Neonatal tetanus, which has been virtually unseen in rich countries for a century, kills half a million babies each year. Around 60-80% of neonatal deaths arise in low-birthweight babies, although many could be saved with simple support for warmth and feeding.

Every hour around 450 babies die before the age of four weeks (the neonatal period), mainly from preventable causes. Neonatal deaths worldwide are double that of HIV/AIDS. Although 99% of these deaths occur in poor countries, almost all published research relates to the 1% of newborn deaths in rich countries.

The four papers in this series address a major gap in knowledge and provide new evidence detailing the causes of these deaths and the simple, effective interventions that are available to prevent them.

The deaths of 10,000 newborn children everyday, largely ignored in global policy, demand immediate and sustained action from international agencies, professional organisations and national governments of both rich and poor countries.

Four Million Newborns Dying Each Year

The first paper in the series provides powerful statistics to help reduce deaths of newborn children in countries where most of these deaths occur. Globally, three-quarters of neonatal deaths occur in the first week of life, with the highest risk of death on the first day of life. Of all deaths in children under the age of five years, nearly 40% occur during the first four weeks of life.

South-central Asia has the highest absolute number of neonatal deaths, while subSaharan Africa has the highest rates. Two-thirds of deaths occur in 10 countries (Afghanistan, Bangladesh, China, Democratic Republic of Congo, Ethiopia, India, Nigeria, Pakistan, Indonesia, and the United Republic of Tanzania).

Major Causes of Neonatal Deaths

The major direct causes of neonatal deaths globally are infections (36%), premature birth (28%), and asphyxia (23%). A baby in a low-resource, high mortality country is 11 times more likely to die of infection than a baby in a rich, low mortality country.

Neonatal tetanus, which has been virtually unseen in rich countries for a century, kills half a million babies each year. Around 60-80% of neonatal deaths arise in low-birthweight babies, although many could be saved with simple support for warmth and feeding.

More than half of women in Africa and South Asia give birth at home without the presence of a skilled attendant. Countries with the highest neonatal mortality rates were generally found to have the lowest skilled attendance and institutional delivery rates.

First Four Weeks

The authors write that preventing neonatal deaths has been neglected in both child survival and safe motherhood programmes. Currently, child survival programmes focus on preventing pneumonia, diarrhoea and malaria, which are important causes of death, but after the first month of life.

"Every year, 4 million babies still die in their first 4 weeks of life, most from preventable causes," says lead author Dr. Joy Lawn (Saving Newborn Lives/Save the Children-USA and The Institute of Child Health, UK). "This number is double the deaths due to HIV/AIDS; although AIDS is rightly hailed as a global emergency, newborn deaths are largely ignored. While we neglect these challenges, 450 newborn children die every hour, mainly from preventable causes, which is unconscionable in the 21st century."

Saving Newborn Lives

Nearly three-quarters of neonatal deaths could be avoided by 16 interventions, highlighted in the second paper in the Lancet series. These include tetanus toxoid vaccinations for pregnant women, promoting clean delivery, prompt and exclusive breastfeeding, extra care for lowbirth-weight babies, and antibiotics for neonatal infection.

The paper emphasises that combining interventions into packages, which are delivered within existing maternal care and child survival programs, will be more cost effective than creating a separate program. Despite the availability of cost-effective interventions to prevent neonatal mortality, coverage of many of these interventions is low.

"Early success in preventing neonatal deaths is possible, even in settings with high mortality and weak health systems, by improving home care practices, raising demand for skilled care and increasing care-seeking for illness through outreach services and a family-community care package," comments lead author Dr. Gary Darmstadt (Johns Hopkins School of Public Health, USA).

"However, in order to achieve the kinds of reductions in neonatal mortality that are needed to meet the Millennium Development Goal for child survival, we must also begin strengthening and expanding clinical care for both mothers and babies," Dr. Darmstadt adds.