[No solution for neonatal mortality in sub-saharan Africa? Evaluation and perspectives in the urban environment of Niamey, Niger].

Niger has one of the highest mortality rates of infants (222/1000) and children under five years old (318/1000), with 15% of them suffering from malnutrition. Yet, neonatal mortality was not considered as the top priority of public health in Niger, where 85 to 90% of the deliveries succeed without any medical care and 70% of the population live more than 10 kilometers from the nearest medical center. Also, in the African countries which have adopted expensive neonatal care centers following the occidental model, the lethality rate is high and maintenance is difficult. Thus, alternative strategies should be considered to reduce the neonatal mortality, according to the local possibilities. This was carried out in Niamey, the capital of Niger. A retrospective study of the activities in the pediatric and obstetric wards was carried out from 1985 to 1992. This was associated with a descriptive prospective survey of a sample of 149 pregnant women followed from the first prenatal consultation to the end of the neonatal period. Results showed that possibilities exist in Niamey to reduce neonatal mortality. The concentration of medical personnel was high compared to the rest of the country, and the health infrastructure was diversified. However, the knowledge of neonatal care was lacking. Use of prenatal care was high and deliveries at home without medical assistance concerned only 14.3% of the total births. Mortality observed in the obstetrical ward (6.7/1000) corresponded to less than a quarter of the estimated neonatal mortality (28.6/1000). Neonatal mortality in the pediatric ward was high (43.8%), predominantly on the first day of admittance (45% of the deaths), especially for the low birth weights (under 2,500 g) (62.4%). These figures underline the necessity to improve the care of the newborns and to link prenatal prevention, obstetrical care and pediatrics. The prospective survey showed that although the ratio of prenatal visits per woman was high (3.8), the quality of the care was inadequate. Correct newborn care was rare and no examination could detect or prevent complications during the short stay of less than 24 hours in the obstetrical ward. To lower the neonatal mortality, service could be improved concerning the material conditions of prenatal consultations, reorientation of prenatal consultations towards detection, correct treatment of the risk factors of neonatal mortality, obstetrical screening and care, and training of the midwives. The adoption of inexpensive measures was suggested, including the training of pediatric nurses in each maternity ward, screening and treatment of newborns at risk in small units integrated within the obstetrical ward, and the requirement of a consultation before the traditional feast of giving names, which occurs on the seventh day of life in Niger. These measures were considered as priorities before considering construction of expensive neonatal centers and assume the participation of the public health personnel and policy makers. Some of these suggestions are now being implemented.