Perinatal and Neonatal Care in Developing Countries

Dharmapuri Vidyasagar and Anil Narang

The science and practice of modern neonatology evolved as a medical specialty in the United States and the Western world over the last 60 years. Neonatology as a specialty in developing countries is still evolving. The increased attention to improving newborn care at a global level can be traced to the recognition by the World Health Organization (WHO) of unacceptably high infant mortality in low- and middle-income countries (LMIC). The Alma Ata Declaration ¹⁸ was the first serious effort by WHO to address the problem of high infant mortality rate (IMR) among developing countries. Since then several policies have been proposed and implemented to decrease the infant mortality rate (IMR) and neonatal mortality rate (NMR) across the globe. The latter part of the twentieth century has seen slow but steady improvement in overall global newborn care resulting in the reduction of NMR and IMR in LMIC. These developments can be attributed to rapid globalization of health-related information and technology from developed high-income countries (HIC) to LMIC. Also, increased awareness of health and change in care-seeking behavior among women during the past decade has improved maternal child health. The major factors responsible for overall improvements in neonatal and maternal care in LMIC include: (1) improved access to medical and technical information, (2) rapid transfer of technology, and (3) international campaigns such as the advocacy of the Millennium Development Goals (MDGs)⁶⁹ across the globe. Ever since the declaration of MDGs, considerable progress has been made in reducing maternal and neonatal mortality in developing countries; however, many challenges remain. This chapter attempts to provide the reader an overview of global neonatal and perinatal problems, presents data on the changing trends in IMR and NMR, and discusses some of the strategies to decrease the IMR and NMR in developing countries.

Global Initiatives to Reduce Infant Mortality Rate and Neonatal Mortality Rate: From Alma-Ata to Millennium Development Goals

Because of concerns of high global IMR, numerous interventions have been proposed and implemented by world organizations over the past four decades (Table 10-1). The Alma-Ata Declaration of 1978 by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) set a goal to achieve “Health for all by the year 2000.”³⁹ The declaration included a goal for the reduction of maternal and infant mortality through primary care. In 1987, the International Conference on Safe Motherhood drew attention to high maternal mortality rates (MMR) in developing countries and encouraged policymakers to develop new strategies to reduce maternal mortality.⁷⁶ This action led to the worldwide program of Safe Motherhood, placing an emphasis on antenatal care. A similar resolution, the Bamako Initiative, was instituted at the annual meeting of the African Ministries of Health in 1987.²² The objective was the achievement of universal maternal-child health coverage at the periphery by 2000. In 1988, the Task Force for Child Survival set objectives for a reduction in MMR and IMR.⁶⁵ One of these objectives was a worldwide reduction in mortality by at least half, or by 50 to 70 per 1000 live births, whichever can be achieved first, for children 5 years old and younger. Another objective was the reduction of MMR worldwide by at least half.

TABLE 10-1

Global Initiatives to Decrease Neonatal, Child, and Maternal Mortality

Initiative	Organization	Year and Occasion	Goals
Declaration of Alma-Ata	WHO, UNICEF	Sept 1978, USSR, International Conference on Primary Health Care	Health for all by 2000
Safe Motherhood Initiative	WHO, UNICEF, UNFPA, World Bank, and others	1987, Nairobi, International Safe Motherhood Conference	Reduce maternal mortality to half the present rate by 2000
Bamako Initiative	UNICEF, WHO	September 1987, Bamako, Mali, Annual Meeting of African Ministers of Health	Achieve universal maternal and child health coverage at the peripheral level by 2000 Revitalize peripheral public health systems Supply basic drugs Establish revolving funds Involve communities in health care
Task Force for Child Survival	WHO, UNICEF, World Bank, UNDP, Rockefeller Foundation	March 1998, Talloires, France, Protecting the World’s Children, an Agenda for the 1990s	Global eradication of polio Virtual elimination of neonatal tetanus, 90% reduction in cases of measles and 95% reduction in its fatalities, 25% reduction in fatalities owing to ARI Reduction of IMR and MMR by half or 50-70/1000, whichever is greater Reduction of MMR by at least half
Mother-Baby Package	WHO	Sept 1994, Cairo, International Conference on Population and Development	Reduce maternal mortality to half of 1990 levels by 2000
			Reduce perinatal and neonatal mortality from 1990 levels by 30%-40% and improve newborn health
Making Pregnancy Safer	WHO	1999, Safe Motherhood Initiative	Accelerate reduction of high maternal and perinatal mortality and morbidity by refocusing WHO strategies in national and international health sectors
Millennium Development Goals	WHO	2000-2015	Reduce child mortality Reduce by two thirds the mortality rate for children <5 years old between 1990 and 2015
Newborn Care Training	NIH	2010	Essential newborn care training of community-based birth attendants has reduced the stillbirth rate.*

