29 August 2008

SAVING NEWBORNS IN DEVELOPING COUNTIRES

Newborn babies are dying. Four million babies die each year during their first days of life, most during the first hours after birth. 98% of these deaths occur in developing countries. Three fourths, or 3 million of these deaths are preventable. They are preventable not with our new expensive technology, but with simple proven interventions that are universally available, inexpensive and can be easily used in every corner of the world.
Recent years have seen marked reductions in maternal mortality in developing countries, and a 50% reduction in child mortality. However there has been no accompanying decrease in the mortality of newborns in the developing world. According to some experts, the Global Community has made the newborn a second tier priority. Most deliveries and most deaths occur at home without any intervention by the health care system. There is often a fatalistic attitude about newborns within families and communities, and even on the part of health care personnel. The underlying expectation is that the baby may die.
Many factors affect neonatal survival, including larger societal issues such as poverty, lack of education, social inequalities, cultural practices, and the chaos of war and civil unrest.
Approximately 1/3 of new babies die of pregnancy related causes, 1/3 from complications of delivery, and 1/3 from infection. We need to look at the pregnant mother for part of the explanation, the birth itself for another part, and those critical first few weeks of life for the rest.
Antenatal care is often sporadic or non-existent. The pregnant mother is subject to infection, malnutrition, and anemia. Sexually transmitted diseases are prevalent. Recurrent chronic malaria is the rule during pregnancy in Sub-Saharan Africa.
Over 90% of babies in developing countries are born at home. Very few births are attended by a trained health worker. Most deliveries are supervised by a traditional birth attendant (TBA), or by a family member. TBAs have little or no relationship with the local health system. They often use traditional practices related to local customs, some good and some not so good. They often do not use basic sanitation, such as hand washing and a clean cloth. They usually pay most attention to the mother and sometimes neglect the baby. They have no training in basic resuscitation. The cord is sometimes cut with an unclean instrument and at times smeared with mud or cow dung. The baby is often not fed for some time, and colostrum is discarded. Most newborn deaths in developing countries occur at home without medical intervention. This massive loss of new life is morally wrong and spiritually unacceptable.
During the past few years, this relative neglect has markedly changed. Care of the newborn has rapidly emerged as a global priority. A worldwide effort has been marshaled to address this alarming situation. The Bill and Melinda Gates Foundation-Save the Children has been a major agent of change, and contributed major funding. The World Health Organization has launched several important programs supported by a number of governmental and non-governmental agencies. During the past 2 years a number of major comprehensive reviews have appeared in the medical literature that have summarized current work in the field and made a number of important recommendations.

Sixty years ago the so-called developed nations had newborn mortality rates that looked like Africa’s do today. The greatest reductions were achieved in three basic areas of intervention
Universal (often free) prenatal care
Skilled birth Attendants
Availability of antibiotics
The same interventions are indicated today. These simple practices are all well known, proven, and inexpensive
Interventions which need to take place during pregnancy

Mother needs to be incorporated into a prenatal care system
The “prenatal care package” includes
Treatment for anemia
Folate supplementation
Maternal tetanus toxoid, in order to prevent 250,000/year fatal cases of neonatal tetanus
Rx of Urinary Tract Infections and Sexually Transmitted Disease. Nivirapine to prevent AIDS transmission from mother to infant
Rx of malaria-- some recommend interval presumptive treatment during pregnancy
Nutritional advice

At Birth, the attendant
washes hands
Uses clean cloth
Uses clean instrument to cut cord
Keeps cord dry. No stuff on it
Keeps baby warm and dry.
Focuses on the baby as well as the mother
Is trained in simple resuscitation measures

The newborn
Is treated with silver nitrate or antibiotic drops in the eyes
Is breast fed early and the colostrum is used
Is observed for signs of infection.

Items necessary for basic care during birth have been incorporated into delivery kits and packaged for wide distribution. The kits are inexpensive and can be used by families and birth attendants with basic instruction. They are heavily promoted by WHO and Save the Children. Many studies have shown remarkable success when the kits are widely distributed and used appropriately.

The key to the success of all of these interventions is in their implementation. We need to implement what has already been shown to work. The reality is that the majority of women in developing countries will not have access to trained health workers as birth attendants. The obvious strategy is to train the traditional birth attendants and the families. This is not easy. The delivery of a baby in the home is often a private matter outside of the health system. Practices that have existed for centuries require a change in ways of thinking. Education has to be available and it also needs to be acceptable to the TBA and the family. This education has to be part of a community program that uses educators, health workers and promoters that are a part of that community. Many excellent, community based primary health care programs have successfully used many or all of these interventions as part of a comprehensive health program, and have achieved developed nation status in regard to both maternal and neonatal mortality.
As short-term volunteers with different language and culture, it is very difficult for us to integrate ourselves into the community and build a trust relationship sufficient to actively participate in these interventions.
What we can do is:
Observe and listen. Learn as much as we can about local status of pregnant women and newborns, birth practices and patterns of newborn care.
Encourage and support programs that train community Traditional Birth Attendants, families, and local health workers in the elements of maternal and newborn care.
Participate in the training process, if feasible
Encourage and support programs that distribute and train in the use of delivery kits and “packages” of care WHO and Save the Children
Help supply and promote the use of basic equipment, including delivery and cord care kits, bag and masks, as well as basic medicines and vitamins.
Encourage data collection and clinical research by the agencies with which we work.
Conclusions:
We need a global political commitment to Newborn Health at all levels of government from local to national.
We must promote an increased focus on the newborn within existing child and maternal programs
We need to implement the interventions that have already been shown to work in reducing neonatal mortality
We must reach out to the weakest and most helpless of all humanity, the newborns of the developing world.
In partnership with families and communities, local health providers and local health systems, we can work together to make a difference in the survival and well being of newborns in developing countries.

“No investment in Global Health has a greater return than saving the life of a child”
Melinda Gates
Article submitted by Roger Boe, MD

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