Antibiotic use for inpatient newborn care with suspected infection: EN-BIRTH multi-country validation study.

BACKGROUND: An estimated 30 million neonates require inpatient care annually, many with life-threatening infections. Appropriate antibiotic management is crucial, yet there is no routine measurement of coverage. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aimed to validate maternal and newborn indicators to inform measurement of coverage and quality of care. This paper reports validation of reported antibiotic coverage by exit survey of mothers for hospitalized newborns with clinically-defined infections, including sepsis, meningitis, and pneumonia. METHODS: EN-BIRTH study was conducted in five hospitals in Bangladesh, Nepal, and Tanzania (July 2017-July 2018). Neonates were included based on case definitions to focus on term/near-term, clinically-defined infection syndromes (sepsis, meningitis, and pneumonia), excluding major congenital abnormalities. Clinical management was abstracted from hospital inpatient case notes (verification) which was considered as the gold standard against which to validate accuracy of women's report. Exit surveys were conducted using questions similar to The Demographic and Health Surveys (DHS) approach for coverage of childhood pneumonia treatment. We compared survey-report to case note verified, pooled across the five sites using random effects meta-analysis. RESULTS: A total of 1015 inpatient neonates admitted in the five hospitals met inclusion criteria with clinically-defined infection syndromes. According to case note verification, 96.7% received an injectable antibiotic, although only 14.5% of them received the recommended course of at least 7 days. Among women surveyed (n = 910), 98.8% (95% CI: 97.8-99.5%) correctly reported their baby was admitted to a neonatal ward. Only 47.1% (30.1-64.5%) reported their baby's diagnosis in terms of sepsis, meningitis, or pneumonia. Around three-quarters of women reported their baby received an injection whilst in hospital, but 12.3% reported the correct antibiotic name. Only 10.6% of the babies had a blood culture and less than 1% had a lumbar puncture. CONCLUSIONS: Women's report during exit survey consistently underestimated the denominator (reporting the baby had an infection), and even more so the numerator (reporting known injectable antibiotics). Admission to the neonatal ward was accurately reported and may have potential as a contact point indicator for use in household surveys, similar to institutional births. Strengthening capacity and use of laboratory diagnostics including blood culture are essential to promote appropriate use of antibiotics. To track quality of neonatal infection management, we recommend using inpatient records to measure specifics, requiring more research on standardised inpatient records.

Provider- and patient-level costs associated with providing antiretroviral therapy during the postpartum phase to women living with HIV in South Africa: A cost comparison of three postpartum models of care.

OBJECTIVE: To compare the unit and total costs of three models of ART care for mother-infant pairs during the postpartum phase from provider and patient's perspectives: (i) local standard of care with women in general ART services and infants at well-baby clinics; (ii) women and infants continue to receive care through an integrated maternal and child care approach during the postpartum breastfeeding period; and (iii) referral of women directly to community adherence clubs with their infants receiving care at well-baby clinics. METHODS: Capital and recurrent cost data (relating to buildings, furniture, equipment, personnel, overheads, maintenance, medication, diagnostic tests and immunisations) were collected from a provider's perspective at six sites in Cape Town, South Africa. Patient time, collected via time-and-motion observation and questionnaires, was used to estimate patient perspective costs and is comprised of lost productivity time, time spent travelling and the direct cost of travelling. RESULTS: The cost of postpartum ART visits under models I, II and III was US $13, US $10 and US $7 per visit for a mother-infant pair, respectively, in 2018 US$. The annual costs for the mother-infant pair utilising the average visit frequencies (a mean of 4.5, 6.9 and 6.7 visits postpartum for models I, II and III, respectively) including costs for infant immunisations, visits, medication and diagnostic tests for both mothers and infants were: I - US $222, II - US $335 and III - US $249. Sensitivity analysis to assess the impact of visit frequency on visit cost showed that Model I annual costs would be most costly if visit frequency was equalised. CONCLUSION: This comparative analysis of three models of care provides novel data on unit costs and insight into the costs to provide ART and care to mother-infant pairs during the delicate postpartum phase. These costs may be used to help make decisions around integrated services models and differentiated service delivery for postpartum WLH and their children.

