POVERTYNEONATALOUTCOMES

and

How Nurses Around the World Can Make a Difference

Carole Kenner, DNS, FAAN | Noreen M. Sugrue | Anita Finkelman, MSN

It’s estimated that approximately 2 million babies die each year within

the fi rst 24 hours of life and that 4 million die within the fi rst month of

life; 26 percent of newborns die as a result of infections occurring due

to the birth (World Health Organization [WHO], 2004, 2007). Most of the

4 million annual neonatal deaths are preventable; they occur because of

poverty and the lack of resources associated with being poor. Interventions

to save the lives of these babies exist, but they cannot be implemented

without appropriate community, regional, national and international

infrastructures, including clean water, sanitation, medical supplies and

health care professionals trained in the best practices available.

The United Nations (UN) adopted a set of Millennium

Development Goals (MDGs), which are aimed at obliterating

some of the worst health and social welfare inequities in the

world (UN Population Fund, 2007) (see Box 1). Signifi cantly,

reducing childhood mortality is one of the most important

goals, making neonatal nursing care one of today’s most im-

portant global health policy issues. Determining the adequate

numbers of neonatal nurses required and ascertaining the most

appropriate training and education levels are central to the

international health care agenda.

Over the past decade, neonatal nurses from around the

globe have expressed an interest in forming an international

council of neonatal nurses. The impetus for wanting this group

is the need for access to curriculum, research, continuing edu-

cation, consulting experts and patient information. Globally,

neonatal nurses recognize the need for continuous education

and training as well as access to research in a fi eld with an ever-

changing and growing knowledge base. The demand is for a

group devoted to improving the care and lives of infants, most

especially neonates. Focus on neonates is essential because ap-

proximately 40 percent of the mortality for children under the

age of 5 years occurs in the fi rst 28 days of life (WHO, 2004).

Council of International Neonatal NursesIn response to the demand by nurses and to poor infant and

child health statistics (especially neonatal death rates), an in-

ternational organization dedicated to neonatal nursing was

established—the Council of International Neonatal Nurses

(COINN). Prior to the development of COINN, there was no

formal global effort for neonatal nurses to collaborate.

Affecting overall infant and childhood mortality rates re-

quires globally coordinated efforts during the neonatal stage,

hence the focus on neonatal nurses. COINN links scholars en-

gaged in research with bedside and academic neonatal nurses

and provides resources to nurses globally. Members participate

in international conferences, which bring together neonatal

nurses from both developed and developing countries to facili-

tate networking, increase knowledge, create research partner-

ships and provide materials for the nurses to use in their home

countries.

While reaching all of the MDGs is important, the childhood

mortality goal (MDG 4) may be the most important, because

it measures how committed each nation is to protecting the

health and welfare of its most vulnerable citizens. If nations

“get it right” with the youngest, most vulnerable members of

the population, there’s reason to believe that the rest of the

population will receive attention and care. But if a nation lets

its most vulnerable citizens suffer and die of preventable cau-

ses, then it appears that such a nation does not care about the

health and welfare of its people.

Because so many neonatal deaths are preventable, the neo-

natal death rate is a refl ection of poverty. It refl ects the micro-

level poverty that women and children, especially, live in, and it

also represents a macro- or national level of poverty. Combat-

ing poverty is important and necessary, and such an initiative

will have many successes as well as setbacks. Poverty reduction

requires time and patience; however, there are steps that will

mitigate some of the immediate consequences of poverty, and

preventing neonatal mortality is an excellent example.

470 © 2007, AWHONN http://nwh.awhonn.org

Carole Kenner, DNS, FAAN, is dean of the College of Nursing; Anita Finkelman, MSN, is a professor in the College of Nursing; both are affi liated with the University of Oklahoma Health Sciences Center, Oklahoma City, OK; Noreen M. Sugrue is a professor in Women and Gender in Global Perspectives, University of Illinois at Urbana—Champaign, Champaign, IL.

DOI: 10.1111/j.1751-486X.2007.00214.x

Box 1 Health Targets Included in the MDGs

Between 1990 and 2015:

• Halve the proportion of people who suffer

from hunger

• Reduce by two-thirds the under-5 mortality

rate

• Reduce by three-quarters the maternal

mortality rate

By 2015:

• Have halted and begun to reverse the spread

of HIV/AIDS

• Have halted and begun to reverse the

incidence of malaria and other major diseases

• Halve the proportion of people without

sustainable access to safe drinking water

and sanitation

By 2020:

• Have achieved a signifi cant improvement in

the lives of at least 100 million slum dwellers

General:

• In cooperation with pharmaceutical compa-

nies, provide access to affordable, essential

drugs in developing countries.

