Ending Newborn Deaths

ENDING NEWBORN DEATHS Ensuring every baby survives Front cover: A newborn baby at a clinic in northern Nigeria (Photo: Lucia Zoro/Save the Children) ENDING NEWBORN DEATHS Ensuring every baby survives

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Acknowledgements This report was written by Simon Wright with Kirsten Mathieson, Lara Brearley, Sarah Jacobs, Louise Holly and Ravi Wickremasinghe from Save the Children, with work by Alex Renton. The authors would like to thank colleagues from Johns Hopkins School of Public Health who undertook the Lives Saved Tool (LiST) analysis included in the report. We are grateful for the comments and improvements received from several Save the Children colleagues, in particular Michel Anglade, Asma Badar, Claire Bader, Chantal Baumgarten, Anna Bauze, Rachel Bhatia, Smita Baruah, Nina Caplan, Berhanu Demeke, Valerie Foulkes, Binyam Gebru, Wanja Gironga, Steve Haines, Ben Hewitt, Louise Hill, Stephen Hodgins, Debra Jones, Anjana KC, Kate Kerber, Rajesh Khanna, Mike Kiernan, Joy Lawn, William Lynch, Mary Kinney, Sara Lindblom, Arshad Mahmood, Alice McDonald, Cicely McWilliam, Angela Muriuki, Eva Nofdfjell, Nora O’Connell, Jo David Olayemi, Olusola Ooladeji, David Oot, Ann Paradis, Martha Parsons, Joy Riggs-Perla, Sayed Rubayet, Jawara Saidykhan, Nirupama Sarma, Aleks Sawyer, Liz Stuart, Yenealem Tadess, Kim Terje Loraas, Abdul Waheed, Steve Wall, Patrick Watt, Abimbola Williams, Sarah Williams and Kate Worsley. External comments were received from Robert Marten at The Rockefeller Foundation, Rob Yates at the World Health Organization and Ceri Averill at Oxfam GB.

Some names in case studies have been changed to protect identities.

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First published 2014

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CONTENTS

The story in numbers iv

Executive summary vii

1 A crisis and an opportunity 1 The crisis in newborn mortality 1 Dying poor: the inequality of newborn mortality 2 2014 – the opportunity for life-saving change 6

2 How can newborn deaths be prevented? 9 Clinical causes of newborn mortality 9 How health workers save newborn babies’ lives 9 The global shortage of midwives and other health workers at birth 11 The challenge to health systems 13 Social determinants of newborn health 14

3 Meeting the challenge 17 Achieving universal coverage in skilled birth attendance 17 Who pays? Funding for universal healthcare 21 Framing healthcare as a right – making governments accountable 25

4 Country case studies 26

Conclusion 32

Recommendations 33

Appendix: Newborn mortality statistics by country 37

Endnotes 42 NEWBORN SURVIVAL THE STORY IN NUMBERS

2 MILLION 1 MILLION

The number of newborn babies who The number of babies who did not could be saved each year if we end survive their first – and only – day of preventable newborn mortality. life in 2012.

2.9 MILLION 6.6 MILLION

The number of babies who died The number of children who died within 28 days of being born in 2012. before their fifth birthday in 2012, The number of deaths in this newborn most from preventable causes. period is four times higher in This number has almost been halved Africa than it is in Europe. since 1990, but still means that 18,000 children died every day.

1.2 MILLION 7.2 MILLION

The number of stillbirths in 2012 The global shortage of midwives, where the heart stopped beating nurses and doctors. during labour.

vi 51% 950,000

The percentage of births in The number of newborn deaths sub-Saharan Africa that were not that could be prevented each year attended by a midwife or other if essential health services were properly qualified health worker. more equitably distributed. This This percentage is 41% in would reduce newborn mortality south-east Asia. by 38%.

40 MILLION $5

The number of mothers across the Increasing health expenditure by world who give birth each year just US$5 per person per year could without any help from a midwife or prevent the deaths of 147 million other trained and equipped health children and 5 million women, and worker. 2 million women report 32 million stillbirths – and result in that when they last gave birth they economic and social benefits worth were completely alone. up to nine times that investment by 2035.

40% VS 76% 2025

The percentage of deliveries attended Universal coverage of skilled qualified by a skilled health worker in rural birth attendance could be achieved by areas vs. urban areas in the least 2025 if we double the current rate of developed countries. progress. If the rate doesn’t increase, this won’t be achieved until 2043.

vii “OVERWHELMED WITH GRIEF”

Shefali, who lives in a village in Bangladesh, has given birth to six children, but three died within a week of being born. She gave birth at home each time, without medical assistance. Shefali lives in an isolated community in Sylhet that is surrounded PHOTO: COLIN CROWLEY/SAVE THE CHILDREN THE CROWLEY/SAVE COLIN PHOTO: by water or swamps for most of the year, and she says it takes five or six hours to get to the nearest doctor. Shefali and her husband say that they couldn’t afford the costs involved, and there would be no one to look after their other children. “I’ve given birth to six children, all here in my home and without a doctor. Three of these children died within a week of birth. They died because of a lack of treatment. “We can’t go to a doctor because we can’t afford it. We know that’s why the children die. But what can we do if we can’t afford it? We can’t save money. We have difficulty making enough money just to have food to eat. How can we afford to see a doctor? “Whenever a child is born and then dies, we’re overwhelmed with grief. It’s terrible. We feel like we need to take the child to the doctor but we can’t. I’m not the only one here who has lost children – there are many other mothers like me.”

Nationwide, Bangladesh has achieved a halving of neonatal deaths in the last 20 years. Those communities with a lower risk of newborn deaths have seen major reductions in family size: as newborn babies’ chances of survival have increased, families have chosen to have fewer children. Save the Children is supporting the government by building a health clinic near Shefali’s village. EXECUTIVE SUMMARY

The world has made remarkable progress This report also reveals that the crisis is much bigger in the fight to end child mortality in recent than we might think. In 2012 there were another years. Since 1990, we have almost halved 1.2 million tragic losses: stillbirths where the heart the number of children who die every year stopped beating during labour. These are not part before the age of five – from 12.6 million to of the fourth UN Millennium Development goal, 6.6 million.1 which aims to reduce child mortality by two-thirds. However, they deserve to be counted in future This amazing achievement – even more impressive maternal, newborn and child health frameworks, given that the populations in the poorest countries especially to understand the specific risks around have grown by 70% during this period2 – allows us labour and delivery. This report therefore focuses on to start to imagine a world where no child is the 2.2 million combined newborn deaths on the first born to die from easily preventable causes. day and stillbirths during labour. And yet, in spite of this progress, child mortality There’s a huge amount at stake. As the 2015 deadline remains one of the great shames of our modern for the Millennium Development Goals approaches, world. Every day, 18,000 children under five die, it is vital that the world acts to make sure more and most from preventable causes. countries can get on-track to achieve MDG4. It has now become clearer we won’t be able to do this unless we urgently tackle the crisis of newborn deaths. NEWBORN CRISIS We won’t be able to go further and to talk about THREATENS PROGRESS ending all preventable child deaths unless essential healthcare is the reality for every woman and baby. This reduction in child mortality has been achieved through action on immunisation, family planning, nutrition and treatment of childhood illnesses, as well THE CAUSE AND THE CURE as improving economies. However, far less attention has been paid to tackling the life-threatening dangers The causes of stillbirths, newborn and maternal children face when they are newborn and most deaths are closely related, and we know what needs vulnerable – at birth and in their first month of life. to happen. The solution needs specific and urgent attention. The key way to stop newborn deaths This report shows that, in 2012, 2.9 million babies is to ensure that essential care is provided around died within 28 days of being born: two out of every labour, delivery and immediately afterwards when five child deaths. Of these, 1 million babies died the risks are greatest. That means having a skilled, 3 within 24 hours, their first – and only – day of life. well-equipped birth attendant available to assist Causes of these deaths include premature birth, women and newborns during delivery. While complications during birth and infections. This is we focus on this, there are also tremendous heart-breaking and unacceptable. opportunities to reduce maternal and newborn Unless we urgently start to tackle deaths among mortality and stillbirths through key interventions newborn babies, there is a real danger that progress during pregnancy and in the later postnatal period. in reducing child deaths could stall and we will fail in In many cases, small but crucial interventions can our ambition to be the generation that can end all save lives in danger. Skilled care during labour could preventable child deaths. reduce the number of stillbirths during labour by 45%

ix x ENDING NEWBORN DEATHS and preventand deaths. 43% newborn of with little education. Despite little with global commitments or group ethnic fromaminority areas, from rural communities, poorest fromthe –women babies their losing of at risk are most who are those birth give they when help life-saving get to able be to likely least women the of Many birth. and labour during need they care good-quality the get not do mothers or the mother.or the baby the of save life to the equipped and trained worker health another or fromamidwife any help without year each give birth still mothers million 40 breathing. begin to assistance need country every in 10% newborns all of Around mortality. reduce to available universally made be must –which babies for premature support special and severe of infections treatment including – birth around interventions essential the identifies PHOTO: SUZANNE LEE/SAVE THE CHILDREN 5 Many babies die each year because because year each die babies Many 4 This report report This

in these countries by 38%. countries these in mortality newborn –reducing newborns 950,000 of 47 deaths in prevent could the key countries services health essential of distribution fairer that estimates report for this commissioned Research are needed. they places in healthworkers skilled are enough there that and funding of starved are not services health public ensuring means also It them. afford cannot family the because need they healthcare the babies and mothers deny which – services health child and newborn for maternal, payments cash –direct fees user of removal the includes only not This at birth. care proper access to are able communities hardest-to-reach and poorest the ensure to are needed reforms Substantial families. richest the as ababy lose to likely as are twice families poorest the countries many in healthcare, and survival to right universal the to Nepal. Pushpa, baby Newborn EXECUTIVE SUMMARY xi

that

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with increase remove

6 sector,

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companies, should help address unmet needs by solutions increasing and innovative developing availability the for poorest to and new existing products maternal, for newborn and child health. Governments and partners issue a defining and accountable declaration to end all preventable newborn mortality, saving 2 million newborn lives a year and stopping million the stillbirths 1.2 during labour 2025by every birth is attended trained by and equipped health workers who can deliver essential newborn health interventions leastat the WHO minimum of US$60 per capita to the for pay training, equipping and support of health workers newborn and child health services, including emergency obstetric care END DEATHS ALL PREVENTABLE must be clear:We newborn deaths not are inevitable. Most easily are if the avoided simplest of interventions made are available to all. Systemic change is needed from governments, donors and offershealth an 2014, professionals. This year, unprecedented opportunity to focus on this topic and set in motion the revolutions needed. can we ensure that no baby is born to die. Together, Save theSave Children is calling on leaders, world philanthropists andthe private sector – this year – to commit toa Newborn Promise to endall preventable deaths: newborn • • Governments, • Governments • Governments • The THE NEWBORN PROMISE

The must world not squander the opportunity that offers. 2014 This change must happen in the countries where child mortality rates high, are in partnership with donors and other stakeholders. need a new We sense of purpose from the global community. However, a plan on paper is not enough.However, It must concerted by be followed political action the at highest its to levels achieve implementation. Stopping newborns dying unnecessarily preventing and stillbirths, and hugely accelerating progress towards ending child and maternal mortality, will require a substantial change in our approach to health services. And for the first time ever, countries And the for and institutions first timeever, around the will world sit down to agree an ‘Every Newborn an agreement Action to Plan’, tackle this deplorable problem of lack of attention to babies in their first of life. days the ChildrenworkingSave is to ensure that this plan is ambitious and robust enough to end all preventable newborn deaths as as well tackle stillbirths during labour. 2014 will be a crucial year. Political will support be a crucial year. for 2014 universal health coverage the – availability of a basic package of healthcare everyone, for a package which countriescan increase as resources increase – is aroundgrowing the world. The best place to start is is denied ensuring poor, by thathowever no family, life-saving care birth. at 2014: THE OPPORTUNITY 2014: FOR CHANGE LIFE-SAVING PAYING WITH THEIR LIVES

Derese, a farmer in Ethiopia, is doing his best to look after his children and earn enough to feed them since his wife died three months ago during childbirth. Five of the ten children they had together did not survive. “The tenth child died at childbirth, along with my wife,” says Derese. In her last pregnancy, Derese’s wife was only taken to the health centre one and a half days after going into labour. With the help of neighbours, Derese carried her on a stretcher for more than an hour to the local health centre. When she arrived there the health centre did not have the staff or equipment to help. They advised taking her to the hospital in Dessie, the nearest big town, which is located a four-hour drive away. But by then it was too late – she died shortly after they got her on the ambulance. Most women living in rural areas of the country give birth at home, on their own, with no access to skilled health workers. So if there are complications during labour, they are often unable to get to a health centre in time. Many of them die due to the lack of a skilled birth attendant. “If you could see inside me, you would be able to see the fire that’s burning me,” says Derese. “I know that it’s because of the fact that I am poor and do not have money that I was unable to save my wife. Every time I think of her, I feel guilty.”

Save the Children has supported government services and provided an ambulance for Derese’s community to help pregnant women access skilled medical care at a health centre or hospital. But many roads, particularly

during the rainy season, are still only PHOTO: CAROLINE TRUTMANN/SAVE THE CHILDREN accessible on foot. As part of our work to reduce the number of women and children who die during childbirth, we have also built new maternity wards in health centres in three other districts, and provided training for health workers and community health promoters. 1 A CRISIS AND AN OPPORTUNITY

The global effort to tackle child mortality over THE CRISIS IN NEWBORN MORTALITY the past two decades has made remarkable advances. But now, further progress – though DYING WITHIN 28 DAYS desperately needed – is under threat. Of the 6.6 million children under-five who died in 2012, almost half – 2.9 million – died within the Since 1990 the number of children dying each year first 28 days, the newborn period.9 This time is the has fallen sharply. In that time we have almost halved most vulnerable for a child as he or she has to adapt the number of children who die every year before quickly to life outside the womb. Progress in reducing 7 the age of five from 12.6 million to 6.6 million. It is mortality among newborn babies has been much an impressive achievement, even more so given that slower than among children under the age of five in populations in the least developed countries have general, as Figure 1 shows. grown by 70% during this period.8 Progress in tackling child mortality has been DYING WITHIN 24 HOURS achieved through the expansion of measures such Recent data shows that the day of birth is the most as immunisation, distribution of insecticide-treated dangerous day of all. In 2012, more than 1 million bed-nets, treatment of childhood illnesses and family babies (1,013,000) did not survive their first – and planning. Strong economic development in certain only – day of life.10 countries where child mortality was once very high, Save the Children’s State of the World’s Mothers 2013 such as Vietnam and China, has also been key, as have report compiled a ‘Birth day risk index’ that ranked investments in education and literacy, particularly countries according to mortality rates on the day for women. of birth.11 The report found that key causes for high But in spite of these advances, child mortality still first-day death rates in sub-Saharan Africa and south remains one of the great wrongs of our modern Asia include: world, with 18,000 children under five dying every • high numbers of preterm births and of low day, mostly from preventable causes. birthweight babies • poor maternal health and nutrition And while the world has undoubtedly made progress • girls and young women having children at in tackling mortality among children under five, death a young age rates among the most vulnerable group – newborn • low contraception use babies – have failed to decrease at the same speed. • lack of healthcare for mothers, with only half of We are still failing to prevent the deaths of millions of all women in sub-Saharan Africa having skilled newborn babies who die within 28 days of their birth, care during birth. including those who die on their first – and only – day of life, as well as stillbirths that occur during Guinea, Niger, Sierra Leone and Somalia were found labour. As this report shows, the continuing high rate to have fewer than two doctors, nurses and midwives of newborn mortality in many developing countries is per 10,000 people (the critical threshold is generally a crisis of neglect and inequality. Unless we urgently considered to be 23). Afghanistan, Bangladesh and start to tackle deaths among newborn babies, there Nepal have six to seven health workers per 10,000 is a real danger that progress in reducing child deaths people. The report highlighted four low-cost and could stall. under-used solutions that have the potential to save more than 1 million newborn babies if they were available to all.12

1 2 ENDING NEWBORN DEATHS during labour.during stillbirths the day plus first the on deaths newborn –the million 2.2 the on focuses therefore report this crisis, the of magnitude full To the understand delivery.and labour around risks specific the highlight to and care good-quality of marker asensitive as frameworks, health global and national in counted and acknowledged be to deserve labour in occur However, that by two-thirds. stillbirths mortality child reduce to aims which Goal, Development Millennium UN fourth the of part as counted not are lost lives These ones. higher-income in than countries low-income in higher much is stillbirths’ 2.6 million stillbirths occurred worldwide in 2012. in worldwide occurred stillbirths 2.6 million estimated An birth. before evenor moments hours just are lost pregnancies many that consider also we must picture, full To the understand TRAGEDY A HIDDEN Observatory Health Global WHO, Source: was during labour. during was beating stopped heart the when moment 45% –the –around 1.2 stillbirths million approximately For

