ending newborn deaths report

8/12/2019 Ending Newborn Deaths Report

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Ensuring every baby survives

ENDING NEWBORN DEATHS


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Front cover: A newborn baby at a rural healt h unit near Taclobanin the Philippines (Photo: Lynsey Addario/Save the Children)

Save the Children works in more than 120 countries.We save childrens lives. We ght for their rights.We help them full their potential.

Published bySave the Children1 St Johns LaneLondon EC1M 4ARUK+44 (0 )20 7012 6400savethechildren.org.uk

First published 2014

The Save the Children Fund 2014

The Save the Children Fund is a charity registered in England and Wales (213890)and Scotland (SC039570). Registered Company No. 178159

This publication is copyright, but may be reproduced by any method without

fee or prior permission for teaching purposes, but not for resale. For copying inany other circumstances, prior written permission must be obtained from thepublisher, and a fee may be payable.

Typeset by Grasshopper Design Company

AcknowledgementsThis report was written by Simon Wright with Kirsten Mathieson, Lara Brearley, Sarah

Jacobs, Louise Holly and Ravi Wickremasinghe from Save the Children, with work byAlex Renton. The authors would like to thank colleagues from Johns Hopkins School ofPublic Health who undertook the Lives Saved Tool (LiST) analysis included in the report.

We are grateful for the comments and improvements received from several Save theChildren colleagues, in particular Michel Anglade, Asma Badar, Claire Bader, ChantalBaumgarten, Anna Bauze, Rachel Bhatia, Smita Baruah, Nina Caplan, Berhanu Demeke,Valerie Foulkes, Binyam Gebru, Wanja Gironga, Steve Haines, Ben Hewitt, LouiseHill, Stephen Hodgins, Debra Jones, Anjana KC, Kate Kerber, Rajesh Khanna, MikeKiernan, Joy Lawn, William Lynch, Mary Kinney, Sara Lindblom, Arshad Mahmood, AliceMcDonald, Cicely McWilliam, Angela Muriuki, Eva Nofdfjell, Nora OConnell, Jo DavidOlayemi, Olusola Ooladeji, David Oot, Ann Paradis, Martha Parsons, Joy Riggs-Perla,Sayed Rubayet, Jawara Saidykhan, Nirupama Sarma, Aleks Sawyer, Liz Stuart, YenealemTadess, Kim Terje Loraas, Abdul Waheed, Steve Wall, Patrick Watt, Abimbola Williams,Sarah Williams and Kate Worsley. External comments were received from RobertMarten at The Rockefeller Foundation, Rob Yates at the World Health Organizationand Ceri Averill at Oxfam GB.

Some names in case studies have been changed to protect identities.
http://www.savethechildren.org.uk/http://www.savethechildren.org.uk/


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CONTENTS

The story in numbers iv

Executive summary vii

1 A crisis and an opportunity 1 The crisis in newborn mortality 1 Dying poor: the inequality of newborn mortality 2 2014 the opportunity for life-saving change 6

2 How can newborn deaths be prevented? 9 Clinical causes of newborn mortality 9 How health workers save newborn babies lives 9 The global shortage of midwives and other health workers at birth 11 The challenge to health systems 13

Social determinants of newborn health 14

3 Meeting the challenge 17 Achieving universal coverage in skilled birth attendance 17 Who pays? Funding for universal healthcare 21 Framing healthcare as a right making governments accountable 25

4 Country case studies 26

Conclusion 32

Recommendations 33

Appendix: Newborn mortality statistics by country 37

Endnotes 42


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NEWBORN SURVIVALTHE STORY IN NUMBERS

iv

2 MILLIONThe number of newborn babies whocould be saved each year if we endpreventable newborn mortality.

6.6 MILLIONThe number of children who diedbefore their fth birthday in 2012,most from preventable causes.This number has almost been halvedsince 1990, but still means that18,000 children died every day.

2.9 MILLIONThe number of babies who diedwithin 28 days of being born in 2012.The number of deaths in this newborn

period is four times higher inAfrica than it is in Europe.

1 MILLIONThe number of babies who did notsurvive their rst and only day oflife in 2012.

1.2 MILLIONThe number of stillbirths in 2012where the heart stopped beatingduring labour.

7.2 MILLIONThe global shortage of midwives,nurses and doctors.


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v

40 MILLIONThe number of mothers across theworld who give birth each yearwithout any help from a midwife orother trained and equipped healthworker. 2 million women reportthat when they last gave birth theywere completely alone.

51%The percentage of births insub-Saharan Africa that were notattended by a midwife or otherproperly qualied health worker.This percentage is 41% insouth-east Asia.

40% VS 76%The percentage of deliveries attendedby a skilled health worker in ruralareas vs. urban areas in the leastdeveloped countries.

950,000The number of newborn deathsthat could be prevented each yearif essential health services weremore equitably distributed. Thiswould reduce newborn mortalityby 38%.

2025Universal coverage of skilled qualiedbirth attendance could be achieved by2025 if we double the current rate ofprogress. If the rate doesnt increase,this wont be achieved until 2043.

$5Increasing health expenditure by justUS$5 per person per year couldprevent the deaths of 147 millionchildren and 5 million women, and32 million stillbirths and result ineconomic and social benets worthup to nine times that investmentby 2035.


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OVERWHELMED WITH GRIEF

Shefali, who lives in a village in Bangladesh, hasgiven birth to six children, but three died within aweek of being born. She gave birth at home eachtime, without medical assistance. Shefali lives in an

isolated community in Sylhet that is surroundedby water or swamps for most of the year, and shesays it takes ve or six hours to get to the nearestdoctor. Shefali and her husband say that theycouldnt afford the costs involved, and there would be no one to look after their other children.

Ive given birth to six children, all here in myhome and without a doctor. Three of thesechildren died within a week of birth. They diedbecause of a lack of treatment.

We cant go to a doctor because we cant affordit. We know thats why the children die. But whatcan we do if we cant afford it? We cant savemoney. We have difculty making enough money

just to have food to eat. How can we afford tosee a doctor?

Whenever a child is born and then dies, wereoverwhelmed with grief. Its terrible. We feellike we need to take the child to the doctorbut we cant. Im not the only one here who

has lost children there are many othermothers like me.

P H O T O : C O L I N C R O W L E Y / S A V E T H E C H I L D R E N

Nationwide, Bangladesh has achieved a halvingof neonatal deaths in the last 20 years. Thosecommunities with a lower risk of newborndeaths have seen major reductions in familysize: as newborn babies chances of survivalhave increased, families have chosen to havefewer children.

Save the Children is supporting the governmentby building a health clinic near Shefalis village.


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E N D I N G N E W B O R N D E A T H S

viii

and prevent 43% of newborn deaths. 4 This reportidenties the essential interventions around birth including treatment of severe infections and specialsupport for premature babies which must be madeuniversally available to reduce mortality. Around10% of all newborns in every country need assistance

to begin breathing.40 million mothers still give birth each year withoutany help from a midwife or another health workertrained and equipped to save the life of the babyor the mother. 5 Many babies die each year becausemothers do not get the good-quality care they needduring labour and birth. Many of the women leastlikely to be able to get life-saving help when they givebirth are those who are most at risk of losing theirbabies women from the poorest communities,

from rural areas, from a minority ethnic group orwith little education. Despite global commitments

to the universal right to survival and healthcare, inmany countries the poorest families are twice aslikely to lose a baby as the richest families.

Substantial reforms are needed to ensure thepoorest and hardest-to-reach communities are ableto access proper care at birth. This not only includesthe removal of user fees direct cash paymentsfor maternal, newborn and child health services which deny mothers and babies the healthcarethey need because the family cannot afford them.It also means ensuring public health services are notstarved of funding and that there are enough skilledhealthworkers in places they are needed.

Research commissioned for this report estimatesthat fairer distribution of essential health servicesin 47 key countries could prevent the deaths of950,000 newborns reducing newborn mortalityin these countries by 38%.

Newborn baby Pushpa,Nepal.

P H O T O : S

U Z A N N E L E E / S A V E T H E C H I L D R E N


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E XE C UT I V E S UM

MA R Y

ix

2014: THE OPPORTUNITYFOR LIFE-SAVING CHANGE

2014 will be a crucial year. Political support foruniversal health coverage the availability of a basicpackage of healthcare for everyone, a package which

countries can increase as resources increase isgrowing around the world. The best place to start isby ensuring that no family, however poor, is deniedlife-saving care at birth.

And for the rst time ever, countries and institutionsaround the world will sit down to agree an EveryNewborn Action Plan, an agreement to tackle thisdeplorable problem of lack of attention to babies intheir rst days of life. Save the Children is working toensure that this plan is ambitious and robust enough

to end all preventable newborn deaths as well astackle stillbirths during labour.

