PART I
Meeting the Challenge in the Developing World



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Improving Birth Outcomes: Meeting the Challenge in the Developing World PART I Meeting the Challenge in the Developing World

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Executive Summary The death of a mother, fetus, or neonate is tragic whenever it occurs. While relatively rare in the industrialized world, maternal, fetal, and neonatal deaths occur disproportionately in developing countries, where the vast majority of the 515,000 maternal deaths, 4 million late fetal deaths (beyond 22 weeks’ gestation), and 4 million neonatal deaths are conservatively estimated to occur each year. In Eastern Africa, 1 in 11 women dies of pregnancy-related causes, a lifetime risk of maternal death 500 times greater than that faced by women in some industrialized countries. Most maternal, neonatal, and fetal deaths occur between late pregnancy and the end of the first month of the child’s life and many are preventable. Yet this important period has received inadequate attention in the health care programs of most countries. This report reviews the evidence on key interventions that could greatly improve birth outcomes1 in developing countries. STUDY PURPOSE AND APPROACH The Centers for Disease Control and Prevention requested that the Institute of Medicine’s Board on Global Health undertake a study to exam- 1   In this report, a successful birth outcome is defined as the birth of a healthy baby to a healthy mother.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World ine the steps needed to improve birth outcomes in the developing world. The National Institute for Child Health and Human Development of the National Institutes of Health and the U.S. Agency for International Development joined the sponsorship of the project. The specific charge to the committee was: Birth outcomes worldwide have improved dramatically in the past 40 years. Yet there is still a large gap between the outcomes in developing and developed countries. This study will address the steps needed to reduce that gap. The study will: review statistics on low birth weight, premature infants, and birth defects; review current knowledge and practices; identify cost-effective opportunities for improving birth outcomes, reducing maternal, infant, and fetal mortality, and supporting families with an infant handicapped by birth problems; and recommend priority research, capacity building, and institutional and global efforts to reduce adverse birth outcomes in developing countries. The committee will base its study on data and information from several developing countries, and provide recommendations that can assist the Centers for Disease Control and Prevention, the National Institute of Child Health and Human Development of the National Institutes of Health, and the U.S. Agency for International Development in tailoring their international programs and forging new partnerships to reduce the mortality and morbidity associated with adverse birth outcomes. Initial discussions convinced the committee and the Board on Global Health of the importance and need for a broader study. As a result, the scope of the study was extended from addressing neonatal outcomes to including maternal and fetal outcomes in developing countries. In addition, the discussion of perinatal transmission of HIV/AIDS was expanded to a full chapter. The committee also wrote a companion report, Reducing the Impact of Birth Defects: Meeting the Challenge in the Developing World. To conduct the current study, the Institute of Medicine assembled a committee with broad international expertise in public health, neonatology, obstetrics, genetics, epidemiology, pediatrics, and clinical research. The members of the committee were also chosen for their experience on birth outcomes in a range of developing countries. The committee members are listed at the beginning of the report, and their brief biographies are given in Appendix D. Many health services offered to pregnant women in developing countries are based on traditions and “common wisdom.” Relatively few of these have been demonstrated to be effective and safe. The goal of this

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Improving Birth Outcomes: Meeting the Challenge in the Developing World study is to provide evidence-based recommendations founded on rigorous evaluations. The data for the study were assembled by the committee, consultants, and staff through bibliographic references on related topics and through databases such as Medline, university libraries, and Internet sites of organizations associated with research and services for birth outcomes. Although much of the published information on birth outcomes in developing countries was found in international and national journals and reports, some of the evidence has appeared in local journals, the proceedings of meetings, and unpublished reports. To tap this knowledge base, the committee enlisted experts with recent research or service experience in developing countries. Data and supportive evidence were provided by these experts through workshop presentations