Deaths per 1,000 live births FIGURE 1 100 140 120 80 40 20 60 990 0 1

G LOBAL CHANGE AND IN NEONATAL UNDER-FIVE MORTALITY RATES 14 The rate of these ‘intrapartum ‘intrapartum these of rate The 1 995

2 000

to 2015 to 75 Countdown for the data relevant of range A full higher. fivetimes or is four figure that Asia of parts and Africa in but beyond days, 28 survive not do (see thousand every 2).in Figure 5.9 Europe In babies deaths newborn in variation regional huge is There COUNTRY AND MORTALITY BY REGION NEWBORN MORTALITY NEWBORN OF DYING INEQUALITY THE POOR: are among the highest for preventable deaths. for preventable highest the are among fragile areor considered conflict recent experienced have that Countries for newborns. rates mortality have highest the countries poorest the Generally, Table in are shown labour 1.during stillbirths and mortality for first-day rates combined the worst with countries ten The financing. health government and attendance birth skilled of coverage labour, during stillbirths deaths, first-day mortality, newborn on data with report, this to Appendix the in given –is mortality child and newborn maternal, of 2 005 15

countries – those with the highest burdens burdens highest the with –those countries 2 010

2 012 rate mortality Neonatal rate mortality Under-five

1 A CRISIS AND AN OPPORTUNITY 3 Europe

Intrapartum Intrapartum stillbirths and neonatal deaths on day of birth (per 1,000 total births) 40.7 32.7 30.8 29.7 29.4 29.0 28.9 28.3 27.5 27.4

Americas

Pacific Western Western

Intrapartum Intrapartum stillbirth rate (per 1,000 total births) 26.4 19.4 13.9 14.0 13.7 16.6 20.6 13.3 11.8 11.7

Eastern Eastern

Mediterranean

Asia South-east South-east 9

15 14 18 16 16 13 15 16 16 Risk of neonatal death on day of birth (per 1,000 live births) Africa EONATAL MORTALITY RATES BY REGION BY RATES (2012) MORTALITY EONATAL N

T Global

0 5 15 10 35 30 20 25 FIGURE 2 Pakistan Nigeria Sierra Leone Somalia Guinea-Bissau Afghanistan Bangladesh Democratic Republic of Congo Lesotho Angola Country Source: WHO, Global Health Observatory Source: See Appendix Data 1. drawn from forthcoming Lancet Global Health publication on first-day Stillbirthdeaths. Intrapartum Series. stillbirths from Lancet TABLE 1 TABLE DURING LABOUR EN COUNTRIES WITH AND THE DEATHS STILLBIRTHS HIGHEST OF FIRST-DAY RATES 4 ENDING NEWBORN DEATHS newborn mortality rate for the poorest fifth of fifth poorest for the rate mortality newborn the shows column each of top The inequalities. greatest the with countries ten 3showsthe Figure mortality. newborn of determinant amajor is wealth are available, data where country every In newborn deaths. preventable all end to needed is what determining mortality. experiencing considerably higher of rates newborn generally groups marginalised other and communities poorest the with babies, for newborn rates death in inequalities are dramatic there countries poor Within WITHIN COUNTRIES MORTALITY VARIATIONS NEWBORN IN 28%. just been has fall the Africa However, by 39%. fallen has sub-Saharan in mortality newborn nations a56% Pacific the in drop, and been has there America Latin In possible. is progress what –show 51% for example the Cambodia, in reduction – world’s the nations of achieved some in poorest declines Steep over of 60%. saw declines Egypt and 1990 2012, and Between China others. than deaths newborn reducing in progress more have much made however, regions and notable, is It countries some that ratios for newborn mortality between wealthiest and poorest households, by wealth quintile. wealth by households, poorest and wealthiest between highest mortality the with newborn for ratios countries ten the for 2005), (since data Survey Household and Demographic recent most of analysis Children the Save Source:

Newborn mortality rate HOUSEHOLDS, TOP TEN COUNTRIES WITH HIGHEST INEQUALITIES 3 FIGURE 80 40 20 50 60 30 70 10

Peru (2012) 0 17

Indonesia (2012) key is to inequality this Understanding

G AP IN NEWBORN MORTALITY BETWEEN POOREST AND WEALTHIEST WEALTHIEST AND POOREST MORTALITY BETWEEN NEWBORN IN AP

Bolivia (2008)

Cambodia (2010) 16

India (2006)

Philippines (2008)

Nepal (2011) the risk that she might lose a newborn baby. loseanewborn might she that risk the of predictor strong another is level education of Amother’s areas. urban than mortality newborn of have rates higher usually populations Rural wealth. of basis the on solely are not Inequalities mortality newborn and inequalities social Other have to likely it. are least at birth care of need in most those –meaning services health essential of in coverage inequality of patterns reflect also mortality newborn in inequalities these Chapter 2, in discussed As families. poorest the among births thousand per deaths babies’ 68 newborn with compared babies, 41 is 1,000 population per the of fifth wealthiest the among rate mortality newborn the Leone, Sierra In life. of month first their in die 1,000 of out babies 56 newborn households poorest the among whereas babies, 1,000 26is per rate mortality newborn the population the of 20% wealthiest the among India, in 3shows, Figure As mortality. newborn in inequality the greater the column, the taller the households: well-off most for the rate show the columns the of bases the country; aparticular in households

Namibia (2006)

Bangladesh (2011)

Sierra Leone (2008) Wealthiest Poorest 1 A CRISIS AND AN OPPORTUNITY 5

PHOTO: GREG FUNNELL/SAVE THE CHILDREN

Rural Urban

Rwanda (2010) Rwanda

India (2006) India

of Congo (2006) Congo of Democratic Republic Republic Democratic

It is unacceptable to regard national low GDP aslevels a legitimate reason countries for not to make necessary progress in tackling newborn mortality. It is also unacceptable that a baby’s chances of immediate survival depend on where he or she is born and on the life chances of his or her parents. The international community and national governments can and must do better than this.

Philippines (2008) Philippines

Niger (2006) Niger

Indonesia (2012) Indonesia

Albania (2009) Albania Burundi (2010) Burundi

AP IN NEWBORN BETWEEN MORTALITY RURAL AND URBAN HOUSEHOLDS, G (2008) Bolivia

10 30 60 50 20 40

Newborn mortality rate mortality Newborn Cambodia (2010) Cambodia FIGURE 4 TOP TEN COUNTRIES WITH HIGHEST INEQUALITIES HIGHEST WITH COUNTRIES TEN TOP Source: Save the Children analysis of most recent Demographic and Household Survey data (since 2005), for the ten countriesratios for newborn with the mortality highest between urban and rural households. Social, political and environmental factors closely are intertwined. Rural populations often are extremely a long from frontline way medical servicespoor, and without access to hospitals. Minority ethnic groups living in rural areas be may subject to discrimination and more likely to are in areas live that remote are and poorly-serviced in terms of newborn healthcare. By contrast, in urban areas it is household wealth alone that predominantly determines to access newborn healthcare. A newborn baby at a hospital Centralin African Republic. 6 ENDING NEWBORN DEATHS for a two-thirds reduction in the newborn mortality mortality newborn the in reduction for atwo-thirds atarget proposing is Plan Action Newborn Every The topic. neglected this on needed action the out set to others 50 at and least Organization World the UNICEF, Health with developed jointly being is and fromcountries demand to response in is plan The mortality. maternal and child address to movement Child Woman Every Every General’s Secretary- UN year, the of this of May in part as Assembly World the to Health presented be will Plan Action Newborn Every The stillbirths. preventable and mortality newborn of crisis the tackle to 2014In opportunity we have unprecedented an PLAN ACTION EVERY NEWBORN LIFE-SAVING CHANGE 2014 FOR OPPORTUNITY –THE PHOTO: JEFF HOLT/SAVE THE CHILDREN healthcare at birth. at birth. healthcare good-quality of lack the especially mortality, newborn of causes the address to action political for real spur the be to Plan Action Newborn Every the for calling is Children Save the mortality. newborn tackling in progress of lack the address to action of forefront at the been has programme Lives Newborn Children’s Save the years, Saving ten than more For labour. during stillbirths preventable all end to target a proposing also is Plan Action Newborn Every The deaths. fewer newborn 2million approximately been achieved 2012, in been had would haverate there Turkey. and Mexico Chile, as such countries in this If achieved been has what to 2012. close is target This from21 in down 1,000 per live births, 1,000 7 per of rate a2035 in global would result which rate, at a clinic in Bangladesh. in aclinic at delivered being after day the girl baby A newborn 1 A CRISIS AND AN OPPORTUNITY 7

20 Other initiatives have 19 TRADITIONAL ATTENDANTS BIRTH In many settings, the only support during a birth bemay a ‘traditional birth attendant’ (TBA). Throughout history, other women from the community who formal do not have training support provided have during birth, based on their experience. been successful enlisting at TBAs to encourage community acceptance of trained health workers at birth. By contrast, some countries, including Sierra Leone, taken have the decision to ban TBAs. Where no support women have all at from professional health workers during birth, providing some medical training and close supervision to TBAs be may beneficial. For example,reduce it may harmful practices such as applying dirt to the umbilical or giving cord a newborn baby substances other than breast milk. By acting on newborn now mortality – in by particular, ensuring universal access to good-quality healthcare at birth babies for and mothers can – we start to reduce newborn deaths and preventable stillbirths and build a whereworld no baby dies of preventable causes. CHILD AND MORTALITY AGENDA THE POST-2015 Within the debate growing about what might thefollow Millennium Development Goals, there is underlying recognition that the progress the world has the made past over two decades in reducing the number of children dying has brought us to a tipping point. Our generation could be the first to end preventable child deaths. The feasibility of a target to end all preventable newborn and child mortality was set out theby governments of the USA, Ethiopia andIndia, along with Promise UNICEF, in the ‘A countries. movement,Renewed’ supported 174 by What is clear is that there is no substitute for formal health workers during delivery. there 18 Coverage rates of skilled birth attendance are based on surveys of households and rely on the assumptionmother’s about whether a skilled health was worker present during childbirth. The rates do not measure which services were or theirprovided quality. Skilled birth attendance means not only the presence of the health attendant), (the worker 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 be may a midwife, worker a specialist in birth techniques whose training has concentrated a doctor or a nurse may on this role. However, also be a skilled birth attendant. In many resource- poor and rural settings, it is much more likely to be a general health who worker responds to all the health problems of the community, rather than a midwife. dedicated The World HealthThe World Organization defines a skilled birth health professional attendant accredited as “an – 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.” MIDWIVES AND SKILLED ATTENDANCE BIRTH GROWING MOMENTUMGROWING FOR COVERAGE UNIVERSAL HEALTH HealthFollowing the World Report 2010, hasbeen momentum growing the for principle that governments responsible are ensuring for that their whole population can access the good- quality healthcare theyneed without facing financial hardshipin – other words, a movement universalfor healthcare coverage (UHC). Bank The and World the HealthWorld Organization both have made UHC theirtop priority health. the for world’s In turn, many countries made UHC have their priority for health service reform. Newborn mortality is arguably a sensitive indicator UHC. for PHOTO: JODI BIEBER/SAVE THE CHILDREN THE FOR STRUGGLE SURVIVAL birth gave Rose a local at health clinic in the Democratic Republic She of Congo. isfortunate to near live a clinic, was so able to get there on foot when her labour started. leaving her little had a long labour, Rose energy to push, the so nurses the at clinic helped with son the But delivery. when Rose’s was born breathing. he wasn’t Thankfully, after resuscitation with a bag-and-mask device, her son started breathing. “I was happy when that I saw child was my – God alive helped him survive,” said“I Rose. was lucky that baby survived, my as many women not are lucky so here in Congo.” Rose with her newborn son at Tudikolela hospital in Democratic Republic of Congo 2 HOW CAN NEWBORN DEATHS BE PREVENTED?

Understanding the reasons why newborns die on the first day of life and reducing stillbirths during and the life-saving role that health workers labour require different actions and a different type can play is crucial in getting the right action of health service from that needed for children who to prevent these deaths. Having skilled and have survived beyond 28 days. properly-equipped health workers delivering the right services during birth is critically HOW HEALTH WORKERS SAVE important in preventing stillbirths and reducing newborn and maternal mortality.21 NEWBORN BABIES’ LIVES For this report, Save the Children has identified eight essential services – which midwives and other skilled CLINICAL CAUSES OF health workers should provide during labour, birth NEWBORN MORTALITY and immediately afterwards – to reduce newborn mortality and prevent intrapartum stillbirths. This The main causes of newborn babies’ deaths are list of essential interventions and packages is drawn problems arising from premature birth, complications from the Every Newborn Bottleneck Analysis Tool23 during labour and delivery, and infections acquired by and from the wealth of evidence in the 2005 Lancet the baby during or after birth. The major causes of Neonatal Series, disseminated through the Healthy stillbirths include childbirth complications, maternal Newborn Network and the Partnership for infections and hypertension.22 Addressing deaths Maternal, Newborn and Child Health.24

FIGURE 5 GLOBAL DISTRIBUTION OF NEONATAL DEATHS, BY CAUSE (2012)

Other 6% Diarrhoea 2% Tetanus 2%

Congenital abnormalities 9% Preterm birth complications 34%

Pneumonia 10%

Sepsis/meningitis 12%

Intrapartum-related complications 24%

Source: UNICEF, Committing to Child Survival: A promise renewed – progress report 2013 Note: Due to rounding percentages do not add up to 100.

9 10 ENDING NEWBORN DEATHS the non-breathing baby, and immediately begin the the begin baby, immediately and non-breathing the recognise prepared, be worker must health the that meaning breathing, begin to assistance of type some require babies 10% as many newborn of As immediately. resuscitate to need workers health then breathe, not do and are born babies If needed. if section caesarean labour, improvedduring care through is including deaths these reduce way to important most The asphyxia. birth or deaths intrapartum-related called –technically delivery and at labour complications of result are the deaths newborn of aquarter Nearly BIRTH COMPLICATIONS (see care box above).mother kangaroo as known is babies, for preterm especially for this, technique effective Abrilliantly contact. skin skin-to- through warm baby the keep to her support can and exclusive breastfeeding, establish mother the help can born is baby the when present workers immediate care and support to survive. to support and care immediate needs baby premature and underweight an birth, After needed. is action when indicates distress of signs and rate heart foetal the of monitoring careful labour, During steroids. antenatal of use well as as services other and supplements nutrition infections, for screening planning, family through birth before addressed be can these of Some (premature) births. preterm with associated complications of result are the deaths newborn of athird than More BIRTHS PRETERM asic newborn care (focus on cleanliness (focus cleanliness care on newborn asic 3 (including birth preterm of anagement 2 obstetric emergency and at birth care killed 1 BIRTH AROUND INTERVENTIONS HEALTH-WORKER SUPPORTED ESSENTIAL, EIGHT

B M S signs and care seeking) care and signs danger of recognition breastfeeding, immediate for support and warmth, cord care, including babies) preterm in problems other and breathing reduce to labour preterm threatened with for mothers corticosteroids antenatal complications with babies and for women care timely ensuring needed) if section caesarean and delivery vaginal assisted (including care 25 Health Health air to the lungs, including by using a bag and mask. and abag by using including lungs, the air to or breathing stimulate to quickly act can workers health Skilled disabilities. long-term in result also can oxygen of Lack resuscitation. neonatal of steps revention of mother-to-child transmission transmission revention ofmother-to-child 8 small and for sick care supportive npatient 7 (focus infections severe of newborn reatment 6 (skin-to-skin, care mother angaroo 5 not do who for babies resuscitation eonatal 4 needed, reduces stillbirths by 75%. stillbirths reduces needed, if caesarean including care, obstetric emergency stillbirths, of number the reduce can at birth care Skilled prevent stillbirths. to important is conditions other and syphilis malaria, pregnancy,treating or preventing During STILLBIRTHS survival. of chance the increase dramatically antibiotics with treatment complete and prompt and of severeinfections identification are followed. Early practices these ensuring rolein play acrucial workers health infections; of risk the reduce breastfeeding cord exclusive and umbilical for the hygienic care and practices birth Clean risk. the reduce can syphilis for treatment and screening immunisation, tetanus maternal as such Preventive measures birth. after or delivery and labour during baby byacquired the infections to are due deaths newborn of A third INFECTION save to lives. are essential delivery) vaginal assisted or (eg, caesarean distress of signs to response in action timely and rate heart labour, foetal of During monitoring disabilities. term long- in result also –can at birth breathe to failure –from brain the to flow blood oxygenated of Lack

P I T K N immediate newborn period). the and (during HIV pregnancy,of labour use) oxygen safe and support (focusfluids/feeding IV on newborns on early identification and use of antibiotics) and small babies) for premature especially support breastfeeding at birth spontaneously breathe 27 and comprehensive comprehensive and 28 26

