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Editorial Safeguarding the First Year of Life
Ten expectant mothers and 200 children under the age of five died in the ten minutes it took you to brew your coffee this morning. Another 10 and an additional 200 died as you drank your first cup and so on throughout the day so that 10.6 million children and 529,000 pregnant or new mothers will have died by the end of each year.[1,2] The overwhelming majority of these children (7 million), die within four weeks of birth, mostly in the developing world. As if these statistics weren't sobering enough, consider that most of these deaths are preventable. According to the World Health Organization's 2005 World Health Report: Make Every Mother and Child Count, six causes are responsible for nearly 90% of infant deaths: acute neonatal conditions (premature birth, birth asphyxia and infections); lower respiratory infections, mostly pneumonia (19%); diarrhea (18%); malaria (8%); measles (4%); and HIV/AIDS (3%).[3] The reason so many newborns die at such an alarming rate can be summed up in one word: poverty. In all its guises, poverty takes millions of neonatal and post neonatal lives annually. Unavailability of clean water, absence of medical assistance during pregnancy and birth, and malnourishment among expectant mothers are among the leading causes - all preventable - of mother and infant deaths. For example, UNICEF's report Childhood Under Threat: State of the World's Children 2005, found that around 400 million children (one in five), in developing countries have no access to clean water and another 500 million (one in three) have no access to sanitation facilities, causing 1.4 million deaths each year.[4] "It's a scandal," said Marie-Paule Kieny, head of the WHO's family and community health division, adding that "newborns must be quickly washed, kept warm and preferably breastfed within an hour after birth." Such simple steps could "substantially" lower infant mortality rates, she said, and are included in the UN's Millennium Development Goals, which aim to lower maternal mortality by 75% and infant mortality by 67% by 2015. To achieve this, the 75 most affected countries will have to invest US$9 million annually over the next ten years in their public health systems.[5] Chronic illnesses associated with pregnancy (e.g., anemia), women giving birth at very young ages, and women having many children in succession have also been identified as causes contributing to infant mortality. Indeed, Charles MacCormack, president and CEO of Save the Children, provides a clue to improving global infant mortality rates when he says, "the quality of children's lives is inextricably linked to the health and education of their mothers."[6] Still, how to curb this global crisis is no mystery; pick an international organization (e.g., UN, WHO, PAHO, etc) and you'll find reports and analyses on this public health issue that is poised to cripple countries facing growing populations coupled with scarce resources. "The challenge is to find a better way of establishing continuity between care during pregnancy, at birth and when the mother is at home with her baby," according to the WHO's recent report, which calls this ideal 'continuum of care.' In Cuba, this care is provided within the Maternal-Child Health Program, the scope of which extends to young women beginning in their reproductive years, and follows children from infancy into their teens. Key to the program is the emphasis on the First Year of Life, our focus of this month's issue (see Spotlight: Well Babies: Cuba's National Program; MR Interview: Fernando Dominguez Dieppa, Vice President, Cuban Society of Pediatrics ). Cuba has reached record lows in infant mortality for the country and the region - 5.8 per 1,000 live births in 2004 - precisely because there is an explicit 'continuum of care' for prospective mothers and their babies. The program begins with family planning and comprehensive care for pregnant women which includes an average of 12 physician consultations during pregnancy, (more for at-risk mothers or if specialized testing indicates malformations, see Infant Mortality Due to Congenital Malformations). Ensuring safe deliveries is also key, and 99.9% of all births are attended by skilled medical personnel[7]. This last, in particular, becomes a vital statistic when problems do arise (Prenatal Hydronephrosis: A Proposal for Postnatal Study & Follow-Up; The Skin-to-Skin Method (Kangaroo Care): Age Adjusted Evaluation of Neuro-behavior at One Year; Relationship between Weight at Birth and the Number and Size of Renal Glomeruli in Humans: A Histomorphometic Study). The well-baby program is based on regular visits to the family doctor and pediatrician during the first year of life, and a schedule of 13 vaccinations are administered to all children, which has resulted in a 98% rate of vaccination for Cuban children under the age of two. Access to these and other health care services in Cuba are free and universal, obviating equity issues and providing a space for health education through family doctor offices and community clinics. Health system policies have progressed over the last years to encourage greater participation by both parents in caring for and raising their children, from the moment the couple is expecting (Accompanied Labor: A New Step in Cuba's Maternal-Infant Program) , Of course, even they have to contend with traditional roles (Cuba's Maternity Leave Extended to Fathers, But Few Dads Take It ). Yet, when it comes to a healthy first year of life, the WHO, UNICEF and all major research indicate that health services are a fraction of the solution: literacy rates among prospective mothers (96.7% in Cuba),[8] and access to safe water sources are among the key indicators that provide environmental supports for this delicate stage of life. One ongoing effort that aims to improve Cuba's 'continuum of care' is the Isle of Youth Study-ISYS (Cuban Nephrologists Present Isle of Youth Study at Nephrology 2005) that maps and follows risk markers of chronic kidney disease in an entire population - including 1200 babies from one day to one year old - in order to design prevention strategies for CKD and related conditions. The data gathered over time is expected to inform prevention strategies germane to both developing and developed nations in the fight against this chronic disease epidemic worldwide. On the news front, this issue of MEDICC Review carries several stories generated by South-South cooperation (Cuba and Guatemala: Innovations in Physician Training; Cuba and Venezuela Step Up Health Cooperation: Sight-Saving Initiative for Region's Poor) . Last, we're pleased to share A Conversation with Internationalist Aleida Guevara, MD , who speaks as the daughter of a legendary man, but more so in her own voice as a pediatrician who has served in Central America and Africa, where she made her personal commitment to health as a fundamental human right. Certainly, and unequivocally, newborns everywhere are entitled to it. REFERENCES
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