However, a plan on paper is not enough. It mustbe followed by concerted political action at thehighest levels to achieve its implementation. Stoppingnewborns dying unnecessarily and preventingstillbirths, and hugely accelerating progress towardsending child and maternal mortality, will require asubstantial change in our approach to health services.

This change must happen in the countries wherechild mortality rates are high, in partnership withdonors and other stakeholders. We need a newsense of purpose from the global community.The world must not squander the opportunity that2014 offers.

THE NEWBORN PROMISE

Save the Children is calling on world leaders,philanthropists and the private sector this year tocommit to a Newborn Promise to end all preventablenewborn deaths:

Governments and partners issue a dening andaccountable declaration to end all preventablenewborn mortality, saving 2 million newborn livesa year and stopping the 1.2 million stillbirthsduring labour 6

Governments, with partners, must ensure thatby 2025 every birth is attended by trained andequipped health workers who can deliver essentialnewborn health interventions

Governments increase expenditure on health toat least the WHO minimum of US$60 per capita

to pay for the training, equipping and support ofhealth workers

Governments remove user fees for all maternal,newborn and child health services, includingemergency obstetric care

The private sector, including pharmaceuticalcompanies, should help address unmet needs bydeveloping innovative solutions and increasingavailability for the poorest to new and existingproducts for maternal, newborn and child health.

END ALL PREVENTABLE DEATHS

We must be clear: newborn deaths are notinevitable. Most are easily avoided if the simplestof interventions are made available to all. Systemicchange is needed from governments, donors andhealth professionals. This year, 2014, offers anunprecedented opportunity to focus on this topicand set in motion the revolutions needed.

Together, we can ensure that no baby is born to die.


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PAYING WITH THEIR LIVES

Derese, a farmer in Ethiopia, is doing his best tolook after his children and earn enough to feedthem since his wife died three months ago duringchildbirth. Five of the ten children they had

together did not survive. The tenth child diedat childbirth, along with my wife, says Derese.

In her last pregnancy, Dereses wife was only takento the health centre one and a half days after goinginto labour. With the help of neighbours, Deresecarried her on a stretcher for more than an hourto the local health centre. When she arrivedthere the health centre did not have the staff orequipment to help. They advised taking her to thehospital in Dessie, the nearest big town, which is

located a four-hour drive away. But by then it wastoo late she died shortly after they got her onthe ambulance.

Most women living in rural areas of the countrygive birth at home, on their own, with no accessto skilled health workers. So if there arecomplications during labour, they are often unableto get to a health centre in time. Many of themdie due to the lack of a skilled birth attendant.

If you could see inside me, you would be able

to see the re thats burning me, says Derese.I know that its because of the fact that I ampoor and do not have money that I was unable tosave my wife. Every time I think of her, I feel guilty.

P H OT O

: CA R OL I NE T R UT MA NN

/ S A V E T HE

CHI L DR E N

Save the Children has supportedgovernment services and provided anambulance for Dereses community tohelp pregnant women access skilledmedical care at a health centre orhospital. But many roads, particularlyduring the rainy season, are still onlyaccessible on foot. As part of our workto reduce the number of women andchildren who die during childbirth, wehave also built new maternity wards in

health centres in three other districts,and provided training for health workersand community health promoters.


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2

A HIDDEN TRAGEDYTo understand the full picture, we must alsoconsider that many pregnancies are lost just hoursor even moments before birth. An estimated2.6 million stillbirths occurred worldwide in 2012. 13 For approximately 1.2 million stillbirths around45% the moment when the heart stopped beatingwas during labour. 14 The rate of these intrapartumstillbirths is much higher in low-income countriesthan in higher-income ones. These lives lost are

not counted as part of the fourth UN MillenniumDevelopment Goal, which aims to reduce childmortality by two-thirds. However, stillbirths thatoccur in labour deserve to be acknowledged andcounted in national and global health frameworks,as a sensitive marker of good-quality care and tohighlight the specic risks around labour and delivery.

To understand the full magnitude of the crisis, thisreport therefore focuses on the 2.2 million thenewborn deaths on the rst day plus the stillbirths

during labour.

DYING POOR: THE INEQUALITYOF NEWBORN MORTALITY

NEWBORN MORTALITY BY REGIONAND COUNTRY

There is huge regional variation in newborn deaths(see Figure 2). In Europe 5.9 babies in every thousanddo not survive beyond 28 days, but in Africa andparts of Asia that gure is four or ve times higher.

A full range of relevant data for the 75 Countdownto 2015 15 countries those with the highest burdensof maternal, newborn and child mortality is given inthe Appendix to this report, with data on newbornmortality, rst-day deaths, stillbirths during labour,coverage of skilled birth attendance and governmenthealth nancing. The ten countries with the worstcombined rates for rst-day mortality and stillbirthsduring labour are shown in Table 1.

Generally, the poorest countries have the highestmortality rates for newborns. Countries that haveexperienced recent conict or are considered fragileare among the highest for preventable deaths.

FIGURE 1 GLOBAL CHANGE IN UNDER-FIVE AND NEONATAL MORTALITY RATES

Source: WHO, Global Health Observatory

1990 1995 2000 2005 2010 2012

140

120

100

80

60

40

20

0

D e a t h s p e r 1 , 0 0 0 l i v e b i r t h s

Under-vemortalityrate

Neonatalmortalityrate


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A N OP P OR T UNI T Y

3

TABLE 1 TEN COUNTRIES WITH THE HIGHEST RATES OF FIRST-DAY DEATHS AND STILLBIRTHSDURING LABOUR

Country Risk of neonataldeath on day ofbirth (per 1,000 livebirths)

Intrapartumstillbirth rate (per1,000 total births)

Intrapartumstillbirths andneonatal deaths onday of birth (per1,000 total births)

Pakistan 15 26.4 40.7

Nigeria 14 19.4 32.7

Sierra Leone 18 13.9 30.8

Somalia 16 14.0 29.7

Guinea-Bissau 16 13.7 29.4

Afghanistan 13 16.6 29.0

Bangladesh 9 20.6 28.9

Democratic Republic of Congo 15 13.3 28.3

Lesotho 16 11.8 27.5

Angola 16 11.7 27.4

Source: See Appendix 1. Data drawn from forthcoming Lancet Global Health publication on rst-day deaths. Intrapartum stillbirths from LancetStillbirth Series.

FIGURE 2 NEONATAL MORTALITY RATES BY REGION (2012)


35

30

25

20

15

10

5

0

G l o b a l

A f r i c a

S o u t h -

e a s t A s i

a E a s

t e r n

M e d i t e

r r a n e a

n W e

s t e r n

P a c i c

A m e r i c

a s E u r

o p e


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4

It is notable, however, that some countries and regionshave made much more progress in reducing newborndeaths than others. Between 1990 and 2012, Chinaand Egypt saw declines of over 60%. Steep declinesachieved in some of the worlds poorest nations the 51% reduction in Cambodia, for example show

what progress is possible. In Latin America there hasbeen a 56% drop, and in the Pacic nations newbornmortality has fallen by 39%. However, in sub-SaharanAfrica the fall has been just 28%. 16

VARIATIONS IN NEWBORN MORTALITYWITHIN COUNTRIES

Within poor countries there are dramatic inequalitiesin death rates for newborn babies, with the poorestcommunities and other marginalised groups generallyexperiencing considerably higher rates of newbornmortality. 17 Understanding this inequality is key todetermining what is needed to end all preventablenewborn deaths.

In every country where data are available, wealthis a major determinant of newborn mortality.Figure 3 shows the ten countries with the greatestinequalities. The top of each column shows thenewborn mortality rate for the poorest fth of

households in a particular country; the bases ofthe columns show the rate for the most well-offhouseholds: the taller the column, the greater theinequality in newborn mortality.

As Figure 3 shows, in India, among the wealthiest20% of the population the newborn mortality rateis 26 per 1,000 babies, whereas among the pooresthouseholds 56 newborn babies out of 1,000 diein their rst month of life. In Sierra Leone, thenewborn mortality rate among the wealthiest fthof the population is 41 per 1,000 babies, comparedwith 68 newborn babies deaths per thousandbirths among the poorest families. As discussed inChapter 2, these inequalities in newborn mortalityalso reect patterns of inequality in coverage ofessential health services meaning those most in

need of care at birth are least likely to have it.

Other social inequalities andnewborn mortality

Inequalities are not solely on the basis of wealth.Rural populations usually have higher rates ofnewborn mortality than urban areas. A motherslevel of education is another strong predictor ofthe risk that she might lose a newborn baby.

