Can Available Interventions End Preventable Deaths in Mothers, Newborn Babies, and Stillbirths, and at What Cost?

Abstract

Despite progress in lowering death rates in children younger than 5 years, progress in reducing newborn deaths has been slower and should focus on effective interventions, intentional investment, and implementation. This report offers an update of the evidence for interventions, the potential for lives saved, and running costs of implementation. Specific interventions across the continuum of pregnancy care were evaluated along with delivery platforms for these interventions and methods to improve care. All major databases were searched to identify quality systematic reviews in various domains using standardized methodology. Interventions before and between pregnancies include delaying the age at the first pregnancy, family planning, optimal interpregnancy intervals, and enhancement of prepregnancy nutrition. Antenatal interventions include maternal immunization, management of infections and preexisting chronic diseases or pregnancy-induced disorders, detection and management of significant in utero growth retardation, prevention of RhD alloimmunization, improvements in nutrition and psychosocial health, and treatment of drug misuse. Interventions during or close to labor include obstetric care with labor monitoring, skilled delivery and provision of emergency obstetric care as needed, and management of preterm labor and postterm pregnancy, as well as clean/sterile birth practices to reduce neonatal sepsis and tetanus deaths and use of antenatal steroids. Interventions at birth for every newborn include immediate drying and stimulation, provision of warmth, delaying of cord clamping, hygienic care, support for immediate breast-feeding, and administration of vitamin K. Neonatal resuscitation is crucial for babies who do not breathe immediately and could include prevention and management of meconium aspiration. Beginning breast-feeding within 1 hour of birth, exclusive breast-feeding of infants until age 6 months, and continuation of breast-feeding until age 2 years are strongly recommended. Interventions for small and ill newborn babies include prevention of hypothermia; management of respiratory distress syndrome, neonatal pneumonia, sepsis, and hyperbilirubinemia; and skin care with emollient and massage therapy. Kangaroo mother care involves early and continuous skin-to-skin contact, breast-feeding support, early discharge from hospital, and supportive care in stable neonates. Use of continuous positive airway pressure, anticonvulsants, and animal-derived surfactant can reduce neonatal morbidity and mortality. Care of neonates in intensive care units has become increasingly sophisticated in high-income countries, and creation of neonatal intensive care units is being implemented in low- and middle-income countries. Delivery platforms and strategies to reach mothers and neonates are important for delivery of high-quality care to underserved populations. Community-based delivery platforms, especially if linked to local health facilities, can increase coverage of essential interventions and reduce inequities. Changes in household behaviors and practices, tetanus immunization, use of clean birth kits, facility births, early initiation of breast-feeding, and seeking of health care for neonatal illnesses are all factors in reaching mothers and neonates. Community mobilization and antenatal and postnatal home visits by health workers can complement facility-based care and promote family contact with the health system at crucial times. Community-based packages of preventive and basic care, promoted by outreach workers and women's groups, empower women to facilitate these vital changes. One method to enhance these improvements is to create financial incentives as strategies to ease poverty, reduce financial barriers, and improve health outcomes in poor populations. To determine the financial aspects of these major changes to health care delivery in underserved populations, the Lives Saved Tool was used to model the effects of these interventions within the health systems of 75 countries that account for more than 95% of maternal, neonatal, and child deaths worldwide. The Lives Saved Tool estimates the country-by-country cause-specific effects of increasing coverage of individual interventions from baseline levels of 2012 on stillbirth and neonatal and maternal mortality. With high coverage by 2025, 71% (56%-76%) of neonatal mortality, 33% (23%-38%) of stillbirths, and 51% (44%-53%) of maternal deaths could be averted. If 90% of all women giving birth in facilities in 2020 received highly effective interventions, an estimated 113,000 maternal deaths (84% of the total deaths averted by 2020), 531,000 stillbirths (76%), and 1.325 million neonatal deaths (77%), including 300,000 preterm deaths, would be prevented. The incremental annual costs (in US dollars) of providing these care packages would be approximate to$4.5 billion ($0.91/person) by 2020, rising to $5.65 billion ($1.15/person) in 2025 (or $1928 for each maternal and infant life saved). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1.9 million [1.6-2.1 million]), 33% of stillbirths (0.82 million [0.60-0.93 million]), and 54% of maternal deaths (0.16 million [0.14-0.17 million]) annually. Available interventions can reduce preterm, intrapartum, and infection-related deaths by 58%, 79%, and 84%, respectively. Closing the quality gap for facility births is imperative. Many of the current differentials in quality relate to ethnicity, geography, and other forms of social marginalization. Strategies to overcome these obstacles are required to create and maintain health systems to benefit women, babies, development outcomes, and economic capital.