ARI, Acute respiratory infection; IMR, infant mortality rate; MMR, maternal mortality rate; UNDP, United Nations Development Program; UNFPA, United Nations Fund for Population Activities; UNICEF, United Nations Children’s Fund (formerly United Nations International Children’s Emergency Fund); WHO, World Health Organization.

^*From Carlo WA, et al. Newborn-care training and perinatal mortality in developing countries. N Engl J Med. 2010;362:614.

In 1994, WHO developed the Mother-Baby Package to help reduce MMR and NMR further.⁴³ Recognizing that MMR remained high, in 1999 WHO re-emphasized the need for an acceleration of national and international efforts to decrease MMR and perinatal mortality rate through the Safe Motherhood program. At the 48th World Assembly of WHO, the concept of integrated management of childhood illness was adopted to improve the well-being of the whole child younger than 5 years old.⁶⁸ This concept included an emphasis on improved care of newborns. By the end of the twentieth century, a significant decrease in MMR and IMR was reported as one of the top 10 achievements of the century.⁶⁶ However, the high IMR and NMR in the LMIC continued to be a major concern to global policymakers. The World Bank initiated the Global Burden of Disease study,¹⁰ which showed that perinatal conditions, including infant mortality, form a significant portion (39%) of the global burden of disease. It showed that developing countries are the major contributors to global perinatal and neonatal mortality. Perinatal mortality constitutes one of the 10 leading causes of death in developing countries. Neonatal mortality is the major part of perinatal mortality. These findings underscore the importance of improving perinatal and neonatal care in developing countries, as declared in the MDGs in 2000.⁶⁹

The Millennium Development Goals

In 2000, 192 nations and 13 major international organizations worked under the aegis of the United Nations to develop the MDGs to be achieved by 2015.⁶⁹ At the Millennium Summit, the leaders committed to a new global partnership to meet a series of eight goals with a deadline of 2015. These goals are time-bound with specific targets to be achieved by 2015. The targets are measured by preset quantifiable measures. Another unique aspect of MDGs is that the goals do not focus only on specific health issues, but also emphasize social, economic, and public health and health-policy matters that affect the “health” of the people. Health is also considered a basic human right of the people of the world. The eight MDGs are listed in Table 10-2.

TABLE 10-2

The Eight Millennium Development Goals

1. To eradicate extreme poverty and hunger;

2. To achieve universal primary education;

3. To promote gender equality and empower women;

4. To reduce child mortality;

5. To improve maternal health;

6. To combat HIV/AIDS, malaria, and other diseases;

7. To ensure environmental sustainability; and

8. To develop a global partnership for development

Details of Millennium Development Goals #4 and #5
Goals	Targets	Indicators
Goal 4 Reduce child mortality	Target 5: Reduce the under-5 mortality rate by two thirds between 1990 and 2015	Indicator 13: under-5 mortality rate (deaths per 1000 live births)
		Indicator 14: infant mortality rate (deaths per 1000 live births)
		Indicator 15: proportion of 1-year-old children immunized against measles
Goal 5 Improve maternal health	Target 6: Reduce the maternal mortality rate by three fourths between 1990 and 2015	Indicator 16: maternal mortality ratio (deaths per 100,000 live births)
		Indicator 17: proportion of births attended by skilled health personnel

The eight goals are aimed at reducing global poverty, achieving universal education, decreasing maternal and child mortality, and reducing epidemics of infections. Of these eight goals MDG #4 and MDG #5 are specific to women and children. Gender equality and empowerment of women are critical to achieving MDG #4 and #5. They directly focus on reducing MMR, NMR, and IMR and under-5 mortality. It was recognized that neither goal can be achieved in isolation (Figure 10-1). Individually, each goal is significant on its own merits; however, collectively they are interdependent, and improvement in any of the six MDGs will have far more effect on MDG #4 and #5.