FIGURE 3 GAP IN NEWBORN MORTALITY BETWEEN POOREST AND WEALTHIESTHOUSEHOLDS, TOP TEN COUNTRIES WITH HIGHEST INEQUALITIES

Source: Save the Children analysis of most recent Demographic and Household Survey data (since 2005), for the ten countries with the highes tratios for newborn mortality between wealthiest and poorest households, by wealth quintile.

80

70

60

50

40

30

20

10

0

N e w b o r n m o r t a l i t y r a t e

Poorest

Wealthiest B o l i v

i a ( 2 0 0

8 )

C a m b o d

i a ( 2 0 1

0 )

I n d i a (

2 0 0 6 )

P h i l i p p i n

e s ( 2 0 0

8 )

N e p a l

( 2 0 1 1 )

N a m i b

i a ( 2 0 0

6 )

B a n g l a d e

s h ( 2 0 1

1 )

S i e r r a L e o n

e ( 2 0 0 8

)

P e r u ( 2

0 1 2 )

I n d o n e s

i a ( 2 0 1

2 )


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1 A CR I S I S A ND


5

FIGURE 4 GAP IN NEWBORN MORTALITY BETWEEN RURAL AND URBAN HOUSEHOLDS,TOP TEN COUNTRIES WITH HIGHEST INEQUALITIES

Source: Save the Children analysis of most recent Demographic and Household Survey data (since 2005), for the ten countries with the highes tratios for newborn mortality between urban and rural households.

60

50

40

30

20

10

0

N e w b o r n m o r t a l i t y r a t e

RuralUrban

B u r u

n d i ( 2 0

1 0 )

A l b a

n i a ( 2 0

0 9 )

I n d o n e

s i a ( 2 0

1 2 )

N i g e r (

2 0 0 6 )

P h i l i p p

i n e s ( 2

0 0 8 )

D e m o c r a t

i c R e p u

b l i c

o f C o n g o

( 2 0 0 6 )

I n d i a (

2 0 0 6 )

R w a

n d a ( 2 0

1 0 )

C a m b o d

i a ( 2 0 1

0 )

B o l i v i a

( 2 0 0 8 )

Social, political and environmental factors are closely

intertwined. Rural populations are often extremelypoor, a long way from frontline medical services andwithout access to hospitals. Minority ethnic groupsliving in rural areas may be subject to discriminationand are more likely to live in areas that are remoteand poorly-serviced in terms of newborn healthcare.By contrast, in urban areas it is household wealthalone that predominantly determines access tonewborn healthcare.

It is unacceptable to regard low national GDP

levels as a legitimate reason for countries not tomake necessary progress in tackling newbornmortality. It is also unacceptable that a babyschances of immediate survival depend on where heor she is born and on the life chances of his or herparents. The international community and nationalgovernments can and must do better than this.

A newborn baby at a hospitalin Central African Republic.

P H OT O

: GR E GF UNNE L L / S A V E T HE

CHI L DR E N


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2014 THE OPPORTUNITY FORLIFE-SAVING CHANGE

EVERY NEWBORN ACTION PLAN

In 2014 we have an unprecedented opportunityto tackle the crisis of newborn mortality andpreventable stillbirths. The Every Newborn ActionPlan will be presented to the World Health Assemblyin May of this year, as part of the UN Secretary-Generals Every Woman Every Child movement toaddress child and maternal mortality. The plan isin response to demand from countries and is being

jointly developed with UNICEF, the World HealthOrganization and at least 50 others to set out theaction needed on this neglected topic.

The Every Newborn Action Plan is proposing a target

for a two-thirds reduction in the newborn mortality

rate, which would result in a 2035 global rate of7 per 1,000 live births, down from 21 per 1,000 in2012. This target is close to what has been achievedin countries such as Chile, Mexico and Turkey. If thisrate had been achieved in 2012, there would havebeen approximately 2 million fewer newborn deaths.

The Every Newborn Action Plan is also proposing atarget to end all preventable stillbirths during labour.

For more than ten years, Save the Childrens SavingNewborn Lives programme has been at the forefrontof action to address the lack of progress in tacklingnewborn mortality. Save the Children is calling forthe Every Newborn Action Plan to be the spurfor real political action to address the causes ofnewborn mortality, especially the lack of good-qualityhealthcare at birth.

A newborn baby girl theday after being deliveredat a clinic in Bangladesh.

P H O T O : J

E F F H O L T / S A V E T H E C H I L D R E N


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7

MIDWIVES AND SKILLED BIRTH ATTENDANCE

The World Health Organization denes a skilledbirth attendant as an accredited health professional

such as a midwife, doctor or nurse who has

been educated and trained to prociency in theskills needed to manage normal (uncomplicated)pregnancies, childbirth and the immediate postnatalperiod, and in the identication, management andreferral of complications in women and newborns.

Skilled birth attendance means not only thepresence of the health worker (the attendant), butalso the equipment, the medicines and the systemof management, support and referral that allowthem to do their job effectively. In many settings,the health worker may be a midwife, a specialist inbirth techniques whose training has concentratedon this role. However, a doctor or a nurse mayalso be a skilled birth attendant. In many resource-poor and rural settings, it is much more likely tobe a general health worker who responds to all thehealth problems of the community, rather than adedicated midwife.

Coverage rates of skilled birth attendance arebased on surveys of households and rely on themothers assumption about whether a skilledhealth worker was present during childbirth.The rates do not measure which services wereprovided or their quality.

TRADITIONAL BIRTH ATTENDANTS

In many settings, the only support during a birthmay be a traditional birth attendant (TBA).

Throughout history, other women from thecommunity who do not have formal traininghave provided support during birth, based ontheir experience.

Where women have no support at all fromprofessional health workers during birth, providingsome medical training and close supervision toTBAs may be benecial. For example, it may reduceharmful practices such as applying dirt to theumbilical cord or giving a newborn baby substances

other than breast milk.19

Other initiatives havebeen successful at enlisting TBAs to encouragecommunity acceptance of trained health workers atbirth. By contrast, some countries, including SierraLeone, have taken the decision to ban TBAs. 20 What is clear is that there is no substitute forformal health workers during delivery.

GROWING MOMENTUM FORUNIVERSAL HEALTH COVERAGE

Following the World Health Report 2010, 18 therehas been growing momentum for the principlethat governments are responsible for ensuringthat their whole population can access the good-

quality healthcare they need without facing nancialhardship in other words, a movement for universalhealthcare coverage (UHC). The World Bank andthe World Health Organization have both madeUHC their top priority for the worlds health. Inturn, many countries have made UHC their priorityfor health service reform. Newborn mortality isarguably a sensitive indicator for UHC.

CHILD MORTALITY ANDTHE POST-2015 AGENDA

Within the growing debate about what mightfollow the Millennium Development Goals, there isunderlying recognition that the progress the worldhas made over the past two decades in reducing the

number of children dying has brought us to a tippingpoint. Our generation could be the rst to endpreventable child deaths. The feasibility of a targetto end all preventable newborn and child mortalitywas set out by the governments of the USA, Ethiopiaand India, along with UNICEF, in the A PromiseRenewed movement, supported by 174 countries.

By acting now on newborn mortality in particular, byensuring universal access to good-quality healthcare atbirth for babies and mothers we can start to reduce

newborn deaths and preventable stillbirths and build aworld where no baby dies of preventable causes.


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P H OT O

: J O

DI B I E B E R / S A V E T HE

CHI L DR E N

THE STRUGGLE FOR SURVIVALRose gave birth at a local health clinic in the Democratic Republicof Congo. She is fortunate to live near a clinic, so was able to getthere on foot when her labour started.

Rose had a long labour, leaving her little energy to push, so the

nurses at the clinic helped with the delivery. But when Roses sonwas born he wasnt breathing. Thankfully, after resuscitation witha bag-and-mask device, her son started breathing.

I was happy when I saw that my child was alive God helpedhim survive, said Rose. I was lucky that my baby survived, asmany women are not so lucky here in Congo.

Rose with her newborn sonat Tudikolela hospita l inDemocratic Republic of Congo


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PRETERM BIRTHS

More than a third of newborn deaths are theresult of complications associated with preterm(premature) births. Some of these can be addressedbefore birth through family planning, screening forinfections, nutrition supplements and other servicesas well as use of antenatal steroids. During labour,

careful monitoring of the foetal heart rate and signsof distress indicates when action is needed. Afterbirth, an underweight and premature baby needsimmediate care and support to survive. 25 Healthworkers present when the baby is born can help themother establish exclusive breastfeeding, and cansupport her to keep the baby warm through skin-to-skin contact. A brilliantly effective technique for this,especially for preterm babies, is known as kangaroomother care (see box above).

