Achievement of MDG-4 requires increased focus on neonatal mortality. Improved data collection and analysis from countries in which infant mortality is high are necessary to develop cost-effective and successful programmes aimed at neonatal health.13
Impeding progress in addressing these issues is the lack of local data from many countries regarding neonatal deaths, which may provide raw material from which broader-scale intervention studies can be based.
These data further provide specific information on neonatal mortality from a region where information on cause of death and neonatal treatment is not well characterised.
Pneumonia and sepsis constituted 46% of all admission diagnoses and was associated with 59% of overall mortality compared with 26% internationally.16
Hypothermia contributed to 22.9% of patient morbidity—within the range of worldwide estimates of prevalence in the developing world.22
Diarrhoea causes 3% of worldwide neonatal deaths but did not account for Eritrean mortality, despite being frequently encountered as the primary diagnosis for 15.5% of patients. Congenital anomalies caused 7% of deaths in the SNCU and are estimated at 7% worldwide. Malformations often require specialised surgical correction, a degree of technology not available widely in the developing world.
Worldwide, 25%–45% of neonatal deaths occur in the first 24 h of life. This international trend was lower than our unit's experience where the number was almost 70% (58/87), though not all these data were based on time of presentation, which may differ from actual age given delays in care-seeking.1
Given that over 50%–90% of births take place outside medical facilities (in Eritrea this number is 40%–72%), introduction of skilled nursing care at birth by community health workers may reduce early neonatal morbidity.2
Similar to other developing nations, hypothermia remains significantly associated with morbidity and mortality in the developing world.24
Hypothermia is an independent associative factor for mortality in our logistic regression model and may play a role in the increased morbidity in patients with pneumonia.25–27
In Eritrea, hypothermic patients were of lower gestational age and birth weight. Low birth weight has been commonly cited in all countries as a risk factor for hypothermia at birth.28–32
The incidence of obtaining temperature in home births in an Indian cohort was only 11% in 189 neonates.33
However, our data support the notion that throughout the developing world, cold stress is a major factor associated with neonatal outcome.34
One-fifth of our birth cohort was SGA, a potent risk factor for both mortality and increased length of stay. While being SGA increases susceptibility to death by other means, the Child Health Epidemiologic Research Group estimates that 2% of all worldwide deaths are directly attributable to in utero growth restriction.35
Interventions to reduce SGA births are costly and face several barriers. Increased prenatal surveillance of mothers with an emphasis on safe pregnancy initiatives and nutrition reduce the number of SGA infants.13
Information for cause-of-death analysis is unavailable for 97% of neonatal deaths. Thus, estimates are the only source of data on the 3.8 million babies who die in the first 28 days of life. This study sought to determine patterns of morbidity and mortality in a centralised SNCU in Eritrea and contribute relevant region-specific data in an area where information is lacking.2
Improved epidemiological data are essential, and Eritrea provides a rich source of data which may inform programme development for the region.
Systematic analysis of neonatal mortality is hampered by limitations. As the only regional neonatal referral centre, these data are based on the small percentage of newborns born in Eritrea who needed care and presented to medical attention in this urban hospital. Thus, they may not be representative of the national population. Rates of home deliveries were lower than the national average, potentially skewing cause-of-death information and explaining our observed differences from national findings. Also, the mean day of presentation to hospital care was 4 days, thus, home-born infants who die in the first 24 h of life escape analysis.9
Information was obtained in 2006 and may not be indicative of real-time annual changes in NMR. However, it should be noted the latest WHO Estimates of Global Mortality in Children were published in 2005 and represented the first update since 1995.16
In that context, a 3–5-year delay in data analysis may be acceptable. Furthermore, information on birth weight, Apgar score and temperature must always be viewed through the experience of an area where many home births occur, a commonly encountered problem for research in the developing world.36
Particularly difficult is the inclusion of pneumonia versus sepsis as two distinct categories. While one neonatologist determined the diagnosis for all patients, creating consistency in case definition, WHO combines sepsis and pneumonia into a single category, owing to the similarity of clinical presentation in neonates.
Our data suggest the impact of skilled neonatal resuscitators may merit future study. Theoretically, use of skilled resuscitators would improve Apgar scores, reduce peripartum hypothermia and may lead to prompt diagnosis of pneumonia, improving care and potentially increasing survival. Improvements in prenatal care may lead to delivery at an older gestational age, alter C-section rates and improve birth weights.
Achieving substantial reductions in neonatal mortality is possible without significant increases in costs. Greater attention to home birth attendance, avoidance of hypothermia and improved access to postnatal care should play a large role in further reducing Eritrean neonatal mortality.