Early neonatal death: A challenge worldwide

https://doi.org/10.1016/j.siny.2017.02.006Get rights and content

Abstract

Early neonatal death (ENND), defined as the death of a newborn between zero and seven days after birth, represents 73% of all postnatal deaths worldwide. Despite a 50% reduction in childhood mortality, reduction of ENND has significantly lagged behind other Millennium Developmental Goal achievements and is a growing contributor to overall mortality in children aged <5 years. The etiology of ENND is closely related to the level of a country's industrialization. Hence, prematurity and congenital anomalies are the leading causes in high-income countries. Furthermore, sudden unexpected early neonatal deaths (SUEND) and collapse have only recently been identified as relevant and often preventable causes of death. Concomitantly, perinatal-related events such as asphyxia and infections are extremely relevant in Africa, South East Asia, and Latin America and, together with prematurity, are the principal contributors to ENND. In high-income countries, according to current research evidence, survival may be improved by applying antenatal and perinatal therapies and immediate newborn resuscitation, as well as by centralizing at-risk deliveries to centers with appropriate expertise available around the clock. In addition, resources should be allocated to the close surveillance of newborn infants, especially during the first hours of life. Many of the conditions leading to ENND in low-income countries are preventable with relatively easy and cost-effective interventions such as contraception, vaccination of pregnant women, hygienic delivery at a hospital, training health care workers in resuscitation practices, simplified algorithms that allow for early detection of perinatal infections, and early initiation of breastfeeding and skin-to-skin care. The future is promising. As initiatives undertaken in previous decades have led to substantial reduction in childhood mortality, it is expected that new initiatives targeting the perinatal/neonatal periods are bound to reduce ENND and provide these babies with a better future.

Introduction

As the deadline for the Millennium Developmental Goals approaches, the related achievement of a significant reduction in maternal and child mortality from 1990 to 2013 has been widely acknowledged (Fig. 1). Laudable as these results are, it is striking that the reduction of neonatal mortality rates (death before 28 days after birth) has lagged remarkably compared with post-neonatal mortality rates (death between 28 days and 5 years of age). Hence, whereas post-neonatal death has been reduced by 56%, neonatal mortality rates have only reached 40%. Of all the 2.8 million newborn infants who die worldwide each year during the neonatal period, 73% do so during the first week after birth (early neonatal deaths, ENND) [1], [2], [3] (Fig. 2). Therefore, deaths in the newborn period and especially ENND are increasingly contributing to overall infant mortality at age <5 years [4], [5], [6], [7], [8]. This is illustrated, for example, in countries such as Brazil, Ghana, and Uganda, where post-neonatal infant mortality has been largely reduced through better coverage of primary care, vaccinations, and nutritional programs. However, interventions improving perinatal mortality have been less widely implemented. It could be considered that the first week of life is the most critical for a neonate, with 36% of deaths (one million) occurring in the first 24 h after birth, 37% (one million) in the early neonatal period, and 27% (0.8 million) between days 7 and 27 of life, as reported in 2013 [9], [10], [11]. Maternal and early neonatal deaths and stillbirths are closely linked: almost half of all maternal deaths, stillbirths, and early neonatal deaths occur during the critical 48 h window comprising labor and delivery (Fig. 3). This underscores the need for an integrated intrapartum approach to saving the lives of both mother and newborn [5], [8], [12].

The leading causes of neonatal death globally in 2013 were related to (i) prematurity-associated complications, (ii) birth-related complications such as birth asphyxia or trauma, and (iii) infections such as neonatal sepsis, pneumonia, tetanus, and diarrhea. However, global estimates do not take into account variations between countries. Thus, in high-income countries the rate of neonatal deaths caused by congenital anomalies plays a significant role, whereas the role of other causes, especially infections, is lower [13]. Sudden unexpected early neonatal deaths (SUEND) or sudden unexpected postnatal collapse (SUPC) is a rare event, but it has attracted attention in the epidemiological studies of high-income countries as a relevant cause of ENND [14], [15], [16], [17]. On the other hand, information about SUEND in low-income countries is almost non-existent (Table 1).