BIRTH COMPLICATIONSNearly a quarter of newborn deaths are the resultof complications at labour and delivery technicallycalled intrapartum-related deaths or birth asphyxia.The most important way to reduce these deathsis through improved care during labour, includingcaesarean section if needed. If babies are born anddo not breathe, then health workers need toresuscitate immediately.

As many as 10% of newborn babies require sometype of assistance to begin breathing, meaning thatthe health worker must be prepared, recognisethe non-breathing baby, and immediately begin the

steps of neonatal resuscitation. Lack of oxygen canalso result in long-term disabilities. Skilled healthworkers can act quickly to stimulate breathing orair to the lungs, including by using a bag and mask. 26 Lack of oxygenated blood ow to the brain fromfailure to breathe at birth can also result in long-term disabilities. During labour, monitoring of foetal

heart rate and timely action in response to signs ofdistress (eg, caesarean or assisted vaginal delivery)are essential to save lives.

INFECTION

A third of newborn deaths are due to infectionsacquired by the baby during labour and delivery orafter birth. Preventive measures such as maternaltetanus immunisation, screening and treatment forsyphilis can reduce the risk. Clean birth practicesand hygienic care for the umbilical cord and exclusivebreastfeeding reduce the risk of infections; healthworkers play a crucial role in ensuring these practicesare followed. Early identication of severe infectionsand prompt and complete treatment with antibioticsdramatically increase the chance of survival.

STILLBIRTHS

During pregnancy, preventing or treating malaria,syphilis and other conditions is important toprevent stillbirths. Skilled care at birth can reduce

the number of stillbirths,27

and comprehensiveemergency obstetric care, including caesarean ifneeded, reduces stillbirths by 75%. 28

EIGHT ESSENTIAL, HEALTH-WORKER SUPPORTED INTERVENTIONSAROUND BIRTH

1 Skilled care at birth and emergency obstetriccare (including assisted vaginal delivery and

caesarean section if needed) ensuring timelycare for women and babies with complications2 Management of preterm birth (including

antenatal corticosteroids for mothers withthreatened preterm labour to reduce breathingand other problems in preterm babies)

3 Basic newborn care (focus on cleanlinessincluding cord care, warmth, and support forimmediate breastfeeding, recognition of dangersigns and care seeking)

4 Neonatal resuscitation for babies who do notbreathe spontaneously at birth

5 Kangaroo mother care (skin-to-skin,breastfeeding support especially for prematureand small babies)

6 Treatment of severe newborn infections (focuson early identication and use of antibiotics)

7 Inpatient supportive care for sick and smallnewborns (focus on IV uids/feeding supportand safe oxygen use)

8 Prevention of mother-to-child transmissionof HIV (during pregnancy, labour and theimmediate newborn period).


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2 H O W CA NNE WB OR NDE A T H S B E P R E V E NT E D ?

11

THE GLOBAL SHORTAGEOF MIDWIVES AND OTHERHEALTH WORKERS AT BIRTH

Every year 40 million women give birth withoutsupport from anyone with professional qualications. 29 51% of births in sub-Saharan Africa and 41% in south-east Asia are not attended by a midwife or anotherproperly qualied health worker. In Ethiopia, only 10%of births have skilled attendance at birth. 30 Globally,2 million women report that when they last gave birththey were completely alone. 31 Many babies die each

year because mothers do not get the quality care theyneed during labour and birth.

As with newborn mortality, coverage of skilled birthattendance is grossly unequal between countriesand within them. In Europe, the Americas and thewestern Pacic, almost all women give birth withthis vital service. In south-east Asia, Africa and partsof western Asia (or eastern Mediterranean in theWHO classication) rates are much lower (seeFigure 6). Unsurprisingly, national rates for skilledbirth attendance are at their lowest in some of thepoorest countries in the world (see Figure 7).

FIGURE 7 BIRTHS ATTENDED BY SKILLED HEALTH PERSONNEL (%), BY COUNTRY INCOMEGROUP (20052012)


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FIGURE 6 BIRTHS ATTENDED BY SKILLED HEALTH PERSONNEL (%), BY WHO REGION (20052012)

Source: WHO, Global Health Observatory* The eastern Mediterranean region includes Somalia, Yemen, Afghanistan and Pakistan.

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FIGURE 8 BIRTHS ATTENDED BY SKILLED HEALTH PERSONNEL (%), BY AREA OF RESIDENCE(20072012)

Source: The State of the Worlds Children 2013 , UNICEF global databases 2012, from MICS, DHS and other nationally representative sources.

FIGURE 9 GAP IN BIRTHS ATTENDED BY SKILLED HEALTH PERSONNEL (%) BETWEEN RURALAND URBAN HOUSEHOLDS, TOP TEN COUNTRIES WITH HIGHEST INEQUALITIES

Source: Save the Children analysis of most recent DHS data (since 20 05), for the ten count ries with the highest ratios for SB A coverage betweenurban and rural households.

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World

Skilled birth attendance has been designated a globalpriority. Millennium Development Goal 5, on reducingmaternal mortality, set a target of 80% coverage ofskilled birth attendance by 2005, 85% by 2010 and

90% coverage by 2015. But the world is way off track.By 2012 the global rate had only reached 70%. 32

Between 2000 and 2009 and even though countriessuch as Malawi and Rwanda have made impressive

progress global coverage of skilled birth attendancehas only increased at a rate of 1.1% a year. If rates ofskilled qualied birth attendance continue to increaseat this rate, it will take until 2043 for the world to

achieve universal coverage.33

Save the Children hascalculated that this will mean 354 million birthsbetween 2014 and 2043 would be unattended andmillions of unnecessary lives lost.


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UNEQUAL ACCESS TO NEWBORN CAREWITHIN DEVELOPING COUNTRIES

In developing countries, skilled birth attendance isthe least equitable of all maternal and child healthservices.34 The inequality within some countries isshocking. In Ethiopia, for example, where 29 per 1,000

newborns die, 46% of all births in the richest fth ofhouseholds had skilled birth attendance, comparedwith just 2% of those in the poorest households. 35 Coverage of skilled birth attendance must beexpanded and systems that are failing to reach thepoorest communities must be overhauled.

In the least developed countries, 40% of deliveries inrural areas of the developing world are attended byskilled health workers; in urban areas the rate is 76%. 36

THE CHALLENGE TOHEALTH SYSTEMS

The demands that preventing newborn babies deathsand stillbirths puts on a health system are quitedifferent from those involved in delivering life-savingchild health interventions, such as immunisation,

bednet distributions or family planning. Ensuringthe attendance of a skilled and equipped healthworker during and after a birth is evidently not anintervention that can be scheduled for a convenienttime: midwives and other skilled birth attendantsmust be available 24-hours-a-day, seven-days-a-week.

At the same time, improving the rate of skilled birthattendance in a country on its own may not reducenewborn mortality. As Figure 10 shows, while thereis a correlation between lower rates of rst-daydeaths and higher rates of skilled birth attendance,the relationship is not one of simple causality, nor isit consistent across all countries. For example, therate of skilled birth attendance in Malawi is muchhigher than in Bangladesh but the rate of newbornmortality is about the same.

To ensure good-quality healthcare at birth, a healthsystem needs to deliver in-depth training in newborncare to trainee health workers, refreshers forqualied birth attendants, supportive supervision,monitoring and data analysis for quality improvement.This systematic approach needs to be accompaniedby community-based approaches to improvehousehold practices and care seeking.

FIGURE 10 RELATIONSHIP BETWEEN FIRST-DAY MORTALITY AND SKILLED BIRTH ATTENDANCEBY COUNTRY

Sources: Data on rst-day deaths updates from State of the Worlds Mothers , updated for 2012, from forthcoming Lancet Global Health publication;skilled birth attendance data from WHO Global Health Observatory, for 20052012

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SOCIAL DETERMINANTSOF NEWBORN HEALTH

This unequal distribution of health-damagingexperiences is not in any sense a naturalphenomenon but is the result of a toxic combination

of poor social policies and programmes, unfaireconomic arrangements, and bad politics.

Sir Michael Marmot, WHO Commissionon Social Determinants of Health 2008

Health services are only one part of the picture. Anumber of social factors also underlie the crisis innewborn mortality.

Malnutrition in pregnancy and amongyoung children

Pregnant women who are malnourished are morelikely to have low birth-weight babies. So arewomen who were undernourished during theirown childhood. 37 In 2012, an estimated 162 millionchildren were stunted as a result of malnutrition inthe thousand days between their mothers pregnancyand their second birthday. 38

Huge change is needed not only in health services,but in areas such as agriculture, food marketsand social structures, to address access to decent

food and nutrition and reduce newborn and childmortality. 39 Challenging cultural traditions such asthose that demand women eat last and least withinthe household is one urgent priority.

