yousef s. khader, mohammad alyahya, and anwar batieha · 2019-05-22 · yousef s. khader, mohammad...

Perinatal and Neonatal Mortality in Jordan

Yousef S. Khader, Mohammad Alyahya, and Anwar Batieha

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Jordan’s Neonatal Mortality Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Risk Factors for Neonatal Mortality in Jordan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Leading Causes of Perinatal and Neonatal Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Preventability of Neonatal Death and Stillbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Organization and Delivery of Perinatal and Neonatal Health Services . . . . . . . . . . . . . . . . . . . . . . . . . 10Quality of Maternal and Neonatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Information and Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Recommendations to Improve the Process of Registration of Births . . . . . . . . . . . . . . . . . . . . . . . . 18Recommendations to Improve the Process of Registration of Deaths . . . . . . . . . . . . . . . . . . . . . . . 19

Conclusions and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

AbstractDespite the extraordinary improvements in child survival over the past 25 years,little progress has been made in reducing neonatal mortality (NNM) in manydeveloping countries. According to the Jordan Perinatal and Neonatal Mortalitystudy, stillbirth, neonatal, and perinatal mortality rates were 11.6/1,000 totalbirths, 14.9/1,000 live births, and 23.7/1,000 total births, respectively. Maternalage (<20 years old), history of preterm or low birth weight delivery, history of

Y. S. Khader (*) · A. BatiehaDepartment of Community Medicine, Public Health and Family Medicine, Faculty of Medicine,Jordan University of Science and Technology, Irbid, Jordane-mail: [email protected]; [email protected]

M. AlyahyaDepartment of Health Management and Policy, Faculty of Medicine, Jordan University of Scienceand Technology, Irbid, Jordane-mail: [email protected]

© Springer Nature Switzerland AG 2019I. Laher (ed.), Handbook of Healthcare in the Arab World,https://doi.org/10.1007/978-3-319-74365-3_161-1

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https://doi.org/10.1007/978-3-319-74365-3_161-1

neonatal death or stillbirth, preeclampsia, mother’s hospitalization duringthe current pregnancy, primiparity, breach presentation, and male offspring aresignificantly associated with increased risk of neonatal mortality in Jordan.Newborns who have congenital defects, multiple births, and babies born towomen who do not use antenatal care services are at higher risk of neonatalmortality. Preterm babies and low birth weight babies are almost 20 times morelikely to die during the neonatal period compared to full-term babies and normalbirth weight babies, respectively. Most neonatal deaths in Jordan are due tocongenital anomalies (27.2%), multiple births (26.0%), or unexplained immatu-rity (21.7%). Other important causes include maternal disease (6.7%), specificinfant conditions (6.4%), and unexplained asphyxia (4.9%). The main causesof stillbirths are maternal diseases (19.5%), unexplained immaturity (18.8%),congenital anomalies (17.6%), unexplained antepartum stillbirths (17.6%),obstetric complications (8.4%), placental abruption (5.7%), and multiple births(5%). Previous research in Jordan reported that about 30% of all neonatal deathsare preventable and that 44.3% are possibly preventable with optimal care. Anefficient referral system which directs high-risk pregnancies to institutions withoptimum facilities and equipment, personnel technical skills, and specializationof neonatal intensive care units (e.g., through regionalization) is needed toimprove perinatal outcomes. Moreover, interventions that reduce mortality andmorbidity in preterm babies need immediate attention. Improved survival for themajority of moderate to late preterm (32 to <37 weeks) and early pretermneonates (28 to <32 weeks) can be attained by improving essential newborncare and utilizing a range of low-cost and evidence-based interventions. Suchinterventions include the prevention and management of hypothermia, hypogly-cemia, and infection, and providing adequate respiratory and feeding support.

KeywordsPerinatal mortality · Stillbirth · Neonatal mortality · Cause of neonatal deaths ·Jordan

Introduction

A high number of children die shortly after birth in many parts of the world; manyof these children die during the first 4 weeks of life (neonatal deaths), with most ofthose deaths occurring in the first week (early neonatal deaths). Despite the extraor-dinary improvements in child survival over the past 25 years, little progress has beenmade in reducing neonatal mortality (NNM) in many developing countries. A child’srisk of dying is nearly 15 times greater in the first month of life than at any other timeduring the first year of life. Almost 98% of neonatal deaths occur in developingcountries. About 45% of annual deaths of children younger than 5 years take placein the neonatal period, and the relative magnitude of these deaths increases as childmortality is reduced (Liu et al. 2016; Black et al. 2003). When under-five mortalityis less than 35 per 1,000, more than 50% of all children are dying as neonates.

2 Y. S. Khader et al.

About three-quarters of all neonatal deaths occur in the first week of life, with thehighest risk of death being on the first day (Lawn et al. 2005; Sankar et al. 2016).

The WHO estimates that almost four million stillbirths occur each year world-wide, accounting for over half of all perinatal deaths (Stanton et al. 2006; WorldHealth Organization 2006). While countries in Southeast Asia report the highestoverall numbers of stillbirths, countries in Africa have the highest stillbirth rates.In high-income countries, stillbirth rates are as low as 6 per 1,000 live births,whereas in less developed countries, they can be as high as 26 per 1,000 live births(World Health Organization 2006). Stillbirth rates also vary within countries, beinghigher in economically poorer communities. One third to one fourth of all stillbirthsoccur during delivery, with the remaining proportion estimated taking place beforedelivery. In settings where women receive appropriate care during childbirth,intrapartum deaths represent less than 10% of stillbirths and are mainly due tounexpected complications. This suggests that stillbirths are closely linked to theuse and quality of maternal services (World Health Organization 2006; Cousens etal. 2011). Most stillbirths are avoidable, as evidenced by the low stillbirth rate fordeveloped countries.

The causes and determinants of neonatal deaths and stillbirths differ from thoseof postneonatal and child deaths. Neonatal deaths and stillbirths stem from poormaternal health, inadequate care during pregnancy, inappropriate management ofcomplications during pregnancy and delivery, poor hygiene during delivery and thefirst critical hours after birth, and inadequate care of the newborn. Several factors,including the status of women in a society, the mothers’ nutritional status at the timeof conception, early childbearing, multiple closely spaced pregnancies, and harmfulhealth practices – such as inadequate cord care, leaving the baby wet and cold afterbirth, and discarding the colostrum – are deeply rooted in cultural practices and canbe difficult to understand.

