LA ESCUELA AMBIENTAL

A mother’s death in childbirth in developing countries particularly means that her newborn will almost certainly die and that her older children are more likely to suffer from disease. In Nepal, for instance, infants of mothers who died during childbirth were six times more likely to die in the first week of life, 12 times more likely between 8 and 28 days, and 52 times more likely to die between 4 and 24 weeks (Katz, West Jr, Khatry, Christian, LeClerq, Pradhan & Shrestha 2003:717-725). Moreover, when mothers are malnourished, ill, or receive inadequate care, their newborns face a higher risk of disease and premature death (Abu-Saad & Fraser 2010:5-25; Tinker & Ransom 2002:1-6). Almost one-quarter of newborns in developing countries are born low birth weight, largely due to their mothers’ poor health and nutritional status, which results in increased vulnerability to infection and a higher risk of developmental problems. The quality of care that both mother and newborn receive during pregnancy, at delivery, and in the early postnatal period is essential to ensuring women remain healthy and that children get a strong start (Oestergaard, Inoue, Yoshida, Mahanani, Gore, Cousens, Lawn & Mathers 2011:1080; Tinker, Hoope-Bender, Azfar, Bustreo & Bell 2005: 822-825).

Many stillbirths and newborn deaths could be averted if more women were in good health, well-nourished, and received quality (life-saving) care during pregnancy, labour and delivery, and if both mother and newborn received appropriate care in the postpartum period (Darmstadt, Bhutta, Cousens, Adam, Walker & De Bernis

2005:977-988; Tinker 1997:15-20). Health policies and programs in the fields of maternal, newborn, and child health have generally focused on one issue alone. Targeting interventions to only one of these groups will obscuring important linkages. For example, antenatal care and skilled birth attendance (SBA) not only address the three major causes of maternal mortality (bleeding, hypertensive diseases and infections), but also the three main causes of neonatal death (infections, complications arising from preterm birth and intrapartum-related neonatal deaths). Lower coverage of SBA correlates with higher neonatal mortality, with 77% of neonatal deaths occurring in countries where coverage of SBA is 50% or less. Simple treatments such as cleansing of the umbilical cord and promotion of immediate breastfeeding can prevent a significant portion of neonatal infections. Providing birth attendants with basic training and equipment (bag and mask) for neonatal resuscitation is a low-tech, low-cost opportunity for reducing intrapartum-related neonatal deaths. When approached together and incorporated into integrated programs, these interventions could save millions of lives at a lower cost than separate initiatives (Lassi, Majeed, Rashid, Yakoob

& Bhutt 2013:3-53; Kerber, De Graft-Johnson, Bhutta, Okong, Starrs & Lawn 2007:1358-69; Sines, Tinker & Ruben 2006:1-7).

Linking interventions can reduce costs by allowing greater efficiency in training, monitoring and supervision, and use of resources. Grouping interventions will help families more easily access and take advantage of them. Linking interventions also avoids the duplication and competition over resources that can divert attention from each cause. When overall levels of financial investment are limited, working together and pooling resources can have a stronger impact.

Perhaps, the inextricable link between mothers and newborns may best explained by the conceptual framework for maternal and neonatal mortality and morbidity of UNICEF:

Many of the causal factors responsible for maternal and neonatal morbidity and mortality are quite interrelated, as illustrated in UNICEF conceptual framework in the underneath figure. As clearly stimulated in the document (UNICEF 2009:16-20); while there are still many gaps in the knowledge of the extent and causes of maternal mortality and newborn deaths, certainly enough interventions are known that could save millions of lives. Given that the risks of maternal and newborn death are greatest during the first 24–48 hours after birth, post-natal care urgently needs to be expanded during this period, and greater emphasis needs to be placed on follow-up visits for babies and

mothers. Visits shortly after birth are vital for new mothers, who may remain at higher risk of mortality and morbidity for up to a year after birth. This is usually not possible, however, as maternal and newborn services are often greatly lacking in the poorest countries and communities where the most deaths occur. Particularly in Sub-Saharan Africa, factors such as distance, migration, urbanisation, armed conflict, disease and lack of investment in public health have left severe shortages of skilled health professionals. Thus, the theoretical framework may be considered and will be tested as key way-out.

UNICEF's conceptual framework described below on the causes of maternal mortality and newborn deaths illustrates that health outcomes are determined by interrelated factors, encompassing nutrition, water, sanitation and hygiene, health-care services and healthy behaviours, and disease control, among others. These factors are defined as proximate (individual), underlying (household, community and district) and basic (societal). Factors at one level influence other levels. The framework is devised to be useful in assessing and analysing the causes of maternal and newborn mortality and morbidity, and in planning effective actions to enhance community-based maternal and newborn health care provisions.

Figure 2.1: Conceptual framework for maternal and neonatal mortality and morbidity

(Adapted from UNICEF 2009)