Here we aim to present epidemiologic data, describe the etiologic factors contributing to ENND in both low-income and high-income countries, and describe initiatives to reduce early neonatal mortality.

Section snippets

Standardized definitions

Classification of a child's life into well-defined and globally accepted periods is essential for the standardization of health care objectives. First, it is important to set forth the most widely employed definitions in the scientific literature regarding the epidemiology of ENND.

The neonatal period, which has been defined by the World Health Organization (WHO) as “beginning at birth and ending at 28 completed days of life” [9], is recognized as the most vulnerable time in an infant's life.

Prematurity

Prematurity is the leading cause of neonatal mortality, although neonatal deaths in preterm infants have continued to decrease during the last 20 years in North America and Europe. A register-based comparison of perinatal outcomes in Europe, the European Perinatal Health Report, was compiled in 2004 and 2010 [23]. According to the latest report, 61–85% of neonatal deaths occurred during the first week of life. These European reports showed a decline in neonatal mortality in all but one of 23

Congenital anomalies

The European Perinatal Health Report [23] related 5–38% of neonatal deaths to congenital anomalies. Congenital anomalies seem to have a bigger role in ENND in high-income countries, which have been more successful in decreasing mortality in other disease groups. For example, congenital anomalies explained about 10% of neonatal deaths in China [49], whereas they contributed (although not necessarily explained alone) to 43% of ENND in Finland from 2008 to 2011 [50]. The large variations in the

Intrapartum-associated events (birth asphyxia)

Birth asphyxia (BA) is one of the leading causes of early neonatal mortality worldwide. BA is estimated to account for about two million perinatal deaths, including intrapartum stillbirths and early neonatal deaths. BA is reported to have consistently accounted for about 25% of early neonatal deaths in low- and middle-income countries over the past decade [3]. Low-income countries carry 98–99% of the burden of deaths due to BA. In high-income countries, BA accounts for 7.1% of mortality, taking

Present and future initiatives to reduce early neonatal death globally

There are evidence-based ways to tackle the challenge of early neonatal deaths. An implementation of evidence-based practices would decrease early neonatal deaths both in high-income countries and in low- and middle-income countries. In both groups of countries, national strategies should be created to ensure adequate resources for perinatal care and reliable data collection to ensure service coverage in both rural and urban areas and to optimize regionalization of more demanding care.

It has

Conclusions

ENND plays an increasing role in childhood mortality both in high-income and in low-income countries. Both high-income and low-income countries have a large potential to improve their performances by increasing resourcing and implementing evidence-based practices in perinatal care. Relatively simple and cost-effective interventions can lead to a substantial increase in the survival of newborn infants beyond the neonatal period. Preventing deaths caused by birth asphyxia and infections in

Conflict of interest statement

None declared.

Funding sources

None.

References (94)

  • P.D. Gluckman et al.

    Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicenter randomized trial

    Lancet

    (2005)
  • C. Chafer-Pericas et al.

    Preliminary case control study to establish the correlation between novel peroxidation biomarkers in cord serum and the severity of hypoxic ischemic encephalopathy

    Free Radic Biol Med

    (2016)
  • R.E. Black et al.

    Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality in 2008: a systematic analysis

    Lancet

    (2010)
  • L. Liu et al.

    Global, regional and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000

    Lancet

    (2012)
  • A.C. Seale et al.

    Estimates of possible severe bacterial infection in neonates in sub-Saharan Africa, south Asia, and Latin America for 2012: a systematic review and meta-analysis

    Lancet Infect Dis

    (2014)
  • A.K. Zaidi et al.

    Hospital-acquired neonatal infections in low-income countries

    Lancet

    (2005)
  • S.J. Schrag

    Group B streptococcal vaccine for resource-por countries

    Lancet

    (2011)
  • W.E. Benitz et al.

    Reappraisal of guidelines for management of neonates with suspected early-onset sepsis

    J Pediatr

    (2015)
  • N. Marin et al.

    Severe apparent life-threatening event during “skin-to-skin”: treatment with hypothermia

    An Pediatr (Barc)

    (2013)
  • K.E. Dickson et al.

