Improving Birth Outcomes Meeting the Challenge in the Developing World (2003) / Chapter Skim
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3. Reducing Neonatal Mortality and Morbidity
3. Reducing Neonatal Mortality and Morbidity
Pages 90-133
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From page 91... ...
, and nearly three-quarters suffered low-risk morbidities, some in addition to high-risk conditions (Bang et al., 2001~. CAUSES OF NEONATAL MORBIDITY AND MORTALITY Most neonatal deaths occur at home, following unsupervised deliveries; thus little accurate information is available as to their causes (Stoll, 91
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From page 92... ...
Strategies to reduce mortality and morbidity associated with low birth weight are discussed in Chapter 6; those associated with birth defects, in Chapter 7; and those associated with perinatal transmission of HIV, in Chapter 8. Infectious Diseases Infections are the major cause of mortality and morbidity in infants under 3 months of age in developing countries (Stoll, 1997~.
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From page 93... ...
Maternal infections, including sexually transmitted diseases (STDs) such as HIV (the topic of Chapter 8)
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From page 94... ...
Because localized umbilical infection is not prevented and may be inadequately treated in developing-country settings, it may be associated with the subsequent development of necrotizing fasciitis and/or neonatal sepsis (Faridi et al., 1993; Weber et al., 2001~. Moreover, omphalitis in patients with neonatal tetanus (discussed below)
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From page 95... ...
In preterm neonates of low birth weight, respiratory distress syndrome, due to surfactant deficiency, is a major risk for early death (MIay and Manji, 2000~. Information on the prevalence of this disorder in developing countries is especially difficult to obtain because most infants of very low birth weight (those weighing less than 1500 grams, who are at greatest risk)
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From page 96... ...
. Risk factors for neonatal tetanus occur in the antenatal, perinatal, and neonatal periods: failure to immunize the mother against tetanus; unhygienic delivery and cutting of the umbilical cord at birth; and unsterile , ~ , 1 11 - ~ 1 1 · 1 1 1 ~ 1 - ~ '_ 1 1 · 1 hanullng ot the cow in the early days ot late.
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From page 97... ...
; in South Africa, rates of infection in pregnant women have been reported to range from 6 to 19 percent (Rotchford et al., 2000~. Untreated syphilis during pregnancy increases the risk of late fetal death, low birth weight, preterm birth, and severe neonatal disease (Lumbiganon et al., 2002~.
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From page 98... ...
Active infection with syphilis in pregnant women is estimated to result in fetal or infant death or disability for 50 to 80 percent of affected pregnancies (Gloyd et al., 2001)
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From page 99... ...
. Antibiotic treatment is associated with reductions in preterm delivery and low birth weight (Smaill, 2003~.
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From page 100... ...
Hypothermia Hypothermia, defined as a body temperature below 36.5°C, is frequent in newborns, especially those of low birth weight. Several studies have shown that without adequate care, many newborns will experience severe
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From page 101... ...
They found that thermal control practices were frequently lacking in the following areas: ensuring a warm environment at the time of delivery, initiation of breastieeding and contact with the mother, bathing, checking the baby's temperature, thermal protection of low-birth-weight neonates, and care during transport. The study also demonstrated that health professionals involved in newborn care underestimate the impact of hypothermia on neonatal morbidity and mortality.
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From page 102... ...
Late sequelae of kernicterus include extrapyramidal abnormalities, choreoathetosis, involuntary muscle spasms, and sensorineural deafness. INTERVENTIONS Reducing neonatal mortality and morbidity often involves established interventions or strategies along with the means to make them effective in each setting.
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From page 103... ...
A community-based, randomized trial of STD control in the Rakai district of Uganda (where the HIV infection rate is higher) demonstrated that reduction of STDs improved pregnancy outcome (reduced the rate of low birth weight, infant ophthalmia, and early neonatal mortality)
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From page 104... ...
Urinary tract infection. Evidence from several randomized controlled trials indicates that antibiotic treatment of urinary tract infection and/or asymptomatic bacteriuria reduces the risk of low birth weight, but the mode of prevention is unclear.
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From page 105... ...
Moreover, maternal tetanus immunization has been associated not only with lower neonatal mortality but also with lower early childhood mortality (Luther, 1998~. In a study in Bolivia, traditional birth attendants employed single-use, prebilled injection devices to immunize more than 2,000 pregnant women against tetanus during routine antenatal visits.
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From page 106... ...
In many countries, however, HiB remains an important cause of life-threatening infections in infancy, particularly pneumonia and meningitis. Maternal immunization with HiB polysaccharide-tetanus protein conjugate vaccine has been shown to increase both maternal and neonatal antibody concentrations: at 2 months of age, 60 percent of the infants of vaccinated mothers had protective levels of antibody (Mu~holland et al., 1996~.
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From page 107... ...
A multicenter randomized, controlled trial conducted in more than 50 clinics in Argentina, Cuba, Saudi Arabia, and Thailand concluded that women assigned to the new mode! of essential antenatal care that called for an average of five visits per pregnancy had similar rates of low birth weight, postpartum anemia, urinary tract infection, and several secondary outcomes to those of women enrolled in a standard antenatal care program with an average of eight visits (Villar et al., 2001~.