2 HOW CAN NEWBORN DEATHS BE PREVENTED? 11

igh Africa H

income *

Eastern Eastern Mediterranean income pper middle pper U

Western Pacific Western come year because mothers do not get the quality care they need during labour and birth. As with newborn mortality, coverage of skilled birth attendance is grossly unequal between countries and within them. In Europe, the Americas and the western Pacific, almostwomen all birthgive with this vital service. In south-east Asia, Africa and parts of western ‘eastern Asia Mediterranean’ (or in the WHO classification) (see rates much are lower Unsurprisingly, nationalFigure 6). rates skilled for birth attendance their at are lowest in some of the poorest countries Figure 7). in the (see world in

ower middle ower

Americas L 29

Europe Globally, Globally, ow 30 come L in Many babies die each

South-east Asia South-east

G Global IRTHS ATTENDED BY SKILLEDIRTHS ATTENDED BY PERSONNEL HEALTH INCOME COUNTRY BY (%), lobal IRTHS ATTENDED BY SKILLEDIRTHS ATTENDED BY PERSONNEL HEALTH WHO REGION BY (%), (2005–2012) B 0 B 70 60 50 90 40 80

60 20 40 80

100

Percentage Percentage FIGURE 7 FIGURE 6 GROUP (2005–2012) GROUP The ‘eastern Mediterranean’ region includes Somalia, Yemen, Afghanistan and Pakistan. Afghanistan and Somalia, includes Yemen, Mediterranean’ region ‘eastern The 2 million women report that when they last birth gave they completely were alone. Source: WHO, Global Health Observatory Source: WHO, Global Health Observatory * Every year 40 million women birth give without qualifications. with professional support anyone from THE GLOBAL SHORTAGE THE SHORTAGE GLOBAL OFMIDWIVES AND OTHER BIRTH WORKERS AT HEALTH 51% of births in sub-Saharan51% in south- Africa and 41% east Asia not are attended a midwife by or another properly qualified In Ethiopia, health10%worker. only of births skilled have attendance birth. at 12 ENDING NEWBORN DEATHS Source: Save the Children analysis of most recent DHS data (since 2005), for the ten countries with the highest ratios for SBA coverage between between coverage SBA for urban and households. rural ratios highest the with countries ten the for 2005), (since data DHS recent most of analysis Children the Save Source: have impressive Rwanda and made Malawi as such countries even –and though 2009 and 2000 Between 70%. reached 2012By only had rate global the by coverage 2015. track. 90% way off world is the But 85% by 2010 by 2005, and attendance birth skilled of coverage 80% of atarget set mortality, maternal reducing on 5, Goal Development Millennium priority. aglobal designated been has attendance birth Skilled 2013 Children World’s the of State The Source: AND URBAN HOUSEHOLDS, TOP TEN COUNTRIES WITH HIGHEST INEQUALITIES HIGHEST WITH COUNTRIES TOP TEN HOUSEHOLDS, URBAN AND 9 FIGURE (2007–2012) 8 FIGURE Least developed developed Least Southern Africa Southern Percentage and East Middle Central Africa Central East Asia and and Asia East Sub-Saharan North Africa North 80 40 90 20 50 60 30 70 10 Eastern and and Eastern

0 South Asia South the Pacific West and and West Ethiopia countries World Africa

B G IRTHS ATTENDED BY SKILLED HEALTH PERSONNEL (%), BY AREA OF RESIDENCE RESIDENCE OF (%), BY AREA HEALTH PERSONNEL BY ATTENDED IRTHS SKILLED AP IN BIRTHS ATTENDED BY SKILLED HEALTH PERSONNEL (%) BETWEEN RURAL RURAL BETWEEN (%) HEALTH PERSONNEL BY ATTENDED SKILLED BIRTHS IN AP

Niger 1 0

Mali 2 0 , UNICEF global databases 2012, from MICS, DHS and other nationally representative sources. representative nationally other and DHS MICS, from 2012, databases global , UNICEF

Guinea 3 0

Haiti 32 4 0

Timor-Leste Percentage 5 0 millions of unnecessary lives lost. ofunnecessary millions and 2014between unattended would be 2043 and births million 354 mean will this that calculated achieve universal coverage. universal achieve world to for the 2043 until take will it rate, at this increase to continue attendance birth qualified skilled 1.1% of at arate increased only has ayear. of rates If attendance birth skilled of coverage –global progress

Bangladesh 6 0

Zambia 0

8 0

Liberia 33 Save the Children has has Children Save the 9 0

Nigeria 100 Urban Rural Rural Rural Urban 2 HOW CAN NEWBORN DEATHS BE PREVENTED? 13 00 1

0 9

0 8

0 7 bednet distributions or familyplanning. Ensuring the attendance of a skilled and equipped health duringworker and after a birth is evidently not an intervention that can be scheduled a convenient for time: midwives and other skilled birth attendants must be available 24-hours-a-day, seven-days-a-week. theAt same time, improving therate of skilled birth attendance in a country on its not own may reduce newborn mortality. shows, As while there Figure 10 iscorrelation a between rates lower of first-day deaths and higher rates of skilled birth attendance, the relationship is not one of simple causality, nor is it consistent all across countries. For example, the rate of skilled birth attendance in Malawi is much higher than in Bangladesh but the rate of newborn mortalityis about the same. ensure good-qualityTo healthcare birth, at a health system needs to deliver in-depth training in newborn care to trainee health workers, ‘refreshers’ for qualified birthattendants, supportive supervision, monitoring and data analysis quality for improvement. This systematic approach needs to be accompanied community-basedby approaches to improve household practices and care seeking. , updated for 2012, from forthcoming Lancet Global Health publication; 36

35 Skilled birth attendance (%)

0 6

0 5 ELATIONSHIP BETWEEN AND SKILLED MORTALITY BIRTH ATTENDANCE FIRST-DAY R

40 The inequality within some countries is

8 6 4 2 0 34

14 12 16 18 10

20 First day mortality rate mortality day First FIGURE 10 BY COUNTRY shocking. In Ethiopia, example, for where per 1,000 29 newborns die, of all births 46% in the richest fifth of households had skilled birth attendance, compared with just ofthose 2% in the poorest households. Coverage of skilled birth attendance must be expanded and systems that failing are to reach the poorest communities must be overhauled. In developing countries, skilled birth attendance is the least equitable ofall maternal and child health services. UNEQUAL NEWBORNACCESS TO CARE COUNTRIES DEVELOPING WITHIN Sources: Data on first-day deaths updates from State of the World’s Mothers skilled birth attendance data from WHO Global Health Observatory, for 2005–2012 The demands that preventing newborn babies’ deaths and stillbirths puts on a health system quite are different in delivering from those involved life-saving child health interventions, such as immunisation, THECHALLENGE TO SYSTEMSHEALTH In the least developed countries, 40% of deliveries in rural areas of the developing attended are world by skilled health workers; in urban areas the rate is 76%. 14 ENDING NEWBORN DEATHS the household – is one urgent priority. priority. urgent one –is household the within least and last eat women demand that those own childhood. their during were undernourished who women are So babies. have to likely low birth-weight are more are malnourished who women Pregnant young children among and pregnancy in Malnutrition mortality. newborn in crisis the underlie also factors social of number A picture. the of part one are only services Health OF HEALTH NEWBORN DETERMINANTS SOCIAL and their second birthday. second their and mother’s their pregnancy days between thousand the in malnutrition of aresult as were stunted children mortality. child and newborn reduce and nutrition and food decent to access address to structures, social and markets food agriculture, as such areas in but services, health in only not needed is change Huge are often poorly staffed and equipped, with huge huge with equipped, and staffed poorly are often sector. health public the outside or abroad opportunities career and conditions working better may seek They are greatest. needs the workwhere to not choose workers health reasons are many There needed. are most they where found be to likely least are often exist do who workers health those that fact the is important equally But 7.2 million more. world needs the that estimated is It doctors. and nurses midwives, of shortage global wider the reflect attendance birth skilled of Low rates HEALTH FOR FAIR CONDITIONS WORKERS economic arrangements, and bad politics.” bad and arrangements, economic unfair programmes, and policies social of poor combination of atoxic result the is but phenomenon a‘natural’ sense any notin is experiences of health-damaging distribution unequal “This 43 39 Health facilities in poor communities communities poor in facilities Health Challenging cultural traditions – such as as –such traditions cultural Challenging 37 In 2012, an estimated 162 2012, In estimated an million 42 Sir Michael Marmot, WHO Commission Commission WHO Marmot, Michael Sir on Social Determinants of Health 2008 Health of Determinants Social on 38

and need flexible terms and opportunities. opportunities. and terms flexible need and carers family are workers also health Many areas. desirable least the workin to incentives offered be and wage aliving receive should workers Salaried issues. these address must governments deaths, levels newborn of highest the with communities in workers health more retain and attract to order In for staff development. for staff opportunities or support little and caseloads lead a hand-to-mouth existence. ahand-to-mouth lead may workers health even highly-skilled inadequate: aged 20–29 years. 20–29 aged mothers than birth after week first the within baby their lose to or have to likely more astillbirth 50% are 20 under –mothers later mothers become who women than babies their losing of risk are at greater 16. of age by the They mothers 10% become girls of almost overall countries low- middle-income and In Young mothers be insecure. be may environment working the and children, their for schooling with and housing with problems face in neonatal mortality. in neonatal a23% and reduction mortality maternal in a37% reduction with associated is groups these with pregnancy during contact women’s that data shows trial the of Analysis and happiness. for health valuable network provide asupport groups the mothers-to-be, with Interacting them. implement to others and politicians teachers, leaders, community local with working problems, these tackle to strategies develop that groups facilitate women These babies. newborn of care and pregnancy, childbirth with associated problems identify help to are trained area local the in Women recruited and depression. maternal mortality neonatal women’s reduce groups show how participatory Nepal and Malawi, India, Bangladesh, in Studies PARTICIPATORY WOMEN’S GROUPS 46

41 44 40 Salaries are frequently are frequently Salaries

45 They may also They may also 2 HOW CAN NEWBORN DEATHS BE PREVENTED? 15

PHOTO: COLIN CROWLEY/SAVE THE CHILDREN

48 Spacing between pregnancies Spacing Lack of spacing between pregnancies is also closely withlinked child mortality. Children born less than two years after a sibling two are times more likely to die within the firstyear of life than those born after three years. more or low- and middle-incomelow- countries. Research shows that children whose mothers died in childbirth the likely toare worst have survival rates, poorer health and less economic and educational success. There further are devastating effects to families from the loss of the person likely to be the first andoften caregiver, the main of income. source As skilled will be discussed birth later, attendance and newborn care must be delivered within a framework of wider health services mother for and child.

47 Pregnancy and childbirth complications the are leading cause in of death of girls aged 15–19 The solutions offered this by report, particularly improving the quality of care through skilled birth attendance, the will lives save of newborns, reduce stillbirths the and lives save of women. Maternal mortality is declining, but the rate of decline is and in too many societiestoo slow, the rights of women to survival, to health and to essential services not are realised. The deaths of women and their babies in childbirth unacceptable are and cause great damage to families and communities. TACKLING MATERNAL MORTALITY THROUGH MORTALITY MATERNAL TACKLING SKILLED ATTENDANCE BIRTH Very young mothers young Very face more pregnancy-related problems. also are They prone to obstructed labour because their pelvic bones still are developing, and premature more likely toare babies have and also are themselves higher at risk of fistula. Midwife Farhiya Muse Ali holds Zakaria on his first day of life. When Zakaria was born, in a clinic in Somalia, he did not start breathing straight Farhiya away. helped save his life. SAVING NEWBORN LIVES

Immediately after birth, Asha’s baby girl was not breathing. Pushpa, a midwife and auxiliary nurse in a rural district in Nepal, saved the baby’s life. Pushpa had recently been trained in newborn care on a Save the Children programme. “I have seen many babies born like that, not breathing,” says Pushpa. “Since the training, I have already saved a few babies with the bag and mask technique.” Pushpa was inspired to become a health worker by her own harrowing experience of childbirth. She was only 16 and, when her labour became protracted, her hands were tied to a branch of a tree for four days. “It was supposed to help me push the baby out,” she says. After that traumatic event, Pushpa decided to train to become a nurse. “I became a health worker thinking I will help women,” she says, “but now I am also saving newborn babies.” PHOTO: SANJANA SHRESTHA/SAVE THE CHILDREN 3 MEETING THE CHALLENGE

ACHIEVING UNIVERSAL COVERAGE A study in The Lancet in 2013 concluded that without IN SKILLED BIRTH ATTENDANCE accelerated coverage of the full range of proven interventions to women and children’s health, the For many countries with high rates of newborn targets could not be reached.49 All children and mortality, achieving universal health coverage – mothers need access to good-quality healthcare not especially good-quality care available for all births just on the day of birth, but right across a ‘continuum – requires radically different thinking about the of care’ that covers reproductive, maternal, newborn entitlements of the poor and the way services are and child health. provided. This chapter explores the concept of universal health coverage – an approach that has built THE WHOLE PICTURE up considerable momentum in global and national Save the Children is calling on governments and debates in recent years, and which is crucial to multilateral agencies to compile accurate figures on reducing and ending preventable newborn mortality. stillbirths both before and during labour, as well as on As momentum for the goal of universal healthcare first-day deaths. Only by doing this can we show the coverage has grown (see page 7) this has set down true picture of the estimated 2.2 million tragic losses clear challenges to countries and governments, around the time of labour – 1 million deaths on the particularly in terms of reaching poor, rural and first day of life and 1.2 million stillbirths that occur disadvantaged communities. In particular, universal during labour – in addition to maternal deaths. health coverage suggests three measures for the Compiling figures for stillbirths and first-day deaths development of countries’ health systems: will give a sharper focus on the importance of • Who is covered by health service schemes? healthcare to all babies and mothers during labour • Which services are covered? and immediately after birth. And it will highlight the • How fair is the way it is paid for? fact that, in 2012, 40 million mothers and their babies miss out on life-saving healthcare interventions at INCREASING THE NUMBER OF MIDWIVES this crucial time. AND OTHER HEALTH WORKERS The average annual increase in skilled birth attendance between 2000 and 2009 was just 1.1% (see page 12). However, if we double our efforts and increase coverage by 2.3% a year, it is possible What Save the Children is calling for to achieve universal coverage by 2025. Governments and partners to issue a For most countries at risk of failing to meet their defining and accountable declaration to end MDG4 target on reducing child mortality, this will all preventable newborn mortality, saving require wide-ranging reform of the structure 2 million newborn lives a year and stopping and staffing of their health services, as well as the 1.2 million stillbirths during labour.50 increased funding.

17 18 ENDING NEWBORN DEATHS health. The greatest gains accrue to poorer people. poorer to accrue gains greatest The health. improved and population care necessary to access better to leads generally coverage health broader that concludes London College by Imperial Research BABYNEWBORN AND EVERY MOTHER REACHING the countries covered by Countdown to 2015. covered to by Countdown countries the 47 in of –were eliminated infections newborn of treatment and planning family at birth, care quality good- as –such services health child and mother to access in inequities major the if impact the considered This averted. deaths on services health essential of coverage equitable more of impact the Saved Tool Lives estimate the to applied (LiST) that research we commissioned report, this For but it’s more than 800,” says Hawa. says Hawa. 800,” it’sbut than more can’t I’ve delivered, you how children “I tell many hospital. local the to are referred cases complicated more centre; at the babies delivers and check-ups antenatal out for 12 carries Hawa years. centre health amaternal in working been has She Somalia. of region Mudug the in amidwife is Hawa CARE FRONTLINE 52

by 2030. by 1.4 additional saved an year lives per million mean would That 1,000. 23 per to live births 1,000 30 per from rate mortality under-five global average the reduce could inequality income reducing that found recently by Children Save out the carried A study health. on effects beneficial have powerful poverty tackling and inequality reducing that clear is It newborn babies’ deaths in the 47 the in countries. deaths babies’ newborn of 60% –almost save babies 1.8 newborn million could by 2030 population whole for the coverage further, 95% achieving Going 38%. of a reduction avoided, would be babies 950,000 newborn almost by 2015, of that, deaths the estimated research Our and healthy.” boy. –ababy safely born He’s was baby now safe The care. of alot with case We that handle to had got stuck. head the but out baby’s came the body of rest the baby. delivery abreach the had During who we amother had “Recently example: following the through describes Hawa as work, It’s life-saving 54