Jordan’s Neonatal Mortality Rate

Jordan’s infant mortality reflects the country’s position along the continuumof global socioeconomic development. Jordan, with an infant mortality rate (IMR)reported in 2007–2008 as varying from 19.0 per 1,000 live births (Departmentof Statistics [Jordan], Macro International Inc. 2008) to 24.0 per 1,000 live births(Population Reference Bureau 2008), ranks about midway between the average IMRreported for more developed countries (6 per 1,000 live births) and less developedcountries (54 per 1,000 live births) (Population Reference Bureau 2008). Jordan’sIMR is roughly comparable to some countries in North Africa and the Middle Eastincluding Syria (19 per 1,000 live births), Lebanon (19 per 1,000 live births), Libya(21 per 1,000 live births), and Tunisia (19 per 1,000 live births) (PopulationReference Bureau 2008).

From the late 1980s to the early to mid-1990s, the infant mortality rate in Jordansaw a slight improvement. However, during this time, the country’s neonatal mor-tality rate remained relatively constant at 19 neonatal deaths per 1,000 live births

Perinatal and Neonatal Mortality in Jordan 3

(Department of Statistics [Jordan], ORCMacro 2003). In the late 1990s, the neonatalmortality rate fell to 15 neonatal deaths per 1,000 live births and remained relativelyconstant as Jordan transitioned into the new millennium. According to the 2002Jordan Population and Family Health Survey (JPFHS), the neonatal mortality ratewas 16 neonatal deaths per 1,000 live births for the 5-year period studied, accountingfor 73% of total infant mortality (Department of Statistics [Jordan], ORC Macro2003). The findings of the 2007 JPFHS show only a modest improvement (14neonatal deaths per 1,000 live births) in spite of extensive efforts to improve thequality of primary health care, including antenatal and neonatal care, hospital care,and maternity services (Department of Statistics [Jordan], Macro International Inc.2008). For example, about 99% of women who experienced a pregnancy in Jordanfrom 2002 to 2007 received some antenatal care, and their babies were delivered bya health professional, with 98.6% delivering in a hospital (Dababneh et al. 2008).

According to the Jordan Perinatal and Neonatal Mortality study (Batieha et al.2016), stillbirth, neonatal, and perinatal mortality rates were 11.6 per 1,000 totalbirths (TB), 14.9 per 1,000 live births (LB), and 23.7 per 1,000 TB, respectively,using the gestational age cutoff value of �20 weeks. The rates generally decreasedas the gestational period increased to �28 weeks and reached 9 per 1,000 TBfor stillbirth, 11.6 per 1,000 LB for neonatal mortality, and 18.1 per 1,000 TB forperinatal mortality (Table 1).

By excluding babies that were <1,000 g in weight and <28 weeks’ gestationalage (to be consistent with the WHO and UNICEF’s annual neonatal mortalityreports), the stillbirth rate was 8.2/1,000 TB, the neonatal mortality rate was10.5/1,000 LB, and the perinatal mortality rate was 16.5/1,000 TB. The highestneonatal mortality rate was observed in the middle region (16.9/1,000 LB), followedby the north (12.6/1,000 LB) and lastly the south (11.7/1,000 LB) ( p = 0.02).The variations in rates according to region are explained by the fact that high-riskdeliveries from the north and the south are referred to the referral hospitals inthe middle region. The neonatal mortality rate was highest in the military sector(27/1,000 LB) and lowest in the private sector (6.2/1,000 LB). Again, this isexplained by the fact that complicated cases attending the private sector are referredto military hospitals.

The neonatal mortality rate in Jordan was higher than the rates reported froma number of other Arab countries including Syria (8.7 per 1,000 live births, 2008),Lebanon (10.8 per 1,000 live births, 2004), and Libya (11 per 1,000 live births,2006) (World Health Organization 2018). In 2000, the Egyptian Demographic andHealth Survey (EDHS) (Campbell et al. 2004) took place in 27 governorates. TheIMR was 44 per 1,000 live births; the stillbirth rate was 17 per 1,000 births; theperinatal mortality rate was 34 per 1,000 live births; the neonatal mortality rate was25.4 per 1,000 live births; the early neonatal mortality rate was 17.2 per 1,000 livebirths; and the late neonatal mortality rate was 8.2 per 1,000 live births. Of the totalneonatal deaths, about 30% of neonates died on the first day of life, 46% died1–6 days after birth, and 24% died during the late neonatal period.


Table 1 Stillbirth rate (per 1,000 total births), neonatal mortality rate (per 1,000 live births), andperinatal mortality rate (per 1,000 total births) by gender using different cutoff values for gestationage, Jordan, 2011–2012

Weeks ofgestation/rates

Males Females Total

Rate [95% CI]a Rate [95% CI] Deaths Rate [95% CI]

�20 gestation weeks

Stillbirthsrate

11.4 [9.5–13.5] 11.7 [9.8–13.9] 261 11.6 [10.2–13.0]

Neonatalmortality rate

16.5 [14.2–19.1] 13.2 [11.1–15.5] 327 14.9 [13.3–16.6]

Earlyneonatalmortality rate

13.9 [11.9–16.3] 10.2 [8.4–12.3] 266 12.1 [10.7–13.7]

Late neonatalmortality rate

2.6 [1.7–3.7] 3.0 [2.0–4.2] 61 2.8 [2.1–3.6]

Perinatalmortality rate

25.4 [22.5–28.5] 22.0 [19.3–25.0] 527 23.7 [21.7–25.8]


Stillbirthsrate

11.1 [9.2–13.1] 11.3 [9.4–13.5] 252 11.2 [9.8–12.6]


16.4 [14.1–18.9] 13.1 [11.0–15.4] 324 14.8 [13.2–16.5]


13.8 [11.7–16.1] 10.1 [8.3–12.2] 263 12.0 [10.6–13.5]


2.6 [1.7–3.7] 3.0 [2.0–4.2] 61 2.8 [2.1–3.6]


24.9 [22.1–27.9] 21.4 [18.8–24.4] 515 23.2 [21.2–25.3]


Stillbirthsrate

10.5 [8.6–12.3] 10.7 [8.7–12.6] 238 10.6 [9.2–11.9]


16.4 [14.0–18.7] 13.0 [10.8–15.1] 318 14.7 [13.1–16.3]


13.7 [11.6–15.9] 9.9 [8.1–11.8] 257 11.9 [10.4–13.3]


2.6 [1.7–3.6] 3.0 [2.0–4.1] 61 2.8 [2.1–3.5]


23.6 [20.8–26.4] 20.2 [17.6–22.9] 495 21.9 [20.0–23.9]


Stillbirthsrate

8.7 [7.1–10.6] 9.2 [7.5–11.2] 201 9.0 [7.8–10.3]


12.8 [10.8–15.0] 10.4 [8.6–12.5] 254 11.6 [10.2–13.1]

(continued)


Risk Factors for Neonatal Mortality in Jordan

Earlier studies documented a large number of risk factors with respect to perinatalmortality and led to the identification of risk factors that are related either to themother or to the infant. Well-known risk factors for the mother are age, marital status(especially single motherhood), pregnancy history, socioeconomic status, nutritionalstatus, ethnic origin, smoking, drinking alcohol, fertility treatment, chronic diseases,complications during pregnancy, and childbirth. Infant risk factors include durationof the pregnancy, weight at birth, multiple births, sex, presentation of the fetus (theposition of baby in the uterus), and congenital abnormalities (Richardus et al. 1998;Obeidat et al. 2019).