OBJECTIF: Comparer le coût et unitaire et total de trois modèles de soins ART pour les paires mère-enfant pendant la phase post-partum selon les perspectives du fournisseur et du patient: (I) - normes locales des soins avec les femmes dans les services généraux de l'ART et les nourrissons dans les cliniques de bien-être pour bébés; (II) - les femmes et les nourrissons continuent de recevoir des soins via une approche intégrée de soins maternels et infantiles pendant la période d'allaitement post-partum; et (III) - orientation des femmes directement vers les clubs d'adhésion communautaires, leurs nourrissons recevant des soins dans les cliniques de bien-être pour bébés pour bébés. MÉTHODES: Les données sur les coûts d'investissement et les coûts récurrents (relatifs aux bâtiments, au mobilier, à l'équipement, au personnel, aux frais généraux, à l'entretien, aux médicaments, aux tests de diagnostic et aux vaccinations) ont été recueillies selon le point de vue du prestataire sur six sites à Cape Town, en Afrique du Sud. Le temps du patient, recueilli via l'observation du temps et des mouvements et des questionnaires, a été utilisé pour estimer les coûts selon le point de vue du patient, et comprend le temps de productivité perdu, le temps passé en déplacement et le coût direct du déplacement. RÉSULTATS: Le coût des visites ART post-partum dans les modèles I, II et III était respectivement de 13 USD, 10 USD et 7 USD par visite pour une paire mère-enfant en USD de 2018. Les coûts annuels pour la paire mère-enfant en utilisant la fréquence moyenne des visites (une moyenne de 4,5 ; 6,9 et 6,7 visites post-partum pour les modèles I, II et III respectivement), y compris les coûts des vaccinations infantiles, des visites, des médicaments et des tests diagnostiques pour les mères et les nourrissons étaient: I - 222 USD, II - 335 USD et III - 249 USD. L'analyse de sensibilité pour évaluer l'impact de la fréquence des visites sur le coût des visites a montré que les coûts annuels du modèle I seraient les plus élevés si la fréquence des visites était égalisée. CONCLUSIONS: Cette analyse comparative de trois modèles de soins fournit de nouvelles données sur les coûts unitaires et un aperçu des coûts de fourniture de l'ART et de soins aux paires mère-enfant pendant la phase délicate du post-partum. Ces coûts peuvent être utilisés pour aider à la prise des décisions concernant les modèles de services intégrés et la prestation de services différenciés pour les femmes en période de post-partum et leurs enfants.

Maternal and newborn care during the COVID-19 pandemic in Kenya: re-contextualising the community midwifery model.

Peripartum deaths remain significantly high in low- and middle-income countries, including Kenya. The COVID-19 pandemic has disrupted essential services, which could lead to an increase in maternal and neonatal mortality and morbidity. Furthermore, the lockdowns, curfews, and increased risk for contracting COVID-19 may affect how women access health facilities. SARS-CoV-2 is a novel coronavirus that requires a community-centred response, not just hospital-based interventions. In this prolonged health crisis, pregnant women deserve a safe and humanised birth that prioritises the physical and emotional safety of the mother and the baby. There is an urgent need for innovative strategies to prevent the deterioration of maternal and child outcomes in an already strained health system. We propose strengthening community-based midwifery to avoid unnecessary movements, decrease the burden on hospitals, and minimise the risk of COVID-19 infection among women and their newborns.

Close to Home: Perinatal Palliative Care in a Community Hospital.

BACKGROUND: Advances in prenatal testing and diagnosis have resulted in more parents learning during pregnancy that their child may die before or shortly after birth. These advances in testing and diagnosis have also resulted in more parents choosing, despite the diagnosis, to continue their pregnancies and pursue a palliative approach to their infant's short life. Perinatal hospice and palliative care is a growing model of care developed in response to these parents' previously unmet needs. A seldom-discussed opportunity to provide this care exists in outlying community hospitals, which are ideally placed to provide care close to home for families who have chosen comfort measures and time with their child. PURPOSE: This article reviews the definition and utility of perinatal palliative care, the population it serves, attempts to support a rational for development of community-based programs, and describes one community hospital's experience with perinatal palliative care in their community. METHODS/SEARCH STRATEGY: This article describes the development and processes of a perinatal palliative care program at a community hospital in Fredericksburg, Virginia. IMPLICATIONS FOR PRACTICE: Perinatal palliative care can be developed with the assistance of already existing training materials, resources, and staff. While the cohort of patients may be small, implementing perinatal palliative care in a community setting may result in wider availability of this care and more accessible options for these families. IMPLICATIONS FOR RESEARCH: Research possibilities include developing a template for creating a perinatal palliative care program at community hospitals that could be replicated elsewhere; assessing parental satisfaction and quality indicators of perinatal palliative care at community hospitals and at referral hospitals; and assessing outcomes in various settings.

