMCI
Community-Based Health

Services
Malaria Reduction
Reduction of Premature and
IUGR Births

Research Priorities for

Neonatal Infections
Community-based surveillance to

identify the principal bacterial and

viral agents of neonatal infections
Determination of the antimicrobial
resistance profiles of the common
bacterial agents of serious infections
in neonates on a regional basis, in
both community and hospital
settings;

Research Priorities for

Neonatal Infections
Studies of neonatal care provided in the

home by caretakers, traditional birth

attendants, and community health workers,
and follow cohorts of neonates for infectious
outcome, and
Case-control studies to identify the principal
risk factors for neonatal infections. Risk
factors to be evaluated include low birth
weight; unhygienic delivery, skin and
umbilical cord care; birth asphyxia;
hypothermia; smoke inhalation; and feeding
practices

Research Priorities for

IMCI
Identification of historical information

and clinical signs and symptoms that

are most predictive of the presence
of acute neonatal infection;
Development of an algorithm for use
in identifying neonatal infection, and
Training and testing the abilities of
community-health workers to use the
algorithm to identify acutely infected
neonates

Research Priorities for

Community-Based Health
Services

Community-based studies to

determine existing obstetric

practices, neonatal care, and healthseeking behavior for neonatal
illnesses;
Training of traditional birth attendants
and community health workers to
implement the package of basic
neonatal care practices;

Research Priorities for

Community-Based Health
Services

Strategies to improve access to

emergency obstetric care, and

methods to increase referral rates for
complicated pregnancies, and
Design of a package of simple
practices for the routine post-delivery
care of neonates born in the
community.

Research Priorities to
Reduce Malaria
Efficacy studies of presumptive,

intermittent treatment to prevent

malaria as part of routine antenatal
care in areas of high transmission;
Design of methods for treatment of
malaria during pregnancy using safe,
effective and simple regimens in
areas of high, medium, and low
transmission;

Research Priorities to
Reduce Malaria
Evaluation of the safety and efficacy

of newly available antimalarial drugs

(alone or in combinations) for
treatment and prevention in
pregnancy, and
Reduction of malaria exposure during
pregnancy using methods such as
insecticide-permeated bed nets.

Research Priorities to
Reduce
Premature and IUGR Births
Evaluation of simple methods for

detection of bacterial vaginosis, and

appropriate treatment, such as
comparing a once versus three-times
daily treatment with metronidazole;
Development of strategies to improve
knowledge and practice of methods
to prevent sexually-transmitted
diseases;

Research Priorities to
Reduce
Premature and IUGR Births
Evaluation of the safety and efficacy

of maternal caloric supplementation

for reducing low birth weight, and
methods to reduce maternal anemia
through the use of iron supplements,
antihelminths and antimalarials, and
Evaluation of micronutrient
supplementation for the reduction of
LBW, and improved neonatal health.

 An ongoing dialogue must be

established between governments

and researchers to combat perinatal
and neonatal mortality
Governments must be able to call
upon researchers to help them solve
health problems, and research
results must be used to formulate
national programs and policies.

We must create
sustainable interventions
in countries where the
needs are greatest

More than nine million

children will continue to die
before or just after birth each
year, unless the international
health community finds
solutions for and implements
programs to reduce their
numbers.
Duff Gillespie, Ph.D.,
Deputy Assistant Administrator
USAID Population Health and Nutrition/Global Programs

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