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Thinking beyond global neonatal mortality rates

What can this issue provide that has not already been covered in other journals? The Millennium Development Goals have focused attention on reducing neonatal mortality, but there are still 2.9 million newborn deaths each year. In addition, there are 2.6 million stillbirths every year, including 1.2 million during labour. To address this, the Every Newborn Action Plan has set out ambitious targets of ten or fewer neonatal deaths and ten or fewer stillbirths per 1000 births in every country by 2035, and interventions have been systematically reviewed and costed. It is also now accepted that newborn health is a crucial component of the continuum of care incorporating reproductive, maternal, newborn and child and adolescent health (RMNCAH). The answer is that, rather than offering another global overview of reducing newborn mortality rates, this issue on neonatal care in lowand middle-income countries (LMICs) provides a more local perspective. The articles on public health reflect issues in specific groups or individual countries, and those on neonatal care reflect issues encountered in daily clinical practice and therefore provide valuable, more detailed information on some of the main issues confronting neonatal care. It is well recognised that the main causes of neonatal mortality are prematurity, intrapartum-related deaths, infection and congenital abnormalities. Okomo and co-authors describe the neonatal referral unit in Banjul, The Gambia, a country with a neonatal mortality rate of 28/1000 live births. They report on the difficulties they experience in providing quality neonatal care in a poorly resourced environment. There is an extremely high mortality of 35% of all admissions, with not only 54% of very low birthweight infants dying, but also a high mortality amongst larger infants (34% of 1500–2499 g and 29% of 2500–3999 g birthweight). The problems they describe, some of which will be considered in more detail below, are similar to those encountered in innumerable neonatal units in low-income countries. Training of staff is a major issue. Good neonatal care is vitally dependent on good nursing care. However, training in neonatal care usually falls outside the curriculum of general or even paediatric nurse training. David Woods’ imaginative Perinatal Education Programme, developed in South Africa, has been highly successful in providing neonatal nurse training. Instead of instruction and teaching, it uses self-directed learning by groups of nurses using specially prepared course books without the need for trainers. It is enhanced by simple skills workshops and multiple-choice tests and all the material is available free of charge via their website. However, it does require the formation of a group of motivated nurses, which can be problematic in units with minimal staffing levels like the one described in the Gambia. E-learning and text messaging offer new opportunities for enhancing training, and have been incorporated into this programme. Imaginative use of modern technology also allows the opportunity for direct teaching and advice by experts and mentorship. Short courses such as Helping Babies Breathe, ETATz (Emergency Triage, Assessment and Treatment plus Admission), the WHO Essential Newborn Care Course and others also have an important role. However, I believe that more attention also needs to be paid to training in leadership and good role modelling as well as to direct practical patient care as these are important but often deficient. Staffing levels in most neonatal units in low-income countries are grossly inadequate. The situation described in the unit in the Gambia with only one trained nurse and one nurse covering 31 cots at night is all too common. This understaffing, together with frequent rotation of staff, poor remuneration, lack of leadership and high mortality of infants admitted, as highlighted by the data from The Gambia, all contribute to low morale. The high profile given to neonatal care by the Every Newborn Action Plan will hopefully assist in motivating governments and hospital managers to address these problems. Correspondence to: Tom Lissauer, Imperial College Healthcare Trust, London W2 1NY. Email: t.lissauer@imperial.ac.uk