Young mothers

In low- and middle-income countries overall almost10% of girls become mothers by the age of 16. They

are at greater risk of losing their babies than womenwho become mothers later mothers under 20 are50% more likely to have a stillbirth or to lose theirbaby within the rst week after birth than mothersaged 2029 years. 41

PARTICIPATORY WOMENS GROUPS

Studies in Bangladesh, India, Malawi, and Nepalshow how participatory womens groups reduceneonatal mortality and maternal depression.Women recruited in the local area are trainedto help identify problems associated withpregnancy, childbirth and care of newbornbabies. These women facilitate groups thatdevelop strategies to tackle these problems,working with local community leaders, teachers,politicians and others to implement them.Interacting with mothers-to-be, the groupsprovide a support network valuable for healthand happiness.

Analysis of the trial data shows that womenscontact during pregnancy with these groupsis associated with a 37% reduction inmaternal mortality and a 23% reductionin neonatal mortality. 40

FAIR CONDITIONS FOR HEALTH WORKERS

Low rates of skilled birth attendance reect thewider global shortage of midwives, nurses anddoctors. It is estimated that the world needs7.2 million more. 42

But equally important is the fact that those healthworkers who do exist are often least likely to befound where they are most needed.

There are many reasons health workers choosenot to work where the needs are greatest. Theymay seek better working conditions and careeropportunities abroad or outside the public healthsector. 43 Health facilities in poor communitiesare often poorly staffed and equipped, with huge

caseloads and little support or opportunitiesfor staff development. 44 Salaries are frequentlyinadequate: even highly-skilled health workers maylead a hand-to-mouth existence. 45 They may alsoface problems with housing and with schooling fortheir children, and the working environment maybe insecure. 46

In order to attract and retain more health workersin communities with the highest levels of newborndeaths, governments must address these issues.Salaried workers should receive a living wage and

be offered incentives to work in the least desirableareas. Many health workers are also family carersand need exible terms and opportunities.


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Very young mothers face more pregnancy-relatedproblems. They are also prone to obstructed labour

because their pelvic bones are still developing, andare more likely to have premature babies and are alsothemselves at higher risk of stula. 47

Spacing between pregnancies

Lack of spacing between pregnancies is also closelylinked with child mortality. Children born less thantwo years after a sibling are two times more likely todie within the rst year of life than those born afterthree or more years. 48

TACKLING MATERNAL MORTALITY THROUGHSKILLED BIRTH ATTENDANCE

The solutions offered by this report, particularlyimproving the quality of care through skilled birthattendance, will save the lives of newborns, reducestillbirths and save the lives of women. Maternalmortality is declining, but the rate of decline istoo slow, and in too many societies the rightsof women to survival, to health and to essentialservices are not realised. The deaths of womenand their babies in childbirth are unacceptable andcause great damage to families and communities.

Pregnancy and childbirth complications are theleading cause of death of girls aged 1519 in

low- and middle-income countries. Research showsthat children whose mothers died in childbirthare likely to have the worst survival rates, poorerhealth and less economic and educational success.There are further devastating effects to familiesfrom the loss of the person likely to be the rstcaregiver, and often the main source of income.

As will be discussed later, skilled birth attendanceand newborn care must be delivered within aframework of wider health services for motherand child.

Midwife Farhiya Muse Aliholds Zakaria on his rst dayof life. When Zakaria wasborn, in a clinic in Somalia,he did not start breathingstraight away. Farhiya helpedsave his life.

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SAVING NEWBORN LIVES

Immediately after birth, Ashas baby girl was not breathing.Pushpa, a midwife and auxiliary nurse in a rural district in Nepal,saved the babys life. Pushpa had recently been trainedin newborn care on a Save the Children programme.

I have seen many babies born like that, notbreathing, says Pushpa. Since the training,I have already saved a few babies with thebag and mask technique.

Pushpa was inspired to become a healthworker by her own harrowing experienceof childbirth. She was only 16 and, whenher labour became protracted, herhands were tied to a branch of a treefor four days. It was supposed to

help me push the baby out, she says.After that traumatic event, Pushpadecided to train to become a nurse.I became a health worker thinkingI will help women, she says, butnow I am also saving newborn babies.

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ACHIEVING UNIVERSAL COVERAGEIN SKILLED BIRTH ATTENDANCE

For many countries with high rates of newbornmortality, achieving universal health coverage especially good-quality care available for all births

requires radically different thinking about theentitlements of the poor and the way services areprovided. This chapter explores the concept ofuniversal health coverage an approach that has builtup considerable momentum in global and nationaldebates in recent years, and which is crucial toreducing and ending preventable newborn mortality.

As momentum for the goal of universal healthcarecoverage has grown (see page 7) this has set downclear challenges to countries and governments,particularly in terms of reaching poor, rural anddisadvantaged communities. In particular, universalhealth coverage suggests three measures for thedevelopment of countries health systems: Who is covered by health service schemes? Which services are covered? How fair is the way it is paid for?

INCREASING THE NUMBER OF MIDWIVESAND OTHER HEALTH WORKERS

The average annual increase in skilled birthattendance between 2000 and 2009 was just 1.1%

(see page 12). However, if we double our effortsand increase coverage by 2.3% a year, it is possibleto achieve universal coverage by 2025.

For most countries at risk of failing to meet theirMDG4 target on reducing child mortality, this willrequire wide-ranging reform of the structureand stafng of their health services, as well asincreased funding.

A study in The Lancet in 2013 concluded that withoutaccelerated coverage of the full range of proveninterventions to women and childrens health, thetargets could not be reached. 49 All children andmothers need access to good-quality healthcare not

just on the day of birth, but right across a continuumof care that covers reproductive, maternal, newbornand child health.

THE WHOLE PICTURE

Save the Children is calling on governments andmultilateral agencies to compile accurate gures onstillbirths both before and during labour, as well as onrst-day deaths. Only by doing this can we show thetrue picture of the estimated 2.2 million tragic lossesaround the time of labour 1 million deaths on therst day of life and 1.2 million stillbirths that occurduring labour in addition to maternal deaths.

Compiling gures for stillbirths and rst-day deathswill give a sharper focus on the importance ofhealthcare to all babies and mothers during labourand immediately after birth. And it will highlight thefact that, in 2012, 40 million mothers and their babiesmiss out on life-saving healthcare interventions atthis crucial time.

3 MEETING THE CHALLENGE

What Save the Children is calling for

Governments and partners to issue adening and accountable declaration to endall preventable newborn mortality, saving2 million newborn lives a year and stoppingthe 1.2 million stillbirths during labour. 50


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REACHING EVERY MOTHER ANDNEWBORN BABY

Research by Imperial College London concludes thatbroader health coverage generally leads to betteraccess to necessary care and improved populationhealth. The greatest gains accrue to poorer people. 51

For this report, we commissioned research thatapplied the Lives Saved Tool (LiST) to estimatethe impact of more equitable coverage of essentialhealth services on deaths averted. This consideredthe impact if the major inequities in access tomother and child health services such as good-quality care at birth, family planning and treatmentof newborn infections were eliminated in 47 ofthe countries covered by Countdown to 2015. 52

Our research estimated that, by 2015, the deaths ofalmost 950,000 newborn babies would be avoided,a reduction of 38%. Going further, achieving 95%coverage for the whole population by 2030 couldsave 1.8 million newborn babies almost 60% ofnewborn babies deaths in the 47 countries. 53

It is clear that reducing inequality and tacklingpoverty have powerful benecial effects on health.A study carried out by Save the Children recentlyfound that reducing income inequality could reducethe average global under-ve mortality rate from30 per 1,000 live births to 23 per 1,000. That wouldmean an additional 1.4 million lives saved per yearby 2030. 54

FRONTLINE CARE

Hawa is a midwife in the Mudug region of Somalia.

She has been working in a maternal health centrefor 12 years. Hawa carries out antenatal check-upsand delivers babies at the centre; more complicatedcases are referred to the local hospital.

I cant tell you how many children Ive delivered,but its more than 800, says Hawa.

Its life-saving work, as Hawa describes through the

following example: Recently we had a mother whohad a breach baby. During the delivery the rest ofthe babys body came out but the head got stuck.We had to handle that case with a lot of care. Thebaby was born safely a baby boy. Hes now safeand healthy.

