Two therapeutic hypothermia trials provided updated information on mortality and the incidence of abnormal neurodevelopmental outcomes infants with moderate to severe HIE. [27, 28] In these trials, 23-27% of infants died prior to discharge from the neonatal intensive care unit (NICU), whereas the mortality rate at follow-up 18-22 months later was 37-38%. In these trials, neurodevelopmental outcomes at 18 months were as follows:
Childbirth and the postnatal period, spanning from right after birth to the following several weeks, presents a time in which the number of deaths reported still remain alarmingly high. Worldwide, about 800 women die from pregnancy- or childbirth-related complications daily while almost 75% of neonatal deaths occur within the first seven days of delivery and a vast majority of these occur in the first 24 hours. Unfortunately, this alarming trend of mortality persists, as287,000 women lost their lives to pregnancy and childbirth related causes in 2010. Almost all of these deaths were preventable and occurred in low-resource settings, pointing towards dearth of adequate facilities in these parts of the world. The main objective of this paper is to review the evidence based childbirth and post natal interventions which have a beneficial impact on maternal and newborn outcomes. It is a compilation of existing, new and updated interventions designed to help physicians and policy makers and enable them to reduce the burden of maternal and neonatal morbidities and mortalities. Interventions during the post natal period that were found to be associated with a decrease in maternal and neonatal morbidity and mortality included: advice and support of family planning, support and promotion of early initiation and continued breastfeeding; thermal care or kangaroo mother care for preterm and/or low birth weight babies; hygienic care of umbilical cord and skin following delivery, training health personnel in basic neonatal resuscitation; and postnatal visits. Adequate delivery of these interventions is likely to bring an unprecedented decrease in the number of deaths reported during childbirth.
The number of deaths reported during childbirth and postnatal period still remain alarmingly high. Worldwide, about 800 women die from pregnancy- or childbirth-related complications daily and approximately 287,000 women lost their lives to pregnancy and childbirth related causes in 2010 . Every year an estimated 2.9 million babies die in the first 4 weeks of life [2, 3]. Almost all (99%) neonatal deaths occurs in low- and middle-income countries (LMICs), yet most epidemiological and other research focuses on mere 1% of deaths occurring in high income countries (HICs) . The fact that almost all of these deaths were preventable and occurred in low-resource settings, points to a dearth of adequate facilities in these parts of the world. Preterm birth, birth asphyxia (lack of breathing at birth), and infections cause most neonatal deaths.The critical postpartum period starts from about an hour after the delivery of placenta and extends over the following six weeks. Postpartum care should respond to the special needs of the mother and baby during this critical period and should include prevention and early detection; treatment of complications and disease; attention to hygienic care; advice and support of exclusive breastfeeding; birth spacing; immunization; and maternal nutrition .
Since the postnatal period is a critical time to deliver interventions, failure to do so leads to detrimental effects on the survival and future health of both mother and neonate. Many women die as a result of complications during and following childbirth. The major complications that account for 80% of all maternal deaths are severe bleeding (mostly bleeding after childbirth), infections (usually after childbirth), high blood pressure during pregnancy (pre-eclampsia and eclampsia), and unsafe abortion. The remainder are caused by or associated with infectious diseases during pregnancy such as malaria and AIDS. A practical and viable strategy for reducing maternal and neonatal morbidity and mortality rates from preventable causes and meeting maternal health related Millennium Development Goal (MDG) targets, is by integrating improved childbirth facilities and postnatal care for newborns and mothers . The 4th MDG focuses on reducing child mortality and is closely associated with maternal health MDG. In developing countries alone, if mothers start practicing early initiation of breastfeeding, it is estimated that it can save as many as 1.45 million lives annually by reducing deaths mainly due to lower respiratory tract infections and diarrhoeal diseases . To reduce the high burden of neonatal mortality and morbidity, postnatal care should be integrated into existing health programs. Community based education and health promotive workshops on exclusive breastfeeding and preventing vertical transmission of HIV will help increase the coverage of the postnatal interventions and improve maternal and newborn health.
