Source: Bill & Melinda Gates Foundation (Seattle)
The Global Newborn Health Conference (#Newborn2013) taking place next week in Johannesburg, South Africa is an impressive indication of how far the newborn health agenda has come in the past decade.

Newborn health during those critical 28 days after birth now has a space on the global health policy, program and research stage.

When I started out as a pediatrician 21 years ago and turned my professional attention toward global public health, we were all focused on children under five. But there was a huge gap in the agenda – the newborn period – that captured my passion and focus. There was a perception, a myth, that newborn care was too difficult. It was largely an unknown area for public health professionals; not only was it unclear which interventions were feasible for implementation in low resource settings, but how to reach newborns and what the impact might be were also unknown. So we focused on the 'easy' things for child health, those things that were better understood and for which we had interventions available at the time — scaling up immunizations, prevention and treatment of diarrhea, pneumonia and malaria. Many of those 'easy' things – with the glaring exception of addressing pneumonia – have been done rather successfully or have made relatively greater advances; now newborn care is also the 'easy' thing to do, with better understanding of causes and interventions.

In 2000, neonatal deaths were not visible, and little data was available on the burden and causes of death. By 2005 we had modeled the causes of death and identified effective interventions. Newborn health gained increased visibility as the global health community began to realize that Millennium Development Goal 4 for child survival would not be achieved with business as usual – without substantially increased focus on newborn survival.

As we developed a better understanding of the causes of newborn mortality and saw, from experience in research and programmatic settings, that something could be done about it, the evidence exploded the myth that addressing neonatal health is necessarily complex, expensive, highly technical and specialized, and thus requires neonatal intensive care units staffed by neonatologists. We now know that simply is not true. In fact, many of the interventions for newborns can be provided by mothers, families and frontline health workers, and are highly cost-effective. Among the easy life saving things to do are keeping newborns warm though skin-to-skin contact, initiating breastfeeding within an hour of childbirth, hand-washing, cleansing the umbilical cord with the antiseptic chlorhexidine, and treating newborns with suspected serious infections with antibiotics.
This was a paradigm-changing idea. No longer could we ignore the newborn period – excuses were gone.

Although there have been improvements in reduction of newborn deaths globally in the past decade, that rate of decline is half that for maternal deaths and only a third that for children from one month to five years of age. About 7 million children under 5 die each year; and of those, 43% or nearly 3 million, die in the first month of life, the vast majority in low- and middle-income countries. And new data on trends in mortality over time show that the proportion of under-five deaths that occur in the newborn period is rising, exceeding 50% in a number of countries, particularly in South Asia, such as India, Nepal and Bangladesh.

As we prepare for this conference, we are seeking efficient and effective ways to achieve impact at scale for reducing newborn deaths – both doing the right thing and doing it right.

We can gain some insight into key factors for achieving impact at scale from a few countries that have made notable reductions in neonatal mortality rates, specifically Bangladesh, Nepal, Pakistan, Malawi and Uganda. Some broad generalizations can be made about approaches used in these countries. Aspirational yet achievable goals for reducing newborn deaths were established, along with specific indicators for tracking progress. Each country used locally-adapted evidence to inform strategies that are now being taken to scale. Integrating newborn care into national health sector strategies and delivery platforms improved newborn survival, and successful approaches brought care closer to communities through engaging frontline health workers and mothers while including critical social and behavioral change components. The initial interest in newborn health was sparked by a small informal network of committed proponents of newborn survival from both low and high income countries. Improvements are also linked to better education for girls and the opportunity for women and girls to plan their families, leading to reduced fertility rate and greater ability to provide for their children.

I mention these factors to make two key points. For one, we cannot change the rate of neonatal mortality decline without clear, well-defined goals with measures to mark progress and ways to improve implementation along the way. We can now start to track changes in neonatal mortality rate by using some "smart" (specific, measureable, actionable, relevant, time-based) intermediate indicators such as changes in the practice and utilization of key interventions for newborn care including skin-to-skin care, immediate breastfeeding, and an early (within 48 hours) postnatal checkup in addition to antenatal care and childbirth with a skilled attendant at birth. We also need more information on the process of scaling up interventions so that we can identify both programmatic successes to build on and failures to learn from, leading to improved implementation.

My second point is that the newborn community cannot do this alone as so many other factors influence a newborn's health and chance of survival. We know of the influence a mom's health and care has on a newborn, as well as cultural norms, policies related to education, especially for girls, or even the nutritional status of young women before they become pregnant. A healthy newborn has more opportunities to grow into a healthy child with more chances to become a healthy, productive adult, to start the cycle again. We know that the newborn is the nexus to improving everything else along that lifecycle. Improving services and care before and beyond the newborn period, throughout the 1000-day window from conception to age 2 years, will also improve the chances of a newborn being born healthy and with a strong start to life. We can't look at newborn health without considering all other aspects holistically.

The conference is focused on newborns, but our panoramic view involves partnerships across many sectors. As the proverb goes, a bundle of sticks is not easily broken. To raise the profile of newborn survival, we need a strong bundle of sticks. We need catalytic partnerships, when partners purposefully choose actions that lead to better, faster and greater health outcomes and to positive change that would not have happened otherwise. My hope is that this conference is the spark that brings partners together to put the focus on newborn health within the broader context of healthy productive lives.