and technical consultation on the report chapters (see Appendix A). The framework for the committee’s examination of birth outcomes included an overview of epidemiological parameters; a review of the current knowledge base on interventions; and a review of the feasibility, cost, and impact of proposed interventions. The combined weight of such evidence, the committee believes, has produced an accurate account of the state of knowledge concerning the epidemiology of neonatal and maternal mortality and morbidity and fetal mortality, prevention and care in developing countries, and the capacity of health care systems to provide appropriate prevention and care with limited resources. Evaluation of the evidence base enabled the committee to identify gaps in knowledge and to propose strategies for a research agenda that would fill these gaps. The findings, strategies, and recommendations included in the report were developed from this broad base of evidence; areas are noted in which the data are inadequate to support definitive conclusions. While the committee explicitly searched for the best evidence available on interventions with the potential to improve birth outcomes, and has built its recommendations on this scientific foundation, a note of caution is in order with regard to the nature and adequacy of the evidence base. The best available evidence is sometimes inadequate for a satisfactory evaluation of the cost and effectiveness of promising health care interventions in developing countries. It is often difficult to generalize the results of studies carried out in developed countries to developing-country settings. The results of an intervention can differ from one setting to another, and the delivery of interventions is likely to vary considerably across settings. Thus the committee’s recommendations regarding the effectiveness of certain interventions in different health care systems are informed by expert judgement as well as scientific research. The committee’s research recommendations emphasize the importance of research to recognize priority reproductive health problems, identify effective interventions to address these problems, implement the interventions, monitor and assess their effectiveness in diverse settings, and tune them for maximal clinical- and cost-effectiveness.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World PRINCIPAL ATTRIBUTES OF THE PROBLEM The Social, Cultural, and Economic Context While recognizing the profound influence of social, cultural, and economic factors on birth outcomes and supporting efforts to counteract their negative effects, this study focuses on interventions and health care services that can rapidly reduce maternal, neonatal, and fetal mortality. However, it is clear that to be successful, such interventions must not only be clinically effective, but must take into account the following major influences on birth outcomes. Poverty At the individual and the population level, poverty tends to reduce the availability of all types of health services. Populations with high infant mortality generally have low GDP per capita and significant inequalities in income. Women in poverty face higher rates of infectious disease, including malaria, rubella, and HIV/AIDS, that also pose risks to the fetus and neonate. Unhygienic conditions, frequently associated with poverty, increase the risk of maternal and neonatal sepsis. Malnourished mothers are at increased risk for complications and death during pregnancy and childbirth and their infants are more likely to have low birth weight, fail to grow at a normal rate, and have higher rates of disease and death. Women’s education and socioeconomic status Maternal education, literacy, and overall socioeconomic status are powerful influences on the health of both mother and newborn. Where women’s social or economic status is low, maternal mortality tends to be higher. The educational level of women relative to men in a society both determines and is determined by the degree of autonomy and power held by women. Women’s educational and socioeconomic status also influence age at marriage and first pregnancy, use of family planning, and the prevalence of domestic violence. Female literacy has been found to be a strong predictor of family size and birth spacing, which in turn strongly affect birth outcome. Female literacy also appears to influence the proportion of physicians and nurses in a population. Unintended pregnancy Worldwide estimates indicate that between 100 and 150 million married women want to postpone or stop childbearing, but lack access to

