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The Greatest Risks to Life are in its Beginning
Although a good start in life begins well before birth, it is just before, during, and in the very first hours and days after birth that life is most at risk. Babies continue to be very vulnerable throughout their first week of life, after which their chances of survival improve markedly (see Figure 5.1).
Globally, the largest numbers of babies die in the South-East Asia Region: 1.4 million newborn deaths and a further 1.3 million stillbirths each year. But while the actual number of deaths is highest in Asia, the rates for both neonatal deaths and stillbirths are greatest in sub-Saharan Africa. Of the 20 countries with the highest neonatal mortality rates, 16 are in this part of the world.
The conditions causing newborn deaths can also result in severe and lifelong disability in babies who survive. While data are limited, it is estimated that each year over a million children who survive birth asphyxia develop problems such as cerebral palsy, learning difficulties and other disabilities (
). Babies born prematurely or with low birth weight are more vulnerable to illnesses in later childhood (
) and often experience impaired cognitive development (
). There are indications that poor fetal growth during pregnancy may trigger the development of diabetes, high blood pressure and cardiovascular disease, consequences that become apparent
only at a much later age (
). Rubella virus infection during pregnancy can lead to miscarriage and stillbirth, but also to congenital defects, including deafness, cataract, mental retardation and heart disease. About 100 000 babies each year are born with congenital rubella syndrome, which is avoidable through widespread introduction of rubella vaccine.
Newborns die from different causes than older children; only pneumonia and respiratory tract infections are common to both. Older infants and children in developing countries generally die of infectious diseases such as acute respiratory infections, diarrhoea, measles and malaria. These diseases are responsible for a much smaller proportion of deaths in newborns: deaths from diarrhoea are much less common, and measles and malaria are extremely rare. The interventions designed to prevent and treat these conditions in older infants and children have less impact on deaths within the first month of life.
Prematurity and congenital anomalies account for more than one third of newborn deaths, and these often occur in the first week of life. A further quarter of neonatal deaths are attributable to asphyxia – also mainly in the first week of life. In the late neonatal period, that is, after the first week, deaths attributable to infection (including diarrhoea and tetanus) predominate; together, these causes are responsible for more than one third of newborn deaths. The importance of tetanus as a cause of neonatal death, however, has diminished sharply, thanks to intensified immunization efforts.
Direct causes of newborn death vary from region to region (see Figure 5.2). In general, the proportions of deaths attributed to prematurity and congenital disorders increase as the neonatal mortality rate decreases, while the proportions caused by infections, asphyxia, diarrhoea and tetanus decline as care improves. Patterns of low birth weight vary considerably between countries (
). Babies with a low birth weight are especially vulnerable to the hazards of the first hours and days of life, particularly if they are premature. The majority of low-birth-weight babies are not actually premature but have suffered from in utero growth restriction, usually because of the mother’s poor health. These babies too are at increased risk of death.
The main causes of neonatal mortality are intrinsically linked to the health of the mother and the care she receives before, during and immediately after giving birth. Asphyxia and birth injuries usually result from poorly managed labour and delivery and lack of access to obstetric services. Many neonatal infections, such as tetanus and congenital syphilis, can be prevented by care during pregnancy and childbirth. Inadequate calorie or micronutrient intake also results in poorer pregnancy outcomes (
). It has been argued that nearly three quarters of all neonatal deaths could be prevented if women were adequately nourished and received appropriate care during pregnancy, childbirth and the postnatal period (
1 Best practices: detecting and treating newborn asphyxia. Baltimore, MD, JHPIEGO, 2004 (http://www.mnh.jhpiego.org/best/detasphyxia.pdf, accessed 16 February 2005).
2 Verhoeff FH, Le Cessie S, Kalanda BF, Kazembe PN, Broadhead RL, Brabin BJ. Post-neonatal infant mortality in Malawi: the importance of maternal health. Annals of Tropical Paediatrics, 2004, 24:161–169.
3 Grantham-McGregor SM, Lira PI, Ashworth A, Morris SS, Assuncao AM. The development of low birth weight term infants and the effects of the environment in northeast Brazil. Journal of Pediatrics, 1998, 132: 661–666.
4 Godfrey KM, Barker DL. Fetal nutrition and adult disease. American Journal of Clinical Nutrition, 2000, 71(Suppl.):1344S–1352S.
5 UNICEF/WHO. Low birthweight: country, regional and global estimates. New York, NY, United Nations Children’s Fund, 2004.
6 Caulfield L. Nutritional interventions in reducing perinatal and neonatal mortality. In: Reducing perinatal and neonatal mortality. Report of a meeting, Baltimore, MD, 10–12 May 1999. Baltimore, MD, Johns Hopkins School of Public Health, 1999 (Child Health Research Project Special Report, Vol. 3, No. 1).
7 Tinker A. Safe motherhood is a vital social and economic investment. Paper presented at: Technical Consultation on Safe Motherhood, Safe Motherhood Inter-Agency Group, Colombo, Sri Lanka, 18–23 October, 1997 (http://safemotherhood.org/resources/pdf/aa-06_invest.pdf, accessed 15 February 2004).
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