Source: WHO (2007).

October November 2007 Nursing for Women’s Health 471

Impact of Neonatal NursesThe presence of skilled birth attendants has, in part, reduced

maternal mortality rates. For example, in Angola and Mo-

zambique, approximately 47 percent of births are attended by

skilled birth attendants, and the maternal mortality rates are

1,700 per 100,000 and 1,000 per 100,000, respectively, even

though the region’s maternal mortality rate is 840 per 100,000

(Buor & Bream, 2004; WHO, 2004). While approximately 95

percent and 88 percent of births are attended by a skilled at-

tendant in developing countries such as Botswana and Cape

Verde, respectively, their respective maternal mortality rates are

10 per 100,000 and 150 per 100,000, again compared with a

regional rate of 840 per 100,000 (Buor & Bream; WHO, 2004).

These differing rates document the importance of specially

trained medical personnel in effecting health outcomes.

Globally, policy makers, academics and clinicians support

increasing the presence of skilled birth attendants, contending

that the work performed by these health care workers decreases

the morbidity and mortality of women giving birth. They also

assume that if these skilled workers were in the delivery room,

they would provide a “trickle-down effect.” That is, the pres-

ence of skilled health care providers caring for women would

be able to provide care and support to neonates, thereby reduc-

ing the neonatal morbidity and mortality rates. In other words,

the working assumption is that improved maternal outcomes

translate into improved neonatal outcomes.

While this may be true in some cases, the overall effect is not

as great as assumed. If the effect of the skilled birth attendants

was as signifi cant as implied or hoped for, neonatal mortal-

ity rates should be signifi cantly lower than they are. A nation,

therefore, with a low or relatively low rate of maternal mor-

tality, attributable to the presence of skilled birth attendants,

should have a low or relatively low neonatal and overall infant

mortality rate. The following example represents data trends

we fi nd, and these patterns do not support this explanation.

For example, in Botswana where there are skilled attendants at

the overwhelming numbers of births, 0.01 percent of mothers

die, whereas 41 percent of neonates die. As this example shows,

when a decrease in maternal mortality is attributable to the

presence of skilled birth attendants, neonatal mortality hasn’t

shown a comparable decrease.

What is evident from the data is that mothers do better

when there is a skilled attendant present. If the outcomes for

mothers are improved with the presence of specialized skilled

attendants, then isn’t it logical to assume that neonatal nurses

present in the delivery room will improve the outcomes for the

neonates? In short, the presence of neonatal nurses should de-

crease the neonatal mortality rate just as the presence of skilled

maternal attendants for mothers has contributed to the reduc-

tion in maternal mortality. This assumption needs verifi cation

• Poverty has signifi cant effects

of neonatal mortality and

morbidity.

• While individual efforts are

important, so, too, are institu-

tional strategies.

• Nursing organizations are

involved in assisting nurses in

developing countries to create

the infrastructure to improve

nursing care.

Most of the 4 million annual neonatal deaths

are preventable; they occur because of

poverty and the lack of resources associated

with being poor.

472 Nursing for Women’s Health Volume 11 Issue 5

through research, but it’s an assumption worth testing and an

intervention worth advocating.

About COINNCOINN is a nongovernmental organization (NGO) created

to address the educational and training needs of neonatal nur-

ses globally, and most especially in developing countries. The

importance of this NGO may be the fact that through better

training and support of neonatal nurses and by lobbying for

the presence of these nurses at births, the global neonatal mor-

tality rate is likely to decrease.

COINN has many goals (see Box 2). COINN acts as an inter-

national leader in the development and revision of professional

standards of neonatal nursing. These activities allow COINN

members to infl uence international health policy; work as ex-

perts in maternal, child and neonatal health; and assist nations

in meeting their MDG targets. In short, COINN participates in

training, education, research, policymaking and service deliv-

ery, all of which are designed to break the link of poverty and

neonatal outcomes.

COINN isn’t an individual membership-driven organiza-

tion but rather an organization to which other professional or-

ganizations join to better facilitate collaboration, and through

this collaborative partnership, COINN has 15,000 members.

COINN focuses on global health policy, advocacy, building ca-

pacity, research and developing regional networks throughout

the world for nurses who specialize in the care of newborn in-

fants and their families. To achieve the greatest success possible,

global collaborations and partnerships structure each of the ac-

tivities noted. As part of the growing international community

of nurses, COINN represents a resource in both developed and

developing countries for nurses who want to form national or

local organizations, create guidelines for care and professional

standards or receive advice on up-to-date research related to

neonatal nursing care.

