This report is the second in a series addressing neonatal survival. 1 The first article 2 discussed the unacceptably high number of neonatal deaths that happen every year (4 million), their inequitable distribution, the increasing proportion of child deaths that take place in the neonatal period, and the importance of reducing neonatal mortality to meet the Millennium Development Goal for child survival (MDG-4). Most neonatal deaths occur at home in low-income and middle-income countries against a backdrop of poverty, sub-optimum care seeking, and weak health systems. [1][2][3][4] Globally, neonatal deaths now account for 38% of deaths in children aged younger than 5 years. 2 Child survival and safe motherhood strategies have yet to adequately address mortality in the neonatal period. A major barrier to action on neonatal health has been the erroneous perception that only expensive, high-level technology and facility-based care can reduce mortality. 5,6 Increasing access to skilled, facility-based care is an important long-term aim, but what can be done in lowincome and middle-income countries in the shorter term? Are there cost-effective interventions and healthcare strategies that can be implemented now, and how many lives could be saved?
Here, we summarise the findings of a review of the evidence on the efficacy (implementation under ideal conditions) and effectiveness (implementation under conditions that pertain within health systems) of a wide range of potential interventions to reduce perinatal and neonatal mortality. We present an analysis of the costeffectiveness of individual interventions, and of interventions packaged to facilitate their delivery by health systems. We derive estimates of the proportion and number of neonatal deaths that could be prevented with these interventions in 75 countries, and the associated cost.
Identification of effective interventions
The Bellagio child survival series [7][8][9][10][11] has been important in drawing attention to the unfinished child survival agenda. Writing for the series, Jones and colleagues 8 estimated that implementing existing evidence-based interventions at high coverage (99%) could avert 63% of all child deaths and 35-55% of neonatal deaths. These estimates have limitations, however, especially in terms of putting the interventions into a health systems context. 1,12 Several potential interventions, particularly those that target mothers, were not included in the Bellagio analysis because a systematic review of perinatal and neonatal health interventions was not available. 13 Of the 23 interventions listed, eight were specific to neonates, but five of the eight were assumed to need skilled care, 8 leaving few choices for settings with low coverage of skilled care.
We did a systematic review of the evidence on the efficacy and effectiveness of interventions with the potential to reduce perinatal or neonatal mortality, or both (panel 1). [13][14][15][16][17][18][19][20][21][22][23][24][25][26] Our aim was to identify interventions for use in low-income and middle-income countries. We did not, therefore, include costly, high-tech interventions, such as assisted ventilation or surfactant therapy.