TEN COUNTRIES WITH THE HIGHEST RATES OF FIRST-DAY DEATHS AND STILLBIRTHS DURING LABOUR
| Country | Risk of neonatal death on day of birth (per 1,000 live births) | Intrapartum stillbirth rate (per 1,000 total births) | Intrapartum stillbirths and neonatal deaths on day of birth (per 1,000 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 first-day deaths. Intrapartum stillbirths from Lancet Stillbirth Series.
MIDWIVES AND SKILLED BIRTH ATTENDANCE
The World Health Organization defines a skilled birth attendant as "an accredited health professional – such as a midwife, doctor or nurse – who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns."
Skilled birth attendance means not only the presence of the health worker (the attendant), but also the equipment, the medicines and the system of management, support and referral that allow them to do their job effectively. In many settings, the health worker may be a midwife, a specialist in birth techniques whose training has concentrated on this role. However, a doctor or a nurse may also be a skilled birth attendant. In many resource-poor and rural settings, it is much more likely to be a general health worker who responds to all the health problems of the community, rather than a dedicated midwife.
Coverage rates of skilled birth attendance are based on surveys of households and rely on the mother’s assumption about whether a skilled health worker was present during childbirth. The rates do not measure which services were provided or their quality.
TRADITIONAL BIRTH ATTENDANTS
In many settings, the only support during a birth may be a ‘traditional birth attendant’ (TBA). Throughout history, other women from the community who do not have formal training have provided support during birth, based on their experience.
Where women have no support at all from professional health workers during birth, providing some medical training and close supervision to TBAs may be beneficial. For example, it may reduce harmful practices such as applying dirt to the umbilical cord or giving a newborn baby substances other than breast milk.
19 Other initiatives have been successful at enlisting TBAs to encourage community acceptance of trained health workers at birth. By contrast, some countries, including Sierra Leone, have taken the decision to ban TBAs.20 What is clear is that there is no substitute for formal health workers during delivery.COUNTRY CASE STUDIES INCLUDING - SIERRA LEONE
As Sierra Leone emerged from civil war, health outcomes were atrocious and coverage of health services was extremely low. In 2008, the neonatal mortality rate was the fourth highest in the world, with 49 babies in every 1,000 dying within their first month of life. That year, just one in four of the poorest mothers had skilled attendance during birth.
149 Overcoming such a challenge is not easy. The health system was weak, underfunded and reliant on user fees from the population, which deterred the majority from seeking care.A crucial step towards better maternal and child health outcomes has been the Free Health Care Initiative (FHCI), launched in April 2010 to remove user fees for pregnant and lactating women, and children under five. This was led by the President, Ernest Koroma, who acknowledged the scale of the crisis and thus made maternal and child health a key priority. The FHCI has been implemented with increased public financing and wider system reforms to strengthen the quality of care provided, by increasing the numbers of health workers and improving the drug supply.
In 2014, Sierra Leone will finalise and implement its Every Newborn Plan, which must be closely situated within the health sector plan to ensure an integrated approach is taken to scale up coverage of essential services. A focus on newborns, within the consolidation of the FHCI, has huge potential to accelerate progress on child survival in Sierra Leone.
RECOMMENDATIONS
Save the Children is calling on world leaders, philanthropists and the private sector to implement – this year – a five-point Newborn Promise to end all preventable newborn deaths:
• Governments and partners issue a defining and accountable declaration to end all preventable newborn mortality, saving 2 million newborn lives a year and stopping the 1.2 million stillbirths during labour
• Governments, with partners, ensure that by 2025 every birth is attended by trained and equipped health workers who can deliver quality care including essential newborn health interventions
• Governments increase expenditure on health to at least the WHO minimum of US$60 per capita, to pay for the training, equipping and support of health workers
• Governments remove user fees for all maternal, newborn and child health services, including emergency obstetric care
• The private sector, especially pharmaceutical companies, should help address unmet needs by developing innovative solutions and increasing availability for the poorest to new and existing products for maternal, newborn and child health.
Governments of countries with high burdens of newborn mortality need to make significant policy changes in order to:
• commit to addressing the newborn deaths and stillbirths as a top priority
• commit to universal coverage of high-quality care during birth, as part of integrated reproductive, maternal, newborn and child healthcare
• increase budget allocations for health at least to meet the African Union Abuja target of 15% of government expenditure on health
• address the health worker crisis through programmes to recruit, train, retain, deploy, support and appropriately remunerate health
workers, including midwives with the skills and equipment to save newborns as well as mothers
• remove and eliminate direct payments for maternal and newborn healthcare including emergency obstetric care
• ensure that less than 20% of all national expenditure for health is from out-of-pocket payments. Governments must also tackle informal payments and other barriers such as transport and opportunity costs that deter the poor from using services
• develop integrated national reproductive, maternal, newborn and child health action plans that ensure universal access to good-quality healthcare and lay out evidence-based paths to ending preventable maternal and
child deaths.
The Every Newborn Action Plan – which should be presented to the World Health Assembly in May 2014 and lead to a global push – should have as its priorities:
• ending all preventable newborn and child deaths and stillbirths. This should be achieved in all wealth quintiles and all segments of society with accountability mechanisms as part of Every Woman Every Child
• universal coverage of quality care at birth by 2025
• calling for the future monitoring and inclusion of stillbirths as an indicator in reproductive, maternal, newborn and child health frameworks
• endorsement of the principles of universal health coverage including eliminating financial and other barriers and establishing financial risk protection
• ensuring that underlying factors such as maternal nutrition, reproductive health and women’s empowerment are addressed to end all preventable newborn deaths
• ensuring its targets are integrated within the post-2015 framework, so that they achieve global priority.