53 PHOTO: COLIN CROWLEY/SAVE THE CHILDREN THE CROWLEY/SAVE COLIN PHOTO: 3 MEETING THE CHALLENGE 19

PHOTO: ANDY HALL/SAVE THE CHILDREN

55 What the Save Children is calling for Governments, with partners, to ensure that 2025,by every birth is attended trained by and equipped health workers who can deliver the essential newborn health interventions. newborn care needs to be part of a comprehensive primary care system in every country – providing good-qualityantenatal care, immunisation, nutrition, family planning and treatment of childhood illnesses – along with access to secondary care. in Gadchiroli, India, Dr Abhay Bang pioneered an approach in the where 1990s care community by health workers reduced newborn deaths by identifying high-risk babies, supporting breastfeeding managingand hypothermia infection.and In addition to services around the time of birth, antenatal home checks women for during pregnancy and follow-up care mothers for and newborns in the days after birth essential. are Community health workers can make a difference. For example, PIONEERING COMMUNITY-BASED APPROACH NEWBORN SAVING BABIES’TO LIVES Newborn and maternal mortality and stillbirths are sensitive indicators of the strength ofhealth a system and its ability to reach all communities. Essential HEALTH SYSTEMSHEALTH AND NEWBORN CARE Births cannot be ‘scheduled’ to fit within normal workinghours; healthstaff, health facilities, medicines and equipment must be available around the clock. Frontline health workers needto be able to call on the support of specialist services and highly qualified workers as required. Caesarean sections and blood interventions life-saving transfusion key services are womenfor and babies. Those services need to be supported systems by to transport a pregnant woman quickly to emergency obstetric care as required. 20 ENDING NEWBORN DEATHS of low birth-weight babies. babies. lowof birth-weight chances improvesurvival to order the in method, this in nurses and doctors train to Ethiopia of government the supported has Children Save the grams. 400 gained Abayanesu’s daughter month first her In 41 old. was weeks daughter her until –for 24 hours-a-day contact skin-to-skin through warm ababy keeping of –amethod care kangaroo mother practise to Abayanesu advised (1lb grams 800 2oz). just weighed and Nurses premature, amonth born was Abayanesu’s daughter MOTHER CARE KANGAROO Simple, • • difference. big a make can innovations few of resources, places In INNOVATIONS CARE NEWBORN IN • • develop faster. baby’s to the lungs help can labour premature Corticosteroids effects even where intensive care is available. is care intensive even where effects long-term have to shown beneficial been has it But warm. baby apremature keep to available were not incubators where situations with to cope developed first below) atechnique is Care Mother Kangaroo naturally. start not does breathing if babies newborn at helping effective for umbilical cord care, can reduce newborn newborn reduce can cord care, for umbilical chlorhexidine The antiseptic

low-cost

are are devices mask and bag given to a mother going into into going amother to given

(see photo caption (see caption photo , used in gel form form gel in , used techniques to every community and every birth. every and community every to techniques and products resources, human these deliver can system health properly. astrong are used Only sure make they can techniques and training with up-to-date is and births supports regularly who worker ahealth Only babies. and mothers all reach can that systems without impossible is scale at full However, used them mortality. reducing in getting are valuable developments and techniques These and packaging, with costs as low as possible. low as as costs with packaging, and anew produce formula to GSK with working is Children Save the product. useful this of supplies more for Women recommends Children and Commission Commodities UN on Life-Saving The by infections. acquired preventing mortality

56 PHOTO: CAROLINE TRUTMANN/SAVE THE CHILDREN THE TRUTMANN/SAVE CAROLINE PHOTO: 3 MEETING THE CHALLENGE 21

62 63 as significant are 61 What the Save Children is calling for Governments user to fees remove all for maternal, newborn and child health services, emergencyincluding obstetric care. cost-effectiveness of the most expensive treatments. But good-quality care birth at by – provided midwives and other skilled birth attendants – and newborn care must be the top priority. High rates of child and maternal mortality have encouraged many countries direct to remove payments fees’ patients – ‘user – by and their families maternal,for newborn and child health services. The effects of this can be dramatic. Large reductions in child mortality in Nigerin part are attributed to the removal of user fees, the removal of fees alone is insufficientHowever, to health outcomes, the improve improving including survival chances of newborn babies. Other financial barriers also deter care-seeking. When financial barriers lifted, are demand health for services surges. This threatens to undermine the quality of care provided. It puts pressure on the health workers and on stocks of medical supplies. Staff continue may to collect cash from users in the form of ‘gifts’ and patients be may expected to buy equipment or medicine. Some countries emergency include do not obstetric care in their free package, which can saddle families with very highunexpected bills. increases inuse of maternity services in Sierra Leone. user fees persistin some countries,However, for example, Democratic Republic of Congo, as do high rates of newborn mortality. There a strong is now consensus against out-of- pocket payments health for services. The World with synonymous Bank, time one at organisation an promotion of user fees, has undergone a reversal its President, Kim,on the issue. In Jim 2013, Yong who hasdeclared: health provided “Anyone care to poor people knows that out-of-pocket tiny even charges can drastically reduce their use of needed services. This is both unjust and unnecessary.” Encouragingly, many countries decided have to user feesremove first from maternal and child health services, recognising this as priority a area.

delaying

girls 60

and

–

– is vital in tackling 57 empowering under-age

longer

and

which brings together 59 education marriage

the

good-quality

girls

the age which at they start having children. sex education a wealth of resources on techniques and procedures that can reduce newborn mortality. These include the actions that communities familiesand take, should reducing including delays in seeking care, changing care practices in the home, addressing the of role fathers and, highlightingcrucially, cultural attitudes towards women, babies and children. Save theSave Children has helped found the Healthy Network, Newborn HEALTHY NEWBORN NETWORK HEALTHY the crisis in newborn mortality. Access to family planning and the right to control when and how frequently they become pregnant is a vital part of and girls’ empowerment andwomen’s of a reduction of newborn mortality. Interventions include: Debates about which services are covered are contentious and important. No one expects that everyone in every country will be able to instantly receive all the possible healthcare services that they might need. Even in wealthy countries, difficult decisions to be have taken based on the Save theSave Children argues that equitable systems of UHC – crucial to saving newborn babies’ lives – need to be financedresourcesby pooled from the whole population, based on and ability to pay, that healthcare should be available based on need. Direct cash payments maternal, for newborn and child health services should be eliminated, to avoid excluding the poor from health services. ELIMINATING ‘USER FEES’ WHO PAYS? FUNDING FOR WHO PAYS? UNIVERSAL HEALTHCARE

• providing • keeping • preventing Addressing the social determinantsof health – as part of universal health coverage OF NEWBORNHEALTH OF ADDRESSING SOCIAL DETERMINANTS DETERMINANTS SOCIAL ADDRESSING 22 ENDING NEWBORN DEATHS paying what Iowe.” what paying than other hospital leave wayto forthe me other no is there and me help can who have any family don’t “I sosaid. yet,” do she to able hasn’the been and amonth here Ihave been But out. me get to together money the get to trying is husband “My by bike. transport pédaleurs workas husband her and She husband. her with who home were at children older five has Marie by Children. Save the interviewed was That’s she why I’m here,” when said still she (£35). francs don’t “I pay that. haveto money the Congolese 53,000 is operation the of cost The hospital. leaveto the allowed not was Marie aresult, As operation. the have not did pay for they to money birth, ‘ordinary’ pay for to an money aside set had husband her and Marie while danger, of were son out baby but, her and She caesarean. haveto emergency an had Marie birth, the with complications to Due birth. giving after for amonth Congo of Republic Democratic the in ahospital in held was Marie HOSTAGEHELD HOSPITAL IN – buying and selling goods, which they they which goods, selling and –buying home.” go can woman like this patients sure make that to it we use havewe money always When the moment. at the fund we don’t have equity any the in money because case this in “It’s difficult Josephine. says Dr things,” these afford to able be to everyone want we because operation acaesarean of and a birth –we’ve of price the reduced healthcare affordable access to able be to everyone help to “We try fund. the in money no was there gave birth, Marie when month the in But Union. European for by paid the holds, hospital the that fund equity froman paid fees medical their get sometimes can care medical pay for their cannot who Patients so. do to aren’t leavewho to are unable supposed patients ensure to ward hospital the of door the on guards with tight, was Security situation. same the in there women were other four says there Josephine, Dr held, being is Marie province where Oriental Kasai in hospital at the doctors the of One

Interviews were carried out on 22 November 2013. November 22 on out carried were Interviews PHOTO: SAVE THE CHILDREN THE SAVE PHOTO: 3 MEETING THE CHALLENGE 23 there 66

69 65 Recently the Global Investment 67 The UN estimates least that the world’s 68 What the Save Children is calling for includingThe private pharmaceutical sector, companies, shouldhelp address unmet needs developing by innovative solutions and increasing availability the for poorest to new andexisting products maternal, for newborn and child health. Framework for Women’s and Children’s Health and Children’s Framework Women’s for thatshowed increasing health expenditure just by US$5 per person countries per year in the with 74 the highest burden of child mortality could result in up to nine times that value in economic and social benefits by and 2035, prevent the deaths of children, million stillbirths, 32 147 million and 5 million women. Save theSave Children is working with RB (formerly known as Reckitt Benckiser) to develop a public– civil society–private partnership model to reduce innovative, through diarrhoea mortality, including and low-cost products and services and through influencing others. Fairer taxation of income and wealth, and particularly of industries that extract and export commodities from poorer countries, make a difference would to the ability of countries to fund universal health FOR UNIVERSALPAYING COVERAGE HEALTH TAXES THROUGH As Health the showed, World Report 2010 is considerable scope governments for to raise additional domestic their revenues for health sectors. Many more health services could be if provided governments efficiencies improved resources in how raised,are pooled and spent. As as well the long- standing of African of 15% Union Abuja Target government expenditure to health, recent estimates of the money needed to reach the health Millennium Development Goals suggest that countries need to spend least at US$60 per capita each yearto fund a specified mix of interventions and health system costs. Countries whose general government revenues and compulsory health insurance contributions are thanlower about 5–6% of gross domestic product struggle(GDP) to ensure health service coverage thefor poor. developed countries need to raise tax that revenue is equivalent to least at to achieve 20% of their GDP, the Millennium Development Goals. Looking to private 64 Core businessCore The private sector has a particularly important role in ensuring the reliable supply of good-quality products that can benefit health. Its products and services must be available to those who need them. withWorking the private sector can identify unmet needs and develop innovative products and solutions, such as adaptations and delivery mechanisms that can reach the poorest and those without access to services, medicines. for especially, but not only, In systems of UHC, wealthier citizens can still pay greaterfor or convenience comfort in the private the existence of privatecare they receive. However, services must not be a newborn to allowed prevent baby or a mother receiving life-saving treatment. Wealthier citizens who use private services should not be to allowed opt-out of paying into the general funds, or to discourage governments from raising fair taxes to fund healthcare all. for Crucial to system any of UHC is the mandatory subsidisation those by who wealthyare and healthy and of people who poor, are of those who sick. are Many governments and international institutions talk and governments Many about looking to the private sector to raise funds healthcare.for For example,private health insurance schemes can protect their members from some catastrophic health costs but too are expensive for average families. It is unrealistic to expect these schemes to cross-subsidise from the rich to the poor essential for services. As a recent study the by BankWorld and the Government of Japan notes: “No countryhas reached UHC relying on private voluntary sources.” funding Save theSave Children believes that private healthcare providers can potentially form part of a publicly- financed universal system health of fair, coverage, but they need would to be integrated and strongly stewarded the by government, with services free at the point of use, least at the for poor. Private providers of healthcare providersPrivate of Private providers ofhealthcare birth at found are in everycountry. rangeThey from high-quality, specialist maternity hospitals to traditional birth attendants. Many of these private providers paid are in cash as ‘out-of-pocket expenditure’. PRIVATE AND PUBLIC PRIVATE and community-based health insurance schemes is therefore a distraction from the evidence of what works. 24 ENDING NEWBORN DEATHS institutions demanded cuts in public spending which which spending public in cuts demanded institutions financial international decades, recent In pressures. external harsh of acontext in exist countries However, UHC. world’s with the poorest forward move to needed decisions the make to people, their with consultation in governments, for national is It A GLOBAL RESPONSIBILITY current trends. 2029, by 2016,on than target projected MDG rather mortality achievechild could the awhole as Africa sub-Saharan curtailed, be to flows were illicit that, judges Development and Cooperation Economic for Organisation by the report Arecent coverage. countries, donors and civil organisations society of (IHP+) agrowing alliance is Partnership Health 2007, in International the Established announced. be to continue new ones streams, numberthe of initiatives, and mechanisms funding reduce to efforts Despite health. of ministries for overstretched time-consuming and costly aid donor managing make which cycles, budget and requirements reporting priorities, different have donors Different and fragmented. inefficient complex, aid is health that acknowledged widely is It countries. poorest the in particularly lives, saving rolein important play an to continue will However, governments. national played and aid has of budgets fromthe comes health child and newborn maternal, in invested money the of Most INTERNATIONAL HEALTHTHE PARTNERSHIP equipping and support of health workers. health of support and equipping training, pay for to the capita per US$60 of minimum WHO the at least to health on expenditure increase to Governments for calling is Children Save the What 70 development framework. post-2015 the within agreed goals health-related any of support in and health, newborn of support in efforts partners’ of impact the maximising for mechanism harmonising and important and arelevant be to continue will IHP+ The 59. to up signatories of number total the IHP+, –joined bringing USAID and Haiti –Guinea-Bissau, new partners three 2013, May In costs. transaction and duplication reduce and systems and funds existing of use better make aid, their align and harmonise ownership, and leadership national strengthened support to agreed signatories to the IHP+ Global Compact Global IHP+ the to signatories All aid make effective. more and try to committed ownpriorities. their meet that activities fund project- than rather plans, health comprehensive led nationally- behind resources their put to encouraged are being donors initiatives, these Through adifference. are making Partnership+ Health International the and Effectiveness Aid of Principles Paris the through coordination and effectiveness improve to aid commitments donors’ And donors. for and for countries direction aclear – provides World now by and backed the by– led WHO Bank coverage health universal towards movement The systems. comprehensive health have might built that energy and space up taking services, and diseases different prioritised have often institutions multilateral and Donors for healthcare. responsibility fromtaking states discouraged actively should support comprehensive health services. health comprehensive support should money, Donor available, is it where short-term. the own in their on UHC fund to struggle will countries poorest the However, taxation, fairer even with sources. fromdomestic come already healthcare essential fund to resources of majority The 72 have have 71

3 MEETING THE CHALLENGE 25

PHOTO: ANNA KARI/SAVE THE CHILDREN

73 Where governments made these have commitments and delivered progress, they can reap electoral rewards, such as in the re-election of Sierra Leone’s President – partly thanks to the Health Free Care Initiative. towards UHC, and others to make only limited attempts: “Having health care access embedded in the Constitution as a right important provided institutional underpinning to UHC initiatives … reformersproviding with a legal basis UHC for many countries,advocacy…In social movements helped put UHC on the political agenda initially and subsequently held governments accountable after its implementation.” The World BankThe World and Government of Japan studies identify the political and social factors that led some countrieshave to make good progress Few countriesFew can introduce large-scale health engaging in a processreforms of instantly. However, health service reform brings its own benefits. When responsibilities, their to commit publicly governments citizens and civil society organisations time invest and energy in the process and demand good-quality health services as a right, not a privilege. FRAMING HEALTHCARE AS A RIGHT – MAKING GOVERNMENTS ACCOUNTABLE Newborn babies at a health clinic in Liberia. 4 COUNTRY CASE STUDIES

BANGLADESH

Bangladesh has made impressive progress on child Public investment in health is desperately low – at mortality in recent years and is now on track to just 8.9% of total government spending and just over achieve its MDG 4 target. This has been achieved one-third of total health expenditure.77 The system despite seemingly low public health expenditure. depends on out-of-pocket payments – amounting to This may be partly due to a pluralistic landscape of over 60% of total health expenditure.78 This creates healthcare providers. Widespread deployment of major barriers to progress for the poorest people community health workers – mostly women – has and is a substantial cause of financial hardship, with no doubt been instrumental in scaling up coverage the costs of seeking health care accounting for 22% of certain interventions, such as immunisation, oral of all shocks that poor households face.80 rehydration therapy for diarrhoea, TB treatment and Ending all preventable newborn deaths will require a family planning initiatives. Parallel efforts to empower concerted effort to strengthen the health system and women, in addition to social and behaviour change institute health financing policy reforms, to ensure communication, have certainly contributed to the high quality services are provided free at the point health gains. of use. This must involve a shift from reliance on But coverage of essential services remains low, with out-of-pocket payments towards mandatory less than one-third of births attended by a skilled systems for prepayment, including substantial public health worker. 74 Of every 1,000 live births, 24 babies investment.81 The government must also become die within their first month, and 41 under the age a stronger steward, better able to regulate the of five.75 In the words of Mushtaque Chowdhury, proliferating private practitioners.82 “the sad reality [in Bangladesh]… is the iniquitous health system.” 76

Baby Popi, six days old, from Bangladesh, at her first check-up at a local PHOTO: COLIN CROWLEY/SAVE THE CHILDREN THE CROWLEY/SAVE COLIN PHOTO: health centre.

