Early neonatal death: A challenge worldwide
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.
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