“REPORT WRITING ASSINMENT”

This is second article of neonatal survival lancet seriesi with the title of “evidence based ,
cost effective interventions: how many baby can save ?” By Gary L, Zulfiqar A Bhutta,
Simon cousins, Taghreed Adam, Neff Walker and Luc de Bernis. In this article authors
hit middle and low income countries. Globally, neonatal death account for 38% of deaths
in the children of aged younger than 5 yearsii. There aim was to identify interventions for
use in low income and middle income countries. So they did not include costly, high tech
interventions. Many potential interventions targeting mothers are not included because
systematic review of prenatal and neonatal health information was not available. iii They
chose 16 interventions with the proven efficacy. One preconception, five antenatal, five
intrapartum and five post natal. These interventions are combining together in a package
rather than to apply single and three modes of delivery instituted like out reach services,
family and community facility and family based clinical care. They included intermittent
presumptive treatment for malaria, but excluded ITNs. This shows more cost
effectiveness when delivered in the package. They used CHOICE cost effective frame
workiv. Universal coverage of these interventions could prevent 41-72% of estimated
neonatal death worldwide. Effect is two- fold to three-fold higher for the intrapartum and
post natal care than antenatal care. Maximum benefits derived from family-community
care and in area where neonatal mortality is very high. It includes health education and
home care practices. This article showing that there is need of expansion of clinical care
of babies and mother to achieve MDG4.

There are many gaps in this article. Including that there are few efficacy trials and lack of
large scale effective trials. There are only 10 trials. There is no estimate of cause specific
mortality rather showing all cause neonatal mortality.. They did not included the mutual
benefits of intervention of maternal and child health. Their cost effectiveness analysis and
cost estimates did not include the filling gaps in the infra structure of the health facility
and availability qualified staff. In this regard they underestimate the full benefits and cost
which is required for the development of the programs. They did not mention about the
program integration with the vertical programs like save mother hood and child survival
initiatives. So they placed all financial burdens to neonatal health programs. This would

Dr. Nel o fer 1

Roll # 18
not be appreciated. They did not take into full account resources needed to achieve high
coverage of clinical care package. There are gaps in the knowledge like no effective
approach for promotion of best household and community neonatal care practices,
recognition of illnesses, cultural barriers and increasing demand for quality of care.
Measurement of community engagement and mobilization, and demand for care.
Methods for improving community-based identification and management of serious
infections, birth asphyxia, and preterm and low birth weight babies. Contents and
optimum timings of postnatal care for the benefits of neonatal and mothers. Burden of
neonatal morbidities, including the long term effect of interventions on post- natal
mortality, illness, growth, and developmental disability. Ways to monitor health-systems
performance, including prenatal audit; simplified indicators for assessing neonatal health
and implementation of the program and improved verbal autopsy method to assess cause
specific effect. These are gaps in the knowledge. In many countries health care is
provided by private sector as well but in this article authors mostly considered the public
sector of health system. Integrated public-private management strategies needed and
innovative approach to promote public private partnerships for providing maternal and
neonatal care.v

The proportion of neonatal death in Pakistan in the 1st week of life is high 74% and 1st
month of life is 67%. Infant mortality is 78 death/1000 live births. Under five mortality is
94 deaths/1000 live births. This mean one child in every 11 children in Pakistan dies
before reaching their fifth birthday. So over halve of the death under five occur during the
neonatal period and 26% occurring during post neonatal period. Mortality differentials by
place of residence, province, and education level of the mother and wealth index. It is
lowest in Baluchistan and NWFP. It is due to under reporting. While in Punjab and sindh
it is higher and similar to each other. Childhood mortality rates by sex of the child, age of
the mother at birth, birth order, previous birth interval and birth size. Female mortalities
lower than that of the male for the neonatal period while male have the advantage during
the post natal period up to age 5 years. There is U –shaped pattern of childhood mortality
by mother’s age at birth. With children of youngest and oldest woman experiencing high
risk of death. Generally first birth has higher mortality rate. Short birth interval reducing

Dr. Nel o fer 2

Roll # 18
chances of survival. Children who’s birth size is small or very small have 68% greater
risk of dying before their first birthday than those who’s birth size is average or larger.vi
The situation in Pakistan is almost the same as in most developing countries of middle
and lower class. There are many barriers which we have to be cross. There are many
misconceptions regarding knowledge. It is needed to fill this gap as soon as possible.
Prevention of diseases and promotion of health is needed. The first intervention for
preconception i.e. folic acid supplementation is lacking in our country. There are very
little clinical care services provided by skilled personnel, typically at health facility.
Services are not available around the clock to manage acute clinical problems. No
individual oriented clinical care. No adequately trained, equipped, and supervised
personnel. There are limited population oriented out reach services like routine antenatal
care, immunization programs, and intermittent presumptive treatment of malaria. Less
family-oriented and community-oriented services including support self care and
appropriate care seeking for illness. There is very little community mobilization and the
empowerment of the individuals and communities. Very less demand for the quality of
services. There is need of behavior change communication, community mobilization and
improvemement in ante natal, intra partum and post natal care practices, care seeking for
illness and community- based case management of illness by community health workers.

Dr. Nel o fer 3

Roll # 18
i
1: Lawn J , Cousen S , Bhutta Z , Dramstadt G , M artines J , Paul V. Why are 4 million new born babies dying each year?
Lancet 2004 ; 364 : 399-401.
ii
Lawn Je, Cousens S , Zupan J for the national lancet survival screening Team. 4 million neonatal death :When ? Where?
Why? Published on line March 3 , 2005, http//images.thelancet . com /extras/0start1073web.pdf.
iii
Bhutta Z , Darmstat G , Hasan B , Haws R. Community-based intervention for improving prenatal and neonatal outcome
in the developing countries :a review of the evidence . Pediatrics 2005: 115: 519-617.
iv
http://image.the lancet .com/extras/05art1217webtable3.pdf.
v
Knippenberg R,Lawn JE, Darmstadt GL, et al. Systematic scaling up of neonatal care in countries. Published on line
March 3 , 2005.
vi
Pakistan Demographic and Health Survey. 2006-07