26 4 COUNTRY CASE STUDIES 27

90 Only 10% Only 10% 95 was launched in 2010, followed was followed launched in 2010, 89 A revised strategy A revised to strengthen 88 These represent huge inequalities, which 96 There indications are of the Ministry of Health’s desire the to health improve system, but it is constrainedshortages resource by health to improve infrastructure, salaries, pay and purchase drugs and supplies. in to help guarantee universal access to good-quality healthcare. It was towards also curbing a move people having to services for pay the at point of use. NHIS coverage had only reached about one-third Despite impressive progress on child health outcomes, coverage of some essential health services is still very and equitylow, is a major concern. For example, immunisation coverage is only around 60% nationally, and children from the richest households roughly are twice as likely to be immunised as the poorest. And children in urban areas twice are as likely to be immunised as those inrural areas. by a Nationalby Plan the for Development of the Health affirming Sector, good-quality primary health care available to all, especially vulnerable groups. of women birth give with a qualified healthworker present. A richer woman 20 times is over more likely than a poorer woman skilled to have birth attendance, and a woman living in an urban area is more than ten times more likely to do than so a woman in a rural area. However, this policy has to yet be fully turnedHowever, into practice, due to poor dissemination hence (and application) of the plan provincial, at district and zonal health departments. in 2013, More recently, the government launched a national plan to boost the achievement of MDGs 4 and 5. the health sector are holdingare back further progress. While Ethiopia’s MDG 4 achievements warrant recognition, the job has only just begun. Progress must be significantly accelerated and inequalities tackled that so improved health outcomes shared are all. by

94 These put DRC

83 87 it still falls short well This achievement has 85 92 More than 38,000 health extension User feesendemic are in thecountry 93 86 of WHO targets of $60 per capita and, alarmingly, only a third of thisamount comes from government expenditure. Newborn mortality has also decreased from 54 to between29 and 2012. 1990 amongst the top ten worst-performing ‘Countdown estimates indicate Moreover, that lesscountries’. than of the 25% population has access to a functional health service that they can afford to use. been driven multiple by factors – among them strong political commitment and policy change, leading to health and nutrition improvements, particularly in rural areas. Ghana has a complex health financing system, including private insurance, out-of-pocket payments and the National Health Insurance Scheme (NHIS), which was launched in 2003. The NHIS was brought GHANA Ethiopia launched its Health Extension Programme (HEP) in 2003 to promote universal coverage of primary care. It focuses on making ‘promotive’, preventative and some curative health services available to all, bringing by them to the community the in even level most remote areas, and free to service users. Ethiopia has made great progress in reducing child mortality, recently achieving its MDG 4 targets. ETHIOPIA While per capita health expenditure has slowly risen the years, over $32 at Health outcomes in the Democratic Republic of very are Congo (DRC) remained poor and have relatively stagnant the last over decade. The under- five mortality1,000146 per rate is births live and the rate newborn for mortality is 44. DEMOCRATIC REPUBLICDEMOCRATIC OF CONGO workers (on government been salaries) have trainedworkers (on under the programme and deployed are to more than 15,000 health posts across the country. and a barrier to most people accessing health services when they available. are 28 ENDING NEWBORN DEATHS a skilled health worker present when giving birth, giving when worker present health a skilled have women of 60% than less example, For country. acrossthe low, inequalities huge very also is with services health critical some of Coverage countries. Countdown other to compared high remains still of use for pregnant women and newborn babies. newborn and women for pregnant use of 2011, in programme point at free the services making 2013, in programme Services’ Intervention Early and Screening Health ‘Child Karyakram Swasthya Bal Rashtriya the –eg, out rolled have been initiatives recent more NRHM, the Under programmes. health child and reproductive and control disease existing of anumber integrated also It areas. rural in care primary on delivery, focusing service and infrastructure improve health helped (NRHM) Mission Health Rural National The vulnerable. and poor for the particularly services, health to access improve and challenges address to initiatives and policies of anumber introduced has government The 56. to live births 1990 since halved –from126 than more 1,000 per been has India in rate mortality under-five The factors. economic and cultural social, geographical, from arising remain, inequalities but services, health to access improving in progress made has India INDIA 19% respectively. 90% and – households richest the in is it what aquarter than less households poorest the among coverage with compared with the richest. the with compared households poorest the among higher times three is it groups, population acrossall down come has from 51 31 live to births; 1,000 per period over same the rate mortality newborn the in distribution of health workers health of distribution and uneven protection financial Inequitable by 2011, population the of but enrolment is still not pro-poor. not still is enrolment but poor, by the including utilisation, better to led has and services to accessing barriers financial reduced scheme. the from benefit not do therefore and premium However,women. can’t this afford people many pregnant as such groups for vulnerable exceptions some with premium, haveworkers pay annual an to sector covered, informal areworkers automatically sector formal While for services. pocket of pay out 109 and the Janani–Shishu Suraksha Karyakram Karyakram Suraksha Janani–Shishu the and 98 There are indications that the NHIS has has NHIS the that are indications There 104 While the child mortality rate rate mortality child the While 108 97 105 leaving many having to to having many leaving

There was a reduction areduction was There 100 mean that not not that mean 106 99 this figure figure this 110 107

been introduced at national and state levels. state and at national introduced been have also schemes insurance health Mission). Several Health National the renamed (later Mission Health Urban National the launched government the slums, To in poor urban the improve among coverage universal coverage. to up scaling of aim the with though populations, rural and poor of coverage targeted have initially people in all states. all in people for all progress equitable ensure to done be to needs More others. with well compared exceedingly have mechanisms andsystems implementation done health strong with states Also, packages. benefits expanding and coverage population extending between trade-offs mean resources limited while poor, is schemes between coordination example, For weak. remains implementation and challenges, face yet they initiatives, are promising These engagement. CSO/FBO on leading Coalition, RMNCH+A the to secretariat the is India Children Save the units. RMNCH+A state of establishment the through programmes into integration its ensured Welfare has Family and Health of Ministry the and approach, life-cycle aholistic, to shift aparadigm marks 2013. February in framework The summit Action to Call the during approach strategic RMNCH+A the of launch the been has achievement A landmark initiatives. health for their budget ahigher allocating and districts priority high identifying systemically by inequalities addressing is India health, child and newborn maternal, reproductive, to regards With (92%) lower. much and inequalities higher much is coverage where immunisation, as dropped again when fees were reinstated in 2008. in were reinstated fees when again dropped households), but poorest the amongst impact greater (with increased deliveries facility-based removed, were services for childbirth fees when 2003, In services. health to access have same the people all richest. 95% the of with compared women, poorest the of aquarter –just birth giving worker when health have women of aqualified half Currently, about only 102 This is in contrast to other services, such such services, other to contrast in is This 112

103 111 These These 101

4 COUNTRY CASE STUDIES 29

118 PHOTO: JONATHAN HYAMS/SAVE THE CHILDREN

114 There discussions are about the HSSF 113 – far below the WHO target of 23. 119 for mostfor of the population. The aim of HSSF was cashto improve flow to facilities, after the Public Expenditure Survey (PETS) Tracking revealed that less than half of the funds due actually were received facilitiesby because of bureaucracy, inefficiencies andfailure to comply with government accounting procedures. A midwife visits a three-day-old baby at home in Liberia. being increased toaccommodate loss of income to healthcare facilities due to the removal of user fees. Following its the introduction HSSF in 2010, now nearlycovers 3,000 health facilities. This has led to increased utilisation of healthcare facilities from million to in around 27 nearly million 26 in 2010/11 Initial indicationsimprovements show in 2011/12. prenatal care, deliveries skilled by health workers and immunisation coverage in target facilities. With the recent passing of the Health new Financing it is criticalPolicy, that services remain free the at point of use. This is essential the for policy new itsto achieve goal of “universal access quality for essential health services to all citizens in an equitable, efficient sustainableand manner”. present and coverage is three times amongst lower the poorest households compared withthe richest. Critical health shortages worker a big are issue, with less than health seven workers every for 10,000 people

115

117 This has contributed to 116 To address health low coverage, theTo government new has announced the removal of user fees maternity for services in public health National facilities. Kenya’s Health Sector Strategic Plan II includes a Health Sector Services Fund (HSSF) fund – a revolving directproviding cash transfers to primary healthcare facilities – targeting health centres and dispensaries that the are first point contactof for health care At the national level, Kenya’s health theAt coverage national remains Kenya’s level, Less thanlow. half the of women recommendedhave four antenatal care visits or a skilled health worker when giving birth. When giving birth, poor women are four times less a skilled likely to have health worker present than women richer from households; women in rural areas only are half as a skilled likelyto have health present worker as women from urban areas. KENYA With a free healthcare less than policy, of 10% people who fall ill do not seek care and the poorest households spend only of household around 2% expenditure on health. available to all citizens, free the at point of use, with the aim of tackling communicable diseases and responding to maternal and child health needs at the policy was and revised primary care In level. 2011, a ten-year strategic plan developed. This provides a more comprehensive set of services to strengthen areaskey that continue to perform and adds poorly, servicesnew necessary to address needs all at levels theof healthcare system. Coverage of health services is still poor in some areas and high inequalities a concern. are Only 46% of women birth give with a qualified healthworker Following well over a decade of civil war, Liberia a decadeFollowing over well of was civil war, left with healtha broken system and some of the poorest health indicators in the world. The country has made progress in recent years thanks in part to a National aimed Health launched in 2007, Policy, equitablyat extending health service coverage. The policy introduced a basic package of health services LIBERIA impressive progress on health on outcomes. Under-five progress impressive mortality is roughly one-third what it was in 1990 deaths from 248 (dropping per 1,000 births live in while newborn mortality to deaths 75 1990 in 2012), has been to nearly 27. halved, from 51 NEPAL

Despite grappling with poor infrastructure, difficult The government of Nepal is currently implementing terrain and widespread poverty, Nepal has been a number of health programmes, resulting in many making impressive progress in improving child essential services officially provided free for all, survival.120 The country is on track to reach MDG4, with additional services targeted at the poor and with the under-five mortality rate currently at 42 per marginalised.125 While coverage has surely improved 1,000 deaths – around one-third what it was in 1990. as a result of these programmes, it is still far from Meanwhile, newborn mortality has been halved – from universal. Key challenges include resource and health 121 ENDING NEWBORN DEATHS 53 per 1,000 live births in 1990 to 24 currently. worker shortages (eg, currently there are around six health workers per 10,000 population); direct While improved health outcomes correspond to payments; and inadequate financial protection leading increasing coverage of many health services, coverage to high out-of-pocket payments – these currently of some services remains low, and reaching the poor account for 55% of total health expenditure.126, 127 and marginalised is an issue.122 Just over a third of women have a skilled health worker present when To help overcome these challenges and as a major giving birth, with only one woman covered among step towards UHC, the Ministry of Health and the poorest households for every eight women Population approved the national health insurance among the richest.123 Meanwhile, coverage is more policy in March 2013. The new policy aims to help than twice as high in urban areas as in rural areas.124 improve equitable access to health services by For other health services, progressive coverage has curbing out-of-pocket payments and strengthening been made – eg, national immunisation coverage has the health system.128 reached 90%, with high coverage among both the poorest and richest households.

NIGERIA

Under-five and newborn mortality rates in Nigeria choice of benefits package. Several exemptions are are among the highest in the world, at 123.7 and also in place, including for the poor. 39.2 per 1,000 live births, respectively, in 2012.129 While coverage of the NHIS has increased since its Under-five mortality is nearly 2½ times higher introduction, its reach remains poor – just 3% of the among the poorest households than the richest, population – with huge disparities in coverage between and nearly 30% higher when looking at newborn people in paid employment and people who are poor mortality.130 Coverage of critical health services is and in the informal sector.132 This has meant that extremely low and inequalities are high – only 38% despite some national progress in health outcomes, of women give birth with a skilled health worker, this progress has been limited and unequal. Health while coverage is ten times lower for the poorest system weaknesses need to be addressed and cultural women compared with the richest; coverage in issues tackled if Nigeria is to see improvements in rural areas is about one-third (23%) what it is in health outcomes for mothers and newborn babies. urban areas (67%).131 These inequalities have actually worsened over the years. If the National Health Bill, which went through the third and final senate reading in August 2013, Nigeria suffers from a highly fragmented healthcare is signed into law by the President, it will provide a system across the country, leading to wide disparities breakthrough deal for mothers and children. If the in service coverage and health outcomes. As part of bill is fully funded and implemented, it could lead to efforts to strengthen the system, the government basic life-saving healthcare services being scaled up to introduced the National Health Policy in 2006. This 90% coverage – near universal coverage – improving included a re-designed National Health Insurance healthcare for huge numbers of Nigerians and helping Scheme (NHIS) whereby formal sector workers the country achieve its MDG 4 and 5 objectives. make contributions based on income (with a contribution also from employers) and those in the informal sector make contributions based on their 30 4 COUNTRY CASE STUDIES 31

PHOTO: SAVE THE CHILDREN 141 However, However, 139 and over 90% and over of 142 Health Insurance Policy Almost 60% of the total 137 contributing health to improved

138 140 – a community-based health insurance scheme areas and urban slums. initiatives has been the introduction of Mutuelles de Santé but with national reach. Starting off as a pilot in Mutuelles the 1999/2000, was fully implemented in 2006 indicators among populations covered. populations among indicators Community midwives another are category of frontline health in Pakistan worker brought in to skilledimprove birth attendance in rural areas. community out of a total of 11,996 However, midwives, only had been 45% trained and of them about 64% deployed across the country due to the lack of adherence to selection criteria, ambiguities about remuneration, lack of supervision, poor-quality training and ‘acceptability issues’ community at level. population of Pakistan, mostly rural, by is covered the programme, with more than 90,000 all LHWs the country,over several issues persist, such as delays in the salary disbursements, ‘stock outs’ of medicines, unavailable dysfunctionaland equipment, unhelpful an and referral system. with coverage nearly five times 134

Pakistan is also ranked among the 136 135 There has also been less of a decline in 133 higher among the richest women compared with the poorest. The government of Pakistan first introduced the lady health (LHW) worker with cadre in 1994, the aim of improving access to primary health services and to address unmet health needs in rural countries with the highest stillbirth rates, largely due to delays in receiving appropriate care from a skilled health worker. Rwanda has come a long since way the major disruption of its health system in the mid-1990s, which left it weak during the ensuing years. Since 2000, the government has taken major steps to access and qualityimprove of care.One of its key RWANDA With an under-five mortality 1,000rate of 86 per Pakistan in 1990, birthslive down from 138 in 2012, is making insufficient progress towards MDG4 targets. PAKISTAN A newborn baby’s umbilical cord is cleaned a with chlorhexidine at hospital in Nepal. newborn mortality, to currently. 42 in 1990 from 56 This is accompanied very by coverage of low some critical health services.For example, less than half a skilledof women have health present worker birth,when giving 32 ENDING NEWBORN DEATHS poorest now exempt from having to pay. to fromhaving now exempt poorest the with over years, progressive more the become user fees for pregnant and lactating women, and and women, lactating and for pregnant fees user 2010 April in remove launched to (FHCI), Initiative Care Free Health the been has outcomes health child and maternal better towards step A crucial care. fromseeking majority the deterred which population, fromthe fees user on reliant and underfunded weak, was system health birth. during attendance skilled had mothers poorest the That year,life. of of in four one month just first their within dying 1,000 every in 49 babies with world, the in highest fourth the was rate mortality neonatal the low. 2008, In extremely was services health of coverage and were atrocious outcomes war, fromcivil emerged health Leone Sierra As LEONE SIERRA to 2000 from39% in increased attendance birth skilled- example, For coverage. service health in deSanté of Mutuelles introduction the following haveimpact positive shown Studies development partners. the and funds insurance other by government, subsidised 50% remaining the with premiums, from membership comes deSanté for Mutuelles funding of half Around now is covered. population the 149 Overcoming such a challenge is not easy. not is The achallenge such Overcoming 144 Premium payments have payments Premium 143

, including increases , including increases urban areas than in rural areas. rural in than areas urban in 23% higher about still is coverage –eg, access universal ensure to done be must more though years, the over significantly have decreased also Inequalities a skilled health worker present when giving birth. giving when worker present health a skilled accelerate progress on child survival in Sierra Leone. Sierra in survival child on progress accelerate to potential huge has FHCI, the of consolidation the within newborns, on Afocus services. essential of coverage up scale to taken is approach integrated an ensure to plan sector health the within situated closely be must which Plan, Newborn Every its implement and 2014,In finalise will Leone Sierra improving the drug supply. drug the improving and workers health of numbers the by increasing provided, care of quality the strengthen to reforms system wider and financing public increased with implemented been has a key FHCI The priority. health child and maternal made thus and crisis the of scale the acknowledged who Koroma, Ernest President, the led by was This five. under children 67% 2008. in newborn mortality declined from 38 to 21. to from38 declined mortality newborn (a 55) from151 drop to –and live births 1,000 per 1990 in was it what one-third now nearly mortality under-five with have aconsequence, improved as 145

In 2010, In had 70% around women of PHOTO: SEBASTIAN RICH/SAVE THE CHILDREN THE RICH/SAVE SEBASTIAN PHOTO: who is just eight hours old. hours eight just is who baby, newborn her holds holds amother Rwanda in centre ahealth At 147 Health outcomes outcomes Health 148 146

4 COUNTRY CASE STUDIES 33 – and 161 To help To 163 These payments payments These 162 165 This is seen as allowing 154 While the NHIS, if brought 164