The 2002 JPFHS found that over the previous 10 years, women living in ruralareas were more likely to experience a neonatal death than those living in more urbanareas (20 vs. 17 per 1,000 live births). Women residing in the north were most likelyto experience a neonatal death, followed by those in the south, and finally the centralregion (20, 18, and 16 per 1,000 live births, respectively). Women with no educationor only elementary school education were significantly more likely to have aneonatal death than those with higher education. This pattern applies to infant andchild mortality as well. Male babies were slightly more likely to die in the neonatalperiod than female babies (18 vs. 17 per 1,000 live births), and women younger than20 years of age and older than 40 were more likely to have neonatal deaths than thosein the middle of their childbearing years. A baby with a birth order of seven or higheris at a significantly greater risk of neonatal death (24 per 1,000 live births), whilea first child is at a slightly higher risk (19 per 1,000 live births) than a birth orderof 2–3 or 4–6 (15 and 16 per 1,000 live births, respectively). A birth interval ofless than 2 years is also an important risk factor (20 per 1,000 live births) as ratesdrop dramatically when the interval is 2 years or longer (15 per 1,000 live births).“Small” and “very small” infants, as classified according to size at birth, are morethan twice as likely to die in the neonatal period than “average”- and “above-average”-sized infants (31 vs. 12 per 1,000 live births) (Department of Statistics[Jordan], ORC Macro 2003).

Table 1 (continued)

Weeks ofgestation/rates

Males Females Total

Rate [95% CI]a Rate [95% CI] Deaths Rate [95% CI]


10.4 [8.6 –12.5] 7.7 [6.1–9.5] 199 9.1 [7.9–10.5]


2.3 [1.5–3.4] 2.7 [1.8–3.9] 55 2.5 [1.9–3.3]


19.2 [16.7–21.9] 17.0 [14.6–19.7] 400 18.1 [16.4–20.0]

Data adapted from Jordan Perinatal and Neonatal Mortality study (Batieha et al. 2016)a95% confidence intervals were calculated using the analytical tool for public health developed bythe Association of Public Health Observatories


Data from the 2007 JPFHS showed a similar pattern to the data from JPFHS2002, but there are some important differences. Rural residence was associated witha higher level of postneonatal mortality than urban residence (9 vs. 5 per 1,000 livebirths), but the total neonatal mortality showed an inverse relationship (13 vs. 15 per1,000 live births). Such a finding is difficult to explain; chance variation is apossibility, but other explanations include poor neonatal care after discharge fromthe hospital and poor access to appropriate medical care in rural areas. The southernregion had higher neonatal mortality rates than the rest of the country (19 vs. 14 per1,000 live births). Lower neonatal mortality rates were observed among neonatesfrom the “Badia” (the place where the Bedouin lives, usually in the desert areasof Jordan) compared to the rest of the country (10 vs. 15 per 1,000 live births) andin neonates of women with higher education levels (6 per 1,000 live births).Unexpectedly, the neonatal mortality rate was lowest among the middle wealthquintile and highest among the highest wealth quintile (7 vs. 21 per 1,000 livebirths). This finding has to be validated by further research in the country. Neonataldeaths were more likely among male neonates, neonates with small birth size,neonates born to mothers aged <20 years, and neonates with a birth order �7. Asexpected, birth interval<2 years was associated with a higher risk of neonatal death.

The JPFHS 2007 also reported on perinatal mortality and its sociodemographicand reproductive determinants. The overall perinatal mortality rate was 15 per 1,000live births. Perinatal deaths were most common in women 30–39 years old at thetime of childbirth, previous pregnancy interval <15 months, urban residence, andresidence in the north. The pattern of perinatal mortality with education and wealthwas inconsistent; perinatal mortality was lowest for mothers with preparatory edu-cation and highest for mothers with elementary and secondary education. It was alsolowest for women in the middle quintile of wealth compared to other quintiles(Department of Statistics [Jordan], Macro International Inc. 2008).

The Jordan Perinatal and Neonatal Mortality study (Batieha et al. 2016) showedthat maternal age <20 years, history of preterm or low birth weight delivery, historyof neonatal death or stillbirth, preeclampsia, mother’s hospitalization during thecurrent pregnancy, primiparity, and male gender were significantly associated withincreased risk of neonatal mortality. Newborns who had congenital defects, babiesfrom multiple births, and babies born to women who did not use antenatal careservices were at higher risk of neonatal mortality. Breach presentation comparedto cephalic presentation was associated with higher risk of neonatal mortality(OR = 1.5). Preterm births and low birth weight babies were almost 20 timesmore likely to die during the neonatal period compared to full-term babies andnormal birth weight babies, respectively.

Leading Causes of Perinatal and Neonatal Death

The causes of perinatal and neonatal mortality are common in many parts of theworld, but their distribution varies regionally. Lawn et al. (Lawn 2009) studiedthe causes of more than 110,000 neonatal deaths in 137 countries and estimatedthe distribution of neonatal deaths across program-relevant causes, including


asphyxia, preterm birth, congenital abnormalities, sepsis/pneumonia, neonataltetanus, diarrhea, and “others.”

The major causes of neonatal death globally were estimated – with substantialuncertainty and regional variation – to be infections sepsis/pneumonia, tetanus, anddiarrhea (35%), preterm birth (28%), and asphyxia (23%). About 7% of all deathswere related to congenital abnormalities, and the remaining 7% of deaths wererelated to other causes. The distribution of causes of neonatal death varies betweencountries, correlating with the rate of neonatal mortality in each country. At lowlevels of neonatal mortality (i.e., <15 per 1,000 live births), sepsis/pneumoniaaccounts for less than 20% of deaths, and tetanus and diarrhea are almost nonexistentas causes of neonatal death. Data on causes of neonatal mortality from a numberof countries in the eastern Mediterranean region show some variation. According tothe Egyptian Demographic and Health Survey (2002) (Campbell et al. 2004), themain causes of perinatal deaths were asphyxia (44%), prematurity (21%), stillbirths(14%), and congenital malformations (7%). The main causes of neonatal deaths wereprematurity (39%), asphyxia (18%), infections (7%), congenital malformation (6%),and unclassified causes (29%). In Syria (1996), the major causes of neonatal deathswere prematurity (about 44% of deaths among neonates) and birth-related factorssuch as congenital anomalies and birth weight (30%) (Abou Rashid et al. 1996).

