Why do so many newborns still die?

A recent article from the Million Death Study, published in The Lancet, brings good news for children: between 2000 and 2015, the death rate of children below five years of age in India dropped from about 90 per 1,000 to about 47 per 1,000. That means that the number of child deaths per year dropped from about 2.5 million to about 1.2 million and that many parents who might have experienced the loss of a child did not have to. However, the study also finds that improvements in death rates in the first month of life have been slow, and that deaths from low birthweight remained similar over this period. In this article, I elaborate on these findings and recommends stronger efforts to understand and improve the health of pregnant women.

Comparisons and causes
As encouraging as it is to see death rates among children improving, we might ask whether these gains are fast enough. Over this period in Bangladesh and Nepal, child death rates declined by 59% (from 87 per 1,000 to 36) and 56% (from 82 per 1,000 to 36), respectively, while India’s declined by 47%. The Million Death Study Collaborators explain that India’s child death rates would be falling much faster if it could achieve more improvement in neonatal death rates, or death rates in the first month of life.

Indeed, declines have been too slow to achieve the UN’s Sustainable Development Goal of reaching 12 neonatal deaths per 1,000 by 2030. In order to meet the 2030 goal, reductions in neonatal deaths from 2015 onwards will have to increase from an annual decline of 3.3% to 5.3%. Neonatal death accounts for a large fraction of child death in India: according to the Million Death Study, about 60% of deaths among under-five children happened in the first month. Neonatal deaths are also more common than economic indicators predict: in a descriptive, cross-country regression of neonatal death rates on GDP (gross domestic product) per capita, India has an excess death rate of about 7 per 1,000 beyond what it predicted by its GDP per capita (Coffey and Hathi 2016). This excess is larger than the total neonatal death rate of many countries.

In order to better understand why children are dying, the Million Death Study researchers collaborated with the Registrar General of India (RGI) to collect data on cause of death within the RGI’s existing Sample Registration System (SRS)…The researchers identified separate causes of death in the neonatal period and in months 1-59. Neonatal deaths were categorised into one of nine major causes, and deaths between months 1-59 were categorised into one of 11 major causes.  In 19 of the 20 cause of death categories, death rates fell between 2000 and 2015. Yet, the category in which death rates did not improve – prematurity and low birthweight  – is a very important one. It is the leading cause of both neonatal death and of deaths of under-five year olds. Indeed, more than half of neonatal deaths, and nearly one-third of all under-five deaths, were attributed to this cause alone. The researchers estimate that about 370,000 infants died of this cause in 2015. 

The puzzling death rate
The researchers measured a death rate from low birthweight and prematurity of 12.3 per 1,000 in 2000 and of 14.3 per 1,000 in 2015. This is puzzling considering that death rates from all other causes fell and that there was substantial economic growth over this period. 

Why did death rates from prematurity and low birthweight remain similar or even increase? The Million Death Study says that “most of the increase in prematurity or low birthweight deaths was in term births with low birthweight, not in preterm births,” so it is useful to begin by considering what causes low birthweight. Stress during pregnancy, poor healthcare during pregnancy, the mother’s exposure to infectious disease, and perhaps most importantly, poor nutrition during pregnancy, are causes of low birthweight. 

We know that undernutrition during pregnancy is a widespread problem in India, far more so than in other, poorer, countries. Indeed, data from the National Family Health Survey (NFHS), 2005 show that over 40% of Indian women began pregnancy underweight and that the average pregnant woman gained only about 7 kg during pregnancy…

Possible explanations
The authors of the Million Death Study posit two possible explanations, which I elaborate on here. One possible explanation is that infants who, in 2000, would have died from another cause of neonatal death are now dying of low birthweight instead of one of the other causes. Let’s consider the example of birth asphyxia (breathing problems), the second leading cause of neonatal death. Low birthweight babies are more likely to have breathing problems than higher birthweight babies. If improvements in care at birth have prevented some asphyxia deaths, then some of the low birthweight babies who would have died shortly after birth from asphyxia now survive the first few hours, but eventually die from other complications of low birthweight. Their deaths would then be classified as low birthweight deaths, rather than as asphyxia deaths.  

Another possible explanation is that the death rate from low birthweight remained similar because stillbirths – deaths that happen after 28 weeks gestation but while a foetus is still in the womb – went down. Research shows that undernourished women are more likely to have stillborn babies, and improvements in maternal nutrition lead to reductions in stillbirths…

Need for data, action
Are these explanations correct? High-quality, large-scale, up-to-date health survey data would be necessary to answer this question well. Data that measure the weights and heights of pregnant women, such as the NFHS, 2015, would allow us to quantify improvements in nutrition during pregnancy. The unit-level data from the NFHS, 2015 would also allow us to investigate whether or not there have been changes in the timing of neonatal deaths, such as those implied by the hypothesis that deaths are being shifted from other causes of death to low birthweight…As important as it is to collect and release up-to-date data on maternal and infant health, it is nevertheless clear even from the existing evidence that maternal undernutrition plays an important role in India’s high rates of neonatal death from low birthweight, and that this problem urgently requires a policy response. 

What sort of response might help improve maternal nutrition and reduce low birthweight and neonatal death? One promising policy, a cash transfer for pregnant women, is currently being rolled out by the government. The programme, called the Pradhan Mantri Matritva Vandana Yojana, was designed in response to the 2013 National Food Security Act, which legislates a cash transfer of Rs 6,000 for each pregnant woman. Unfortunately, the programme currently covers only the first pregnancy, not subsequent ones. Considering the magnitude and the stubbornness of the problem of low birth weight, this programme should cover every birth; it should be given early in pregnancy; and the government should be experiment with ways to encourage families to use the cash to invest in nutrition during pregnancy.

By: Diane Coffey
(Courtesy: http://ideasforindia.in; Writer teaches at the University of Texas at Austin and is a visiting researcher at the Indian Statistical Institute, Delhi)