A review of interventions to promote breastfeeding showed increased rates of initiation of breastfeeding (RR 1.53; 95% CI: 1.25, 1.87) ; another review also showed similar results (RR 1.45; 95% CI: 1.14, 1.84) . Community-based intervention packages for reducing maternal and neonatal morbidity and mortality also showed an increase in rates of breastfeeding (RR 1.94; 95% CI: 1.56, 2.42) . Early versus late initiation of breastfeeding was found to be associated with decreased neonatal mortality (RR 0.52; 95% CI: 0.27, 0.98) while the effect of breastfeeding when compared to no breastfeeding also decreased neonatal mortality (RR 0.30; 95% CI: 0.17, 0.53) . Another review showed that early breastfeeding initiation was associated with lower risks of all-cause neonatal mortality among all live births (RR 0.56; 95% CI: 0.40, 0.79) and among LBW babies (RR 0.58; 95% CI: 0.43, 0.78), as well as infection-related neonatal mortality (RR 0.55; 95% CI: 0.36, 0.84) . When evaluating antenatal breastfeeding education, a formal breastfeeding education workshop vs. routine care increased the initiation rate of breastfeeding (RR 1.19; 95% CI: 0.97, 1.45); peer counseling versus routine care showed higher increments in the initiation rates of breastfeeding (RR 1.82; 95% CI: 1.13, 2.93). Less significant increases were observed at 3 months and 6 months after the education workshop . Another review by Imdad et al. 2011 compared breastfed versus non breastfed infants and showed a significant 70% reduction in the risk of neonatal mortality. It also showed that early initiation of breastfeeding versus late reduced neonatal mortality significantly by 48%.
Antiseptic versus dry cord care/placebo decreased cord infection rates (RR 0.53; 95% CI: 0.25, 1.13); alcohol showed lower cord infection rates as well (RR 0.63; 95% CI: 0.19, 2.06]; triple dye also lowered infection (RR 0.68; 95% CI: 0.13, 3.49]; salicylic sugar powder showed significant reductions in infection rates (RR 0.21; 95% CI: 0.01, 4.38). Antiseptics that were aqueous based and alcohol based were effective for cord separation: (WMD -4.76; 95% CI: -5.34, -4.19) and (WMD -10.05; 95% CI: -10.72, -9.38) respectively, when compared with powder based antiseptics . A single study  evaluating the effect of chlorhexidine cleansing of the newborn skin showed reduced rate of bacterial colonization by Staphylococcus aureus (RR 0.65; 95%CI: 0.55, 0.77), Streptococci (RR 0.53; 95%CI: 0.27, 1.04); and E. Coli infections . Chlorhexidine versus no treatment in cleaning skin of LBW newborn decreased neonatal mortality (RR 0.72; 95%CI: 0.55, 0.95) . Another review also indicated that the use of chlorhexidine led to a 23% reduction in all-cause neonatal mortality in the intervention group compared to control (RR 0.77; 95 % CI: 0.63, 0.94) . A study conducted in Nepal found that there was a 28% reduction in mortality among LBW infants when chlorhexidine was used to clean the skin .
Preterm birth (before 37 completed weeks of gestation) is the most important direct cause of neonatal mortality and it accounts for an estimated 27% of the four million neonatal deaths every year [4, 77]. In the early 1970s, motivated by problems arising from shortage of incubators and also the impact of mother and newborn separation, Colombian paediatrician Edgar Ray developed a technologically simple method later named Kangaroo Mother Care (KMC). Acceptance of the KMC method is increasingly widespread and it is considered equivalent to conventional neonatal care for stable preterm infants and more parent and baby friendly .
Maternal and newborn health exists in a synergistic relation. Most maternal deaths are avoidable provided timely and adequate delivery of health-care solutions to prevent or manage complications. An access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth should be provided to all women. The review discussed all childbirth and postnatal interventions which have an impact on reducing maternal, neonatal mortality and which are suitable for delivery in LMICs. The implementations of discussed interventions promise a much needed improvement is maternal and neonatal outcomes around the world. However, some of these interventions must be prioritized over others depending on the clinical indications and keeping in view the limited resources in developing countries. Timely provision of these interventions holds unparalleled significance, particularly those that are delivered during and immediately after childbirth, in places where majority of the births occur, at home. 2b1af7f3a8