In the United Arab Emirates, the main causes of death were related to prematurity(44%), lethal malformations (37%), and asphyxia (15%) (Dawodu 2000). In Qatar,preterm births were the leading cause of neonatal death (42.6%), followed bycongenital anomalies (28%) (Salameh et al. 2009).

On the other hand, data on stillbirth in Jordan are lacking and the causesare poorly understood; a specific cause cannot be identified in about half of allstillbirths, even in developed countries (Silver et al. 2007). In developing countries,the percentage of stillbirths without a clearly defined cause are higher (McClure et al.2006). Infection is the leading cause of stillbirth (Goldenberg and Thompson 2003;Di Mario et al. 2007). Other important causes include prolonged labor, birthasphyxia, preeclampsia/eclampsia, and congenital anomalies (Weiner et al. 2003;Menzies et al. 2007; Ngoc et al. 2006). Inadequate medical care contributes to thehigh stillbirth rates in developing countries (Bhutta et al. 2005).

An ongoing study by Abu-Osba Yet al. (unpublished data) reviewed the medicalrecords of all admissions to the neonatal intensive care unit (NICU) in a privatehospital in Jordan from January 1, 2001, to December 31, 2003. A total of 4,116 livebirths occurred during the study period and 811 patients were admitted to NICU.A total of 16 neonates had major congenital anomalies incompatible with life (fivewith complicated congenital heart diseases, seven with diaphragmatic hernias, andfour with Potter’s syndrome). Major medical problems that contributed to the deathof the other 35 newborns were respiratory distress syndrome (N = 26), sepsis(N = 21), and others (N = 8). In another study in Jordan, Khoury and Mas’ad(2002) found that the leading causes of death during the neonatal period wereconditions originating in the perinatal period. In 2005, the ten leading causesof infant mortality in Jordan were ranked as (1) congenital malformations, deforma-tions, and chromosomal abnormalities; (2) respiratory distress of the newborn; (3)bacterial sepsis of the newborn; (4) intrauterine hypoxia and birth asphyxia; (5)


pneumonia; (6) disorders related to length of gestation and fetal malnutrition; (7)transitory endocrine and metabolic disorders specific to newborns; (8) septicemia;(9) newborns affected by maternal factors and by complications of pregnancy, labor,and delivery; and (10) accidents. These causes accounted for 78% of all infant deaths(Dababneh et al. 2008).

To address clinical causes of neonatal death in 2002, a high-level task forceof clinical experts developed detailed, evidence-based clinical guidelines for the careof newborns in Jordan. Similar clinical guidelines were developed for pregnancy anddelivery care and summarized in “Essential Obstetric Care Clinical Guidelines forPhysicians.” These guidelines were sanctioned by the MOH and established asstandards for the country and were widely disseminated.

According to the Neonatal and Intrauterine Death Classification Accordingto Etiology (NICE) hierarchical classification (Winbo et al. 1998) in the JordanPerinatal and Neonatal Mortality study (Batieha et al. 2016), most neonatal deathsare due to congenital anomalies (27.2%), multiple births (26.0%), or unexplainedimmaturity (21.7%) (Table 2). Other important causes included maternal disease(6.7%), specific infant conditions (6.4%), and unexplained asphyxia (4.9%). Themost common congenital anomalies were congenital heart disease and multiplecongenital anomalies, accounting for 25.8% and 19.1% of all congenital causesof death, respectively. Multiple births and unexplained immaturity were the mostimportant causes of death in neonates weighing <1500 g at birth, while congenitalanomalies, specific infant conditions, and unexplained asphyxia were the mostimportant causes of death in neonates weighing >2500 g.

According to the expert panel, respiratory distress syndrome was the leadingcause of death (53.5%). The most common causes of death following respiratorydistress syndrome were sepsis (16.2%), congenital anomalies (13.8%), and asphyxia

Table 2 Causes of neonatal deaths according to the NICE cause of death classification in Jordana

Cause of death

Early neonataldeaths

Late neonataldeaths

Neonatal deaths(early and late)

N % N % N %

Congenital anomalies 73 27.4 16 26.2 89 27.2

Multiple births 73 27.4 12 19.7 85 26.0

Maternal disease 18 6.8 4 6.6 22 6.7

Specific fetal conditions 1 0.4 0 0.0 1 0.3

Unexplained small-for-dates infants 1 0.4 2 3.3 3 0.9

Placental abruption 3 1.1 1 1.6 4 1.2

Obstetric complications 7 2.6 2 3.3 9 2.8

Specific infant conditions 17 6.4 4 6.6 21 6.4

Unexplained asphyxia 13 4.9 3 4.9 16 4.9

Unexplained immaturity 56 21.1 15 24.6 71 21.7

Unclassifiable cases 4 1.5 2 3.3 6 1.8

Total 266 100 61 100 327 100

Data adapted from the Jordan Perinatal and Neonatal Mortality study (Batieha et al. 2016)aNICE, Neonatal and Intrauterine Death Classification according to Etiology


(10.1%). Considering the multiplicity of the causes for each neonatal death, the mostfrequently mentioned causes were prematurity (72.5%) followed by respiratorydistress syndrome (60.1%), multiple birth (28.7%), congenital anomalies (27.2%),sepsis (18.7%), asphyxia (18.3%), and pulmonary hemorrhage (14.4%).

According to the NICE classification (Winbo et al. 1998), the main causesof stillbirths were maternal diseases (19.5%), unexplained immaturity (18.8%),congenital anomalies (17.6%), unexplained antepartum stillbirths (17.6%), obstetriccomplications (8.4%), placental abruption (5.7%), and multiple births (5%). Thedirect cause of stillbirths was not evident in almost half (46.7%) of all deaths.Congenital anomalies (16.5%), placenta abruption (10%), IUGR (9.6%), and cordcompression (8%) were the main causes of stillbirths, contributing to approximately44.1% of deaths.

Preventability of Neonatal Death and Stillbirth

In the Jordan Perinatal and Neonatal Mortality study (Batieha et al. 2016), theexperts’ panel judged that 30% of all neonatal deaths were preventable and that44.3% were possibly preventable with optimal care. According to the Hermanclassification (Herman et al. 1990), 37% of neonatal deaths were preventable and59% possibly preventable. The panel judged that 34.5% of all fetal deaths werepreventable and 30.3% were possibly preventable with optimal care. On the otherhand, according to the Herman classification, only 21% of fetal deaths were pre-ventable and 69.7% were possibly preventable. According to both classifications,late fetal deaths were more likely to be preventable or possibly preventable com-pared to early fetal deaths.