160 Despite these efforts, a quarter over 159 the public system to better respond to the needs of inequalities overcome in access, Sri To Lankathe poor. has established a rural network of health facilities that extends urban access beyond areas and has ensured servicesavailable are free the at point of use. After user fees removed, utilisation were increased, with greater impact amongst the poorest households. Out-of-pocket payments still are high – accounting nearlyfor 50% of total health expenditure In spite of impressive progress, pockets of poor take-up of services remain. Improvements being are seen in former conflict-affected areas in the north andeast as the result of recovery and development healthprogrammes. issues women for However, and children resident in the central tea estates and persist. plantations rubber to scale, should help to address financial barriers, inequalities be unless fully overcome wider won’t health system issues and bottlenecks human (eg, resource, medicines, health as facilities), as well cultural barriers, tackled. are The government expects the rich to contribute even if they use private services. targeting high burden populations; improving access under-servedfor populations; and prioritising budgets and action plans to end preventable deaths. mainly affect the poorest people. of households a facility do not have within their proximity and utilisation remains due low to poor infrastructure, inadequate supplies, health worker shortages, etc. mitigate out-of-pocket payments and promote equitable access, the government plans to introduce a National Health Insurance Scheme as (NHIS) in 2014 UHC reforms. part of largely stem from indirect costs such as transport, supplementary fees medicine, for and medical personnel illegally charging services. for

151 If 155 Coverage Coverage 157 158 Sri Lanka 152 153 and 99% of births in 150 However, inequalities persist However, 156 has a strong commitment to free universal access to health, while prioritising equitable access for all citizens. With the introduction of democracy citizensin the more empowered were 1930s, to demand access to good-quality services and to hold the government accountable this. providing for Accountability has been important to securing and sustaining the progress. country’s of some important health services also remain low and inequitable. Nationally only 58% of women have a skilled health present worker when giving birth, with coverage twice as high among the wealthiest households, compared with the poorest. The government of Uganda has taken several steps to equitable help improve access to healthcare, including a minimum package of health services for all of healthcare, levels abolishing user fees, and ensuring a health facility within reach (within 5km) of the majority of households. The government has also recently launched plan an improved for RMNCH, which includes: increasing efforts in districts where the majority of under-five deaths occur; Uganda has reduced under-five mortality markedly, especially towards the end of the past decade. UGANDA Sri Lanka’s publicSri health Lanka’s system is financedgeneral by revenues, through income taxes, based on ability to pay. In Sri Lanka, basichealth services in reach are of nearly the whole population, SRI LANKA 2007 attended were qualified by health personnel. This has led to impressive health outcomes, including a halving of the newborn mortality rate from 12 per 1,000 births live to six in 2012. in 1995 between rural and urban areas and regions, as well as between the richest and poorest households. For example, the under-five mortality in 153 rate is Karamoja, compared with 65 in Kampala. this recent accelerated rate of progress is maintained, the country has a chance to meet their MDG 4 The under-five mortalitytarget 2015. by rate was in from 178 per 1,00069 (down births live in 2012 while newborn mortality1990), has come down to 23. from 39 CONCLUSION

Although we have made substantial progress This needs to be followed by genuine political change in reducing deaths of children under five, than can transform the way that health services 2.9 million newborns in 2012 did not live are delivered, so that these services can reach beyond 28 days. 1 million of these babies every birth with good-quality care and the right died on their first – and only – day of life. interventions. This is why Save the Children’s five- In addition, 1.2 million stillbirths occurred point Newborn Promise needs the highest level of political support during 2014. where the heart stopped beating during labour. The Every Newborn Action Plan and the Newborn Promise can benefit from the momentum that This report has focused on these 2.2 million first-day universal health coverage currently has in many deaths and stillbirths during labour – a tragedy for countries. In turn, the focus on newborn mortality their families and communities – because they also will help ensure the fight for universal health reveal a systematic failure to respect the universal coverage concentrates on the outcomes that will right to survival and to health when it comes to the benefit the most vulnerable. poorest and most vulnerable people in our world. First-day deaths and stillbirths during labour reveal The scale and the inequality of newborn mortality deep inequalities across societies, and point to the have to be addressed. The incremental changes that fact that many national health systems, in their very we currently see cannot end all preventable child and design, fail to reach everyone. maternal deaths within an acceptable time frame. The principles of UHC should guide how universal Progress on Millennium Development Goal 4, and on good-quality care at birth is to be achieved. future targets to end all preventable newborn deaths Investment in public services, so that maternal, and stillbirths, cannot be achieved without substantial newborn and child healthcare is free at the point and urgent progress on improving care at birth. of use and of high quality, is key to the solution. 2014 offers a powerful opportunity to address this. These movements offer a real promise that we The Every Newborn Action Plan will be presented to can become the generation to end all preventable the world’s ministers and will drive renewed action. newborn, child and maternal deaths – and ensure By addressing this neglected topic according to the that no baby is born to die. principles of universality and equity, with the aim of ending all preventable newborn deaths, the Action Plan can help to ensure ambitious, substantial change that brings lasting benefits to families and economies.

34 RECOMMENDATIONS

Save the Children is calling on world leaders, workers, including midwives with the skills and philanthropists and the private sector to implement equipment to save newborns as well as mothers – this year – a five-point Newborn Promise to end • remove and eliminate direct payments for all preventable newborn deaths: maternal and newborn healthcare including • Governments and partners issue a defining and emergency obstetric care accountable declaration to end all preventable • ensure that less than 20% of all national newborn mortality, saving 2 million newborn lives expenditure for health is from out-of-pocket a year and stopping the 1.2 million stillbirths payments. Governments must also tackle informal during labour payments and other barriers such as transport • Governments, with partners, ensure that by 2025 and opportunity costs that deter the poor from every birth is attended by trained and equipped using services health workers who can deliver quality care • develop integrated national reproductive, including essential newborn health interventions maternal, newborn and child health action plans • Governments increase expenditure on health to that ensure universal access to good-quality at least the WHO minimum of US$60 per capita, healthcare and lay out evidence-based paths to to pay for the training, equipping and support of ending preventable maternal and child deaths. health workers The Every Newborn Action Plan – which should • Governments remove user fees for all maternal, be presented to the World Health Assembly in newborn and child health services, including May 2014 and lead to a global push – should have as emergency obstetric care its priorities: • The private sector, especially pharmaceutical • ending all preventable newborn and child deaths companies, should help address unmet needs by and stillbirths. This should be achieved in all developing innovative solutions and increasing wealth quintiles and all segments of society availability for the poorest to new and existing with accountability mechanisms as part of Every products for maternal, newborn and child health. Woman Every Child Governments of countries with high burdens • universal coverage of quality care at birth by 2025 of newborn mortality need to make significant • calling for the future monitoring and inclusion policy changes in order to: of stillbirths as an indicator in reproductive, • commit to addressing the newborn deaths and maternal, newborn and child health frameworks stillbirths as a top priority • endorsement of the principles of universal health • commit to universal coverage of high-quality care coverage including eliminating financial and other during birth, as part of integrated reproductive, barriers and establishing financial risk protection maternal, newborn and child healthcare • ensuring that underlying factors such as • increase budget allocations for health at least to maternal nutrition, reproductive health and meet the African Union Abuja target of 15% of women’s empowerment are addressed to end government expenditure on health all preventable newborn deaths • address the health worker crisis through • ensuring its targets are integrated within the programmes to recruit, train, retain, deploy, post-2015 framework, so that they achieve support and appropriately remunerate health global priority.

35 The post-2015 development framework must: The World Bank should: • contain targets for ending preventable child, • support and encourage governments to commit maternal and newborn deaths, using the targets to ending preventable maternal and child deaths of seven newborn deaths per 1,000 live births and UHC and a maximum of ten in every country, as well • support stronger data collection systems as ten stillbirths per 1,000 total births in every • help countries put in place financing reforms to country and every segment of society replace out-of-pocket payments with mandatory • endorse the principles of universal health and equitable pooled contributions. coverage with specific metrics to measure it, Civil society organisations should: including good-quality care at birth • campaign for and monitor government ENDING NEWBORN DEATHS • set a target for ending impoverishment from commitments to end preventable newborn healthcare costs. mortality and preventable stillbirths, including Donor governments must: through universal health coverage • take a leading role in bringing political and financial • mobilise families and communities to address support to ending preventable maternal, newborn cultural and social barriers that drive newborn and child deaths mortality. Key issues include addressing girls’ • invest in better data to ensure accurate tracking empowerment, the demand for good-quality of newborn mortality, across various dimensions healthcare, family planning and immediate and of equity exclusive breastfeeding. • promote universal coverage of good-quality The private sector: care at birth, including through promoting • should support the Every Newborn Action Plan the principles of UHC to enable countries to by making commitments to support universal transform healthcare coverage of healthcare • share relevant knowledge, skills and experience • should – especially pharmaceutical companies to help low-income countries develop their health – help address unmet needs by developing systems in line with these principles innovative solutions and increasing availability • support the development of human resources for the poorest to new and existing products for for health (HRH) – in coordination with national maternal, newborn and child health governments and their HRH implementation • should support, respect and comply with plans – with greater emphasis on supporting regulations that protect the health of newborns pre-service training and children, such as the Code of Marketing of • commit to share expertise on health financing Breastmilk Substitutes. and health system management with low- and medium-income countries to accelerate progress towards UHC and an end to preventable maternal and child deaths • support fairer taxation in countries, transparency of financial flows and closing of tax avoidance loopholes and havens • provide direct financial support to the poorest countries that cannot achieve UHC alone.

36 5 31.61 27.31 42.17 56.91 14.38 43.38 43.54 46.55 56.88 Out-of- pocket expenditure as a % of total health expenditure continued overleaf 5 17.76 39.79 16.05 54.51 10.83 72.99 275.01 132.04 1,088.17 Government expenditure on health capita) (per 4 41.4 49.4 16.6 93.6 63.6 80.4 80.6 Skilled attendance at birth (%) no data available no data available 3 70 240 690 450 230 560 890 540 1,100 Maternal mortality ratio (per live 100,000 births) 2 94.9 53.2 62.0 96.0 149.8 145.7 163.5 128.6 100.3 Under-five Under-five mortality rate (per 1,000 live births) 2 1.4 27.9 31.7 39.7 43.1 24.9 45.4 40.9 43.5 Neonatal mortality rate (per 1,000 live births) 1 16.69 28.25 19.76 Intrapartum stillbirths and neonatal deaths on day of birth (per 1,000 total births) 27.25 25.48 27.39 17.08 22.70 21.55 1 7.8 8.0 11.9 11.9 11.7 11.2 13.6 13.3 Intrapartum stillbirth rate (per 1,000 total births) 10.2 1 9 7 15 12 Risk of neonatal death on day of birth (per 1,000 live births) 14 14 16 11 10 1 67 423 202 9,614 1,983 7,772 1,726 37,177 10,885 Number of intrapartum stillbirths 1 45 310 460 7,800 7,800 1,800 2,200 41,800 14,600 Number of deaths on day of birth 1 112 512 883 3,926 3,783 17,414 15,572 78,977 25,485 Total number of deaths during birth and on day of birth Gabon Democratic Republic of Congo Equatorial Guinea Chad Country Central Africa Angola Central African Republic Sao & Tome Principe Congo Cameroon APPENDIX: NEWBORN MORTALITY STATISTICS STATISTICS APPENDIX: NEWBORN MORTALITY COUNTRY BY This table statistics gives key on newborn mortality countries, in the the Countdown which 75 highest have to 2015 burden of newborn mortality.

37 38 ENDING NEWBORN DEATHS

Country Total Number of Number of Risk of Intrapartum Intrapartum Neonatal Under-five Maternal Skilled Government Out-of- number deaths on intrapartum neonatal stillbirth stillbirths mortality mortality mortality attendance expenditure pocket of deaths day of birth1 stillbirths1 death on rate (per and neonatal rate (per rate (per ratio (per at birth (%)4 on health expenditure during birth day of birth 1,000 total deaths on 1,000 live 1,000 live 100,000 live (per capita)5 as a % of and on day (per 1,000 births)1 day of birth births)2 births)2 births)3 total health of birth1 live births)1 (per 1,000 expenditure5 total births)1

Eastern Africa

Burundi 11,080 5,400 5,680 13 12.9 25.16 35.5 104.3 800 60.3 17.1 43.62

Comoros 593 270 323 11 12.6 23.15 31.0 77.6 280 no data available 33.98 17.02

Djibouti 646 260 386 11 15.8 26.44 31.4 80.9 200 78.4 131.63 31.62

Eritrea 3,642 1,400 2,242 6 9.9 16.08 18.2 51.8 240 no data available 8.29 51.23

Ethiopia 68,092 31,100 36,992 10 11.9 21.90 29.0 68.3 350 10 30 33.76

Kenya 29,615 14,200 15,415 9 10.1 19.40 26.8 72.9 360 43.8 30.49 46.38

Madagascar 13,536 6,000 7,536 8 9.6 17.24 22.0 58.2 240 43.9 24.96 25.20

Malawi 12,252 5,300 6,952 9 11.0 19.39 24.2 71.0 460 71.4 56.53 14.20

Mozambique 22,722 10,000 12,722 11 13.2 23.58 30.2 89.7 490 54.3 26.98 9.01

Rwanda 8,107 3,300 4,807 7 10.6 17.88 20.9 55.0 340 69 76.38 21.38

Somalia 13,619 7,200 6,419 16 14.0 29.70 45.7 147.4 1,000 9.4* no data available no data available

South Sudan** no data available 4,900 no data available 13 no data available no data available 35.7 104.0 no data available no data available no data available 55.43

Uganda 30,240 12,200 18,040 8 11. 5 19.28 22.6 68.9 310 58 33.66 47.77

United Republic 36,528 14,000 22,528 8 11.9 19.30 21.4 54.0 460 48.9 42.45 31.72 of Tanzania

Zambia 13,210 6,100 7,110 10 11.9 22 .11 29.4 88.5 440 46.5 59.38 26.97

Zimbabwe 10,152 6,000 4,152 14 9.3 22.74 28.8 89.8 570 66.2 no data available no data available

Northern Africa

Egypt 12,398 8,100 4,298 4 2.2 6.35 11.8 21.0 66 78.9 125.32 58.17

Morocco 7,137 4,700 2,437 6 3.2 9.37 17.8 31.1 100 73.6 104.27 58.00

Sudan 26,287 12,400 13,887 10 11.1 21.01 28.6 73.1 730 no data available 50.98 69.12

APPENDIX: NEWBORN MORTALITY STATISTICS BY COUNTRY 39

continued overleaf continued

40.39 41.84 43.9 300 95.5 32.6 23.05 11.6 12 2,837 2,800 5,637 Togo

74.92 29.74 60.8 890 181.6 49.5 30.83 13.9 18 3,037 3,700 6,737 Leone Sierra

32.74 69.1 65.1 370 59.6 24.4 24.01 15.7 9 8,312 4,400 12,712 Senegal

60.42 51.17 34.4 630 123.7 39.2 32.69 19.4 14 137,903 94,500 232,403 Nigeria

17.7 590 5 113. 28.2 20.41 10.6 10 8,973 8,300 17,273 Niger 37.58 21.68

37.27 78.08 57.1 510 84.0 33.6 24.29 12.8 12 1,672 1,500 3,172 Mauritania

54.35 33.27 49 540 128.0 41.5 25.08 10.8 15 7,412 9,800 17,212 Mali

17.67 35.52 46.3 770 74.8 26.6 21.77 12.5 9 1,888 1,400 3,288 Liberia

41.33 19.84 44 790 129.1 45.7 29.35 13.7 16 849 970 1,819 Guinea-Bissau

67.35 18.38 46.1 610 101.2 34.4 22.80 11.0 12 4,662 5,000 9,662 Guinea

29.11 50.49 54.7 350 72.0 28.4 20.07 10.2 10 8,165 7,900 16,065 Ghana

22.27 50.65 56.1 360 72.9 28.0 21.67 12.0 10 918 740 1,658 The Gambia,

27.22 31.91 59.4 400 107.6 39.9 26.45 12.7 14 9,329 10,100 19,429 d’Ivoire Cote

36.57 40.79 67.1 300 102.4 27.5 21.70 12.2 10 8,218 6,400 14,618 Faso Burkina

20.86 11.3 10 4,138 3,500 7,638 Benin 42.62 39.69 84.1 350 89.5 27.8

Western Africa Western

13.07 300.94 82 320 79.7 29.5 18.54 8.4 10 315 380 695 Swaziland

no data available data no 300 44.6 15.3 15.09 9.5 6 10,704 6,300 17,004 Africa South 7.21 449.54

17.89 162.06 61.5 620 99.6 45.3 27.46 11.8 16 701 930 1,631 Lesotho

4.97 446.37 99.1 160 53.3 28.5 17.44 7.5 10 370 490 860 Botswana

Southern Africa Southern

total births) total

of birth of live births) live (per 1,000 1,000 (per expenditure

1 1 5

and on day day on and (per 1,000 1,000 (per day of birth birth of day births) births) births) births) total health health total

1 2 2 3

during birth birth during day of birth birth of day deaths on on deaths total 1,000 1,000 live live 1,000 100,000 live live 100,000 live 1,000 as a % of of % a as capita) (per

of deaths deaths of day of birth of day on death stillbirths and neonatal neonatal and (per rate rate (per (per rate ratio (per (per ratio (per rate at birth (%) birth at expenditure expenditure health on

1 1 4

number number on deaths neonatal neonatal intrapartum stillbirths stillbirths stillbirth mortality mortality mortality mortality mortality attendance attendance pocket pocket expenditure