    Every Newborn: health-systems bottlenecks and strategies to accelerate scale-up in countries

    Lancet

    (2014)
  • World Health Organization/UNICEF/UNFPA/World Bank/United Nations Population Division

    Trends in maternal mortality: 1990−2013

    (2014)
  • United Nations Inter-agency Group for Child Mortality Estimation

    Levels and trends in child mortality

    (2014)
  • A.G.K. Maranhão et al.

    Mortalidade infantil no Brasil: tendências, componentes e causas de morte no período de2000 a 2010

  • Welaga P, Moyer CA, Aborigo R, et al. Why are babies dying in the first months after birth? A 7-year study of neonatal...
  • V.K. Nakibuuka et al.

    Perinatal deaths audits in a peri-urban hospital in Kampala, Uganda

    Afr Health Sci

    (2012)
  • World Health Organization

    Neonatal and perinatal mortality: country, regional and global estimates

    (2006)
  • UNICEF/WHO/World Bank/UN

    Levels and trends in child mortality

    (2014)
  • GBD 2013

    Mortality and causes of death collaborators, global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death. 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

    Lancet

    (2015)
  • Bhutta ZA, Das JK, Bahl R, et al. Lancet Newborn Interventions Review Group. Lancet Every Newborn Study...
  • J.Y. Leow et al.

    Sudden, unexpected and unexplained early neonatal deaths in the North of England

    Archs Dis Childh Fetal Neonatal

    (2011)
  • N.J. Pejovic et al.

    Unexpected collapse of healthy newborn infants: risk factors, supervision and hypothermia treatment

    Acta Paediatr

    (2013)
  • J.C. Becher et al.

    Unexpected collapse in apparently healthy newborns – a prospective national study of a missing cohort of neonatal deaths and near-death events

    Arch Dis Child Fetal Neonatal Ed

    (2012)
  • H.C. Glass et al.

    Outcome for extremely premature infants

    Anesth Analg

    (2015)
  • World Health Organization

    ICD-10: international statistical classification of diseases and related health problems

    (2004)
  • A. Garces et al.

    Home birth attendants in low income countries: who are they and what do they do?

    BMC Pregnancy Childbirth

    (2012)
  • L.M. Sibley et al.

    Traditional birth attendant training for improving health behaviours and pregnancy outcomes

    Cochrane Database Syst Rev

    (2012)
  • The European Perinatal Health Report....
  • K. Källén et al.

    EXPRESS group impact of obstetric factors on outcome of extremely preterm births in Sweden: prospective population-based observational study (EXPRESS)

    Acta Obstet Gynecol Scand

    (2015)
  • F. Serenius et al.

    Intensity of perinatal care for extremely preterm infants: outcomes at 2.5 years

    Pediatrics

    (2015)
  • J. Zeitlin et al.

    Declines in stillbirth and neonatal mortality rates in Europe between 2004 and 2010: results from the Euro-Peristat project

    J Epidemiol Community Health

    (2016)
  • L. Rautava et al.

    The effect of birth- or tertiary-level hospitals in Finland on mortality in very preterm infants: a birth-register study

    Pediatrics

    (2007)
  • S.M. Lasswell et al.

    Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis

    JAMA

    (2010)
  • L. Lehtonen et al.

    PERFECT preterm infant study

    Ann Med

    (2011)
  • K. Helenius et al.

    Amount of antenatal care days in a context of effective regionalization of very preterm deliveries

    J Pediatr

    (2016)
  • J. Zeitlin et al.

    Use of evidence based practices to improve survival without severe morbidity for very preterm infants: results from the EPICE population based cohort

    BMJ

    (2016)
  • B.J. Stoll et al.

    Trends in care practices, morbidity, and mortality of extremely preterm neonates, 1993–2012

    JAMA

    (2015)
  • B.W. Alleman et al.

    Individual and center-level factors affecting mortality among extremely low birth weight infants

    Pediatrics

    (2013)
  • Cited by (138)

    • Qualitative Study of Nurses’ Experiences as They Learned to Provide Neonatal Palliative Care

      2024, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
    View all citing articles on Scopus
    View full text