Figure 10-1 The interrelationship of each of six MDGs to MDG #4 and #5. The diagram signifies the importance of social well-being (MDG #1, #2, and #3) and reduction of infections (MDG #6 and #7) to achieve the targets of decreasing maternal, neonatal, and infant mortalities in LMIC countries. The diagram also shows the importance of partnership among developed and developing countries (MDG #7 and #8).

In addition to these developments, the series of landmark scientific publications in The Lancet, popularly known as “The Lancet Series,” provided evidence-based scalable interventions that could reduce NMR and IMR in resource poor countries.14,31 These publications generated great interest among researchers and health policymakers around the globe. The Child Survival series examined the potential impact of scaling up 43 interventions that could reduce child mortality by 2015. In 2005, the series on newborn survival provided the first systematic estimates of neonatal deaths by cause and identified 16 simple and extremely cost-effective scalable interventions that could reduce neonatal deaths by 67% and proposed specific actions that could be adopted in countries globally. The impact of some of the suggested interventions is described in the later part of this chapter.

Tracking the Global Progress of Millennium Development Goals

Worldwide efforts are taking place to implement MDGs, and the progress of MDGs is being tracked closely. To track the global progress of MDGs #4 and #5 we need accurate birth and death data from all participating countries. Unfortunately, collecting accurate NMR, IMR, and under-5 mortality data on a global scale remains a major problem. There are several hurdles to collect these data accurately. Whereas HIC have well-established vital statistics of births and deaths, the LMIC do not. Ostergaard and co-workers ⁴⁹ found that only 60 of the 193 countries studied had fully functioning sources of mortality data; the rest of the countries depend on annual or periodic surveys. There is a need for improvement in accurate vital statistics to establish the true burden of IMR and to develop appropriate strategies to monitor progress.

Global Burden of Maternal and Neonatal Deaths

Maternal Mortality

Maternal mortality has been a major global burden of disease. At the time of and preceding the declaration of MDGs, more than 600,000 women were dying annually from causes related to pregnancy and childbirth.⁶⁷ Asia and Africa had the highest MMR and the highest number of maternal deaths, compared with only 4000 deaths per year in HIC. The causes of maternal death include maternal hemorrhage (25%), sepsis (15%), abortion (13%), hypertensive disorders of pregnancy (12%), and obstructed labor (8%). More than 50% of the deaths related to pregnancy and childbirth were estimated to be preventable using simple, well-accepted interventions. The MDG #5 aimed at reducing the MMR by 75% between 1990 and 2015.

On a positive note, according to a recent report,11,41 global MMR in 2010 has decreased by 47% (from 400/100,000 in 1990 to 210/100,000), accounting for 287,000 maternal deaths in 2010. Although the overall number of maternal deaths has decreased, only 10 countries have reached the goal, 9 countries are “on track,” 50 countries are “making progress,” 14 countries have made “insufficient progress,” and 11 are categorized as having made “no progress” at all. Sub-Saharan Africa (56%) and South Asia (29%) continue to bear the major burden of global MMR (85%), accounting for 245,000 maternal deaths in 2010. Two countries, Nigeria and India, contribute one third of global MMR: India at 19% and Nigeria at 14%.