COINN uses a two-pronged approach to increasing its abil-

ity to foster collaborations with other nurses and to meet its

goals. First, it initiated a membership effort directed at other

health care professional organizations that have common goals

with COINN. This effort has been very successful and is ongo-

ing. COINN’s membership consists of nursing organizations

and nurses from more than 50 countries. Through regional

networks, COINN can link a person with a question or need

to a regional representative; this ensures that there is depth and

breadth to the knowledge of relevant cultural and health care

practices. Moreover, the regional networks allow for a faster

response to queries.

Box 2 Goals of COINN

COINN uses global leaders in neonatal nursing care to

accomplish the following:

Foster excellence in neonatal nursing

Promote the development of neonatal nursing

as a recognized global specialty

Promote high standards of neonatal care

Enhance quality of care for patients and families

Decrease health disparities

Improve health care outcomes

If nations “get it right” with the youngest, most vulnerable members of the population, there’s reason to believe that the rest of the population will receive attention and care.

October November 2007 Nursing for Women’s Health 473

The young are vital to a nation’s successful and sustainable

growth and development. Understanding the links between

poverty and health outcomes, COINN works to provide local

nurses the necessary clinical skills and tools as well as access to

research, training and education to achieve and sustain lower

childhood mortality rates as nations attempt to dig out of pov-

erty. COINN is an example of an NGO that works to sever the

link between health and poverty, thereby lessening and miti-

gating the burden of poverty borne by women and children

globally. NWH

ReferencesBuor, D., & Bream, K. (2004). An analysis of the determinants of

maternal mortality in sub-Saharan Africa. Journal of Women’s Health, 13, 926–938.

United Nations Population Fund. (2007). Advancing the goals of the ICPD and the Millennium Summit. Retrieved July 1, 2007, from http://www.unfpa.org/icpd/#worldsummit00

World Health Organization. (2004). Maternal mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA. Retrieved July 1, 2007, from http://www.who.int/reproductive-health/publications/maternal_mortality_2000/index.html

World Health Organization. (2007). Health in the Millennium De-velopment Goals. Retrieved July 1, 2007, from http://www.who.int/mdg/goals/en/index.html

The second initiative focuses on strategic planning and

development of health policy at the international, national, re-

gional and local levels that engage nurses and other stakeholders.

COINN brings the “voice of neonatal nursing” to international

policy and health care delivery arenas. As an established NGO,

COINN receives invitations from international, national and

local organizations to participate in conferences, intervention

projects, research activities, educational forums, policy meet-

ings and other relevant activities. Most of these invitations are

to participate and collaborate in deliberative processes and

create programs designed to effect health outcomes.

COINN is invited in many countries to assist neonatal

nurses working to mitigate or offset public policy decisions

that appear to reinforce structural poverty. One example is Zim-

babwe. This nation recently introduced a land reform program

in which large tracts of land previously owned by white farmers

have been given to the farmworkers who previously worked the

land for the farmers; a consequence is that women working and

living in remote areas have no access to roads or telephone net-

works and cannot get to clinics for routine medical services and

screening. Moreover, prenatal care and the presence of quali-

fi ed health care professionals at a birth are considered “luxu-

ries” that these women can’t afford. Hence, they deliver at home

without medical attention. COINN has been contacted to assist

Zimbabwean nurses in addressing this critical problem.

Another country-level initiative is providing technical and

educational assistance to nurses who are forming national neo-

natal nursing associations. Nurses and government offi cials in

countries such as Kenya, South Africa and Russia have reques-

ted and received support from COINN as they undertake the

formational national associations.

Finally, at the invitation of Iraqi nurses, COINN has been

assisting them to rebuild nursing in general and neonatal nurs-

ing in particular. The Iraqis need assistance with standards of

care, education and training of nurses and specialized training

of neonatal nurses, as well as support in rebuilding health care

facilities.

These and many other initiatives and activities to assist

nurses in providing quality health care in an effort to offset

some of the most direct consequences of poverty are all initi-

ated, managed and/or supported by COINN.

ConclusionThe need to fi ght global poverty and its effects is vital. It’s also

clear that such efforts are long-term projects, with many steps for-

ward and altogether too many backward. As the world struggles

with fi ghting poverty and structuring a more equitable distribu-

tion of resources, people need assistance. Poor health outcomes

are an example of the consequences of poverty. COINN is one

important example of an NGO committed to assisting people

with their health care needs. COINN’s focus is working with

local nurses to produce better childhood health outcomes.

Get the Facts

COINN

http://www.coinnurses.org

UN Population Fund

http://www.unfpa.org/

WHO

http://www.who.int/en/