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Improving Birth Outcomes: Meeting the Challenge in the Developing World family planning services. Other barriers to women’s control of their own reproduction include poverty, lack of education, and low social status. A major consequence of the unmet need for family planning is maternal mortality and morbidity—including infertility—due to unsafe abortion. The 20 million unsafe abortions estimated to occur each year, 90 percent in developing countries, result in more than 70,000 maternal deaths. Most of these women live in countries where abortion is illegal. Maternal age and parity The following factors have been associated with an increased risk of infant death: a mother older than 35 years; a very young (early adolescent) mother; birth intervals of less than 2 years; and four or more older children. Traditions in many developing countries promote early marriage and frequent childbearing, and many women—due to cultural norms, lack of access to birth control, or both—continue to bear children until they reach menopause. Interpregnancy intervals of less than 6 months may be associated with increased risk of low birth weight. Advanced maternal age has consistently been associated with increased risk for fetal and neonatal deaths, primarily due to chromosomal abnormalities. Cultural barriers to obstetric and neonatal care Life-threatening complications for pregnancy and childbirth frequently go unrecognized in developing countries. Pregnancy is widely considered to be a time of well-being; complications may be viewed as fated due to a woman’s misbehavior. Where such beliefs prevail, women and traditional birth attendants tend to perceive obstetric complications as supernatural and best treated through traditional means. When women recognize the need for obstetric care, the sometimes well-founded belief that care will be of poor quality may inhibit them from seeking that care. Those who reach an appropriate medical facility may also find that differences in language, behavior, and expectations between a woman experiencing complications and the medical staff limit her access to care. The invisibility of many fetal and neonatal deaths that occur at home, along with the widespread acceptance of these deaths, poses major barriers to reducing fetal and neonatal mortality. In many cultures, a child’s birth is not acknowledged until he or she has survived the first days or weeks of life. Until the critical period of survival has passed, mother and infant may be isolated, which can delay access to medical care if either becomes ill. Such delays are particularly dangerous for mothers and neonates with infections, as their survival often depends on receiving care within hours of the appearance of symptoms.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Adverse Birth Outcomes Deaths of both mothers and infants are concentrated in the period spanning the onset of labor through the first 28 days postpartum. During those few weeks, most maternal deaths (except those due to unsafe abortion) and almost two-thirds of infant deaths occur. The intrapartum period is the most likely time for late fetuses to die. Labor is also particularly perilous for the fetus in rural areas, where few women receive skilled assistance at childbirth. Neonates are at greatest risk in the 48 hours after birth. For mothers, both periods are of high risk. Half of maternal, late fetal, or neonatal deaths occur in the intrapartum period and the next 48 hours. Inadequate data on birth outcomes The true magnitude of death, disease, and injury associated with poor birth outcomes in developing countries has not been established. Countries with the highest estimated maternal, neonatal, and fetal mortality rates also have the lowest registration of births and neonatal deaths; an even lower proportion of fetal deaths are recorded. Several factors contribute to this situation, including the absence of national systems for registration of vital statistics, failure to report deaths that occur in the home, the lack of consistent international definitions of neonatal mortality, and cultural practices that confer “personhood” on infants only after they have survived their first days or weeks. Inadequate data on late fetal deaths are partly responsible for their not being included in calculations of the global burden of disease. Maternal mortality Maternal death (death while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management) is a leading cause of death for women between the ages of 15 and 49. Ninety-nine percent of maternal deaths occur in the developing world, where one in four women suffers from an acute or chronic disability related to pregnancy. The five major causes of maternal mortality are hemorrhage, sepsis, unsafe abortion, eclampsia, and obstructed labor. Together these account for more than two-thirds of maternal mortality. Indirect causes of maternal death, which are responsible for approximately 20 percent of maternal mortality, include pre-existing conditions such as malaria and viral hepatitis that are exacerbated by pregnancy or its management.