Neonatal Mortality

Figure 10-2 shows global trends in IMR during 1950 to 2000.⁴² In the 1950s, there were wide variations in IMR among different regions of the world. Infant mortality rate was lowest in industrialized Western countries (33 per 1000). It decreased to around 5 per 1000 by 2000, a reduction of 85%. In 1950, sub-Saharan Africa had the highest IMR (157 per 1000) and showed the least reduction (only 32%) among all the regions of the world during the next 50 years. South Asia, the Middle East/North Africa, and Latin America/Caribbean showed 53%, 70%, and 74% decreases, respectively. At the end of the twentieth century, IMR continued to remain significantly high: 70 per 1000 in South Asia, 45 per 1000 in the Middle East, and 27 per 1000 in Latin America.

Figure 10-2 Changing trends in IMR in different world regions from 1950 to 2005. North America and Europe had significantly lower IMR compared with the other four regions in 1950, whereas IMR was many-fold higher among other regions (Asia, Africa, Latin America, and Oceania). By 2005, there was a noticeable decreasing trend in all regions of the world, although IMR remained high among LMIC. (From Moser K, et al. World mortality 1950-2000: divergence replaces convergence. Mother-Baby Package: Implementing safe motherhood in countries. *WHO*. 1994;83:203-209.)

In a recent analysis of NMR out of 193 countries from 1990 to 2009, the investigators ⁴⁹ found that only 38 countries had a system of civil registration of births and deaths. One hundred fifty-five other countries calculated NMR using statistical models. During the two-decade study, 79 million babies died. More than 98% of deaths occurred in LMIC, the majority in South Asia (31 million) and Africa (21 million). Only 1 million neonatal deaths occurred among HIC during the same period. The annual reduction rate of NMR was twice as high for the period 1999 to 2009 (2.3%) compared with the period 1990 to 1999 (1.1%). There was a lower rate of reduction of NMR in HIC (1.7% in 1999 to 2009 vs. 3.7 % in 1990 to 1999). In spite of these decreases in NMR across the LMIC, the annual rate of NMR reduction was still well below the MDG #4 goal of 4.4%.

Compared with NMR, the under-5 mortality rate (U5MR) decreased considerably from 1990 to 2010. Figure 10-3 shows trends in U5MR and NMR in 193 countries from 1990 to 2010.³³ The U5MR showed a steady decrease during the period, whereas the NMR, although decreasing, did so at a slower rate. The NMR thus constituted a higher proportion of U5MR from 2000 to 2010 compared with 1990 to 2000. Region wise, South Asia accounts for more than half of under-5 deaths. Almost 30% of global neonatal deaths occurred in India. Sub-Saharan Africa, accounts for 38% of global neonatal deaths, with the highest NMR (34/1000 live births) and least progress in reducing that rate over the last two decades. Neonatal deaths there account for about one third of U5MR (1.1 million neonatal deaths). Taking into consideration the current slow rate of reduction in NMR among the LMIC, the authors also calculated the number of years it will take various countries in different regions to achieve NMR levels similar to those currently in HIC (Figure 10-4). It is disconcerting to note that for some countries it will take several decades to reach the low levels of HIC, whereas others may take more than 100 years to reach the low levels of HICs. These disappointing findings underscore the need for serious efforts with a stronger health policy to decrease NMR and IMR in sub-Saharan countries.

Figure 10-3 Trends in under-5 mortality and neonatal mortality in 193 countries during 1990 to 2010, with a projected expected value to be reached by 2015. The upper line shows the under-5 mortality rate trajectory and the lower line the NMR trajectory. The under-5 mortality rate shows a steady decrease during the period, whereas the NMR is decreasing much more slowly. The NMR thus constitutes a higher proportion of the under-5 mortality rate during 2000 to 2010 compared with 1990 to 2000. (From Lawn JE, Kinney MV, Black RE, et al. Newborn survival: a multi-country analysis of a decade of change. *Health Policy Plan*. 2012;27:iii-iii27.)

Causes of Global Neonatal Mortality

Factors that influence NMR and MMR include commonly known maternal and neonatal medical problems, socioeconomic conditions, gender inequality, environmental factors, and economic and political instability. Socioeconomic factors greatly influence health of mother and baby in particular in LMIC, as discussed in the following.