Promoting and Protecting the Gastrointestinal Newborn Microbiome Through Breastfeeding Practices.

Since newborns are a vulnerable population that cannot protect their own microbiome, healthcare professionals can promote, advocate, and assist with breastfeeding promotion to protect the healthy development of the newborn gastrointestinal microbiome. The newborn gastrointestinal microbiome is a dynamic community of bacteria that influence health. Breastfeeding seeds and feeds the newborn gastrointestinal microbiome. A disruption in the balance of the gastrointestinal microbiome can result in adverse health outcomes. This clinical article makes an evidence-based connection between breastfeeding and the establishment of the newborn gastrointestinal microbiome through breastfeeding promotion strategies during the childbearing year. Suggestions for healthcare profession education and future research that will continue to inform the understanding of healthy development of the microbiome will be provided. By assisting with breastfeeding promotion, healthcare professionals can protect the newborn gastrointestinal microbiome and promote overall newborn, infant, and child health.

Continuity of Infant Well Care in a Community Health Center Resident Clinic.

Achieving patient continuity in resident continuity clinic is challenging. Patients, residents and primary care providers (PCP) benefit from this ongoing relationship. We examined rates of continuity of infant well care for first year pediatric residents (PL1) and associated factors in three clinics (W, E and K) in a community health center system. We collected the number of infants who had PL1 PCPs for academic years 2010, 2011 and 2012 and patient demographic data. We measured continuity using the usual provider of care method. We assessed rates of continuity, total numbers of infants and factors associated with continuity and medical home by Chi Square, ANOVA, Student's t test and multivariate linear regression (SPSS version 21). 115 patients had a PL1 PCP and attended 408 visits with 19 residents. The mean number of infants seen per PL1 in each clinic was W 7.8 ± 2.2, E 3.8 ± 1.5 and K 3.7 ± 2.9 (p < .01). PL1 continuity percentage was 66% at W, 47% at E and 54% at K (p < .01). Total continuity of care for all providers at W was 70%, E 65% and K 60% (p < .01 W vs. K only). In multivariate linear regression, only continuity of care for all providers was associated with mean PL1 continuity with ß of 2.24 (95% CI 1.13-3.34), p < .001. PL1 continuity differed significantly between clinic sites. The only predictor of PL1 well care continuity was total clinic continuity of care. Maximizing continuity through the Medical Home practice was significantly associated with increased resident continuity of care.

Nurses' and Physicians' Experiences of the NIDCAP Model Implementation in Neonatal Intensive Care Units in Iran.

PURPOSE: The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) provides comprehensive newborn focused family-centered care in the Neonatal Intensive Care Unit (NICU). The purpose of this study was to investigate nurses' and physicians' experiences of implementing the NIDCAP model to optimize its implementation for both caregivers, infants, and families in the NICU. DESIGN & METHODS: A purposes sample of 11 nurses and four physicians participated in this qualitative study. Data were collected by face-to-face and semi-structured interviews and analysis were guided by principles of thematic analysis as per Graneheim and Lundman (2004). RESULTS: Six themes and 20 sub-themes were constructed during data analysis. These included; NIDCAP as a milestone, Helping to rebuild the core of the family, Caregiver excellence, Realism towards the feasibility of NIDCAP, Proper managerial position of NIDCAP specialists in the health system, and Caring for the caregiver. CONCLUSIONS: The findings of this study highlight how NIDCAP provides a comprehensive and effective care model for premature infants, with the goal to promote neonatal growth and development while also facilitating the self-efficacy of caregivers. Implementation of the NIDCAP model requires attention to be paid to social context, infrastructure, adjustment of the program according to the facilities and resources of each country, and the needs of caregivers. PRACTICE IMPLICATIONS: Health care resources are required to sustain NIDCAP specialists and a favorable environment as the necessary conditions for its multidimensional application across NICU units around the world.

"Self-development matters" - Perception of Sakhis (CHWs) assessing self-development outcomes of their participation in the HBNC Program.