Country Total Total Number of of Number Number of of Number Risk of of Risk Intrapartum Intrapartum Intrapartum Intrapartum Neonatal Neonatal Under-five Under-five Maternal Maternal Skilled Skilled Government Government Out-of- 40 ENDING NEWBORN DEATHS

Latin America and the Caribbean

Bolivia 2,846 1,800 1,046 7 3.9 10.61 18.9 41.4 190 71.1 177.12 25.82

Brazil 16,233 9,800 6,433 3 2.2 5.55 9.2 14.4 56 98.9 476.98 31.34

Guatemala 3,582 2,500 1,082 5 2.3 7.61 15.3 32.0 120 51.3 118.43 53.41

Haiti 3,371 2,400 971 9 3.6 12.50 25.4 75.6 350 26.1 40.96 22.05

Mexico 7,587 5,300 2,287 2 1.0 3.32 7.2 16.2 50 95.3 464.86 46.52

Peru 3,382 2,000 1,382 3 2.3 5.63 9.3 18.2 67 85 278.48 38.35

Central Asia

Kyrgyzstan 1,274 970 304 6 2.0 8.38 14.2 26.6 71 98.3 95.9 34.38

Tajikistan 2,855 2,200 655 8 2.4 10.46 23.0 58.3 65 88.4 40.03 60.12

Turkmenistan 1,073 810 263 8 2.5 10.20 21.9 52.8 67 99.5 152.54 39.24

Uzbekistan 3,826 3,000 826 5 1.3 6.02 13.5 39.6 28 99.6 97.36 43.87

Eastern Asia

China 93,110 55,700 37,410 3 2.0 4.98 8.5 14.0 37 96.3 241.6 37.16

Democratic no data available no data available no data available no data available no data available no data available 15.6 28.8 81 100 no data available no data available People’s Republic of Korea

Southern Asia

Afghanistan 30,879 13,200 17,679 13 16.6 28.99 36.0 98.5 460 36.3 7.87 79.37

Bangladesh 93,405 26,900 66,505 9 20.6 28.93 24.4 40.9 240 31.1 24.61 61.27

India 598,038 275,800 322,238 11 12.5 23.20 30.9 56.3 200 57.7 43.75 59.37

Nepal 12,672 4,900 7,772 9 13.2 21.52 24.2 41.6 170 36 26.86 54.84

Pakistan 204,542 71,700 132,842 15 26.4 40.65 42.2 85.9 260 45 18.74 63.01 APPENDIX: NEWBORN MORTALITY STATISTICS NEWBORN BY COUNTRYAPPENDIX: 5 2.95 11.73 19.32 70.10 39.68 55.92 49.88 55.68 23.36 80.69 78.05 Out-of- pocket expenditure as a % of total health expenditure 5 3.61 91.05 31.85 93.39 43.32 38.42 30.29 56.2 112 .28 297.34 246.33 Government expenditure on health capita) (per 4 88.6 70.1 71 79.8 37 91.9 88.5 35.7 42.7 70.6 Skilled attendance at birth (%) 62.2 3 59 93 43 63 99 470 250 230 220 200 200 Maternal mortality ratio (per live 100,000 births) 2011; 377 (9774): 1319–30; Intrapartum 2011; stillbirth rates from for 2011, 2 39.7 23.0 35.2 60.0 63.0 31.1 31.0 71.8 52.3 Under-five Under-five mortality rate (per 1,000 live births) 29.8 34.4 2 14.0 18.4 12.4 15.0 27.0 24.3 13.8 Neonatal mortality rate (per 1,000 live births) 15.0 27.2 26.3 19.0 1 8.12 9.43 7.66 9.72 9.77 8.25 13.98 12.01 13.09 13.08 15.36 Intrapartum stillbirths and neonatal deaths on day of birth (per 1,000 total births) 1 2011; 377 (9775): 1448–63; 2011; Daily risk of neonatal death, updated from State of the World’s Mothers and in press 2013 Global Lancet Lancet 1.4 3.9 4.9 4.6 3.8 2.4 4.8 4.3 5.5 6.2 4.5 Intrapartum stillbirth rate (per 1,000 total births) 1 5 4 5 9 5 7 9 7 5 10 10 Risk of neonatal death on day of birth (per 1,000 live births) 1 83 415 975 844 1,438 5,891 5,565 2,028 2,826 11,475 22,056 Number of intrapartum stillbirths 1 80 910 1,900 8,700 1,800 6,900 6,900 2,400 6,200 11,40 0 25,600 Number of deaths on day of birth 1 163 9,726 1,325 4,428 2,744 8,338 2,775 11,765 47,656 14,591 22,875 Total number of deaths during birth and on day of birth , Oza S et al.; Number of stillbirths and intrapartum stillbirths updated using to 2012 live births and total births from UN Population Division. Indonesia Lao PDR Myanmar Philippines Vietnam Western Asia Western Azerbaijan Iraq Yemen Oceania Papua New Guinea Solomon Islands Country South-eastern Asia Cambodia Sources: Livebirths from UN Population Division adjusted by UN-IGME for Neonatal 2012; deaths for 2012, from The UN Inter-agency Group for Child Mortality Estimation, www.childmortality.org; 2013, Stillbirth rates for 2009, Source: WHO Global Health Observatory. Based on data from 2012. Source: Ibid. Based on data from 2010. Source: Ibid. Based on data from 2005–2012. Source: Ibid. Based on data from 2011. Health Lawn JE, Blencowe H, et al. Stillbirths: Where? When? Why? How to make the data count? from Cousens S, Blencowe H, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet * This is the figure reported in the WHO Global Health Observatory (2006 data). comesIt should from be householdnoted that surveys,this differs while WHO from usesMultiple modelling Indicator for its estimates. Cluster Survey Due to(MICS) the country data for context, the same year therewhich arereports difficulties coverage** 33%.in of Stillbirthcollecting MICS data accurate and intrapartum representative stillbirth data. data are not available for South Sudan as these are based on 2009 data, before the country was formed. 1 2 3 4 5

41 ENDNOTES

EXECUTIVE SUMMARY 14 Lawn JE et al, Stillbirths: Where? When? Why? How to make the data count? The Lancet, Volume 377, Issue 9775, Pages 1448–63, 23 April 1 United Nations Inter-agency Group for Child Mortality Estimation. 2011. Levels and trends in child mortality: Report 2013. New York, USA: UNICEF, 2013. http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf 15 Countdown to 2015 for Maternal, Newborn, and Child Health is a collaboration of academics, governments, international agencies, 2 This is based on population growth in the least developed countries, health-care professional associations, donors, and nongovernmental which increased from 509,354,000 in 1990 to 878,097,000 in 2012. organisations to promote accountability for MDGs 4 and 5. Save the Reference: United Nations, Department of Economic and Social Affairs, Children is a member. See http://www.countdown2015mnch.org/ Population Division. World Population Prospects: The 2012 Revision. New York: United Nations, 2013. http://esa.un.org/wpp/Documentation/ 16 World Health Organization. Global Health Observatory Data publications.htm Repository. http://apps.who.int/gho/data/node.main (accessed 20 December 2013). 3 Intrapartum stillbirth rate is based on: Lawn JE et al, Stillbirths: Where? When? Why? How to make the data count? Lancet, Volume 377, 17 UNICEF. Progress for children: achieving the MDGs with equity. New Issue 9775, Pages 1448–63, 23 April 2011. Total number of intrapartum York: UNICEF, 2010. http://www.unicef.org/protection/Progress_for_ stillbirths is updated to 2012 using live births and total births from UN Children-No.9_EN_081710.pdf Pop Div latest estimates. 18 World Health Organization. The world health report: health systems 4 Pattinson R, Kerber K, Buchmann E, et al. Stillbirths: how can health financing: the path to universal coverage. Geneva: WHO, 2010. systems deliver for mothers and babies? Lancet 2011; 377: 1610–23. http://www.who.int/whr/2010/whr10_en.pdf 5 Calculated as the number of live births not attended by skilled health 19 Lassi ZS, Majeed A, Rashid S, Yakoob MY, Bhutta ZA. The personnel. Skilled birth attendant coverage based on data from the interconnections between maternal and newborn health – evidence and WHO Global Health Observatory Data Repository: http://apps.who. implications for policy. J Matern Fetal Neonatal Med. 26(Suppl 1): 3–53. int/gho/data/node.main (accessed 20 December 2013). Number of live 20 Whitaker K. Is Sierra Leone right to ban traditional birth attendants? births based on data from State of the World’s Children statistics: The Guardian, 2012. http://www.theguardian.com/global-development/ http://www.unicef.org/sowc2013/statistics.html (accessed 20 December poverty-matters/2012/jan/17/traditional-birth-attendants-sierra-leone 2013). (accessed 17 January 2014). 6 The Every Newborn Action Plan target is for a two-thirds reduction in the newborn mortality rate, which would result in a 2035 global NMR of 7 per 1,000 live births. This rate is similar to the highest NMR 2 HOW CAN NEWBORN DEATHS within the OECD countries and may be taken as a proxy for ending all BE PREVENTED? preventable newborn deaths. If the target of 7/1000 had applied to the 21 Lawn JE, Lee AC, Kinney M, et al. Two million intrapartum-related 2012 NMR (20.8/1000 which resulted in 2.9 million newborn deaths), stillbirths and neonatal deaths: where, why, and what can be done? Int J approximately 2 million lives would have been saved. Gynaecol Obstet 2009; 107(Suppl 1): S5–18, S9. 22 Lawn JE, Blencowe H, Pattinson R, et al. Stillbirths: Where? When? 1 A CRISIS – AND AN OPPORTUNITY Why? How to make the data count? Lancet 2011; 377: 1448–63. 7 See note 1. 23 Every Newborn Bottleneck Analysis Tool. 2013. http://www. 8 See note 2. everynewborn.org/Documents/Every-Newborn-BNA-tool-12- August-2013.docx (accessed 17 January 2014). 9 United Nations Inter-agency Group for Child Mortality Estimation. 24 Levels and trends in child mortality: Report 2013. New York, USA: UNICEF, The Partnership for Maternal, Newborn, and Child Health (PMNCH). 2013. http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf A global review of the key interventions related to reproductive, maternal, newborn and child health: essential interventions, commodities and guidelines. 10 See note 3. Geneva: PMNCH, 2011. http://www.who.int/pmnch/topics/part_ 11 Save the Children. Surviving the first day: State of the World’s publications/essential_interventions_18_01_2012.pdf Mothers 2013. London, UK: Save the Children International, 2013. 25 March of Dimes, PMNCH, Save the Children, WHO. Born Too http://www.savethechildrenweb.org/SOWM-2013 Soon: The Global Action Report on Preterm Birth. Geneva: World Health 12 The four interventions are: corticosteroid injections for women Organization, 2012. http://www.marchofdimes.com/mission/global- with threatened preterm labour; resuscitation devices; chlorhexidine preterm.aspx cord cleansing; and injectable antibiotics. Reference: Save the Children. 26 Coffey P, Kak L, Narayanan I, Bergeson L, Singhal N, Wall S, Surviving the first day: State of the World’s Mothers 2013. London, UK: Save Johnson J, Schoen E. Case Study: Newborn Resuscitation Devices. the Children International, 2013. http://www.savethechildrenweb.org/ United Nations Commission on Commodities for Women’s and SOWM-2013 Children’s Health, February 2012. 13 Stillbirth rate is based on: Cousens S, Blencowe H, Stanton C, et al. 27 Bhutta ZA, Yakoob MY, Lawn JE, et al. Stillbirths: what difference can National, regional, and worldwide estimates of stillbirth rates in 2009 we make and at what cost? Lancet 2011; 377: 1523–38. with trends since 1995: a systematic analysis. Lancet 2011; 377: 1319–30. 28 Total number of stillbirths is updated to 2012 using live births and total Yakoob MY, Ali MA, Ali MU, et al. The effect of providing skilled birth births from UN Population Division latest estimates. attendance and emergency obstetric care in preventing stillbirths. BMC Public Health 2011; 11 Suppl 3: S7.

42 ENDNOTES 43 2013; 382: 2013; 1029–38. . Washington, DC: World 2012; 380: 2012; 917–23. . Geneva: WHO, 2010. . London, UK: Save the Children, . Geneva, London, New York: 2012; 380: 2012; 1169–78. : Policy brief. Johannesburg: African Union, Union, Johannesburg: African brief. Policy : . London, UK: Save the Children, https://www. 2013. M

World Bank. Global conference on universal health coverage for inclusive Stenberg K, Axelson H, Sheehan et al. Advancing P, social and Brearley L, Marten R, O’Connell Universal T. Health Coverage: Save the Children. Getting to Zero: How we can be the generation World Health Organization. The world World health report: health systems Save the Children has a partnership with RB and is a recipient of See note 6. African Commission. Union Nutrition and Reproductive, Maternal, Yates R. Women and children first: an appropriate first step towards Save the Children has a partnership with GSK and is a recipient of Walker N, Yenokyan G, Friberg IK, Bryce J. Patterns in coverage Save the Children. Midwives Missing This LiST analysis was conducted for RMNCH interventions to Jim Kim. Yong Speech to the World Health Assembly, May 2013. 21 Azerbaijan, Bangladesh, Benin, Bolivia, Burkina Faso, Burundi, Marmot M. Universal health coverage and social determinants of See http://www.healthynewbornnetwork.org http://www.healthynewbornnetwork.org See Ibid. Amouzou A, Habi Bensaid O, K, Niger Countdown Case Study Moreno-Serra R, Smith PC. Does progress towards universal health 2011. http://www.savethechildren.org.uk/sites/default/files/docs/Missing_ 2011. Midwives_1.pdf Working G. Reduction in child mortality in Niger: a Countdown to 2015 country case study. Lancet funding donations. funding funding donations. funding http://www.worldbank.org/en/news/speech/2013/05/21/world-bank- group-president-jim-yong-kim-speech-at-world-health-assembly (accessed November 16 2013). Cambodia, Cameroon, Central African Republic, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Egypt, Ethiopia, Gambia, Ghana, Guinea, Guinea-Bissau, Haiti, India, Indonesia, Kenya, Lao People’s Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Nepal, Niger, Nigeria, Pakistan, Peru, Philippines, Rwanda, Senegal, Sierra Leone, Swaziland, Tajikistan, Togo, Uganda, United Republic of Tanzania, Yemen, Zambia, Zimbabwe. of maternal, newborn, and child health interventions: projections of neonatal and under-5 mortality to 2035. Lancet analyse the impact of various population groups. For this report, we have focused on the impact on newborn lives saved. The major assumptions made include: that the national coverage is scaled up to its target coverage of the highest wealth quintile linearly in their period of that to 2015; 2013 interventions coverage did not change between the estimates abstracted from the most recent DHS/MICS and our base year of analysis of 2013. A commitment to closing the gap WHO,Save the Children, UNICEF, RockefellerFoundation, http:// 2013. www.rockefellerfoundation.org/uploads/files/57e8a407-b2fc-4a68-95db- b6da680d8b1f.pdf that ends poverty savethechildren.org.uk/sites/default/files/images/Getting_to_Zero.pdf coverage improve population health? Lancet 65 66 67 68 56 57 health. 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Data Observatory Health Revue des Dépenses Publiques Dépenses des Revue Bank. World the and Health of Ministry DRC annum. per person 1per of norm expected the to compared year per person per consultations 0.21 See http://www.internationalhealthpartnership.net/en/ See http://www.internationalhealthpartnership.net/en/ Based on 2011 data. Reference: World Health Organization. Global Global Organization. Health World Reference: 2011 on data. Based Bangladesh health watch report 2011: report watch health Bangladesh Watch. Health Bangladesh Lane R. Mushtaque Chowdhury: seeking health transition in in transition health seeking Chowdhury: Mushtaque R. Lane What will it take to achieve achieve to take it will What Programme. Development Nations United O’Hare B, Makuta I, Bar-Zeev N, Chiwaula L, Cobham A. The The A. Cobham L, Chiwaula N, Bar-Zeev I, Makuta B, O’Hare Ibid. Based on 2012 on data. Based Business Case and Intervention Summary: Access to Health Health to Access Summary: Intervention and Case Business DFID. Based on 2012 data. Reference: World Health Organization. Global Global Organization. Health World Reference: 2012 on data. Based Global conference on universal health coverage for inclusive inclusive for coverage health universal on conference Global Bank. World Das S and Horton R. Bangladesh: innovating for health. Lancet health. for innovating Bangladesh: R. Horton Sand Das International Health Partnership. Partnership. International Health Based on per capita total expenditure on health (PPP int. $) in 2011. in $) int. (PPP health on expenditure total capita per on Based Per capita government expenditure on health (PPP int. $) was $10.8 in $10.8 in was $) int. (PPP health on expenditure government capita Per Based on 2011 data. World Health Organization. Global Health Health Global Organization. Health World 2011 on data. Based The average utilisation rate of health care services is approximately approximately is services care health of rate utilisation average The How do the poor cope with shocks shocks with cope poor the do How al. et HZ, Rahman I, Sharif I, Santos Ibid.

