The comparison that we made to the NMR among the EMR countries with a utility value was for the purpose of evaluation of the current situation and inputs for future planning improvement. The analysis of the mortality rate provides a real means for comparison, particularly in countries with different health status and health system policies. The results of this study illustrated that there are substantial differences in the NMR among the countries of the region despite the fact that these countries share many common culture and traits, including early marriage, frequency of marriage and inbreeding (13, 14). All of these factors combined, affect health of neonates. It is noted that differences still exist in NM between the countries of the region. Our findings showed that the EMR can be grouped under three categories regarding the NMR; The GCC countries that form the first category with the lowest rates (≤ 10 deaths per 1000 live births); the second category with rates from > 10 to 25 deaths per 1000 live births include Jordan, Egypt, the State of Palestine, Morocco, Iraq; and the third category with the highest rates exceeding 25 deaths per 1000 live births comprise Yemen, Sudan, Djibouti, Afghanistan, Pakistan and Somalia. However, there was a clearly noticeable decline in the NMR between 1990 and 2013 in all the countries, except for Somalia and the State of Palestine, which indicates that great efforts have been exerted to improve the health care services quality and facilities availability. In this time period, Somalia and the State of Palestine are unique in sense that their situation reflects impact of war on humanity and highlights the need to rescue neonates in these countries from the consequences of poverty, lack of resources, political conflict and sanctions that contribute to this high rate of mortality. At the same time and in the following years prevailed the same extreme conditions in Afghanistan, Syria, Iraq, and much harder in Yemen.
Our data analysis also demonstrated the impact of the demographic, social, economic and perinatal care factors on neonatal mortality (15, 16). The main demographic determinant was TFR that appeared very strongly associated to the NMR, while the total birth rate and the total population were weakly correlated with the NMR. There was a negative correlation between the NMR and the annual growth rate where the reason may be due to increase in population density from country to others. Pakistan and Egypt had the highest total population size with annual total births amongst the relatively high fertility rates and annual growth rates. In addition, Somalia and Pakistan were categorized among those countries with the highest neonatal mortality rate.
The rapid progress of the Arabian Peninsula countries over the last two decades clearly reflected the remarkable decline in the neonatal deaths rate due to the different health care for neonates, which could be explained by the circumstances and problems of each individual country. However, it is of some concern that the Arabian Peninsula countries had the highest annual growth rate and fertility rate, especially in Kuwait, as evidenced by the relative rise in population and the total number of annual births. The literacy rate among males and females showed an inverse relationship to the NMR. This reflects the paramount role of socio-economic development and its impact on improving the health status of neonates, and also explains previous reports (17, 18). This factor was found as well in previous study carried out by Abuqamar et al. on the impact of parental education on infant mortality in the Gaza strip. They found a significant inverse correlation between parental education and the survival of infants, where families with low educational levels attainment had a much higher risk of infant mortality (19). Positive relationship with male to female literacy ratio found in this study suggest that the role of literacy and education among mothers is an important factor for improving NMR. This also can be seen with the stronger inverse relationship with NMR for female literacy as compared to male literacy. A high association exists between the education of the female or literacy level and use of the reproductive, maternal and child health services. The NM levels are significantly higher in countries with a high rate of female illiteracy, which is evident in the region (10).
The findings of our study also demonstrated a clear gap between men and women in terms of education opportunities in the countries of the region, which, in turn, indicated the existence of a direct relationship with NMR. In this study, our findings on health factors are in alignment with previous studies in both developing and developed countries, in that they showed the real effects of antenatal care and the birth attendance by skilled health personnel on perinatal outcomes. These included the reduced rates of maternal deaths and low birth weight that are used as quality performance indicators for the perinatal care offered in a society (20), and hence explain some of the differences in NMR among the EMR countries. This indicates the great importance of improving access and quality of the perinatal care coverage and health services offered in the community to reduce mother and child deaths.
As shown in Figure 5, in many countries of the EMR region, there is a marked variation in the economic situation, which is inversely correlated with the NMR. A large variation in total expenditure on health per capita and neonatal mortality is also observed within different SE status of the countries of the EMR, in which the correlation between NM and the expenditure on health per capita is inverse.
Figure 5.
Distribution Neonatal Mortality Rate and Total Health Expenditure Per Capita (US$) by EMR Countries, 2012
This study found that economic factors were strongly associated with inverse NMR. The impact of economic development, maternal education improvement and perinatal health care services through the low-cost, community-based interventions, are evidenced by the success of Qatar, where, over a period of more than 35 years, these developments have had a strong impact on maternal, neonatal, and perinatal survival (15). However, poverty is not just a problem in poor countries; it can also result in disparities between the richest and poorest of the populations of the same country. Therefore, there is a need to focus on drawing attention to the important role of securing sustainable economic growth and its impact on the availability of health services. Through the analysis of health accounts in the countries of the EMR region for the middle and low income, most countries showed that the percentage of total expenditure on health of gross domestic product (GDP) has decreased over time. This leads to a deterioration in the health and equity in the financing of health care (21). The result of the study enhances the imperative need for action for continuing efforts in the EMR region to improve neonatal health and reduce neonatal mortality, and for intensive and accelerated action to empower every women by giving the best opportunity for getting safe and clean birth delivery so that every child has the best possible start in quality of life (22).