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From page 108... ...
Prevention and treatment of neonatal infections Neonatal sepsis and pneumonia. Preterm or prolonged rupture of the membranes, maternal fever during labor, and chorioamnionitis are risk factors for early-onset neonatal sepsis and pneumonia.
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From page 109... ...
Sexually transmitted diseases. Additional intrapartum or immediate postpartum interventions for infants born to mothers with confirmed or suspected STDs can prevent neonatal morbidity.
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From page 110... ...
The treatment generally involves phototherapy but may involve exchange transfusion (Joseph and Kramer, 1998~. Corticosteroids have been found to reduce respiratory distress syndrome, reduce intraventricular hemorrhage, and improve the survival of preterm infants when administered to women in preterm labor in random
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From page 111... ...
The early initiation of breastieeding is important because colostrum has higher levels of many anti-infective factors compared with mature milk, and because early feeding helps establish an adequate milk supply. Many studies have documented a reduction in infectious diseases, including sepsis, diarrhea, and pneumonia (Narayanan et al., 1984; Ashraf et al., 1991; Brown et al., 1989; Glezen, 1991)
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From page 112... ...
Providing supplemental vitamin A to very young infants or vitamin A supplements to women during pregnancy has been associated with reductions in ~oostneonatal morbidity and mortality is 1 ~ developed countries (Humphrey et al., 1996; Christian et al., 2001) , but not fetal or early neonatal mortality (Katz et al., 2000~.
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From page 113... ...
Treatment decisions are based largely on patient history and clinical examination; more accurate prediction of serious infections is needed (WHO Young Infants Study Group, 1999b; Sehgal et al., 1997~. Home-based neonatal care Studies have evaluated the ability of trained village health workers to identify sick newborns in their homes and to treat them appropriately and in a timely manner.
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From page 114... ...
Studies from both industrialized and developing countries have shown that hepatitis B vaccine administered in the immediate newborn period can significantly reduce the rate of neonatal infection and the development of a chronic hepatitis B surface antigen (HBsAg) carrier state (Andre and Zuckerman, 1994~.
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From page 115... ...
Rotavirus vaccines are being developed to prevent severe diarrhea! disease, an important cause of infant and child mortality in developing countries (Glass et al., 1997; Jacobson, 1999; Parashar et al., 1998b)
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From page 116... ...
; supplementation with vitamins and minerals; growth monitoring; early detection and treatment of illness, particularly presumed bacterial sepsis, pneumonia, or meningitis; frequent home visits by trained health workers to identify signs and symptoms of illness and initiate care or refer to a hospital as needed; and monitoring of breastieeding, neonatal growth, and overall well-being (Stoll and Measham, 2001~. Home-based neonatal care described in Box 3-1 produced a 64 percent reduction in case fatality for low birth weight among neonates in rural India (Bang et al., 1999~.
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From page 117... ...
Recommendation 2. Essential neonatal care should be accessible to address all complications of childbirth that cannot be managed by a skilled birth attendant.
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From page 118... ...
This might involve presumptive therapy for all pregnant women or the development of cost-effective diagnostic tests that can be used in field settings to facilitate prompt maternal therapy. · With the exception of HIV, there is a paucity of data from developing countries on the burden of intrauterine, intrapartum, and/or postnatal infections of importance to newborns.
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From page 119... ...
Researchers should also examine whether topical antibiotic treatment of the umbilical cord complements maternal tetanus toxoid immunization and further reduces the risk of neonatal tetanus in countries where that disease is prevalent. · Hospital-based and community studies with accurate laboratory evaluations are needed to determine the etiologic agents responsible for serious infections in neonates (i.e., both early-onset and late-onset sepsis and meningitis)
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From page 120... ...
1998. Prevention of hypothermia of low birth weight infants using the kangaroo method.
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From page 121... ...
1999. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India.
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From page 122... ...
Clinical Infectious Diseases 33(suppl 3)
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From page 123... ...
Pediatric Infectious Diseases 4(3)
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From page 124... ...
Clinical Infectious Diseases 28(2)
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From page 125... ...
1995. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial.
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From page 126... ...
1997. Risk factors for neonatal tetanus in KwaZuluNatal.
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From page 127... ...
Clinical Infectious Diseases 33(suppl 3)
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From page 128... ...
Clinical Infectious Diseases 33(suppl 3)
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From page 129... ...
The increasing burden of tuberculosis in pregnant women, newborns and infants under 6 months of age in Durban, KwaZulu-Natal. South African Medical Journal 91(11)
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From page 130... ...
2002. Efficacy, immunogenicity and safety of heptavalent pneumococcal conjugate vaccine in low birth weight and preterm infants.
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From page 131... ...
1998. Pregnant women as a reservoir of undetected sexually transmitted diseases in rural South Africa: implications for disease control.
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From page 132... ...
Clinical Infectious Diseases 33(suppl 3)
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From page 133... ...
2000. Effect of breastieeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis.
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