BACKGROUND: Community Health Workers (CHWs) play an instrumental role in promoting socio-behavioural change at the community level, which results in changed indicators of community health. While outcomes are mostly reviewed for achieving program objectives, it is pertinent to understand the process of program implementation mainly from the perception of participating CHWs. METHODS: A qualitative study to understand the perception of Sakhi's (CHWs) regarding the outcomes of their participation in Home-Based Neonatal Care (HBNC) Program implemented by a non-governmental organization (NGO). Data consisted of 3 FGDs and 20 in-depth unstructured interviews with participating Sakhis. RESULTS: Sakhis perceived their ability to take decisions at critical phases of the program as an important factor influencing their performance. The opportunity to participate as a Sakhi in the health programme initiated a process of change at the personal level. The changes perceived by Sakhis were enhancement in knowledge, skills and capabilities of Sakhis. The combination of improved skills, knowledge and attitude had culminated in the process of experiencing self-empowerment for the participating Sakhis. Their ability to positively influence the individuals and community with their initiatives to improve women and child health and save lives in critical situations facilitated development of a new identity and improved societal status in their communities. Changed power-relations at the family and community level promoted the involvement of Sakhis in the broader development agenda. Sakhis' ability to strategize goals, evaluate their own abilities, their willingness to upgrade knowledge and take others along in bringing social change, was an evident movement towards self-development. CONCLUSION: An opportunity for local women to participate in development programs creates potential for self-development as a cascading effect in addition to the accomplishment of planned program objective.

Surmounting difficulties to provide home based neonatal care - reflections of community health workers.

BACKGROUND: In India, community health workers' (CHW) effectiveness in providing home-based neonatal care (HBNC) has been well documented. The nature of challenges faced and strategies adopted while providing HBNC services need to be studied in-depth. METHODS: A qualitative study to understand the challenges faced and strategies used by Sakhis (women CHW) while providing services as part of a HBNC program implemented by a non-profit organization. Data consisted of 20 in-depth interviews and three focus group discussions (FGD) with Sakhis. RESULTS: Sakhis negotiated with the community to start working as a CHW. They faced challenges while changing behaviors at individual level and also while bringing about a change in harmful normative practices that increased chances of maternal and neonatal mortality. Managing crises at the time of deliveries and facilitating a safe delivery was the most critical challenge faced by many Sakhis. The key strategies used by Sakhis included: proactively and persistently providing services even when they faced resistance from the woman or her family; evolving contextually suitable counseling techniques and tactics to bring about behavioral change; balancing compliance to traditional practices and promoting HBNC; defying traditional practices and assisting the woman in times of an emergency to save lives. Having on-call support from supervisors and cultivating a good working relationship with health providers facilitated effective service provision by Sakhis. CONCLUSION: CHWs having a strong sense of commitment can develop strategies to address challenges and provide HBNC services effectively if they also have strong supervisory support.

Effectiveness of an action-oriented educational intervention in ensuring long term improvement of knowledge, attitudes and practices of community health workers in maternal and infant health: a randomized controlled study.

BACKGROUND: The potential role of Community Health Workers (CHWs) in improving maternal and child health outcomes, particularly in low and middle-income countries and in disadvantaged communities, is receiving increased attention. Adequate and focused training is among the key requisites for enhancing CHWs performances and research is necessary to identify effective training methods. METHODS: A randomized controlled study was designed to assess the effectiveness of a training course in improving knowledge, attitudes and practices (KAP) of CHWs regarding maternal and infant health. Seventy-eight CHWs belonging to Family Health Units in the city of Recife, Brazil were randomly allocated to intervention and control groups. The intervention group took part in a four-day interactive training course based on an action-oriented guide to perform home visits to pregnant women and their infants throughout pregnancy and infancy until 9 months of age. KAP in intervention group after training and after 1 year were compared to control group and to baseline. RESULTS: Fifty-nine CHWs completed all KAP assessments (31 in intervention and 28 in control group). Baseline characteristics were similar in both groups. At 1 year from training, the intervention group had higher overall KAP score (120.65 vs. 108.19, p <  0.001) as well as knowledge (47.45 vs. 40.54, p <  0.001), practice (53.45 vs. 49.11, p <  0.001) and attitudes scores (19.74 vs. 18.81, p = 0.047) than the control group. Moreover, at 1 year from training, the intervention group maintained significant improvements in overall KAP score (120.65 vs. 106.55, p <  0.001) as well as in knowledge (45.45 vs. 42.13, p <  0.001), and practice (53.45 vs. 45.29, p <  0.001) scores with respect to baseline. In the control group, overall KAP (106.59 vs. 108.19, p = 0.345) as well as separate knowledge, attitudes and practices scores remained unchanged. CONCLUSIONS: A four-day interactive training course on action-oriented home visits to pregnant women and infants produced a sustained improvement of CHWs' KAP and may represent a model to ensure retention of acquired competences. TRIAL REGISTRATION: RBR-9gchqr . Date registered: July 21, 2018 (Retrospectively registered).