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Neonatal mortality The greatest risk of childhood death occurs during the neonatal period. About 40 percent of all deaths to children under 5 years of age, and nearly two-thirds of all infant deaths (between birth and 12 months) occur during the neonatal period (the first month of life). Approximately 98 percent of the approximately 4 million neonates who die each year are born in the developing world. The major causes of neonatal death are asphyxia, infection, complications of preterm birth, and birth defects in the early neonatal period (0-6 days); infections cause the majority of late neonatal (7-27 days) deaths. Health services in the antenatal, labor and delivery, and postnatal periods can be refined to prevent or reduce neonatal mortality and severe morbidity, and can be made both accessible and workable in different developing country settings. Fetal mortality If, after separation from the mother, a fetus does not breathe or show other evidence of life (beating of the heart, pulsation of the umbilical cord, definite movement of voluntary muscles), the death is classified as fetal rather than neonatal. Antepartum fetal deaths occur before the onset of labor and are associated with a variety of risk factors, including maternal conditions, obstetric complications, and advanced maternal age. Intrapartum fetal deaths, which occur during labor, frequently result from maternal conditions or obstetric complications. With skilled assistance and access to the appropriate level of care, such complications can often be handled successfully. Where skilled health care services are not available and where many deliveries occur at home, as in many developing country settings, the proportion of intrapartum fetal deaths and overall fetal mortality are both much higher. The fetal deaths most amenable to prevention generally occur late in gestation (after 28 weeks) and involve a potentially viable fetus. Late fetal deaths are not included in estimations of the global burden of disease. They are not, therefore, recognized by decision makers for their significant role in that burden. Health Care Systems Effective obstetric and neonatal services depend on skilled care at each delivery and, in the case of complicated deliveries, access to good quality referral care. Building this healthcare capacity involves personnel, facilities, equipment, and supplies. Personnel is the most important category, and it is complicated by the shortage of physicians, midwives, and nurses throughout much of the developing world. This shortage is exacerbated by the

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Improving Birth Outcomes: Meeting the Challenge in the Developing World concentration of skilled staff in urban areas and recruitment of staff, particularly nurses, by developed countries such as the United States and the United Kingdom. Another challenge to achieving greater population coverage with effective health interventions, including those to reduce maternal and neonatal mortality, is the low level of total health expenditures in developing countries. With the average annual per capita health care expenditure in low-income countries at US$26 in 2002 and only half that amount in the 48 poorest countries, additional funds are clearly necessary to improve birth outcomes and health care in general. Since the 1980s, many countries have undertaken health reforms, including introduction of user charges, delivery of a more focused set of essential health services, and coordination of donors, in an effort to improve the accessibility, equity, quality, and efficiency of services. Four models of health care are currently provided in communities across the world: Model 1, the most basic, involves home delivery by a nonprofessional; Model 2, home delivery by a professional; Model 3, delivery by a professional in a clinic or hospital with basic essential care; and Model 4, delivery by a professional in a hospital with comprehensive essential care. Model 1 and even Model 2 may not have the capacity to refer complicated cases to a health facility that provides basic or comprehensive essential care (as described in Chapter 2). Experience in developing countries suggests that Model 2 or 3 care is clinically- and cost-effective for uncomplicated deliveries. Model 4 care can be a valuable and cost-effective resource when most of the deliveries are referrals by skilled attendants rather than by patients on their own. Complications of childbirth may lead to neonatal, maternal, or fetal death unless each of the following four steps is taken in a timely way: recognizing the problem, making the decision to seek care, reaching an appropriate medical facility, and obtaining the needed care. For many women in developing countries, each step in this pathway is blocked. Similarly, few neonates in the rural areas of developing countries receive medical care. Most obstetric and neonatal complications can be managed successfully if recognized and treated in a timely manner, but only about half of all births in developing countries are assisted by a skilled birth attendant who has been trained to detect and respond to complications. Even when complications are recognized, many women in rural areas lack access to a medical facility with appropriate services. Their way may be barred by the lack of 24-hour, good quality essential services; distance and the lack of affordable transportation; or the cost of needed services. Clearly, successful strategies to improve birth outcomes must not only address the direct causes of maternal, neonatal, and fetal mortality, but must also address their implementation within health care systems.