Comment

Survival convergence: bringing maternal and newborn health together for 2015 and beyond

Despite major achievements in child survival, the burden of neonatal mortality has remained high and even increased in some countries since 1990. Currently, most neonatal deaths are attributable to being born preterm, small for gestational age (SGA), or with low birthweight (LBW). Besides neonatal mortality, these conditions are associated with stillbirth and multiple morbidities, with short-term and long-term adverse consequences for the newborn, their families, and society, resulting in a major loss of human capital. Prevention of preterm birth, SGA, and LBW is thus critical for global child health and broader societal development. Progress has, however, been slow, largely because of the global community's failure to agree on the definition and magnitude of newborn vulnerability and best ways to address it, to frame the problem attractively, and to build a broad coalition of actors and a suitable governance structure to implement a change. We propose a new definition and a conceptual framework, bringing preterm birth, SGA, and LBW together under a broader umbrella term of the small vulnerable newborn (SVN). Adoption of the framework and the unified definition can facilitate improved problem definition and improved programming for SVN prevention. Interventions aiming at SVN prevention would result in a healthier start for live-born infants, while also reducing the number of stillbirths, improving maternal health, and contributing to a positive economic and social development in the society.

Efforts to achieve the new worldwide goals for maternal and child survival will also prevent stillbirth and improve health and developmental outcomes. However, the number of annual stillbirths remains unchanged since 2011 and is unacceptably high: an estimated 2·6 million in 2015. Failure to consistently include global targets or indicators for stillbirth in post-2015 initiatives shows that stillbirths are hidden in the worldwide agenda. This Series paper summarises findings from previous papers in this Series, presents new analyses, and proposes specific criteria for successful integration of stillbirths into post-2015 initiatives for women's and children's health. Five priority areas to change the stillbirth trend include intentional leadership; increased voice, especially of women; implementation of integrated interventions with commensurate investment; indicators to measure effect of interventions and especially to monitor progress; and investigation into crucial knowledge gaps. The post-2015 agenda represents opportunities for all stakeholders to act together to end all preventable deaths, including stillbirths.

in light of the rising caesarean section rates in many developing countries, we sought to explore women׳s and caregivers׳ experiences, perceptions, attitudes, and beliefs in relation to caesarean section.

qualitative study using semi-structured individual in-depth interviews, focus group discussions, and participant observations. The study relied on a framework of naturalistic inquiry and data were analysed using thematic analysis.

a public university hospital in Dar es Salaam, Tanzania.

we conducted a total of 29 individual interviews, 13 with women and 16 with caregivers, and two focus group discussions comprising five to six caregivers each. Women had undergone a caesarean section within two months preceding the interview and were interviewed in their homes. Caregivers were consultants, specialists, residents, and midwives.

both women and caregivers preferred vaginal birth, but caregivers also had a favourable attitude towards caesarean section. While caregivers emphasised their efforts to counsel women on caesarean section, women had often reacted with fear and shock to the caesarean section decision and perceived that there was a lack of indications. Although caesarean section was perceived as involving higher maternal risks than vaginal birth, both women and caregivers justified these risks by the need to ‘secure’ a healthy baby. Religious beliefs and community members seemed to influence women׳s caesarean section attitudes, which often made caregivers frustrated as it diminished their role as decision-makers. Undergoing caesarean section had negative socio-economic consequences for women and their families; however, caregivers seldom took these factors into account when making decisions.

we raise a concern that women and caregivers might overlook maternal risks with caesarean section for the benefit of the baby, a shift in focus that can have serious consequences on women׳s health in low-resource settings. Caregivers need to reflect on how they counsel women on caesarean section, as many women perceived a lack of indication for their operations. Supportive attendance by a relative during birth and more comprehensive antenatal care counselling about caesarean section indications and complications might enhance women׳s autonomy and birth preparedness.

Almost 7 million children younger than age 5 years died in 2012, mostly from preventable diseases. Although, globally, mortality rates for those younger than 5 have declined by almost 50% from 90 deaths in 1990 to 48 deaths per 1,000 live births in 2012, rates in sub-Saharan Africa continue to be unacceptably high at more than 100 deaths per 1,000 live births. One of the millennium development goals is to reduce child mortality by two-thirds by 2015 by reducing the five major causes of child mortality globally: diarrhea, malaria, neonatal infection, pneumonia, and preterm delivery. Malnutrition and lack of safe water contribute to more than half of these child deaths.