Equity in maternal- and infant-care services in China: A trend analysis based on residence and area (2000-2014).

Equity in maternal- and infant-care services is key to achieving equity in maternal and infant health outcomes. In this study, 12 indicators of maternal and infant services were selected to measure equity in maternal and infant services in China from 2000-2014 using the Theil index and between-group variance, with the result showing that equity has improved steadily and significantly, though serious inequities in premarital and reproductive health services remain. Relatively speaking, equity at the interprovincial level has increased, but equity in urban-rural stratification has improved more, indicating that policies should focus on interprovincial inequities and premarital and reproductive health services.

The need for pragmatic clinical trials in low and middle income settings - taking essential neonatal interventions delivered as part of inpatient care as an illustrative example.

BACKGROUND: Pragmatic randomized trials aim to examine the effects of interventions in the full spectrum of patients seen by clinicians who receive routine care. Such trials should be employed in parallel with efforts to implement many interventions which appear promising but where evidence of effectiveness is limited. We illustrate this need taking the case of essential interventions to reduce inpatient neonatal mortality in low and middle income countries (LMIC) but suggest the arguments are applicable in most clinical areas. DISCUSSION: A set of basic interventions have been defined, based on available evidence, that could substantially reduce early neonatal deaths if successfully implemented at scale within district and sub-district hospitals in LMIC. However, we illustrate that there remain many gaps in the evidence available to guide delivery of many inpatient neonatal interventions, that existing evidence is often from high income settings and that it frequently indicates uncertainty in the magnitude or even direction of estimates of effect. Furthermore generalizing results to LMIC where conditions include very high patient staff ratios, absence of even basic technologies, and a reliance on largely empiric management is problematic. Where there is such uncertainty over the effectiveness of interventions in different contexts or in the broad populations who might receive the intervention in routine care settings pragmatic trials that preserve internal validity while promoting external validity should be increasingly employed. Many interventions are introduced without adequate evidence of their effectiveness in the routine settings to which they are introduced. Global efforts are needed to support pragmatic research to establish the effectiveness in routine care of many interventions intended to reduce mortality or morbidity in LMIC. Such research should be seen as complementary to efforts to optimize implementation.

Bottleneck analysis approach to accelerate newborn care services in two regions in Ghana: implications for national newborn care.

OBJECTIVE: The aim of this work is to describe application of a data-driven approach (bottleneck analysis [BNA] approach process) to accelerate newborn care services in two regions and what effect it had on national-level newborn care interventions in Ghana. STUDY DESIGN: A mixed-method approach was used for the study. The BNA tool generated quantitative data and group discussions provided phenomenological explanations to identified service gaps. METHODS: Regional newborn care health service assessments were conducted in November 2013 through desk reviews, field and health facility visits and coaching/mentorship. The BNA tool (an excel-based tool) directly utilized service coverage data and programme monitoring and review reports in Ghana. Outputs were generated based on service coverage indicators: supply side/health system factors (commodities, human resource and access), demand side (service utilization) and quality/effective coverage. National targets were used as benchmarks to assess gaps in coverage indicators. RESULTS: Key health system bottlenecks included absence/stock-out of essential newborn care commodities/resuscitation kits and absence of updated policies at services delivery points. In both regions, less than 55% of health facilities had at least 80% of midwives trained to provide essential obstetric and newborn care, management of preterm babies, resuscitation and inpatient paediatric care. In addition, less than 35% of pregnant women were assisted by a skilled birth attendant (midwife) and monitored with a partograph in the two regions. Demand-side bottlenecks included cultural preference for home deliveries, limited knowledge on importance of postnatal care and poor community involvement.The BNA approach in the two regions resulted in the development of national and other regional operational plans and monitoring and evaluation framework for newborn care services in Ghana over the period 2012-2016, and a relative improvement in neonatal mortality at the regional and national level. CONCLUSION: The BNA tool and approach provided data-driven planning for newborn care service delivery in a low-income setting. It identified gaps in service coverage based on empirical data at lower levels of the health system and garnered strategies in addressing bottlenecks to newborn care services at the national level.