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HEALTH SYSTEMS AND NEWBORN CARE

Births cannot be scheduled to t within normalworking hours; health staff, health facilities, medicinesand equipment must be available around the clock.Frontline health workers need to be able to call onthe support of specialist services and highly qualied

workers as required. Caesarean sections and bloodtransfusion services are key life-saving interventionsfor women and babies. Those services need to besupported by systems to transport a pregnant womanquickly to emergency obstetric care as required.

Newborn and maternal mortality and stillbirths aresensitive indicators of the strength of a health systemand its ability to reach all communities. Essential

newborn care needs to be part of a comprehensiveprimary care system in every country providinggood-quality antenatal care, immunisation, nutrition,family planning and treatment of childhood illnesses along with access to secondary care.

PIONEERING COMMUNITY-BASED APPROACHTO SAVING NEWBORN BABIES LIVES

In addition to services around the time of birth,antenatal home checks for women during pregnancyand follow-up care for mothers and newbornsin the days after birth are essential. Communityhealth workers can make a difference. For example,

in Gadchiroli, India, Dr Abhay Bang pioneered anapproach in the 1990s where care by communityhealth workers reduced newborn deaths byidentifying high-risk babies, supporting breastfeedingand managing hypothermia and infection. 55

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Governments, with partners, to ensure thatby 2025, every birth is attended by trained andequipped health workers who can deliver theessential newborn health interventions.


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INNOVATIONS IN NEWBORN CARE

In places of few resources, innovations can make abig difference. Corticosteroids given to a mother going into

premature labour can help the babys lungs todevelop faster.

Simple, low-cost bag and mask devices areeffective at helping newborn babies if breathingdoes not start naturally.

Kangaroo Mother Care (see photo captionbelow) is a technique rst developed to copewith situations where incubators were notavailable to keep a premature baby warm. Butit has been shown to have benecial long-termeffects even where intensive care is available.

The antiseptic chlorhexidine , used in gel formfor umbilical cord care, can reduce newborn

mortality by preventing acquired infections. TheUN Commission on Life-Saving Commoditiesfor Women and Children recommends moresupplies of this useful product. Save the Childrenis working with GSK to produce a new formulaand packaging, with costs as low as possible. 56

These techniques and developments are valuablein reducing mortality. However, getting them usedat full scale is impossible without systems that canreach all mothers and babies. Only a health workerwho regularly supports births and is up-to-datewith training and techniques can make sure theyare used properly. Only a strong health systemcan deliver these human resources, products andtechniques to every community and every birth.

KANGAROO MOTHER CARE

Abayanesus daughter was born a month premature,and weighed just 800 grams (1lb 2oz). Nursesadvised Abayanesu to practise mother kangaroocare a method of keeping a baby warm throughskin-to-skin contact for 24 hours-a-day until herdaughter was 41 weeks old. In her rst monthAbayanesus daughter gained 400 grams.

Save the Children has supported the governmentof Ethiopia to train doctors and nurses in thismethod, in order to improve the survival chancesof low birth-weight babies.

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ADDRESSING SOCIAL DETERMINANTSOF NEWBORN HEALTH

Addressing the social determinants of health aspart of universal health coverage 57 is vital in tacklingthe crisis in newborn mortality. Access to familyplanning and the right to control when and howfrequently they become pregnant is a vital part ofwomens and girls empowerment and of a reductionof newborn mortality. Interventions include: preventing the marriage of under-age girls providing good-quality and empowering

sex education keeping girls in education longer and delaying

the age at which they start having children. 58

WHO PAYS? FUNDING FORUNIVERSAL HEALTHCARE

ELIMINATING USER FEES

Save the Children argues that equitable systemsof UHC crucial to saving newborn babies lives

need to be nanced by resources pooled fromthe whole population, based on ability to pay, andthat healthcare should be available based on need.Direct cash payments for maternal, newborn andchild health services should be eliminated, to avoidexcluding the poor from health services. 60

Debates about which services are covered arecontentious and important. No one expects thateveryone in every country will be able to instantlyreceive all the possible healthcare services thatthey might need. Even in wealthy countries,difcult decisions have to be taken based on the

cost-effectiveness of the most expensive treatments.But good-quality care at birth provided bymidwives and other skilled birth attendants andnewborn care must be the top priority.

High rates of child and maternal mortality haveencouraged many countries to remove directpayments user fees by patients and their familiesfor maternal, newborn and child health services.The effects of this can be dramatic. Large reductionsin child mortality in Niger are in part attributedto the removal of user fees, 61 as are signicantincreases in use of maternity services in Sierra Leone.However, user fees persist in some countries, forexample, Democratic Republic of Congo, as do highrates of newborn mortality.

There is now a strong consensus against out-of-pocket payments for health services. The WorldBank, an organisation at one time synonymous withpromotion of user fees, has undergone a reversalon the issue. In 2013, its President, Jim Yong Kim,declared: Anyone who has provided health careto poor people knows that even tiny out-of-pocketcharges can drastically reduce their use of neededservices. This is both unjust and unnecessary. 62 Encouragingly, many countries have decided toremove user fees rst from maternal and child healthservices, recognising this as a priority area. 63

However, the removal of fees alone is insufcient to

improve health outcomes, including improving thesurvival chances of newborn babies. Other nancialbarriers also deter care-seeking. When nancialbarriers are lifted, demand for health services surges.This threatens to undermine the quality of careprovided. It puts pressure on the health workersand on stocks of medical supplies. Staff may continueto collect cash from users in the form of gifts andpatients may be expected to buy equipment ormedicine. Some countries do not include emergencyobstetric care in their free package, which can saddlefamilies with very high unexpected bills.

HEALTHY NEWBORN NETWORKSave the Children has helped found the HealthyNewborn Network, 59 which brings togethera wealth of resources on techniques andprocedures that can reduce newborn mortality.These include the actions that communitiesand families should take, including reducingdelays in seeking care, changing care practicesin the home, addressing the role of fathers and,crucially, highlighting cultural attitudes towards

women, babies and children.


Governments to remove user fees for allmaternal, newborn and child health services,including emergency obstetric care.


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HELD HOSTAGE IN HOSPITAL

Marie was held in a hospital in the DemocraticRepublic of Congo for a month after giving birth.Due to complications with the birth, Marie hadto have an emergency caesarean. She and herbaby son were out of danger, but, while Marie andher husband had set aside money to pay for anordinary birth, they did not have money to pay forthe operation. As a result, Marie was not allowedto leave the hospital.

The cost of the operation is 53,000 Congolese

francs (35). I dont have the money to pay that.Thats why Im still here, she said when she wasinterviewed by Save the Children.

Marie has ve older children who were at homewith her husband. She and her husband work aspdaleurs buying and selling goods, which theytransport by bike.

My husband is trying to get the money togetherto get me out. But I have been here a month andhe hasnt been able to do so yet, she said. I dont

have any family who can help me and there is noother way for me to leave the hospital other thanpaying what I owe.

One of the doctors at the hospital in Kasai Orientalprovince where Marie is being held, Dr Josephine,says there were four other women there in thesame situation. Security was tight, with guards onthe door of the hospital ward to ensure patientswho arent supposed to leave are unable to do so.

Patients who cannot pay for their medical carecan sometimes get their medical fees paid from anequity fund that the hospital holds, paid for by theEuropean Union. But in the month when Marie

gave birth, there was no money in the fund.We try to help everyone to be able to accessaffordable healthcare weve reduced the price ofa birth and of a caesarean operation because wewant everyone to be able to afford these things,says Dr Josephine. Its difcult in this case becausewe dont have any money in the equity fund at themoment. When we have the money we always useit to make sure that patients like this woman cango home.

Interviews were carried out on 22 November 2013.


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PRIVATE AND PUBLIC

Private providers of healthcare

Private providers of healthcare at birth are foundin every country. They range from high-quality,specialist maternity hospitals to traditional birthattendants. Many of these private providers are paidin cash as out-of-pocket expenditure.

Save the Children believes that private healthcareproviders can potentially form part of a publicly-nanced system of fair, universal health coverage,but they would need to be integrated and stronglystewarded by the government, with services free atthe point of use, at least for the poor.

Many governments and international institutions talkabout looking to the private sector to raise funds

for healthcare. For example, private health insuranceschemes can protect their members from somecatastrophic health costs but are too expensive foraverage families. It is unrealistic to expect theseschemes to cross-subsidise from the rich to thepoor for essential services. As a recent study by theWorld Bank and the Government of Japan notes:No country has reached UHC relying on privatevoluntary funding sources. 64 Looking to privateand community-based health insurance schemesis therefore a distraction from the evidence ofwhat works.

