For personal use. Only reproduce with permission from Elsevier Ltd Series www.thelancet.com Published online March 3, 2005 http://image.thelancet.com/extras/05art1216web.pdf 1 Many policymakers and health professionals are unaware that more than 10 000 newborn babies die every day, mostly from preventable causes. The Millennium Development Goal for child survival (MDG-4)—to reduce childhood mortality by two-thirds between 1990 and 2015—will not be met without substantial reductions in neonatal mortality. 1 Low-cost interventions could reduce neonatal mortality by up to 70% if provided universally. 2 Although these interventions are inexpensive and feasible, their coverage rates are extremely low in the highest-mortality settings. Overcoming health-system constraints to provide such interventions at scale is possible, and practical examples of how countries can do so have been described within this series. 3 Here, we address common misconceptions that have restricted implementation of interventions to improve neonatal health in many low-income countries (panel 1). We discuss national and global action needed to improve neonatal survival, and show the estimated cost associated with the packages proposed. Saving lives of newborn children is affordable, but depends on political commitment and leadership at national and international levels. Common myths and misconceptions corrected No country can afford not to address neonatal deaths. Neonatal mortality accounts for a high proportion of deaths among children aged younger than 5 years; 1 38% globally and 24–56% at regional level. Waiting to introduce neonatal interventions will not only delay reducing neonatal deaths; many interventions, such as exclusive breastfeeding and improved care of low birthweight infants, also contribute to reductions in post- neonatal mortality and in rates of acute and chronic illness in children. 2 Furthermore, scaling up the interventions with the highest effect on neonatal deaths will reduce maternal deaths, resulting in progress towards MDG-4 and MDG-5. 3 Success is possible in low-income countries without access to high technology. High-income countries have reduced neonatal mortality rates (NMRs) to an average of four per 1000 livebirths. By contrast, the overall NMR in middle-income and low-income countries (where 99% of neonatal deaths happen) is 33. 1 Can these countries reduce neonatal mortality without intensive care technology and in the absence of great improvement in income? The experience of countries that have reduced neonatal mortality successfully over the past century tells us the answer is a resounding yes. Reductions in neonatal mortality in developed countries preceded the introduction of expensive neonatal intensive care. In England, for example, the NMR fell from more than 30 in 1940 to ten in 1975, a reduction linked to the introduction of free antenatal care, improved care during labour, and availability of antibiotics. 4 In Sweden, perinatal mortality declined at the end of the 19th century by 15–32% in those who used midwives for home deliveries. 5 The training of midwives at that time, working largely in community settings, emphasised keeping the baby warm, neonatal Neonatal Survival 4 Neonatal survival: a call for action Jose Martines, Vinod K Paul, Zulfiqar A Bhutta, Marjorie Koblinsky, Agnes Soucat, Neff Walker, Rajiv Bahl, Helga Fogstad, Anthony Costello, for the Lancet Neonatal Survival Steering Team* To achieve the Millennium Development Goal for child survival (MDG-4), neonatal deaths need to be prevented. Previous papers in this series have presented the size of the problem, discussed cost-effective interventions, and outlined a systematic approach to overcoming health-system constraints to scaling up. We address issues related to improving neonatal survival. Countries should not wait to initiate action. Success is possible in low-income countries and without highly developed technology. Effective, low-cost interventions exist, but are not present in programmes. Specific efforts are needed by safe motherhood and child survival programmes. Improved availability of skilled care during childbirth and family/community-based care through postnatal home visits will benefit mothers and their newborn babies. Incorporation of management of neonatal illness into the integrated management of childhood illness initiative (IMCI) will improve child survival. Engagement of the community and promotion of demand for care are crucial. To halve neonatal mortality between 2000 and 2015 should be one of the targets of MDG-4. Development, implementation, and monitoring of national action plans for neonatal survival is a priority. We estimate the running costs of the selected packages at 90% coverage in the 75 countries with the highest mortality rates to be US$4·1 billion a year, in addition to current expenditures of $2·0 billion. About 30% of this money would be for interventions that have specific benefit for the newborn child; the remaining 70% will also benefit mothers and older children, and substantially reduce rates of stillbirths. The cost per neonatal death averted is estimated at $2100 (range $1700–3100). Maternal, neonatal, and child health receive little funding relative to the large numbers of deaths. International donors and leaders of developing countries should be held accountable for meeting their commitments and increasing resources. Published online March 3, 2005 http://image.thelancet.com/ extras/05art1216web.pdf *Lancet Neonatal Survival Steering Team listed at end of article Departments of Child and Adolescent Health and Development (J Martines PhD, R Bahl MD) and Reproductive Health and Research (H Fogstad MHA), WHO, Geneva, Switzerland; Department of Pediatrics, WHO Collaborating Centre for Training and Research in Newborn Care, All India Institute of Medical Sciences, New Delhi, India (VK Paul MD); Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan (ZA Bhutta PhD); International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh (M Koblinsky PhD); The World Bank, Washington, DC, USA (A Soucat PhD); UNICEF, New York, NY, USA (N Walker PhD); and International Perinatal Care Unit, Institute of Child Health, London, UK (A Costello FRCP) Correspondence to: Dr Jose Martines, Department of Child and Adolescent Health and Development, WHO, Geneva 1211, Switzerland martinesj@who.int