Mothering a Preterm Infant Receiving NIDCAP Care in a Level III Newborn Intensive Care Unit.

UNLABELLED: The purpose of the study is to describe the unique meaning and significance of the essential elements of mothering a preterm infant receiving Newborn Individualized Developmental Care and Assessment Program (NIDCAP) care in a level III NICU. The overall aim was to promote an increased understanding among healthcare practitioners of the experience of this group of women. DESIGN AND METHODS: The authors utilized an existential-phenomenologic method to investigate the experience of 7 mothers of a preterm infant 30weeks gestation or less at birth. RESULTS: Analysis of interview transcripts revealed one overarching theme, parenting with permission, and three essential themes with nine underlying subthemes: choosing to participate (subthemes: managing, settling in, making friends), dealing with people (subthemes: meeting needs, facing judgment, and recognizing not everyone is 'on board,' and coming to feel like a mother (subthemes: overcoming fear, gaining understanding, and feeling empowered). CONCLUSIONS/PRACTICE IMPLICATIONS: Mothers universally praised NIDCAP for the education and support it provided them. However findings also suggest that great sensitivity and patience is required by professionals to assist mothers to overcome their fear, gain confidence, and participate in NIDCAP without feeling judged. In addition private rooms were found to hold great significance for mothers and should be maintained for the entire hospitalization whenever possible. Finally, ongoing NIDCAP education/support for staff and regular team meetings to discuss and problem-solve concerns are suggested. This might address inconsistent adherence to the NIDCAP care plan by some nurses, which is the greatest source of maternal conflict and frustration.

Integrating Safe Sleep Practices into a Pediatric Hospital: Outcomes of a Quality Improvement Project.

A quality improvement project for implementing safe sleep practices (SSP) was conducted at a large, U.S children's hospital. The intervention involved education of staff and standardization of infant sleep practices utilizing a multifaceted approach. Staff surveys and environmental audits were conducted pre- and post-intervention. Safe Sleep Environment (SSE) audits showed an improvement from 23% to 34% (p<0.001) post-intervention. Staff confidence to provide education to caregivers on SSP showed a significant increase. Results from this project demonstrate a successful approach to implement SSP in the hospital setting. Infant safe sleep practices have the potential to reduce infant mortality.

[ISRAEL NEONATOLOGY: PRESENT AND FUTURE].

The practice of neonatology in Israel debuted in the 1970s as local enterprises by individual hospitals that needed to provide sick and preterm newly born infants with up-to-date and effective care. Descriptions of research and advances in humane and gentle treatment during neonatal care for preterm infants and their families, as well as prevention of neonatal infections, follow-up of preterm infants and care of full-term infants are presented in this issue. The Israel National Very Low Birth Weight (VLBW) Infant database provides an excellent source of knowledge, which has led to multiple scientific publications. Recent international comparisons of the outcome of preterm VLBW infants, made possible by this unique database in Israel, has provided the neonatal community and the Ministry of Health with insights as to the differences in prognosis between Israel and other countries, especially among extremely low birth weight infants. At the border of viability, mortality in Israelis significantly higher than that reported in other countries and proactive steps undertaken to examine these differences and prompt correctional action should be pursued. The Israel Ministry of Health started positive initiatives and should ensure that their steps are implemented at the preterm infant's bedside.

Who has been caring for the baby?

Nearly a decade ago, The Lancet published the Neonatal Survival Series, with an ambitious call for integration of newborn care across the continuum of reproductive, maternal, newborn, and child health and nutrition (RMNCH). In this first of five papers in the Every Newborn Series, we consider what has changed during this decade, assessing progress on the basis of a systematic policy heuristic including agenda-setting, policy formulation and adoption, leadership and partnership, implementation, and evaluation of effect. Substantial progress has been made in agenda setting and policy formulation for newborn health, as witnessed by the shift from maternal and child health to maternal, newborn, and child health as a standard. However, investment and large-scale implementation have been disappointingly small, especially in view of the size of the burden and potential for rapid change and synergies throughout the RMNCH continuum. Moreover, stillbirths remain invisible on the global health agenda. Hence that progress in improvement of newborn survival and reduction of stillbirths lags behind that of maternal mortality and deaths for children aged 1-59 months is not surprising. Faster progress is possible, but with several requirements: clear communication of the interventions with the greatest effect and how to overcome bottlenecks for scale-up; national leadership, and technical capacity to integrate and implement these interventions; global coordination of partners, especially within countries, in provision of technical assistance and increased funding; increased domestic investment in newborn health, and access to specific commodities and equipment where needed; better data to monitor progress, with local data used for programme improvement; and accountability for results at all levels, including demand from communities and mortality targets in the post-2015 framework. Who will step up during the next decade to ensure decision making in countries leads to implementation of stillbirth and newborn health interventions within RMNCH programmes?