In systems of UHC, wealthier citizens can still payfor greater convenience or comfort in the privatecare they receive. However, the existence of privateservices must not be allowed to prevent a newbornbaby or a mother receiving life-saving treatment.Wealthier citizens who use private services shouldnot be allowed to opt-out of paying into the generalfunds, or to discourage governments from raising fairtaxes to fund healthcare for all. Crucial to any systemof UHC is the mandatory subsidisation by those whoare wealthy and healthy of people who are poor, andof those who are sick.

Core business

The private sector has a particularly importantrole in ensuring the reliable supply of good-qualityproducts that can benet health. Its products andservices must be available to those who need them.Working with the private sector can identify unmet

needs and develop innovative products and solutions,such as adaptations and delivery mechanisms thatcan reach the poorest and those without accessto services, especially, but not only, for medicines.

Save the Children is working with RB (formerlyknown as Reckitt Benckiser) to develop a public civil societyprivate partnership model to reducediarrhoea and mortality, including through innovative,low-cost products and services and throughinuencing others. 65

PAYING FOR UNIVERSAL HEALTH COVERAGETHROUGH TAXES

As the World Health Report 2010 showed, 66 thereis considerable scope for governments to raiseadditional domestic revenues for their health sectors.Many more health services could be provided ifgovernments improved efciencies in how resourcesare raised, pooled and spent. As well as the long-standing African Union Abuja Target of 15% ofgovernment expenditure to health, recent estimatesof the money needed to reach the health MillenniumDevelopment Goals suggest that countries need tospend at least US$60 per capita each year to funda specied mix of interventions and health systemcosts. Countries whose general government revenuesand compulsory health insurance contributions arelower than about 56% of gross domestic product(GDP) struggle to ensure health service coveragefor the poor. 67 Recently the Global InvestmentFramework for Womens and Childrens Health

showed that increasing health expenditure by justUS$5 per person per year in the 74 countries withthe highest burden of child mortality could resultin up to nine times that value in economic andsocial benets by 2035, and prevent the deaths of147 million children, 32 million stillbirths, and 5 millionwomen. 68 The UN estimates that the worlds leastdeveloped countries need to raise tax revenue thatis equivalent to at least 20% of their GDP, to achievethe Millennium Development Goals. 69

Fairer taxation of income and wealth, and particularlyof industries that extract and export commoditiesfrom poorer countries, would make a differenceto the ability of countries to fund universal health


The private sector, including pharmaceuticalcompanies, should help address unmetneeds by developing innovative solutions andincreasing availability for the poorest to newand existing products for maternal, newbornand child health.


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coverage. A recent report by the Organisation forEconomic Cooperation and Development judgesthat, were illicit ows to be curtailed, sub-SaharanAfrica as a whole could achieve the child mortalityMDG target by 2016, rather than 2029, projected oncurrent trends. 70

A GLOBAL RESPONSIBILITY

It is for national governments, in consultation withtheir people, to make the decisions needed to moveforward with UHC. However, the worlds poorestcountries exist in a context of harsh externalpressures. In recent decades, international nancialinstitutions demanded cuts in public spending which

actively discouraged states from taking responsibilityfor healthcare. Donors and multilateral institutionshave often prioritised different diseases and services,taking up space and energy that might have builtcomprehensive health systems.

The movement towards universal health coverage led by WHO and now backed by the World Bank provides a clear direction for countries and fordonors. And donors commitments to improve aideffectiveness and coordination through the ParisPrinciples of Aid Effectiveness and the InternationalHealth Partnership+ are making a difference.Through these initiatives, donors are beingencouraged to put their resources behind nationally-led comprehensive health plans, rather than project-fund activities that meet their own priorities. 71

The majority of resources to fund essentialhealthcare already come from domestic sources.However, even with fairer taxation, the poorestcountries will struggle to fund UHC on their own inthe short-term. Donor money, where it is available,should support comprehensive health services.

THE INTERNATIONAL HEALTH PARTNERSHIP

Most of the money invested in maternal, newbornand child health comes from the budgets ofnational governments. However, aid has played andwill continue to play an important role in savinglives, particularly in the poorest countries. It iswidely acknowledged that health aid is complex,inefcient and fragmented. Different donors havedifferent priorities, reporting requirements andbudget cycles, which make managing donor aidcostly and time-consuming for overstretched

ministries of health. Despite efforts to reducethe number of initiatives, mechanisms and fundingstreams, new ones continue to be announced.

Established in 2007, the International HealthPartnership (IHP+) is a growing alliance ofcountries, donors and civil society organisations

committed to try and make aid more effective. Allsignatories to the IHP+ Global Compact 72 haveagreed to support strengthened national leadershipand ownership, harmonise and align their aid, makebetter use of existing funds and systems and reduceduplication and transaction costs. In May 2013,three new partners Guinea-Bissau, Haiti andUSAID joined IHP+, bringing the total numberof signatories up to 59.

The IHP+ will continue to be a relevant andimportant mechanism for harmonising andmaximising the impact of partners efforts insupport of newborn health, and in support of anyhealth-related goals agreed within the post-2015development framework.


Governments to increase expenditure onhealth to at least the WHO minimum ofUS$60 per capita to pay for the training,equipping and support of health workers.


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FRAMING HEALTHCARE

AS A RIGHT MAKINGGOVERNMENTS ACCOUNTABLE

Few countries can introduce large-scale healthreforms instantly. However, engaging in a process ofhealth service reform brings its own benets. Whengovernments publicly commit to their responsibilities,citizens and civil society organisations invest timeand energy in the process and demand good-qualityhealth services as a right, not a privilege.

The World Bank and Government of Japanstudies identify the political and social factors thathave led some countries to make good progress

towards UHC, and others to make only limitedattempts: Having health care access embeddedin the Constitution as a right provided importantinstitutional underpinning to UHC initiatives providing reformers with a legal basis for UHCadvocacyIn many countries, social movementshelped put UHC on the political agenda initially andsubsequently held governments accountable afterits implementation. 73

Where governments have made these commitmentsand delivered progress, they can reap electoralrewards, such as in the re-election of Sierra LeonesPresident partly thanks to the Free HealthCare Initiative.

Newborn babies at a health clinic in Liberia.

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ETHIOPIAEthiopia has made great progress in reducing childmortality, recently achieving its MDG 4 targets. 91 Newborn mortality has also decreased from 54 to29 between 1990 and 2012. 92 This achievement hasbeen driven by multiple factors among them strongpolitical commitment and policy change, leading tohealth and nutrition improvements, particularly inrural areas.

Ethiopia launched its Health Extension Programme(HEP) in 2003 to promote universal coverage ofprimary care. It focuses on making promotive,preventative and some curative health servicesavailable to all, by bringing them to the community

level in even the most remote areas, and free toservice users. 93 More than 38,000 health extensionworkers (on government salaries) have been trainedunder the programme and are deployed to more than15,000 health posts across the country. 94

Despite impressive progress on child health outcomes,coverage of some essential health services is still verylow, and equity is a major concern. For example,immunisation coverage is only around 60% nationally,and children from the richest households are roughlytwice as likely to be immunised as the poorest.And children in urban areas are twice as likely tobe immunised as those in rural areas. 95 Only 10%of women give birth with a qualied health workerpresent. A richer woman is over 20 times more likelythan a poorer woman to have skilled birth attendance,and a woman living in an urban area is more thanten times more likely to do so than a woman in a

rural area.96

These represent huge inequalities, whichare holding back further progress. While EthiopiasMDG 4 achievements warrant recognition, the jobhas only just begun. Progress must be signicantlyaccelerated and inequalities tackled so that improvedhealth outcomes are shared by all.

DEMOCRATIC REPUBLIC OF CONGOHealth outcomes in the Democratic Republic ofCongo (DRC) are very poor and have remainedrelatively stagnant over the last decade. The under-ve mortality rate is 146 per 1,000 live births and therate for newborn mortality is 44. 83 These put DRCamongst the top ten worst-performing Countdowncountries. Moreover, estimates indicate that lessthan 25% of the population has access to a functionalhealth service that they can afford to use. 84

While per capita health expenditure has slowlyrisen over the years, at $32 85 it still falls well shortof WHO targets of $60 per capita and, alarmingly,only a third of this amount comes from governmentexpenditure. 86 User fees are endemic in the countryand a barrier to most people accessing healthservices when they are available. 87

There are indications of the Ministry of Healthsdesire to improve the health system, but it isconstrained by resource shortages to improve healthinfrastructure, pay salaries, and purchase drugsand supplies. 88 A revised strategy to strengthenthe health sector 89 was launched in 2010, followedby a National Plan for the Development of theHealth Sector, afrming good-quality primary healthcare available to all, especially vulnerable groups. 90 However, this policy has yet to be fully turned intopractice, due to poor dissemination (and henceapplication) of the plan at provincial, district andzonal health departments. More recently, in 2013,the government launched a national plan to boost

the achievement of MDGs 4 and 5.