Organization and Delivery of Perinatal and Neonatal HealthServices

The findings from several reports suggest that existing referral practices andthe organization of perinatal care services in Jordan could be improved by makingthem more efficient and effective. The capacity of neonatal units (e.g., essentiallifesaving equipment, staffing levels, and staff competencies) to provide complexservices to preterm and critically ill neonates is limited. Neonatal conditions that canbe managed by certain neonatal units are unnecessarily referred to higher-levelmaternity facilities because of a lack of competencies and confidence of staff orthe availability of essential services. In addition, health-care professionals often optto refer to their facility of choice or patients themselves self-direct to tertiary-levelfacilities where they know that they will be admitted for care. This producesa skewed referral system resulting in overcrowding of some hospitals and underuti-lization of others. It is evident that the current system of maternal, perinatal, andneonatal health care in Jordan needs to be better organized and coordinated at


different levels of care with clearly defined competencies and volume of services,staff and equipment, and referral practices.

An efficient referral system which directs high-risk pregnancies to institutionswith optimum facilities and equipment, personnel with technical skills, and trainingof neonatal intensive care (e.g., through regionalization) improves perinatal out-comes in many countries. Such a regionalization of perinatal services requires thedevelopment within a particular geographic area of a coordinated, integrated systemof maternal, perinatal, and neonatal health care. It includes concepts of risk assess-ment, transport of patients, and appropriate application of care in system componentsorganized into different levels of care while guaranteeing treatment that is humane,nearby, safe, and of high quality for the mother and newborn.

Regionalization of perinatal care improves outcomes through high-specialtycenters, and perinatal facilities organized in networks within a given geographicarea can take several forms, for example, a specialized perinatal center that managesthe most complex conditions in pregnant women and/or newborns within a geo-graphic area that is supported by less specialized hospitals (e.g., level I care reservedfor normal births, level II for managing moderate obstetrical problems and pretermbirths >32 weeks, and level III for severe obstetrical problems, specialized medicalconditions, and preterm births <32 weeks). Appropriateness of referrals as well asmissed referrals for both at-risk mothers and babies needs to be monitored throughappropriate indicators, for instance, place of births for preterm births and multiplepregnancies are indicators to assess regionalization in a perinatal network.

Such a reorganization of the maternal, perinatal, and neonatal health care inJordan will ensure improvements over a nonfunctional referral system.

Secondly, an essential component of perinatal care is the transportationof pregnant women at high risk for complications to a facility that can provide therequired obstetric and neonatal care. Effective and efficient neonatal transportsystems need to be developed in Jordan. Outcomes for the newborn are improvedif women are transported antenatally, especially for those preterm infants born at lessthan 32 weeks’ gestation. Therefore, transferring a woman with the baby in utero ispreferable to neonatal transport and should be a primary goal of a maternal andneonatal health-care system. In addition, developing an effective neonatal transportsystem for transfer of critically ill newborns to referral facilities is also needed.

Thirdly, it is essential that the provision of neonatal intensive care beds meets theactual population-based demand for neonatal intensive care, so that neonates requir-ing intensive care are neither denied access nor receive delayed care as is currentlythe situation in Jordan. The required number of beds needed should be determinedon NICU admission criteria, the incidence of very low birth weight babies in thepopulation, and NICU organization and regionalization principles. In addition, foreffective functioning of the system, it is important to establish mechanisms forcentralized information on bed occupancy and neonatal transport.

Finally, regionalization and conditions for referral should include adequate refer-ral facilities and ensure appropriate financing of the health system to minimize thefinancial burden on families who have to make large out-of-pocket payments forcritical care of mothers and newborns.


To reduce perinatal morbidity and mortality and improve survival for preterminfants and other high-risk newborns, a strategy for regionalized and cohesiveperinatal network should be developed and should include the following:

• Develop a stratified model of maternal and neonatal care based on (a) complexityof care with well-defined standards of the various levels of facilities, (b) desig-nation of neonatal units for high-risk newborns, and (c) referral standards,including plan and patient flows to referral centers, and neonatal transport.

• Create a uniform set of national standards such as requirements for equipment,staffing levels, facilities, ancillary services, training, and the organization ofservices (including neonatal transport) for each level of neonatal care.

• Upgrade and expand existing facilities based on this stratified model and nationalstandards, and provide in-service education to the major obstetric and neonatalcaregivers on these standards. Based on this model, hospitals should determinetheir level of commitment to specialty and competencies and should operatewithin those boundaries.

• Develop effective neonatal transport systems for transfer of critically ill newbornsto tertiary care and referral facilities. Transferring a woman with the baby in uterois preferable to neonatal transport and should be the primary goal when develop-ing regionalized models of maternal and neonatal health-care systems.

• Determine the required number of neonatal intensive care units/beds based ontrue population-based demand for neonatal intensive care, so that neonatesrequiring intensive care are neither denied access nor receive delayed care.

• Establish mechanism for centralized information on neonatal intensive care bedoccupancy and neonatal transport.

The establishment of a multidisciplinary working group of local and internationalexperts to elaborate such a stratified model of maternal and neonatal health-careorganization is also suggested. This group would develop required policy docu-ments, establish region-specific estimates for patient flow, define detailed criteria forreferral of pregnant and delivering women, define the equipment and staffingnecessary to fulfill the requirements for relevant levels of care, and develop neonataltransport system requirements and guidelines, including communication and inter-action principles between different level hospitals.

Quality of Maternal and Neonatal Care

Quality of care in terms of safety of clinical practice, using current, evidence-basednorms, guidelines, and protocols, together with experience and information sharingis the essence of modern medicine. Strategies that need to be part of qualityimprovement include financial incentives that reward better results and other regu-latory and governmental strategies. While relatively easy to define, these parametersare difficult to accomplish. Jordan has made great efforts to improve access tomaternal and neonatal health-care services. The country has been following the


WHO- and UNICEF-recommended guidelines for maternal and neonatal healthcare by introducing evidence-based interventions in maternal and neonatal healthunits. These have been translated into significant improvements in obstetric andneonatal care over time and resulted in the use of evidence-based practices such asuse of partograph, active management of third stage of labor, postpartum care ofmothers, rooming-in, and immunization.

Despite this progress, there are other opportunities to improve the quality ofmaternal and neonatal health care and health outcomes. Interventions that reducemortality and morbidity in preterm babies need immediate attention. Improvedsurvival for the majority of moderate to late preterm (32 to <37 weeks) and earlypreterm neonates (28 to<32 weeks) can be attained by improving essential newborncare and utilizing a range of low-cost and evidence-based interventions. Suchinterventions include the prevention and management of hypothermia, hypoglyce-mia, and infection and providing adequate respiratory and feeding support.In addition to this essential care, extremely preterm neonates, i.e., those born before28 weeks (7.6% in the study population), will require the most comprehensiveneonatal intensive care to survive, with expensive equipment and interventions.