Every Newborn: progress, priorities, and potential beyond survival.

In this Series paper, we review trends since the 2005 Lancet Series on Neonatal Survival to inform acceleration of progress for newborn health post-2015. On the basis of multicountry analyses and multi-stakeholder consultations, we propose national targets for 2035 of no more than 10 stillbirths per 1000 total births, and no more than 10 neonatal deaths per 1000 livebirths, compatible with the under-5 mortality targets of no more than 20 per 1000 livebirths. We also give targets for 2030. Reduction of neonatal mortality has been slower than that for maternal and child (1-59 months) mortality, slowest in the highest burden countries, especially in Africa, and reduction is even slower for stillbirth rates. Birth is the time of highest risk, when more than 40% of maternal deaths (total about 290,000) and stillbirths or neonatal deaths (5·5 million) occur every year. These deaths happen rapidly, needing a rapid response by health-care workers. The 2·9 million annual neonatal deaths worldwide are attributable to three main causes: infections (0·6 million), intrapartum conditions (0·7 million), and preterm birth complications (1·0 million). Boys have a higher biological risk of neonatal death, but girls often have a higher social risk. Small size at birth--due to preterm birth or small-for-gestational-age (SGA), or both--is the biggest risk factor for more than 80% of neonatal deaths and increases risk of post-neonatal mortality, growth failure, and adult-onset non-communicable diseases. South Asia has the highest SGA rates and sub-Saharan Africa has the highest preterm birth rates. Babies who are term SGA low birthweight (10·4 million in these regions) are at risk of stunting and adult-onset metabolic conditions. 15 million preterm births, especially of those younger than 32 weeks' gestation, are at the highest risk of neonatal death, with ongoing post-neonatal mortality risk, and important risk of long-term neurodevelopmental impairment, stunting, and non-communicable conditions. 4 million neonates annually have other life-threatening or disabling conditions including intrapartum-related brain injury, severe bacterial infections, or pathological jaundice. Half of the world's newborn babies do not get a birth certificate, and most neonatal deaths and almost all stillbirths have no death certificate. To count deaths is crucial to change them. Failure to improve birth outcomes by 2035 will result in an estimated 116 million deaths, 99 million survivors with disability or lost development potential, and millions of adults at increased risk of non-communicable diseases after low birthweight. In the post-2015 era, improvements in child survival, development, and human capital depend on ensuring a healthy start for every newborn baby--the citizens and workforce of the future.

Roles and responsibilities in newborn care in four African sites.

OBJECTIVES: To explore roles and responsibilities in newborn care in the intra- and postpartum period in Nigeria, Tanzania and Ethiopia. METHODS: Qualitative data were collected using in-depth interviews with mothers, grandmothers, fathers, health workers and birth attendants and were analysed through content and framework analyses. RESULTS: We found that birth attendants were the main decision-makers and care takers in the intrapartum period. Birth attendants varied across sites and included female relatives (Ethiopia and Nigeria), traditional birth attendants (Tanzania and Nigeria), spiritual birth attendants (Nigeria) and health workers (Tanzania and Nigeria). In the early newborn period, when the mother is deemed to be resting, female family members assumed this role. The mothers themselves only took full responsibility for newborn care after a few days or weeks. The early newborn period was protracted for first-time mothers, who were perceived as needing training on caring for the baby. Clear gender roles were described, with newborn care being considered a woman's domain. Fathers had little physical contact with the newborn, but played an important role in financing newborn care, and were considered the ultimate decision-maker in the family. CONCLUSION: Interventions should move beyond a focus on the mother-child dyad, to include other carers who perform and decide on newborn care practices. Given this power dynamic, interventions that involve men have the potential to result in behaviour change.