To scale up efforts to improve the health status of maternal and child health in the EMR Region, the initiative “Saving the lives of mothers and children” was jointly launched by WHO, UNFPA and UNICEF with Member States in a high-level meeting held in Dubai, United Arab Emirates, in January 2013. The meeting concluded with the Dubai Declaration, which was endorsed by the 60th session of the regional committee for the Eastern Mediterranean in October 2013. The main goal of the meeting was to scale up efforts to improve the health status of maternal and child health in the region, and for the high burden countries to commit to developing, launching and implementing maternal and child health acceleration plans to move forward the MDG agenda. In this sense, there is a need to coordinate efforts and direct them according to four priorities: the first is to encourage communities through the work of campaigns and activities of the awareness of the importance of education for members of the community and the positive relationship with children’s lives through the reduction of early marriage and childbearing; in addition, to reduce the number of children and take advantage of the care services in the different stages of pregnancy in the community to increase awareness of the health and hygiene promotion standards. The second priority is the position of neonatal health in the health policies and strategies for all countries of the region, and to recognise it as an important stage of the child. NM represents almost 40% of all under-five deaths, possibly because the health of babies has a close relationship with the mother’s health. An appropriate maternal health care in pregnancy and the post-natal stage leads to a reduction of mortality and morbidity among neonates. However, the care needs of neonates are of a different kind. At the moment, the health care for mothers and children in the region, must address this issue and select appropriate and effective interventions according to the differences within the country, ensure access for the neediest and provide high quality service for antenatal, newborn and postnatal care, as well as continuous education and the training of health professionals who can reach the marginalized and poorest sectors of the population. Monitoring mechanisms should be in place to ensure the implementation of the policies and measure the achievement of the set national goals. Countdown for 2015 is one such initiative that could be used at the country level to assess progress and coverage (23). In addition, there is a need for the establishment of a consumer-provider relationship, as well as a need to focus on the delivery strategies and mechanism for scaling up coverage in the short term. These include innovations for demand creation and service delivery, as well as the removal of financial barriers (24).
The third is to strengthen the health system, in particular the health information system, to be able to track neonatal indicators, which are crucial for sound planning, successful implementation of interventions and monitoring of achievements as well as to reinforce the vital registration system (birth and death certificates) to assist in validating the data available on maternal and neonatal mortality. Two studies conducted in 10 governorates in Yemen in 2005, showed that the availability of basic emergency obstetric care services are extremely limited and maternal newborn health (MNH) services are underutilized in the assessed governorates: (skilled birth attendance around 20%; cesarean proportion less than 1%; and the case fatality rate for obstetric complications > 1%). Both studies revealed a very poor level of data quality: “All the registers available in each of these assessed facilities were accessible but most of them are of poor quality; either the register was not up to date or/and filled out incompletely. This negligence of data use contributes to poor quality of registers and records available (25, 26).
The fourth is the importance of integrating research into the maternal, neonatal and child health acceleration plans and beyond, with a focus on operational or implementation research designed to overcome local barriers and ensure the implementation of strategies that are known to be effective. Capacity building in research methods was identified as a need to be addressed, including through collaboration with local and regional research institutions.
A common motif running through all the presentations was the need for technical support and capacity development in both the technical aspects of maternal, neonatal and child health as well as in the strengthening, research and monitoring, and evaluation efforts of health systems. It was also suggested that small-scale surveys could be implemented in the target areas in order to generate data on service utilization (27).
Conclusion: Despite the fall in the neonatal mortality rate, it remains high in the EMR countries compared to developed countries. It has been shown that the (GNP, total expenditure on health, safe water/ sanitation, and female literacy were negatively correlated with the neonatal mortality rate. On the other hand, the maternal mortality ratio, male/female literacy ratio and TFR were positively correlated with the neonatal mortality rate. Therefore, neonatal health needs to be addressed with a more effective and innovative approach that target support and capacity development of maternal, neonatal and child health services in order to continue and sustain the rapid progress made in reducing the overall reduction of child mortality.
4.1. Recommendation
The Eastern Mediterranean Region countries needs to focus on the improvement of the total of expenditure on health services of GDP, adequate allocation of financial resources to child health, sufficient qualified human resources and high turnover of qualified staff at all levels and addressing disparities within the EMR countries. Reduction in poverty improvement in social and living conditions e.g. adequate sanitation and clean drinking water is prerequisite. Establishing and adoption of the strategy to accelerate the reduction of maternal and neonatal morbidity and mortality through improvement of the availability, accessibility and utilization of essential maternal and neonatal health services and improvement in its quality, as well as enhancement of educational awareness on child survival by delaying marriage, avoid early childbearing, using family planning strategies to reduce the number of children and make practical and effective use of prenatal care services are recommended. Monitoring mechanisms should be in place to ensure the implementation of the policies and measure achievement of the set national goals.
Results of this manuscript may serve as an important source of information to guide the public health policy makers and health care providers to design interventions to reduce child mortality.
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