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Three additional neonatal challenges Three conditions that pose additional challenges to neonatal health in developing countries are low birth weight (LBW), birth defects, and HIV/ AIDS. Each is associated with medical, social, and cultural risk factors that affect their incidence and severity in a given setting. More than 20 million LBW infants are estimated to be born each year. This includes 17 percent of the neonates born in developing countries—nearly three times as many as in developed countries. LBW increases the risk of infant mortality, may lead to problems in infant and child development, and may increase the risk for certain chronic disorders in adulthood. More than 4 million children are born each year with birth defects.2 As infant mortality and morbidity due to infectious diseases and birth asphyxia are controlled, the relative contribution of birth defects increases. Risk factors for birth defects that may be higher in developing countries include infectious diseases and nutrient deficiencies in the mother during pregnancy. HIV/AIDS, a worldwide epidemic, has devastated sub-Saharan Africa and is a serious problem in several other countries. Mother-to-child transmission of HIV produces about 800,000 new HIV infections each year, the vast majority of which occur in developing countries. About one in three children born to HIV-infected mothers in the developing world becomes infected. In developed countries, by contrast, antenatal testing and antiretroviral therapy programs have reduced mother-to-child HIV transmission to about 5 percent. FINDINGS AND FUTURE STRATEGIES Policymakers concerned with maternal and child health have long recognized the need to reduce both maternal and infant mortality. While this study recognizes the common ground between these historically separate goals, it also emphasizes the need to address the specific causes of mortality for mother, neonate, and fetus with practical, affordable interventions. Improving Birth Outcomes Now The committee’s first four recommendations are for implementation now. They are developed in chapters addressing maternal and neonatal mortality, overall health systems, LBW, birth defects, and HIV. The specific recommendations from these chapters are integrated here to provide a 2   See the companion report, Reducing the Impact of Birth Defects: Meeting the Challenge in the Developing World.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World comprehensive set of priority interventions for each stage of pregnancy. The recommendations are given in priority order. The committee identified two interventions they considered key to the reduction of maternal, fetal, and neonatal mortality: skilled attendance during labor and delivery, and in the event of complications that cannot be addressed by the birth attendant, timely access to essential care for the mother and/or neonate. While traditional birth attendants provide invaluable physical and emotional support during the birth process, reducing mortality requires that labor and delivery be handled by skilled medical staff, such as a midwife, physician, or nurse. The components of skilled care include clean and safe delivery practices that minimize maternal and neonatal infection, the use of the partograph to monitor the progress of labor, neonatal resuscitation, recognition of complications requiring a higher level of care, along with the capacity to organize a prompt and appropriate referral. Recommendation 1. Every delivery, including those that take place in the home, should be assisted by a skilled birth attendant (a midwife, physician, or nurse) who has been trained to proficiency in basic techniques for a clean and safe delivery; recognition and management of prolonged labor, infection, and hemorrhage; and recognition and resuscitation of neonates who fail to initiate respiration at birth. Where necessary, the birth attendant should also be prepared to stabilize and swiftly refer the mother and/or neonate to a facility providing essential obstetric and neonatal care (Chapters 2 and 3).3 Future significant reductions in maternal, neonatal, and fetal mortality can be achieved if complications in labor and delivery are anticipated and addressed promptly. For example, treatments for hypertensive disease of pregnancy can prevent or minimize the recurrence of life-threatening convulsions; vacuum extraction, use of forceps, and cesarean section can be used to manage obstructed labor; preventive medications and blood transfusion can reduce maternal deaths due to postpartum hemorrhage. Access for the majority of a population to the appropriate level of care also requires strong referral systems that include communication with, and transportation to, referral facilities. Recommendation 2. Essential obstetric and neonatal care should be accessible to address all complications of childbirth that cannot be managed by a skilled birth attendant. This requires a network of good-quality essential care facilities that provide basic essential obstetric care: administration of antibiotic, oxytocic, and anticonvulsant drugs; 3   This issue is also discussed in Appendix E, Dissenting Note by Dr. Abhay Bang.  