Kangaroo Mother Care (KMC) (the practice of providing continuous skin-to-skincontact between the mother and baby, exclusive breastmilk feeding, and earlydischarge from hospital) and using antenatal corticosteroids, if fully implemented,could immediately and substantially reduce prematurity-related deaths (Garite andCombs 2012). Respiratory distress syndrome (RDS), which accounted for 73.5% ofdeaths in low birth weight babies in the study population, is associated with lungimmaturity and commonly develops in preterm infants without preventive prenatalinterventions in mothers, i.e., antenatal corticosteroids. Only 65% of women whowere hospitalized between 24 and 34 weeks of pregnancy in the research populationreceived antenatal corticosteroids. KMC, despite evidence of its effectiveness inreducing neonatal infections, hypothermia, and the risk of post-discharge mortality,was underutilized in all hospitals visited. The poor implementation of KMC is due tothe lack of awareness of the importance of this practice.

Breastfeeding, thermal protection, and other building blocks of essential newborncare are underutilized and ineffectively implemented. The “warm chain,” a set often interlinked procedures carried out at birth and directly after, is only partiallyimplemented. A majority of hospitals did not have rooms/wards at the desirabletemperature (>25C), lacked equipment for thermal monitoring and protection (e.g.,electronic thermometers, transport incubators, heated cradles), did not provide skin-to-skin contact immediately after birth or soon after, and did not measure/reportnewborn temperature at 30 min after birth and at admission to nursery/NICU.

Furthermore, early and exclusive breastfeeding practices need improvements andincreased utilization. Only 57.8% of babies were exclusively breastfed at the timeof discharge from the hospital. The most frequently noted reasons by mothers fornot exclusively breastfeeding were that bottle-feeding is a routine practice (45.6%),cesarean section (42.7%), insufficient milk (13.8%), and tiredness (12.6%).Breastfeeding knowledge (e.g., knowledge of duration of exclusive breastfeeding,signs of correct attachment, contraindications) was inadequate in a high proportionof interviewed health-care providers.


These findings suggest inadequate breastfeeding counseling and support formothers during hospital stays as well as ineffective implementation of hospitals’breastfeeding policies and training activities.

Feeding practices in the NICU were found to be inconsistent, and clinical pro-tocols on feeding were lacking in the vast majority of hospitals. Despite the fact thatpremature babies benefit from breast milk nutritionally, immunologically, and devel-opmentally, only a small proportion of neonates in NICU were fed by expressedbreast milk (5.6%) and breastfeeding (5.5%).

The general anesthesia (85%) commonly used for cesarean section is an addi-tional barrier for early initiation and successful continuation of breastfeedingin Jordanian maternity facilities. Regional anesthesia should be the preferred optionfor cesarean section births in women who wish to breastfeed. It allows for fasterneonatal-maternal bonding, a significantly higher breastfeeding frequency, and lon-ger breastfeeding periods. Moreover, local/regional anesthesia is preferred overgeneral anesthesia in elective caesarean sections because of the higher Apgar scores,better neurobehavioral of the newborn, and shorter breastfeeding intervals, which allcontribute to a higher chance of successful breastfeeding.

Further, the high cesarean section rate (30%) in the study population raisesimportant issues about its appropriateness, efficiency, and cost-effectiveness. Theremoval of any pressure not to perform a cesarean birth can significantly escalatehospital cesarean section rates. Evidence from other parts of the world shows thathospitals with cesarean section rates of 15–20% have outcomes that are just as goodfor newborns and better outcomes for mothers. Therefore, it will be important torevise clinical management, professional attitudes, and policies toward caesareansections to address concerns about the rising levels of cesarean deliveries in Jordan.

The Jordan Perinatal and Neonatal Mortality study (Batieha et al. 2016) foundthat a handful of preventable and treatable conditions, such as RDS, asphyxia, andsepsis, are responsible for a significant portion of all neonatal deaths. Accordingto Jordan Perinatal and Neonatal Mortality study (Batieha et al. 2016), respiratorydistress syndrome was the leading cause of death. The most common causes of deathfollowing respiratory distress syndrome were sepsis, congenital anomalies, andasphyxia, despite the presence of highly skilled birth attendants. A reduction in theincidence of birth asphyxia requires improved obstetric care. Early identification ofthe fetus at high risk for asphyxia, improved monitoring of mothers during labor forearlier identification of signs of fetal distress, and appropriate and timely interventionwhen such complications arise should be implemented urgently.

Neonatal care practices in the NICU related to antibiotic use for managementof neonatal sepsis and infections as well as in the management and treatment ofcommon conditions in NICUs warrant revision by experts, for example, the use ofampicillin/penicillin and gentamicin as a “first-line” antibiotic therapy as recom-mended by the available evidence versus cephalosporin of third generation andampicillin/penicillin reported by health-care providers.

Perinatal health indicators are strongly associated with the quality of care pro-vided antenatally and during intrapartum period. The Jordan Perinatal and NeonatalMortality study (Batieha et al. 2016) showed that coverage and utilization of


antenatal care services in Jordan are high; 98.9% of pregnant women used antenatalcare services. The majority of women (91.3%) in the study population completedtheir initial visit during the first trimester, 95.0% completed four antenatal visits, andalmost two thirds of women (69.9%) had more than eight antenatal care visits.However, the number of visits is not the only indicator of quality of care: the mostimportant criterion is whether the antenatal care provided corresponds to currentevidence-based practices. A majority of focus group respondents cited issues withthe quality of antenatal care.

The effects of maternal diseases were common in stillbirths; however, the effectsof maternal diseases were more prominent for macerated stillbirths. The NICE causeof death classification showed that hypertensive disorders accounted for 74.5%of stillbirths in the maternal disease category, suggesting that management ofmaternal morbidities during pregnancy may not be adequate. Furthermore, theJordan Perinatal and Neonatal Mortality study (Batieha et al. 2016) demonstratedthat 52.5% of stillbirths were fresh or that intrauterine death occurred during labor(intrapartum deaths). Evidence from other countries shows that there is less than10% of intrapartum deaths when women receive good care during childbirth. Thehigh proportion of fresh stillbirths in the Jordan Perinatal and Neonatal Mortalitystudy (Batieha et al. 2016) suggests deficiencies in the management of pregnancy,with delivery complications and a need for improved obstetric care. In general,effective interventions to reduce stillbirths overlap with those to reduce maternal andneonatal deaths. Therefore, improvements are needed for (1) interventions directedtoward improving the provision of advanced antenatal care (e.g., detection andmanagement of hypertensive disorders during pregnancy, maternal-fetal infections,timely detection and management of fetal growth restriction) and (2) quality ofcomprehensive emergency obstetric care to substantially reduce the high proportionof stillbirths.

