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; pregnancy-
related complications; or delivery-
related 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
140

120

100
Rate per 1000

80
Infant Mortality
60
Neonatal Mortality
40

20
1975 1980 1985 1990 1995

Year
 Comparison of Infant and Neonatal
Mortality Decline in Turkey 1975-1995
140

120

100
Rate per 1000

80

60
Infant Mortality

40
Neonatal Mortality
20
1975 1980 1985 1990 1995

Year
 Comparison of Infant and Neonatal
Mortality Decline in Egypt 1975-1995

140

120

100
Rate per 1000

80
Infant Mortality
60

40
Neonatal Mortality
20
1975 1980 1985 1990 1995

Year
 Comparison of Infant and Neonatal
Mortality Decline in Ghana 1975-1995

140

120

100
Rate per 1000

80
Infant Mortality
60
Neonatal Mortality
40

20
1975 1980 1985 1990 1995

Year
Comparison of Infant and Neonatal
Mortality Decline in Peru 1975-1995
140

120

100
Rate per 1000

80

60
Infant Mortality
40
Neonatal Mortality
20
1975 1980 1985 1990 1995

Year
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
75
Neonatal Mortality Rate

Nepal
50
Pakistan

25 Turkey
Thailand Indonesia
Philippines
Sri Lanka

0
1975 1980 1985 1990 1995

Year
Medium-Term Trends in Neonatal
Mortality in Latin America
75

Neonatal Mortality Rate

50

Peru
25
Colombia

Costa Rica
0
1975 1980 1985 1990 1995

Year
Medium-Term Trends in Neonatal Mortality
in the Middle East and North Africa

75
Neonatal Mortality Rate

50
Yemen
Morocco

Egypt
Tunisia
25
Jordan

0
1975 1980 1985 1990 1995

Year
Medium-Term Trends in Neonatal Mortality
in Sub-Saharan Africa

75
Neonatal Mortality Rate

50 Nigeria

Ghana Senegal

Cameroon
25
Kenya

0
1975 1980 1985 1990 1995

Year
 Early Neonatal Deaths as a Proportion
of Neonatal Mortality in Developing Countries
Early Neonatal Death/Neonatal Mortality
.9

phi
col bot
.8 col zim
gha
nam
col tha ken
sri
gha nga
dr tur tog mli mal
.7 cam bur
per uga zam
tun ken sen rwa lib
nep
per pak sen
.6 ido egy
mor brk
mad ngr
ido
mor
.5
0 50 100 150
Infant Mortality Rate
 Direct Causes of Perinatal Mortality
in Tygerberg, South Africa

Intrauterine
Growth
Retardation
Fetal
Abnormality
6%
8%
Antepartum
Infection
7% 34% Hemorrhage

12%
Preterm Birth 14%

Other
 Causes of Perinatal Mortality
Obstructed
Labor Other Direct
Unsafe 7% 8%
Abortion
13%
Other Indirect
20%

Hypertension
13%

Sepsis Hemorrhage
14% 25%

Joint WHO-UNICEF-UNFPA-WB statement

 Direct Causes of Neonatal
Mortality
Neonatal
Tetanus
Pneumonia
14%
19%

Diarrhea
2%

Asphyxia Other
21% 5%

Prematurity
10%

Injuries Sepsis
11% Congential 7%
abnormalities
WHO Mother and Baby Package, 1993 11%
 Estimated Global Burden of Disease of
Major Neonatal Infections

Infection Number of Case Fatality Rate (%) Number of

Cases Deaths
Acute Respiratory 2,500,000 30 750,000
Infections
Neonatal Tetanus 438,000 85 372,000
Sepsis 750,000 40 300,000
Diarrhea 25,000,000 .6 150,000
Meningitis 126,000 40 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

Number of Case Fatality Number

Infection
cases Rate (%) of Deaths
Acute Respiratory 2,500,000 30 750,000
Infection
Neonatal Tetanus 438,000 85 372,000
Sepsis 750,000 40 300,000
Diarrhea 25,000,000 0.6 150,000
Meningitis 126,000 40 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

25
24.7

20

15

10

5 3.1
1

0
Breastmilk Only Breastmilk + Formula No Breastmilk

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% Sepsis
22%
Other
12%

Asphyxia
Prematurity 26%
31%

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

 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 Egypt
Rep. Iran
El Salvador Morocco Armenia Kyrgyzstan
Haiti Pakistan Azerbaijan Moldova
Honduras Sudan Belarus Tadjikistan
Nicaragua Syria Georgia Turkmenistan
Turkey Kazakhstan Uzbekistan
Yemen
Bangladesh
Bhutan
Cambodia
China
India
Argentina Indonesia
Brazil Laos
Bolivia Myanmar
Colombia Nepal
Ecuador Philippines
Paraguay Viet Nam
Peru Benin Namibia
Venezuela Botswana Niger
Cote d'Ivoire Nigeria
Eritrea Senegal
Ethiopia South Africa
Ghana Tanzania, U.R.
Kenya Togo Status of implementation
Madagascar Uganda Introduction (20 countries)
Malawi Zambia
*Based on information Mali Zimbabwe Early implementation (31 countries)
available in June 1999 Mozambique
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 health-
seeking 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
 THANK YOU
FOR THINKING OF US