Socioeconomic and Cultural Factors

The socioeconomic factors adversely influencing IMR include gender bias against women, maternal education, and economic dependence. MDGs #2 and #3 are aimed at reducing gender inequity. Gender bias is not unique to one region.⁵¹ Gender bias has a negative effect on every phase of a woman’s life, interfering with her education, economic power, and health. Gender-biased discrimination begins its influence early in life, leading to poorer nutrition and health in girls compared with boys. Because of its enormous negative effect on women’s progress, MDG #3 is specifically aimed at promoting gender equality and empowering women. This goal is further strengthened by MDG #1 (eradication of poverty) and MDG #2 (achieving universal primary education). It is anticipated that implementation of programs that improve education and economic autonomy will enable women to gain political empowerment and overcome gender bias. Evidence shows that a woman with more education has fewer children, better economic status, lower fertility rate, lower IMR, and improved quality of life. Even in developed countries, every additional year of education for women decreases mortality rates at all ages.¹⁷ Education increases earning potential, and income reduces mortality. Earning power provides women with economic, social, and political empowerment. In short, education is seen as a means of ensuring health. The microcredit program for women in Bangladesh that makes women economically self-supporting has become an important model for other countries.²⁷ Health-seeking behavior during pregnancy, childbirth, and the neonatal period is influenced by regional, religious, and ethnic differences and by cultural beliefs. Understanding the cultural beliefs and their influences on care of the mother and infant is crucial to providing appropriate counseling to mothers.⁵⁹ Health strategies to improve MMR and IMR in LMIC include improving maternal education, increasing awareness of maintaining health, improving health-seeking behavior, and improving access to health care. These efforts coupled with economic empowerment of women will improve MDG #4 and MDG #5.

Influence of Political Instability, War, and Conflict

Economic stability alone does not guarantee better health of mother and child. For example, oil- and mineral-rich countries (Middle East, Africa, and Latin America) with a sizeable global income are a unique group with wide disparities of wealth and health.⁹ These countries, despite high GNP, have high IMR, high U5MR, high MMR, and low life expectancy. Although the overall IMR has decreased from 200 per 1000 in the 1950s to 50 per 1000 in 2000, in some countries, IMRs are far higher than in Latin America and East Asia.⁵⁷ This disparity is aptly referred to as “the oil curse.”

Political instability and wars have adversely affected perinatal and neonatal outcome. A study from Bosnia ⁵⁶ shows startling evidence of adverse effects on perinatal outcome. Gulf War data showed similar effects on child mortality, including a toll on neonates. War disturbs health services, including access to hospitals, and cuts off water, sanitation, and patient transport systems. Hamod and Sacy²⁶ described the direct effect of war on neonates in a neonatal intensive care unit (NICU) in Lebanon. The major cause for increased perinatal mortality in the Bosnia study was an increase in prematurity and early neonatal mortality. The prematurity rate during war was twice as high as before the war. Similarly, natural disasters such as Hurricane Katrina and tsunamis call for preparedness to care for pregnant women, parturient mothers, and neonates.⁵⁰ Pediatricians and neonatologists serving in areas of war conflicts and those working in the armed forces should be well prepared to manage these situations.

Medical Causes of Neonatal Mortality Rate

In developing countries, birth asphyxia, sepsis, pneumonia, and prematurity continue to constitute a major portion of IMR (Figure 10-5).³³ About 40% of U5MR is owing to NMR. Among the neonatal deaths prematurity leads the list, and intrapartum complications and sepsis follow. Most of the causes are preventable. The WHO estimates that 40% to 60% of neonatal deaths from these causes are preventable. Preterm birth is now the second-leading cause of child death after pneumonia, and is likely to become the top cause of death by 2015 unless rapid scale-up of available interventions occurs. The other leading killers of neonates were intrapartum-related complications and neonatal sepsis or meningitis.^36,37 In a rural study, Baqui and colleagues³ studied the age of occurrence of each of the aforementioned clinical conditions and their impact on neonatal mortality (Figure 10-6). In contrast to the major contributions of prematurity, sepsis, and birth asphyxia in this setting, congenital malformations and prematurity are the dominant causes of neonatal mortality in the developed world. The major causes of neonatal mortality are discussed in detail in the following.