One of the central recommendations for reducing perinatal and neonatal mortalityis the use of and compliance with clinical practice guidelines. A comprehensive setof evidence-based neonatal care clinical guidelines was developed by the Ministry ofHealth, in collaboration with Royal Medical Services (RMS) and Jordanian univer-sities and with the technical assistance of USAID/Jordan. Further efforts are neededon developing guidelines for management of obstetric complications and continuoustraining of health-care professionals on how to use the guidelines.

Improved compliance with the guidelines can be achieved using a system ofperiodic criterion-based clinical audits; this process needs to be implemented. Casereviews (with an appropriate level of confidentiality) must be used to investigatecauses of fetal, neonatal, and perinatal mortality and should focus on identifyingpreventable deaths that are caused by a failure of the health system or insufficientquality of care. Audit results should guide recommendations for improving healthcare, ensuring feedback to clinicians, and identifying actions required to improvequality of care. In addition, periodic action-oriented assessment of all major areasand factors impacting the quality of care, including infrastructure, supplies, organi-zation of services, and case management is needed. Accreditation of maternityfacilities can also serve as a useful tool in providing an overview of the entire


facility, thereby enabling standardization of the quality of maternal and neonatal carepractices and the creation of a better and safer environment for mothers and babies.

The following are important interventions that need to be implemented toimprove the quality of neonatal and obstetric care services in maternity facilities inJordan:

• An emphasis on immediate and exclusive breastfeeding and the implementationof sound hospital policies promoting breastfeeding education and practice andtraining of health-care providers (e.g., pediatric nurses, midwives, breastfeedingconsultants, and other cadres). Continue reassessment of baby-friendly hospitals(a global initiative launched in 1991 by WHO and UNICEF to implement pract-ices that protect, promote, and support breastfeeding) on a regular basis.

• Introduce “Kangaroo Mother Care” to improve care for preterm infants throughtraining of health-care providers (neonatologists, midwives, and pediatric nurses)and the development of clinical practice guidelines, training materials, workpractice aids, supervisory systems, and indicators to track implementation andmonitor KMC outcomes. Establishment of KMC centers of excellence willmaximize KMC expansion, knowledge, transfer of training, and mentoring.

• Increase implementation and compliance with antenatal corticosteroid adminis-tration guidelines for prevention of respiratory distress syndrome and otherproblems of prematurity.

• Introduce and implement comprehensive infection prevention and control pro-grams in maternity units and NICUs (e.g., hand washing compliance programs;standards compliance of infection control in IV fluids, catheter/cannula inser-tions, and other invasive procedures; rational antibiotic policies and guidelines;educational programs in the prevention of hospital infection for personnel;surveillance of hospital infections).

• Improve assessment, management, and monitoring of neonatal critical conditionsin neonatal intensive care units. Areas such as prevention and management ofneonatal infections, management of respiratory distress syndrome, expansion ofnasal continuous positive airway pressure technology, feeding support to preterminfants and parenteral nutrition, and standardization of procedures for monitoringnewborn’s conditions in NICUs need particular attention.

• Improve surfactant therapy at the tertiary level. This intervention is costly andshould be implemented after regionalized perinatal care is developed and thereferral system is functional.

• Support and promote the principles of women and family-centered maternitycare, including empowerment of women and families in collaboration with thehealth-care team to provide opportunities to participate in the care of their babieswhile in NICUs; and make informed decisions regarding treatment, care, anddischarge of both mothers and newborns.

• Conduct an assessment of quality of antenatal care service to determine the gapsand challenges in provision of evidence-based antenatal care, and use the resultsto develop an improvement plan for antenatal care provision.


• Implement perinatal mortality audits in hospitals to enable a systematic approachto the investigation of perinatal deaths. Investigate all neonatal deaths andstillbirths where there is no evidence of a major congenital anomaly, to identifywhether there were avoidable factors. Assess areas for improvement in the qualityof obstetric and neonatal care, and track effectiveness of improvement inprograms.

Human Resources

Improving the quality of maternal and neonatal health services requires a competenthealth workforce and effective policies to address human resources challenges.Insufficient staff, shortages of neonatologists and pediatric nurses, and high absen-teeism are some of the findings from the assessment of health facilities and fromfocus group discussions with health-care providers. The development of a creativehuman resources strategy will address workforce challenges such as compliancewith work schedules, retention of health-care professionals in the face of greateropportunities to work abroad, upgrading the social status of nurses, and settingincentives for high-quality nurses. It will require innovative and concerted effortsby all involved in the development of the health system and will need multi-sectoralcollaboration.

The recommendations made in this section do not deal with the overall reformrequired to strengthen human resources. We believe that efforts to achieve greatertechnical and perceived quality improvements requires upgrading the qualificationsand also changing the attitudes of maternal and neonatal health-care providers, andintroducing new teamwork configurations, mainly through multidisciplinary trainingand supervised clinical practice. A training format that is based on multidisciplinarycollaboration strengthens such collaborations and teamwork between health-careproviders of maternal care. Introduction of evidence-based perinatal care trainingcourses (e.g., WHO/MPS course on effective perinatal care) based on multidiscipl-inary collaboration and teamwork and supervised clinical practice will contribute toimproving the quality and outcome of care for mothers and their babies.

The following are strategies to improve the quality of the neonatal and obstetriccare workforce in maternity facilities in Jordan:

• Develop a training strategy for evidence-based perinatal care and identify keymaternal and neonatal health-care providers to spearhead training efforts.

• Strengthen the continuous medical education (CME) system or develop a systemthat will ensure delivering new knowledge to physicians and ensure itsassimilation.

• Incorporate public health courses on maternal and newborn health as well asevidence-based perinatal care into the formal teaching curricula of medical,nursing, and midwifery schools.

• Develop and implement higher-level courses in midwifery and neonatal intensivecare, including training programs for neonatologists and pediatric nurses in


advanced neonatal care (e.g., STABLE program) to enable them to assess,diagnose, manage, and monitor the wide variety of possible conditions that canoccur in neonatal critical care settings.

• Encourage the participation of professional associations of obstetricians/gynecologists and neonatologists in improving the quality and training ofphysicians.