GHANAGhana has a complex health nancing system,including private insurance, out-of-pocket paymentsand the National Health Insurance Scheme (NHIS),which was launched in 2003. The NHIS was brought

in to help guarantee universal access to good-qualityhealthcare. It was also a move towards curbingpeople having to pay for services at the point of use.NHIS coverage had only reached about one-third


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INDIAIndia has made progress in improving access tohealth services, but inequalities remain, arising fromgeographical, social, cultural and economic factors.The under-ve mortality rate in India has beenmore than halved since 1990 from 126 per 1,000live births to 56. 104 While the child mortality ratehas come down across all population groups, it isthree times higher among the poorest householdscompared with the richest. 105 There was a reduction

in the newborn mortality rate over the same periodfrom 51 to 31 per 1,000 live births; 106 this gurestill remains high compared to other Countdowncountries. Coverage of some critical health servicesis also very low, with huge inequalities across thecountry. For example, less than 60% of women havea skilled health worker present when giving birth, 107 with coverage among the poorest households lessthan a quarter what it is in the richest households 19% and 90% respectively.108

The government has introduced a number of policiesand initiatives to address challenges and improveaccess to health services, particularly for the poorand vulnerable. The National Rural Health Mission(NRHM) helped improve health infrastructureand service delivery, focusing on primary care inrural areas. It also integrated a number of existingdisease control and reproductive and child healthprogrammes. Under the NRHM, more recentinitiatives have been rolled out eg, the RashtriyaBal Swasthya Karyakram Child Health Screeningand Early Intervention Services programme in2013,109 and the JananiShishu Suraksha Karyakramprogramme in 2011, making services free at the pointof use for pregnant women and newborn babies. 110

To improve coverage among the urban poor inslums, the government launched the National UrbanHealth Mission (later renamed the National HealthMission). Several health insurance schemes have alsobeen introduced at national and state levels. 111 Thesehave initially targeted coverage of poor and ruralpopulations, though with the aim of scaling up touniversal coverage. 112

With regards to reproductive, maternal, newbornand child health, India is addressing inequalities bysystemically identifying high priority districts andallocating a higher budget for their health initiatives.A landmark achievement has been the launch of theRMNCH+A strategic approach during the Call toAction summit in February 2013. The frameworkmarks a paradigm shift to a holistic, life-cycleapproach, and the Ministry of Health and FamilyWelfare has ensured its integration into programmesthrough the establishment of state RMNCH+A

units. Save the Children India is the secretariat tothe RMNCH+A Coalition, leading on CSO/FBOengagement.

These are promising initiatives, yet they facechallenges, and implementation remains weak. Forexample, coordination between schemes is poor,while limited resources mean trade-offs betweenextending population coverage and expandingbenets packages. Also, states with strong healthsystems and implementation mechanisms have done

exceedingly well compared with others. More needsto be done to ensure equitable progress for allpeople in all states.

of the population by 2011, 97 leaving many having topay out of pocket for services. While formal sectorworkers are automatically covered, informal sectorworkers have to pay an annual premium, with someexceptions for vulnerable groups such as pregnantwomen. However, many people cant afford this

premium and therefore do not benet from thescheme. 98 There are indications that the NHIS hasreduced nancial barriers to accessing services andhas led to better utilisation, including by the poor,but enrolment is still not pro-poor. 99

Inequitable nancial protection and unevendistribution of health workers 100 mean that not

all people have the same access to health services.In 2003, when fees for childbirth services wereremoved, facility-based deliveries increased (withgreater impact amongst the poorest households),but dropped again when fees were reinstated in2008.101 Currently, only about half of women have

a qualied health worker when giving birth just aquarter of the poorest women, compared with 95%of the richest. 102 This is in contrast to other services,such as immunisation, where coverage is much higher(92%) and inequalities much lower. 103


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NIGERIAUnder-ve and newborn mortality rates in Nigeriaare among the highest in the world, at 123.7 and39.2 per 1,000 live births, respectively, in 2012. 129 Under-ve mortality is nearly 2 times higheramong the poorest households than the richest,and nearly 30% higher when looking at newbornmortality. 130 Coverage of critical health services isextremely low and inequalities are high only 38%of women give birth with a skilled health worker,while coverage is ten times lower for the poorestwomen compared with the richest; coverage inrural areas is about one-third (23%) what it is inurban areas (67%). 131 These inequalities have actuallyworsened over the years.

Nigeria suffers from a highly fragmented healthcaresystem across the country, leading to wide disparitiesin service coverage and health outcomes. As part ofefforts to strengthen the system, the governmentintroduced the National Health Policy in 2006. Thisincluded a re-designed National Health InsuranceScheme (NHIS) whereby formal sector workersmake contributions based on income (with acontribution also from employers) and those in the

informal sector make contributions based on theirchoice of benets package. Several exemptions arealso in place, including for the poor.

While coverage of the NHIS has increased since itsintroduction, its reach remains poor just 3% of thepopulation with huge disparities in coverage betweenpeople in paid employment and people who are poorand in the informal sector. 132 This has meant that

despite some national progress in health outcomes,this progress has been limited and unequal. Healthsystem weaknesses need to be addressed and culturalissues tackled if Nigeria is to see improvements inhealth outcomes for mothers and newborn babies.

If the National Health Bill, which went throughthe third and nal senate reading in August 2013,is signed into law by the President, it will provide abreakthrough deal for mothers and children. If thebill is fully funded and implemented, it could lead to

basic life-saving healthcare services being scaled up to90% coverage near universal coverage improvinghealthcare for huge numbers of Nigerians and helpingthe country achieve its MDG 4 and 5 objectives.

NEPALDespite grappling with poor infrastructure, difcultterrain and widespread poverty, Nepal has beenmaking impressive progress in improving child

survival.120

The country is on track to reach MDG4,with the under-ve mortality rate currently at 42 per1,000 deaths around one-third what it was in 1990.Meanwhile, newborn mortality has been halved from53 per 1,000 live births in 1990 to 24 currently. 121

While improved health outcomes correspond toincreasing coverage of many health services, coverageof some services remains low, and reaching the poorand marginalised is an issue. 122 Just over a third ofwomen have a skilled health worker present when

giving birth, with only one woman covered amongthe poorest households for every eight womenamong the richest. 123 Meanwhile, coverage is morethan twice as high in urban areas as in rural areas. 124 For other health services, progressive coverage hasbeen made eg, national immunisation coverage hasreached 90%, with high coverage among both thepoorest and richest households.

The government of Nepal is currently implementinga number of health programmes, resulting in manyessential services ofcially provided free for all,

with additional services targeted at the poor andmarginalised.125 While coverage has surely improvedas a result of these programmes, it is still far fromuniversal. Key challenges include resource and healthworker shortages (eg, currently there are aroundsix health workers per 10,000 population); directpayments; and inadequate nancial protection leadingto high out-of-pocket payments these currentlyaccount for 55% of total health expenditure. 126, 127

To help overcome these challenges and as a major

step towards UHC, the Ministry of Health andPopulation approved the national health insurancepolicy in March 2013. The new policy aims to helpimprove equitable access to health services bycurbing out-of-pocket payments and strengtheningthe health system. 128


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PAKISTANWith an under-ve mortality rate of 86 per 1,000live births in 2012, down from 138 in 1990, Pakistanis making insufcient progress towards MDG4targets. 133 There has also been less of a decline innewborn mortality, from 56 in 1990 to 42 currently.This is accompanied by very low coverage of somecritical health services. For example, less than halfof women have a skilled health worker presentwhen giving birth,134 with coverage nearly ve timeshigher among the richest women compared withthe poorest. 135 Pakistan is also ranked among thecountries with the highest stillbirth rates, largely dueto delays in receiving appropriate care from a skilled

health worker.136

The government of Pakistan rst introduced thelady health worker (LHW) cadre in 1994, withthe aim of improving access to primary healthservices and to address unmet health needs in rural

areas and urban slums. 137 Almost 60% of the totalpopulation of Pakistan, mostly rural, is covered bythe programme, with more than 90,000 LHWs allover the country, 138 contributing to improved healthindicators among populations covered. 139 However,several issues persist, such as delays in the salarydisbursements, stock outs of medicines, unavailableand dysfunctional equipment, and an unhelpfulreferral system. 140

Community midwives are another category offrontline health worker in Pakistan brought in toimprove skilled birth attendance in rural areas.However, out of a total of 11,996 communitymidwives, only 45% had been trained and of themabout 64% deployed across the country due to thelack of adherence to selection criteria, ambiguitie

ending newborn deaths report

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