Addressing the Challenge of Neonatal
Mortality
Simon Cousens
Millennium Development Goal 4
Reduce by two-thirds, between 1990 and
2015, the under 5 mortality rate
0
25
29
50
75
100
Millennium Development Goal 4
1990
1995
2000
2005
2010
2015
Year
Source: Levels and trends in Child Mortality. Report 2011. Estimates developed by the
Inter-agency Group for Mortality Estimation.
29
50
0
25
Mortality rate
75
100
Millennium Development Goal 4
1990
1995
2000
2005
2010
2015
Year
U5MR
NMR
Sources: Levels and trends in Child Mortality. Report 2011. Estimates developed by the
Inter-agency Group for Mortality Estimation.
Oestergaard et al. PLoS Med. 2011 8:e1001080
Geographical distribution of neonatal mortality in 2009
Region
NMR
% of neonatal
deaths
High income
3.6
1.4%
sub-Saharan Africa
35.9
34%
South East Asia
30.7
36%
Source: Oestergaard et al. PLoS Med. 2011 8:e1001080
0
10
20
30
40
Neonatal mortality rates in England and Wales
1920
1940
1960
Year
Early neonatal mortality
1980
2000
Late neonatal mortality
Source: ONS mortality statistics (www.statistics.gov.uk)
Community-based care: a seminal paper from India
Bang et al. Lancet 1999. 354: 1955-1961
Implemented a home care package in a rural
setting with high NMR
Trained village health workers to perform home
visits, to promote breastfeeding and thermal
management, in simple techniques to manage
birth asphyxia, and to treat infections
Community-based care: a seminal paper from India
Treatment of sepsis

Source: Bang et al. Lancet 1999. 354: 1955-1961
c. 60% reduction
in NMR
The Lancet Neonatal Survival Series (2005)
Editors: JE Lawn and S Cousens
Developed a model to estimate how many neonatal deaths could be
prevented by increasing coverage of a package of relatively simple,
cost-effective interventions
Estimated that 36-67% of neonatal deaths in 75 high mortality
countries could be averted by high coverage (90%) with 16
interventions
Only about half of this reduction was through community-based care
Source: Lancet 2005. 365:977-988
Lives Saved Tool
(LiST)
Freely available
software tool for
programme
planners
http://www.futuresinstitute.
org/pages/Spectrum.aspx
Two recent studies:
The Hala Trial, Pakistan
Lancet 2011. 377: 403-412
The Hala Trial, Pakistan
Intervention:
Lady Health Workers (LHWs) trained in preventive
newborn care
Dais (TBAs) trained in basic newborn care
Communities encouraged to establish Community
Health Committees
16 clusters randomised:
Approximately 23,000 live births identified over a 30
month period
Primary outcome: all-cause neonatal mortality
Lancet 2011. 377: 403-412
The Hala Trial, Pakistan
NMR
Intervention
clusters
Control
clusters
Risk ratio
(95% c.i.)
43.0
49.1
0.85 (0.76, 0.96)
P=0.02
Trial differed from other community-based trials in region in
that intervention principally delivered through government
health system rather than workers employed by research team.
 lower intervention coverage than has been reported in other
trials
 smaller mortality impact
Despite limitations, encouraging that public sector programme
promoting preventive care can produce health benefits
Cord care
WHO recommends dry cord care BUT in a
Cochrane review from 2004
all 21 trials were conducted in hospitals
all but one in high income settings
no systemic infections or deaths in any of the trials
Source: Zupan et al. Cohrane Database Syst Rev 2004. 3: CD001057
Cord care
A subsequent community-based trial of topical
chlorhexidine in Nepal reported:
a 75% reduction in severe omphalitis
a 24% reduction in neonatal mortality
compared with dry cord care
Source: Mullany et al. Lancet 2006. 367:910-918
Chlorhexidine trial, Pakistan
Lancet 2012. 379:1029-1036
Chlorhexidine trial, Pakistan
187 clusters randomly allocated in 2x2 factorial
design
2 interventions
Chlorhexidine (daily for 2 weeks) vs dry cord care
Handwashing promotion vs no handwashing promotion
Interventions delivered through Dais
Facility births excluded
9741 livebirths enrolled over 18 months
Chlorhexidine trial, Pakistan
Neonatal mortality
Neonatal
deaths
(NMR)
Risk ratio
(95% c.i.)
No handwashing
promotion
147 (29.1)
1.0
Handwashing promotion
140 (29.9)
1.08
(0.79, 1.48)
Dry cord care
176 (36.1)
1.0
Chlorhexidine
111 (22.8)
0.62
(0.45, 0.85)
P
0.62
0.003
Chlorhexidine
“We could argue that more research is needed—
questions certainly exist about the duration and
timing of application and about external validity.
Evidence from high-mortality populations in Africa
would be useful. Nevertheless, to demand more
evidence of effectiveness might be to repeat an old
public health debate: if the need is clear, the
possibilities attractive, and the risk low, how much
evidence is necessary before we act on plausible
findings?”
Osrin and Hill. Commentary. Lancet 2012. 379:984-986.
The challenge of neonatal mortality:
what needs to be done?
Effective interventions are available: how do we
make sure they reach mother’s and newborns?
Improve the quality and quantity of data available
to:
assist rational policy making
Monitor progress
Acknowledgements
Joy Lawn, Zulfiqar Bhutta, Gary Darmstadt,
Hannah Blencowe, Susana Scott, Neff Walker,
Mikkel Oestergaard, Colin Mathers and many
others