Information and Information Systems

One of the important findings of the Jordan Perinatal and Neonatal Mortality study(Batieha et al. 2016) relates to reporting of births and deaths and clinical diagnosis ofcauses of perinatal death. There is lack of a uniform and countrywide legal definitionof perinatal events. The first and most important primary activity that has to beundertaken is the development and implementation of legal definitions and criteriafor registering births, training of health-care providers on these legal definitions, andimproving the quality of reporting.

Greater investment of resources to improve vital registration and the routineinformation system in Jordan is needed. Since a high proportion of deaths occurin or after contact with the health system that investments in the ability to reportneonatal deaths are warranted. Research results show substantial underreporting ofneonatal deaths in the Civil Registration Administration. Of the total 268 neonataldeaths identified in the prospective study, 207 (77.2%) neonatal deaths were notregistered (neither as births nor as deaths), 22 (8.2%) neonatal deaths were registeredas alive, and only 39 (14.6%) neonatal deaths were accurately registered as dead.Overall, the rate of under-registration of neonatal deaths was 85.4%. Underreportingis mainly attributable to a dysfunctional reporting system and the fact that families,not the health system, are responsible for registration of births and deaths.

Under-registration of newborn birth and death events in Jordan may have severeconsequences at the local, national, and international levels. At the local and nationallevels, it can result in a lack of awareness of the magnitude of neonatal mortality,leading to indifference toward the problem and sound policy formation, planning,and allocation of funds. At the international level, the perceived low mortality ratemanifests as a lack of investments in perinatal health programs. Furthermore, theregistration of the death of a newborn is not only a matter of statistics but also amatter of human rights that acknowledges that every child is a human being.

The following are recommendations to improve the process of registration ofbirths and deaths.

Recommendations to Improve the Process of Registration of Births

• Introduce legislation requiring hospitals and institutions where deliveries occur toreport the event to the Civil Registration Administration in a timely manner. Since99% of deliveries occur in hospitals, such legislation, if properly implemented


and reinforced, will greatly improve the accuracy of recorded births in Jordan.An electronic system automatically transferring the data to the Civil RegistrationAdministration would be ideal for this purpose.

• Implement awareness programs on the importance of registrations of birth at thenational and local levels.

• Adoption of the national identification number as a prerequisite for receivinghealth-care services.

• Times of infant vaccination can be used to report the birth event to the CivilRegistration Administration.

Recommendations to Improve the Process of Registration of Deaths

The proposed legislation and electronic system to improve registration of birthsdescribed above should also be extended to cover registration of deaths:

• Introduce reporting requirements for fetal demise or stillbirth.• Renew policies on obtaining a burial permit from the municipalities.• Conduct training for health-care providers involved in certifying births and deaths

and also for the coders responsible for assigning the International Classificationof Diseases (ICD)-10 the revision codes. The design of user-friendly forms witheasy-to-follow instructions and introduction of quality control measures for thevital registration personnel will further improve death certification.

• Institutionalize basic training on death certification practices in medical schoolsand postgraduate training curricula.

Conclusions and Recommendations

The reduction of child mortality is a core global health priority as reflected by itsprominence in the UN Millennium Development Goals. Governments of manycountries strive to improve maternal and child health-care services as this hasenormous socioeconomic and developmental benefits. The Jordan Perinatal andNeonatal Mortality study provided measurements for all perinatal and neonatalmortality indicators that can serve as a baseline for efforts to enhance neonatal andperinatal death reporting. The study indicates a high-level of underreporting of vitalrecords and the need for strengthening vital registration systems; this information isto improve the quality of maternal and neonatal health services.

An improved and strengthened perinatal care system must build upon a soundunderstanding of the needs of seriously ill newborns. It must bring together evi-dence-based medicine, modern medical technology, and family-centered care in itsneonatal care units and provide services for high-risk maternal care. It must provideappropriate technologies for the care of the mother and her baby throughout acontinuum of care – pregnancy, childbirth, and the postpartum period. This should


take place at the primary care level for all pregnant women and at higher levels ofcare for women and babies with complications.

In this section are recommendations based on the results of the Jordan Perinataland Neonatal Mortality study. The key underlying principle in developing a plan forimproving neonatal and perinatal care in Jordan has to be a health system approach.The roots of the problems identified by the study are systemic; therefore, it isimportant to avoid fragmentation when identifying appropriate actions for improvedperinatal care. Improving care for both mothers and children requires that all themain pillars of the health system are in place, since improved care and outcomescannot be assured if there are deficiencies in key components such as organizationand delivery of services, health system financing, information systems, humanresources, and management.

Another important dimension of the health system is the stewardship function ofthe Ministry of Health and its role in maternal and child health policy-making andregulation of the health system, overall. Maintaining and strengthening its regulatorycapacity (especially in the context of an expansion of the role of the private sector inprovision of maternity care) and developing and enforcing information reportingregulations are critical. The Higher Health Council (HHC) as an umbrella for thedifferent health sectors in Jordan can play an active role in the coordination andformulation of such policies.

These health system-readiness issues need to be complemented by enablingcomponents such as improved communication, better education campaigns, andstrengthening community outreach to increase the demand for quality maternaland perinatal care services. Efforts should also be made to ensure that prospectiveparents and community members are fully informed about what is considereda healthy pregnancy and its potential complications. An effective communicationcampaign on concepts of birth spacing with special emphasis on prevention ofmorbidity and mortality of children, especially neonates, is needed. Healthy andproductive families will be key to ensure that this evidence-driven recommendationis widely disseminated and will help to change the community norms. In addition,engaging local political and religious leaders to promote birth spacing and seekingthe best ways to work with communities should be strengthened.

The complex nature of maternal and newborn health requires an integratedapproach that maximizes the benefits of a range of activities, both within the healthsystem and with other sectors. Critical to improving maternal and newborn healthoutcomes is the recognition that safe motherhood is a human right that also extendsto child health. Therefore, it is important to review maternal and newborn health,especially related to early marriage, consanguinity, and other cultural norms thatcan negatively affect the health of mothers and their children. Partnership with theeducation sector to increase awareness in young people about the consequences ofearly marriage and consanguinity are crucial to address these cultural norms.

These proposals are based on the Jordan Perinatal and Neonatal Mortality studyand can serve as a basis for elaboration of an action plan to be developed by nationalpolicy-makers, key stakeholders, and partners in relation to specific areas. Acting onthese findings will ultimately result in improvements in the standards and quality of


care, policies, and organization of services and the development of a new researchagenda in perinatal care in Jordan. The recommendations below address the mainfindings from the study and are grouped into four main areas:

1. Rational organization of health service delivery2. Gaps between best practice and the actual care patients receive throughout the

continuum3. Human resources (mix – staff to patient ratio, update and maintenance of knowl-

edge and skills) according to international standards4. Information and data quality to make informed decisions

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