What does it take to save a newborn’s life?
Although India is undeniably on a path toward economic prosperity, losing millions of children every year to preventable deaths undermines this progress
In February, the United Nations International Children’s Emergency Fund (Unicef) released a report highlighting the grim state of the Indian health system for newborns. With an average newborn mortality rate of 25.4 deaths for every 1,000 live births, India leads the list of lower middle-income countries with the highest number of newborn deaths—a staggering 6.4 million per year, or about a quarter of the world’s total. Although India is undeniably on a path toward economic prosperity, losing millions of children every year to preventable deaths undermines this progress.
With the inclusion of vaccines against diarrhoea and pneumonia in the national immunization programme, India was able to reduce the under-five mortality rate by 34% between 1990 and 2006. However, because causes of newborn deaths are different, immunization programmes are unable to prevent these deaths. Some 80% of newborn deaths result from complications from labour and delivery: premature birth, low-birth weight, neonatal infections, and birth trauma. Out of these, infections such as pneumonia and diarrhoeal diseases, account for half of all newborn deaths.
In a perfect world, every health system would be adequately funded, with ample staff, training and equipment to care for the community. While asking for more resources is often warranted, we put poor populations at risk when we focus only on money instead of looking for ways to improve the capacity of the existing health system.
The reality is, simple interventions around the time of birth—such as hand washing, cleaning the umbilical cord with a regular antiseptic, ensuring the newborn is warm, dry, and fed—are affordable and more effective than previously thought and can reduce newborn death rates in low-resource settings. Most of these strategies do not require a specialist.
These practices form the basis for the World Health Organization’s (WHO’s) Essential Newborn Care. Essential Newborn Care is a set of activities that each newborn child needs, irrespective of place or condition at birth. WHO offers brief training courses and provides simple checklists that ensure all the essential steps are carried out at the time of birth.
In public health, we call this approach task-sharing. It strengthens the capacity of the health system by distributing essential responsibilities among a larger group of health workers and emphasizing shared responsibility for high-quality outcomes. For instance, in obstetric care of a newborn, a trained birth attendant or midwife can handle routine cases, freeing up an experienced surgeon or obstetrician to handle complications.
Recent evidence from Karnataka revealed that WHO birth attendant training in Essential Newborn Care reduced perinatal mortality to 36 per 1,000 live births, from 52. Stillbirth rates decreased by about 40%, to 14 per 1,000 live births, and early neonatal death fell by about one-fourth to 22 per 1,000 live births.
Better training of midwives can also reduce newborn deaths. About 70% of the Indian population currently resides in rural areas. Midwives already play a crucial role in delivering obstetrical care in these areas. Most midwives, however, have never been trained in practices of infection control or umbilical cord care. A comprehensive study on the role of midwives in obstetric care reported in the Lancet revealed that strengthening midwifery practices through education, training, and regulation in low- and middle-income countries resulted in more efficient utilization of resources and improved outcomes for both pregnant mothers and newborn children.
So why aren’t these various, relatively simple measures in wider practice? One reason is resistance from professional societies. Doctors may worry about quality, safety, and the dilution of professional obligations. But the fact is that these low-cost and high-impact interventions can save millions of lives. Medical and nursing professional societies play a critical role in this solution. They can also work together to formulate curricula that promote task-sharing practices, so that quality improvement initiatives can be implemented. If these task-sharing practices work in the short term, doctors and nurses may find that this approach could have merit as a long-term solution to improve health outcomes, particularly in resource-poor settings.
Further, there is ample evidence to suggest that obstetric outcomes, such as newborn death and complications, do not increase when task-sharing is implemented. In 2011, the British Medical Journal published an analysis of controlled studies which demonstrated no difference in outcomes for caesarean section and perinatal death between physicians and ancillary staff.
It is not reasonable, moral or practical, to wait until the capacity of the national health system develops sufficiently to handle this public health crisis. Doing so is allowing professional hubris to kill newborn children.
Instead, we must empower and train healthcare providers who work in remote communities and serve populations that are unable to access safe and affordable obstetric care in the current health system. Losing almost a million lives every year to preventable causes is a travesty of sound health policy. The cost of inaction is too high.
Junaid Nabi is a fellow in bioethics and a global health policy researcher at Harvard Medical School, Boston, and a 2018 new voices fellow at Aspen Institute.
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