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Improving Birth Outcomes: Meeting the Challenge in the Developing World manual removal of the placenta; removal of retained products of conception; and assisted vaginal deliveries. Comprehensive essential obstetric care facilities have the capacity to perform these basic services and also surgery and blood transfusion. Services for essential neonatal care should emphasize the diagnosis and treatment of infection. Access for the majority of a population to the appropriate level of care also requires strong referral systems that include communication with, and transportation to, referral facilities (Chapters 2, 3, and 5). The postpartum period—particularly the first 48 hours—is, after labor and delivery, the most important time for reducing maternal and neonatal mortality. Many deaths could be prevented through a combination of clean and safe delivery (by a skilled birth attendant, as described above) and prompt diagnosis and treatment of infection during the first month postpartum. Postpartum maternal complications such as hemorrhage require similar prompt treatment. Postpartum care should also provide guidance on infant feeding, thermal control, and clean and safe neonatal care. Recommendation 3. Postpartum care is critical during the first hours after birth and important throughout the first month. Such care should emphasize: for the mother, the prevention, timely recognition, and treatment of infection, postpartum hemorrhage, and complications of hypertensive disease of pregnancy; and, for the neonate, the prevention, timely recognition, and treatment of infection, thermal control, and promotion and support of early and exclusive breastfeeding4 (Chapters 2 and 3). Several effective preconceptional and antenatal services, beginning with family planning, can reduce the risks for maternal, neonatal, and fetal mortality. These services, which can be provided in about five antenatal visits, can also counsel women on risks to a healthy pregnancy, encourage them to plan clean and safe deliveries with skilled assistance, and alert them to recognize and seek appropriate medical assessment of danger signs during pregnancy, labor, and delivery. Recommendation 4. The following strategies are recommended for incorporation into preconceptional and antenatal care: Greater access for women and men of reproductive age to family planning services that provide effective contraception along with counseling on the risks for adverse birth outcomes (Chapter 2). Discouragement of women from childbearing after age 35 to 4   See also recommendation 4 with respect to HIV.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World minimize the risk of chromosomal birth defects such as Down syndrome (Chapter 7). Immunization against rubella for women before they reach reproductive age (Chapter 7). Routine and continuous provision of 400 micrograms of folic acid per day for all women of reproductive age (Chapter 7). Universal iodine fortification of salt (25-50 milligrams of iodine per kilogram of salt) (Chapter 7). Immunization against tetanus for all women of reproductive age (Chapter 3). Intermittent prophylactic and early treatment of malaria, especially for primiparae (Chapters 2 and 6). Early detection and timely management of syphilis and other sexually transmitted diseases, asymptomatic bacteriuria/urinary tract infection, and tuberculosis (Chapter 3). Counseling of women to limit alcohol consumption during pregnancy (Chapter 7). Counseling and other forms of support to stop smoking during pregnancy (Chapter 6). Early detection and timely management of hypertensive disease of pregnancy (Chapter 2). Early detection and timely management of asymptomatic urinary tract infection (Chapter 6). Counseling of women and their health care providers on locally relevant teratogenic medications to be avoided during pregnancy (Chapter 7). In areas where HIV is a public health problem (seroprevalence exceeds 1 percent), antenatal screening for HIV should be provided to women who, after counseling, give their informed consent. Women who test positive should receive antiretroviral prophylaxis to prevent mother-to-child transmission of the virus, along with appropriate counseling on infant feeding options (Chapter 8). Certain interventions may be overused or are inappropriate. Cesarean section and episiotomy tend to be overused in some middle-income countries. In settings where good hygiene is not guaranteed, vaginal examination is not appropriate. Improving Birth Outcomes in the Future Successful and sustained implementation of the first four recommendations requires the support of an effective health care system. Unfortunately,

