The missing link: neonatal care in rural communities

Editor – Over the past decade, neonatal mortality rates (NMR) and perinatal mortality rates (PMR) in developing countries, especially in sub-Saharan Africa, have failed to decline substantially, unlike infant and under-five mortality rates. There is a serious gap in the care of the newborn infant during and after birth as shown by Fikree et al. from Pakistan (1) who reported a NMR of 47.1–65.5/1000 live births. In the rural areas of these countries, more than

half of the deliveries take place at home without skilled attendants and even when problems arise, professional medical care is rarely sought (1–3). In these countries, NMR and PMR are about 40–60, and 60–80/1000 live births, respectively, thus remaining unacceptably high (2, 3).

The programmes introduced by WHO, UNICEF and USAID through Integrated Management of Childhood Illness (IMCI), Integrated Management of Pregnancy and Childbirth (IMPAC), and Maternal and Neonatal Health (MNH), are aimed at solving these problems. But still, they require active contact between the mothers or carers of the newborn infant and the health services. Qualified obstetric and neonatal care is still institution-centred. Good antenatal care (including tetanus immunization) and obstetric services (including referral and Caesarean section facilities) do reduce maternal and perinatal mortality, as good neonatal treatment units reduce PMR and NMR. But worldwide each year over 50 million mothers deliver, mostly at home, without skilled attendance (3). In our area (the Mbulu District of the United Republic of Tanzania), more than 70% of all deliveries take place under these circumstances (unpublished data). Of the living newborn infants born at home, at least 40–50% of those who require medical attention do not receive it, and die (1, 3–4). In our area, 40% of all neonatal deaths never reached a health facility (Hinderaker SG, personal communication). The reasons for this include, among other factors, traditional beliefs, cultural habits, poor education, and poverty.

New approaches should be explored if the international community is willing to reduce one of the tragedies in international child health. As outlined in the report "Saving newborn lives" (3), a partial solution could be to teach locals to diagnose and possibly treat sick newborns using a community-based approach with regular village visits (3). As studies from rural communities in developing countries have shown, the basics of neonatal care and treatment could be carried out at home; thus substantially reducing NMR and PMR (3– 5). These services could be provided through professional midwives, as used in nineteenth-century Sweden (6), community members, as used in Bolivia (3), or village health workers, as used in India (4). A functioning referral system should also be available with good curative support services, but referrals should not delay the treatment of sick newborns.

Nevertheless, questions remain and this approach may not be suitable everywhere. In nineteenth-century Sweden, community midwives had an impact on both maternal deaths and perinatal deaths. During this time, people had confidence in health personnel. In developing countries, people may not have the same confidence in Western medicine and health systems.

If that is the case, will professionally trained health personnel be willing to become "community-based"? Will there be enough support from formal health institutions? We cannot be sure whether a community approach will have the impact we hope for. But can the interna-tional community afford not to try? n

Carsten Krüger1

Conflicts of interest: none declared.




1. Fikree FF, Azam SI, Berendes HW. Time to focus child survival programmes on the newborn: assessment of levels and causes of infant mortality in rural Pakistan. Bulletin of the World Health Organization 2002;80:271-6.

2. Child Health Research Project. Reducing Perinatal and Neonatal Mortality. Special Report. Vol 3, No 1. Baltimore, 1999. Available from: URL: (accessed on 6 June 2002).

3. Saving newborn lives. State of the world's newborns. Save the Children, Washington (DC), 2001. Available from: URL: (accessed on 6 June 2002).

4. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999;354:1955-61.

5. O'Rourke K, Howard-Grabman L, Seoane G. Impact of community organization of women on perinatal outcomes in rural Bolivia. Revista Panamericana de Salud Publica/Pan American Journal of Public Health 1998;3:9-14.

6. Andersson T, Högberg U, Bergström S. Community- based prevention of perinatal deaths: lessons from nineteenth century Sweden. International Journal of Epidemiology 2000;29:542-8.


1 Paediatrician, Neonatologist, Haydom Lutheran Hospital, Haydom/Mbulu District, United Republic of Tanzania. Address for correspondence: Deipe Stegge 71 D-48653 Coesfeld, Germany (email:

World Health Organization Genebra - Genebra - Switzerland