Worldwide 5.5 million babies are born and die each year without a record of their existence

New Lancet Series finds counting births and deaths is an indicator of progress towards ending three million preventable infant deaths.

Each year 5.5 million babies enter and leave the world without being recorded and one in three newborns-over 45 million babies-do not have a birth certificate by their first birthday, according to new research co-led by the London School of Hygiene & Tropical Medicine. Babies who are stillborn, born too early, or who die soon after birth are least likely to be registered, even in high-income countries. This lack of registration is a key reason for slower progress in recent decades in reducing newborn deaths compared to maternal and child deaths - progress which must be accelerated if international child mortality targets are to be met.

The findings, from the new Every Newborn Series, published in The Lancet, provide the clearest picture to date of a newborn's chance of survival and the steps that must be taken to end preventable infant deaths. The research forms the basis for the forthcoming Every Newborn Action Plan, an evidence-based roadmap towards care for every woman and a healthy start for every newborn baby, which will be launched in June.

The new Lancet series consists of five papers and provides comprehensive new data for 195 countries regarding neonatal deaths, stillbirths, rankings for countries, rates of progress and coverage of birth certification.

New analyses indicates that three million maternal and newborn deaths and stillbirths could be prevented annually with proven interventions - including the promotion of breastfeeding, neonatal resuscitation, kangaroo mother care for preterm babies, antenatal corticosteroids, and the prevention and treatment of infections. These interventions can be implemented for an annual cost of US$1.15 per person. Providing quality care at birth yields a triple return on investment-saving mothers and newborns, and preventing stillbirths-and protects babies from disability.

The series was led by Professor Joy Lawn, Director of the Centre for Maternal, Adolescent, Reproductive & Child Health at the London School of Hygiene & Tropical Medicine, and senior adviser to Save the Children, and by Professor Zulfiqar Bhutta, from the Centre for Global Child Health, Hospital for Sick Children, Canada, and the Centre of Excellence in Women and Child Health, the Aga Khan University, Pakistan, in collaboration with 55 global health experts, researchers, and policymakers from 27 institutions in 18 countries.

The authors estimate that 2.9 million newborn deaths and 2.6 million stillbirths (during the last three months of pregnancy) occur worldwide each year.

According to Professor Lawn, the results highlight an important, yet largely unacknowledged global problem: "In most countries stillbirths do not get birth or death certificates, which contributes to their invisibility; hence, most of the world's newborn deaths and almost all stillbirths enter and leave the world without a piece of paper to record their existence. The fact that the vast majority of these deaths - which have a huge effect on the women and families involved - are never formally included in a country's health registration systems signifies acceptance that these deaths are inevitable, and ultimately links to inaction.

"So far investment targeted to newborn health has been minuscule - nearly half (44%) of all deaths in children under five are in the first month of life, yet only 4% of donor funding to child health even mentions the word 'newborn'. Another critical issue is the need for more midwives and nurses with skills to look after women in labour and small and sick newborns. We now know what needs to be done differently - and the Series outlines bold, but achievable, targets for reducing newborn deaths and stillbirths. The forthcoming Every Newborn Action Plan will build on these targets and provide momentum in many countries for accelerated action."

Over the last decade, the rate of reduction for newborn deaths has been about half the rate of reduction achieved for children under age five. As a result, newborn deaths now account for a larger proportion of under-five child deaths-44% in 2012, compared to 36% in 1990. In most regions of the world, more than half of child deaths are among newborns.

The School's Dr Hannah Blencowe who also worked on the Series said: "There remains an urgent unmet need to provide timely, high-quality care for both mother and baby around the time of birth. Each year 1.2 million stillborn babies die during labour and a further one million babies die on their birth day. By 2035 there will be a further 116 million deaths, 31 million survivors with disabilities, and 68 million with lost developmental potential because of stunting if action to improve birth outcomes is not taken now. Investment is needed to ensure a healthy start for every newborn baby today - they are the citizens and workforce of the future."

Half of the newborn deaths worldwide occur in just five countries: India (779,000), Nigeria (276,000), Pakistan (202,400), China (157,000), and the Democratic Republic of Congo (118,000), although global and national figures conceal huge variations within and between different countries. In 2012, eight of nine countries with neonatal death rates greater than 40 for every 1,000 live births were in sub-Saharan Africa; half of these countries were affected by conflict.

If current trends continue, it will be more than 110 years before an African baby has the same chances of survival as a baby born in North America or Europe. Progress in Africa has been three times slower than what has been achieved in high-income countries, even before the advent of intensive care.

Melinda Gates, co-Chair of the Bill & Melinda Gates Foundation which provided funding for the Series said: "The health and wellbeing of women, newborns, and children is closely linked, and they must be prioritised. We have proven solutions that we know will save newborn lives and accelerate progress for women and children, and we have seen that where there is political will around these solutions significant progress is possible."



Tables with key findings:

Ten riskiest countries for newborns

Country Neonatal mortality rate per thousand live births 2012
Sierra Leone 49.5
Somalia 45.7
Guinea-Bissau 45.7
Angola 45.4
Lesotho 45.3
Democratic Republic of the Congo 43.5
Pakistan 42.2
Mali 41.5
Central African Republic 40.9

Ten safest countries for newborns:

Country Neonatal mortality rate per thousand live births 2012
Japan 1.1
Singapore 1.2
Cyprus 1.5
Estonia 1.6
Finland 1.6
Republic of Korea 1.6
Sweden 1.6
Norway 1.7
Portugal 1.8

Ten high-income countries showing slowest progress (slowest annual rate of reduction [ARR] in neonatal mortality rate):

Countries and territories Neonatal mortality rate per thousand live births 2012 Average Annual Rate (ARR) of NMR reduction 1990-2012 Decline NMR (%)1990-2012 Decline in 1-59 mortality rate (%)1990-2012
Switzerland 3.2 0.78 16% 76%
Canada 3.5 1.03 20% 55%
United States 4.1 1.49 28% 45%
Germany 2.4 1.95 35% 66%
New Zealand 2.8 2.03 36% 57%
United Kingdom 3 2.11 38% 60%
France 2.3 2.14 38% 68%
Australia 2.8 2.33 40% 55%
Netherlands 2.8 2.42 42% 62%
Denmark 2.6 2.56 43% 73%

Ten countries with highest potential for lives saved:

Countries and territories Lives saved estimates for newborns, stillbirths and mothers with high coverage of care by 2025
India 840,400
Nigeria 375,000
Pakistan 217,700
Democratic Republic of the Congo 139,000
Ethiopia 76,800
Bangladesh 76,100
Afghanistan 67,500
United Republic of Tanzania 65,800
Indonesia 56,100
Uganda 54,800

Ten countries where babies least likely to receive a birth certificate before their first birthday:

Countries and territories Percentage of livebirths in 2012 registered by 1st birthday
Somalia 3
Liberia 4
Ethiopia 7
Bangladesh 9
Zambia 13
Chad 13
Guinea-Bissau 14
United Republic of Tanzania 15
Nepal 19
Pakistan 21

Image: Newborn babies. Credit: Save the Children

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