The World Health Organization estimates that more than nine million infants die before
birth or in the first few weeks of life each year, and that nearly all of these deaths
occur in developing countries. Most of these deaths are caused by infectious diseases;
pregnancy-related complications such as placenta previa and abruptio placentae;
delivery-related complications, including intrapartum asphyxia, birth trauma, and
premature birth. Sadly, very few programs currently exist to specifically target perinatal
and neonatal mortality. However, a cost-effective, and efficient way to introduce
interventions would be to make additions to already existing programs.
Priority interventions prior to birth include: increasing the quality and scope of
syphilis screening; improving the diagnosis and treatment of ascending reproductive tract
infections in pregnant women; expanding maternal immunization with tetanus toxoid;
including malaria prophylaxis in routine antenatal care visits, and nutritional support
for pregnant women to improve birth outcomes.
Regarding delivery, programs are urgently needed for regular re-education of community
health workers and the use of economic incentives to improve the identification and
management of malpresentation and prolonged labor; referral of complicated cases to health
center or hospital, and combating the barriers to referral compliance, including
transportation of mothers and care of other children.
In the early weeks of life, the lives of many neonates could be saved by wider use of
resuscitation techniques for asphyxiated infants; proper management of neonatal sepsis and
other infections; skin-to-skin Kangaroo Care for preterm infants, and immediate and
exclusive breastfeeding for all children.
Research is needed to determine the causes of, and risk factors for neonatal infections
at the community level. Specific studies include: community-based surveillance to identify
the principal bacterial and viral agents of neonatal infections and their drug resistance
profiles, and assessment of the consequencies of sexually transmitted diseases to fetuses
and newborns. Also useful would be evaluation of neonatal care provided in the home by
caretakers, traditional birth attendants, and community health workers, and following
cohorts of neonates for infectious outcomes.
Integrated Management of Childhood Illness (IMCI) is being adapted for acute management
of common infectious illnesses in the neonate. Priority research in the design of
diagnosis and management approaches include: identification of the signs and symptoms that
are most predictive of acute neonatal infection; development of an algorithm for use in
identifying neonatal infection, and training and testing the abilities of community health
workers to use the algorithm to identify acutely infected neonates.
Since more than 60% of infants are born at home in developing countries, more knowledge
is needed at the community level regarding obstetric care and care for neonatal illness.
Priority research includes the development of training curricula and continuing medical
education for mid-level health workers, including traditional birth attendants. Also
needed is the design of a package of simple practices for the routine post-partum care of
neonates born in the community, including proper thermal control; recognition and
resuscitation of asphyxiated neonates; promotion of early and exclusive breast feeding;
application of prophylactic antibiotics to the eyes; optimal skin and hygienic cord care;
and provision of immunizations. Evaluation of program effectiveness and impact is also
necessary.
In 1994, 45 million pregnant women were living in malarious areas, with over 23 million
in Sub-Saharan Africa alone. In settings of moderate to high malaria transmission, malaria
may cause up to 30 percent of preventable low birthweight in newborns. Research priorities
for malaria prevention and treatment include: efficacy studies of presumptive,
intermittent treatment as part of routine antenatal care in areas of high transmission;
design of methods for treatment during pregnancy using safe, effective and simple regimens
in areas of high, medium, and low transmission; evaluation of the safety and efficacy of
newly available antimalarial drugs (alone or in combinations) for treatment and prevention
in pregnancy, and studies of means to reduce malaria exposure during pregnancy such as
insecticide-permeated bed nets.
Low birth weight (LBW), or birth weight less than 2500 grams, is one of the principal
contributors to neonatal morbidity and mortality worldwide, and accounts for up to 70% of
neonatal deaths in some countries. Intrauterine growth retardation (IUGR) is the most
common form of LBW in the developing world (accounting for more than 60%), whereas most
low birth weight in infants in developed countries is due to prematurity. Risk factors for
IUGR include untreated urinary tract infections (bacterial vaginosis); ascending
reproductive tract infections, including syphilis, gonorrhea and chlamydia; low
pre-pregnancy maternal weight and height, and low caloric intake and poor weight gain
during pregnancy. Importantly, the problem of low birth weight is intergenerational: low
birth weight infants remain poorly nourished during childhood and grow up to be stunted
adults who in turn give birth to small infants, and thus must be combated at several
points during the life cycle.
Specific research activities to reduce low birth weight due to bacterial vaginosis and
sexually transmitted diseases include: surveillance studies to establish the rate and
etiology of bacterial vaginosis in different countries; evaluation of simple methods for
detection of bacterial vaginosis, and appropriate treatment, such as comparing a once
versus three-times daily treatment with metronidazole, and development of strategies to
improve knowledge and practice of methods to prevent sexually-transmitted diseases.
Studies to increase birth weight by lowering maternal malnutrition and undernutrition
throughout the life cycle include: evaluation of the safety and efficacy of maternal
caloric supplementation for reducing low birth weight; design of strategies to improve
caloric intake before and during pregnancy with the use of locally available and
acceptable food supplements; development of methods to reduce maternal anemia through the
use of iron supplements, antihelminths and antimalarials; evaluation of micronutrient
supplementation (vitamin A, calcium and zinc) for the reduction of LBW, and improved
neonatal health; and testing of optimal delivery methods for micronutrient supplementation
of children, adolescents and women.
One of the greatest challenges facing the international public health community is
creating sustainable interventions in countries where the needs are greatest. Crucial to
the success of programs is national ownership, and public-private partnerships to ensure
long-term funding. Finally, an ongoing dialogue must be established between governments
and researchers to combat perinatal and neonatal mortality. Governments must be able to
call upon researchers to help them solve health problems, and research results must be
used to formulate national programs and policies.
For the full report and presentation
graphics, visit the Child Health
Research Project website.