C 2013. 2013; 382:1695. . 2007. Cited in: see note 87. note see in: . 2007. Cited IHP+ Global Compact Global IHP+ . Dhaka: BRAC, 2012. 2012. BRAC, . Dhaka: . Policy Research Working Paper Paper Working Research . Policy 19 November 2013, early 2013, early 19 November . Washington, DC: World World DC: . Washington, . http://www. . New . New 2013; 2013; uploads/2013/09/2012-2013-Oxfam-Final-Annual-Report-ghana.pdf 2013. http://www.oxfamblogs.org/westafrica/wp-content/ added tax. tax. added (accessed 9 December 2013). 9(accessed December http://apps.who.int/gho/data/node.main Repository. Data Observatory versus 39 amongst the richest, based on 2005 data. Reference: Ibid. Reference: data. 2005 on based richest, the 39amongst versus 9 December 2013). 9 December (accessed http://apps.who.int/gho/data/node.main Repository. uploads/2013/09/2012-2013-Oxfam-Final-Annual-Report-ghana.pdf 2013. http://www.oxfamblogs.org/westafrica/wp-content/ Strengthen the Health System). System). Health the Strengthen 100–9. 41(3): 2007; J Med Ghana regions. two in utilization service delivery in changes of estimates population Ghana: in policy exemption fee 91 90 89 98 97 96 95 94 93 92 110 109 108 107 106 105 104 103 102 101 100 99 Bank, 2013. Bank, report synthesis aglobal growth: sustainable and 2013. http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf 2013. http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf 2013 Report mortality: child in trends and Levels ICF International, 2012. and Agency Statistical Central USA: Maryland, Calverton, and Ethiopia 2011 Survey and Health Demographic International. Ethiopia ICF [Ethiopia], Agency Statistical Central Reference: vaccine. (DPT3) =article&id=79&Itemid=194 (accessed 17 January 2014). 17 (accessed =article&id=79&Itemid=194 January Welfare Family and Health of Ministry of initiative new the Karyakram, Suraksha Shishu Janani on note Abrief Mission. Health National Reference: areas. urban events_13459.html (accessed 17 January 2014). 17 January (accessed events_13459.html 1990 since thirds WHO Global Health Observatory. Health Global WHO Source: data. 2008 on based is data equity while 2012 on data based are figures National richest. the 93% amongst to compared children, poorest the amongst 90% nearly is coverage DTP3 vaccine. (DPT3) Bal_Swaasthya_karyakaram.pdf 2013. http://www.unicef.org/india/7._Rastriya_ India, of Government NRHM under Services Intervention Early and Screening Health Child (RBSK): Karyakram Swasthya Bal Rashtriya Welfare. &Family Health of Ministry Reference: schools. aided Government and Government in enrolled age of 18 to years up children older as well as slums, urban United Nations Inter-agency Group for Child Mortality Estimation. Estimation. Mortality Child for Group Inter-agency Nations United Global conference on universal health coverage for inclusive inclusive for coverage health universal on conference Global Bank. World Oxfam Ghana annual report 2012–2013 report annual Ghana Oxfam. Oxfam Based on coverage of three doses of diphtheria-pertussis-tetanus diphtheria-pertussis-tetanus of doses three of coverage on Based Based on 2011 data. World Health Organization. Global Health Health Global Organization. Health World 2011 on data. Based World Health Organization. Global Health Observatory Data Data Observatory Health Global Organization. Health World Ethiopia meets MDG 4 by cutting under 5 mortality by two- by 5mortality under cutting 4by MDG meets UNICEF. Ethiopia Stratégie pour le Renforcement du Système Santé (Strategy to to (Strategy Santé Système du Renforcement le pour Stratégie Oxfam. This is despite actually contributing to the system through value value through system the to contributing actually despite is This See note 87. note See Services are free in Government health institutions in both rural & rural both in institutions health Government in free are Services Penfold S, Harrison E, Bell J, Fitzmaurice A. Evaluation of the delivery delivery the of Evaluation A. Fitzmaurice J, Bell E, Harrison S, Penfold Based on 2009 data. Reference: Ibid. Reference: data. 2009 on Based Based on coverage of three doses of diphtheria-pertussis-tetanus diphtheria-pertussis-tetanus of doses three of coverage on Based Based on 2008 data. Source: WHO Global Health Observatory. Health Global WHO Source: data. 2008 on Based The programme covers all children aged 0–6 in rural areas and and areas rural in 0–6 aged children all covers programme The The under-five mortality rate amongst the poorest households is 117households poorest the amongst rate mortality under-five The WHO Global Health Observatory data repository. data Observatory Health Global WHO WHO Global Health Observatory data repository. data Observatory Health Global WHO Based on 2005 data. Reference: Ibid. Reference: data. 2005 on Based Ibid. Oxfam Ghana annual report 2012–2013 report annual Ghana Oxfam . http://nrhm.gov.in/index.php?option=com_content&view . 13 September 2013. http://www.unicef.org/ethiopia/ . New York, USA: UNICEF, UNICEF, USA: York, . New . Washington, DC: World World DC: . Washington, . Accra: Oxfam, Oxfam, . Accra: . Accra: Oxfam, Oxfam, . Accra: . Addis Ababa, Ababa, . Addis . New Dehli: Dehli: . New ENDNOTES 45 2013; . Colombo: , 2011, 61(3): 210-215. 61(3): , 2011, . Islamabad: Technical Resource Facility, 2012, New Voices in Global Health. 2011; xlvi: 30. 2011; 2011; 377: 2011; 1319–30. . Geneva: World Health Organization, GHWA, Lu C, Chin B, Lewandowski JL, et al. Towards Universal Health Wazir MS, Shaikh Ahmed BT, A. Nationalprogram for family planning Ibid. World Health Organization. Global Health Observatory Data The benefit package includes inpatient, outpatient and community Hafeez, A, Mohamud, BK, Shiekh, MR, Shah, SAI and Jooma, R. Lady Ibid. Ibid. Lu C, Chin B, Lewandowski JL, et al. Towards Universal Health World Health Organization. Global Health Observatory Data Cousens S, Blencowe H, Stanton C,et al. National, regional, and Coverageis 77% in the richest households, compared in the to 16% Makaka A, Breen S, Binagwaho A. Universal health coverage in World Health Organization. Global Health Observatory Data Khan A. Lady Health Workers and Social Change in Pakistan. Based data. on 2010 Reference: Ibid. World Health Organization. Global Health Observatory Data Global Health Workforce Alliance. Country Case Study: Pakistan’s Lady Technical Resource health child and Facility. maternal national Pakistan Department of Census and Statistics and Ministry of Healthcare and care, and covers a wide range of services from antiretrovirals to coronary bypass surgery. The few exceptions to free access include: family planning commodities; some private-paying wards in a small number of government hospitals; and one tertiary care hospital that was constructed with donor funds and stipulates the charging of user fees. Repository. http://apps.who.int/gho/data/node.main (accessed 9 December 2013). Nutrition. Sri LankaNutrition. Demographic and Health Survey 2006–07 Department of Census and Statistics, 2009. http://www.statistics.gov.lk/ social/DHS%20200607%20FinalReport.pdf Economic & Political Weekly Political & Economic Repository. http://apps.who.int/gho/data/node.main (accessed 17 January 2014). Health Worker Programme Health Worker poorest, based on2006 data. Source: World Health Organization. Global Health Observatory Data Repository. http://apps.who.int/gho/ data/node.main January (accessed 17 2014). 151 152 143 144 145 146 147 148 149 150 134 135 136 137 2008. http://www.who.int/workforcealliance/knowledge/case_studies/ CS_Pakistan_web_en.pdf 138 139 140 141 142 133 Coverage: An Evaluation of Rwanda Mutuelles in its First Eight Years. e39282.PloS One 7(6): 2012; Coverage: An Evaluation of Rwanda Mutuelles in its First Eight Years. e39282.PloS One 7(6): 2012; and primary health care Pakistan: a SWOT analysis. Health Reprod http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3842797/ 60. 10(1): programme: mid-term evaluation programme: http://www.trfpakistan.org/LinkClick.aspx?fileticket=wrJZXuQPX 2013. JI%3D&tabid=2440 Rwanda: a report of innovations to increase enrolment in community- based health insurance. Lancet http://download.thelancet.com/flatcontentassets/pdfs/new-voices/ newvoices2012-11.pdf worldwide estimates of stillbirth rates in 2009 with trends since a 1995: systematic analysis. Lancet health workers programme in Pakistan: challenges, achievements and the way forward. J Pak Med Assoc Repository. http://apps.who.int/gho/data/node.main (accessed 9 December 2013). Repository. http://apps.who.int/gho/data/node.main (accessed 17 January 2014)...... 2007, Government of . New York, USA: UNICEF, . Washington DC: . Brooke Shearer Working Paper . Abuja: National Population Commission, Commission, Population Abuja: National . . Oxford: Oxford Policy Management, 2011. 2012; 27 Suppl 27 2012; 3: iii57–71. Government of Nepal. National Health Insurance Policy 2013 Pradhan YV, Upreti SR, Pratap KCN, et al. Newborn survival in Ibid. Government of Nepal. National Health Insurance Policy 2013 Ibid, based on 2008 data. World Health Organization.Global Health Observatory Data World Health Organization. Global Health Observatory Data Based data. on 2011 World Health Organization.Global Health Government of Nepal. National Health Insurance Policy 2013 Gustafsson-Wright E and Schellekens Achieving O. universal health Ibid. United Nations Inter-agency Group for Child Mortality Estimation. National Commission. Population Nigeria Demographic and Health Based on 2007 data. Reference: Ibid. Lievens Witter T, S. Community health financing: which role in Now known as the Essential Package of Health Services (EPHS). Republic of Liberia, Ministry of Health and Social Welfare, 2012. Ramana GNV. Improving universal primary healthcare by Kenya: Ibid. MOH, Public Expenditure Tracking Survey2007 World Health Organization.Global Health Observatory Data The Rashtriya Swasthya Bima Yojana (RSBY) is a national-level Repository. http://apps.who.int/gho/data/node.main (accessed 9 December 2013). a case study of the Health Sector Services Fund World Bank, 2013, http://www-wds.worldbank.org/external/default/ Bank, 2013, World WDSContentServer/WDSP/IB/2013/02/04/000425962_2013020411030 1/Ren/PDF/750020NWP0Box30ry0Health0Care0KENYA.pdf Observatory Data Repository. http://apps.who.int/gho/data/node.main January(accessed 17 2014). http://www.who.int/providingforhealth/countries/2013_03_Nepal_ Health_Insurance_Policy_fin.pdf Nepal: a decade of change and future implications. Health Policy and Planning health financing in Liberia http://www.mohsw.gov.lr/documents/Community%20Health%20 financing%20Pre%20feasibilith%20study%20OPM.pdf Repository. http://apps.who.int/gho/data/node.main (accessed 17 January 2014). coverage in Nigeria one state at a time: a public-private partnership community-based model health insurance Series. Washington DC: Brookings Institution, http://www. 2013. brookings.edu/research/papers/2013/06/achieving-universal-health- coverage-nigeria-gustafsson-wright scheme introduced in 2008; while state-level schemes include, eg, Rajiv Aarogyasri scheme in AndhraPradesh and Yeshwaswini scheme in Karnataka, Kalinga scheme in Nadu. Tamil Reference: Nagpal S. Expanding Health Coverage for Vulnerable Groups in India UNICO Studies Series Washington 13. DC: World Bank, 2013. 121 122 http://www.who.int/providingforhealth/countries/2013_03_Nepal_ Health_Insurance_Policy_fin.pdf 120 119 118 117 115 116 113 114 112 111 132 130 131 129 128 126 127 125 124 123 http://www.who.int/providingforhealth/countries/2013_03_Nepal_ Health_Insurance_Policy_fin.pdf Kenya: Nairobi. Annual Review Report National Health and Social Welfare Plan 2011–2012. Implementation, Levels and trends in child mortality: Report 2013 http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf2013. Repository. http://apps.who.int/gho/data/node.main (accessed 17 January 2014). 2013. http://www.measuredhs.com/pubs/pdf/PR41/PR41.pdf 2013. Survey 2013: PreliminarySurvey 2013: Report 46 ENDING NEWBORN DEATHS 17 January 2014). 17 January (accessed http://apps.who.int/gho/data/node.main Repository. 159 158 157 156 155 154 153 Uganda 2013 for Report Goals Development 2013. Millennium Development. Economic and Planning Finance, of Ministry Uganda, of Republic The Reference: seven. of afactor by progress of rate annual the increasing 8.1%, to 2011 and increased this 2006 between was 1.2%; mortality under-five Inc. International ICF Maryland: Calverton, and UBOS Uganda: Kampala, 2011 Survey and Health Uganda 2012. Demographic Inc. International opening times, etc. times, opening convenient more queues, shorter facilities, crowded less amenities, better to due care private for opt may patients sector, private and 2008. coverage care health expanding 2011; Planning and 26: ii41–ii51. Policy Health paradox. Uganda the fees: Orem JN, Mugisha F, Kirunga C, Macq J, Criel B. Abolition of user user of Abolition B. Criel J, Macq C, F, Kirunga Mugisha JN, Orem Based on 2011 data. Reference: Uganda Bureau of Statistics and ICF ICF and Statistics of Bureau Uganda Reference: 2011 on data. Based Sri Lanka: “good practice” in in practice” “good Lanka: Sri L. RP, Sikurajapathy Rannan-Eliya Between 1995 and 2006, the average annual rate reduction in in reduction rate annual average the 2006, 1995 and Between World Health Organization. Global Health Observatory Data Data Observatory Health Global Organization. Health World Ibid. While the technical quality of services is similar in both the public public the both in similar is services of quality technical the While . Kampala, Uganda: The Republic of Uganda. of Republic The Uganda: . Kampala, . Colombo: Institute for Health Policy, Policy, Health for Institute . Colombo:

. benefitting the poor? Int Health Jpoor? Equity the benefitting reforms are Uganda: in residents rural and poor among services health 13: 357. 2013; Res Serv Health BMC Uganda. of study acase scheme: insurance health national the behind processes and Players I. Chapcakova O’Connell TS, RK, Basaza 2014. in Reference: operational become and law into passed be to it for now is hope the problems encountering However, year.after 2012/13 the in financial start to expected was and years several for works the in been has It incremental. and slow go.ug/docs/HSSP_III_2010.pdf 2014/15 2010/11– development, socio-economic enhance to health people’s Promoting 164 163 162 161 160 165 2011; Planning and 26: ii41–ii51. Policy Health paradox. Uganda the fees: 2010; 9: 23. 9: 2010; Health in Equity for Journal International scheme? Insurance Health National proposed the is equitable How 2014). 17 January (accessed http://apps.who.int/gho/data/node.main Repository. World Health Organization. Global Health Observatory Data Data Observatory Health Global Organization. Health World Orem JN, Mugisha F, Kirunga C, Macq J, Criel B. Abolition of user user of Abolition B. Criel J, Macq C, F, Kirunga Mugisha JN, Orem Pariyo G, Ekirapa-Kiracho E, Okui O, et al. Changes in utilization of of utilization in Changes al. O, et Okui E, Ekirapa-Kiracho G, Pariyo Orem JN, Zikusooka CM. Health financing reform in Uganda: Uganda: in reform financing Health CM. Zikusooka JN, Orem Health Sector Strategic and Investment Plan: Plan: Investment and Strategic Sector Health Health. of Ministry Despite political commitment, development of NHIS has been been has NHIS of development commitment, political Despite . Kampala: Government of Uganda, 2010. http://www.health. Uganda, of Government . Kampala: 2009: 8: 39. 8: 2009: CHAPTER TITLE 47 ENDING NEWBORN DEATHS Ensuring every baby survives

In 2012, 2.9 million newborn babies died within 28 days. Of these, 1 million babies died on their first – and only – day of life. Unless we urgently start to tackle deaths among newborn babies, there is a real danger that progress in reducing child deaths will stall, and we will fail in our ambition to be the generation that can end all preventable child deaths. But, as Ending Newborn Deaths reveals, the crisis is even bigger. In 2012 there were 1.2 million stillbirths where the heart stopped beating during labour. This report sets out an agenda to tackle the crisis and identifies the essential interventions around birth that a properly skilled midwife or other trained health worker can deliver to save newborn lives and prevent stillbirths during labour. However, access to these services is deeply unequal and, globally in 2102, 40 million women – the poorest and most marginalised – gave birth without a trained health worker present.

To end all preventable newborn deaths and stillbirths during labour, CHILDREN THE ZORO/SAVE LUCIA PHOTO: COVER there needs to be universal access to properly trained and equipped health workers at birth. This report sets out the reforms needed to achieve universal health coverage for the poorest and hardest-to- reach communities. 2014 offers an unprecedented opportunity to tackle the crisis, with countries and global institutions set to agree the Every Newborn Action Plan. In Ending Newborn Deaths, Save the Children calls on governments, world leaders, philanthropists and the private sector to make that opportunity count and to commit to the five-point Newborn Promise to end all preventable newborn deaths.

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