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Improving Birth Outcomes: Meeting the Challenge in the Developing World evaluation of health care systems often relies on studies that are less rigorous than those used to evaluate individual interventions. In addition, health care systems and priorities vary with local mortality rates and the resources available for obstetric and neonatal care. This report, therefore, describes processes by which reproductive and neonatal health care may be strengthened. Key elements of this process include: A country strategy, a framework of activities, and the support of key leaders to reduce mortality associated with childbirth. Field trials to test locally appropriate models of reproductive and neonatal health care during pregnancy, labor and delivery, and postpartum. The strengthening of health care capacity through staff development and reforms, reforms in financing, and reforms in the delivery of effective health services. Staff development involves the training and supervision of skilled birth attendants as well as staff in the clinics and hospitals. Surveillance of key birth outcomes to establish a sound database for identifying the priority problems to be addressed. Monitoring, evaluation, and action on new and old interventions to tune the interventions and the health system to be clinically- and cost-effective. The capacity of the health care infrastructure, local health priorities, and resources—personnel and financial—all influence the speed with which maternal, neonatal, and fetal mortality can be reduced. To improve birth outcomes over the long term, strategies need to be advanced at every level, from local communities to international bodies. National public health policy should seek to control preventable risk factors for maternal, neonatal, and fetal mortality, and to coordinate the many institutions and organizations involved in comprehensive reproductive care. The first steps toward developing this important health capacity are to identify the goal, the process by which it can be accomplished, adequate resources, and to gain the support of political and health care leaders who can ensure success. Recommendation 5. Each country should develop a strategy to reduce maternal, fetal, and neonatal mortality; a framework of activities by which this can be accomplished; and the commitment of health leaders to accomplish these goals (Chapter 5). The first step in improving maternal, neonatal, and fetal health is the identification of priority outcomes, which must be measured with as much precision as is practical. Surveillance of maternal, neonatal, and fetal mortality and other outcomes can provide the foundation for identifying and evaluating interventions. All outcomes must be clearly defined in order to identify and evaluate interventions that address the distinct causes of mortality for each of these populations.

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Improving Birth Outcomes: Meeting the Challenge in the Developing World Recommendation 6. To determine the true burden of disease associated with adverse birth outcomes and measure the effectiveness of interventions to address these problems, basic epidemiological and surveillance data must be collected, analyzed, interpreted, and acted upon. Each country should, as resources permit, incrementally develop complete national demographic data and ongoing surveillance of maternal, neonatal, and fetal mortality and morbidity (Chapter 5). Health care services can be improved continuously over time by recognizing priorities that need to be addressed, identifying interventions that address them, implementing the interventions, assessing their effectiveness, and tuning them to be more effective. Recommendation 7. Each country should strengthen its public health capacity for recognizing and implementing interventions that have proven effective in reducing maternal, neonatal and fetal mortality in similar populations. This also involves monitoring and tuning interventions for clinical- and cost-effectiveness in the local setting (Chapter 5). CONCLUSIONS Health care services to reduce maternal, neonatal, and fetal mortality—particularly during the period spanning late pregnancy through the first month of a child’s life—have shown inadequate improvement in most developing countries. After more than a decade of increased attention to maternal health care in the developing world, maternal mortality rates have not measurably declined. Meanwhile, although significant reductions in mortality rates in children under 5 years have been achieved during the 1990s, neonatal mortality rates, which now account for the majority of infant mortality, have declined far less quickly. Over the past 15 years, however, researchers have built a significant body of knowledge on pregnancy outcomes in low-resource settings. There is increasing agreement on the interventions most likely to reduce maternal, neonatal, and fetal mortality and recognition that some interventions can benefit all three populations. Mortality rates could approach those in developed countries by effectively implementing strategies already established as effective: skilled attendance at all deliveries; referral of all deliveries with complications to good-quality essential obstetric and neonatal care; and effective antenatal and postpartum maternal and neonatal care. Continued and sustained improvement of birth outcomes, however, will require an investment in the development of effective health care systems. This will require strong health care policies supported by appropriate resources, good collection of basic surveillance data, and the public health capacity to recognize priority interventions and implement them effectively.