Neonatal mortality remains a major health challenge across the world, which involves neonatal sepsis and other related factors of prematurity. Though many strides have been done in reducing NMR, there is a need for more appropriate interventions and strategies directed towards addressing the rise in the escalation of AMR. Combating AMR will be critical in improving neonatal survival rates while giving each newborn a healthier start into life globally.

The newborn period is the key period for infant health, and the first 28 days of life are critically important-both for survival and as a base to set lifetime health and development. Neonatal deaths globally have witnessed a significant decline over the past couple of decades. The neonatal mortality count has significantly reduced dropping from a high of 5 million in 1990 to as low as 2.3 million as of 2022. However, this decline notwithstanding, neonatal mortality is still staggeringly high across low-and middle-income nations.

Neonatal mortality rates are 22 per 1000 live births in India. Neonatal sepsis and prematurity are the main causes of neonatal deaths in these tragic events. Recognizing the gravity of the issue the Indian government started the Indian Newborn Action Plan (INAP) in 2014. The goal is to take NMR down to the single digits by 2030. This initiative has brought in several key interventions, including antenatal care (vaccines, micronutrient supplementation), skilled birth attendance, clean birth practices, and neonatal resuscitation techniques. More promisingly, postnatal interventions, including early initiation of breastfeeding and skin-to-skin contact, have been proven to work well in improving newborn survival rates.

Despite these improvements, one of the biggest concerns in neonatal care today is the growing problem of antimicrobial resistance (AMR) which seriously threatens efforts to reduce neonatal mortality.

What is Antimicrobial Resistance?

Antimicrobial resistance occurs when microorganisms such as bacteria, viruses and fungi evolve over time and become resistant to commonly used antibiotics and other medications. This resistance makes infections more difficult to treat, increasing the risk of mortality and complicating treatment options. The World Health Organization has classified AMR as one of the most urgent global health threats since it not only causes death and disability but also places immense pressure on healthcare systems, significantly raising the economic burden.

The sources of AMR are many, including poor hygiene and infection control in healthcare settings, overuse and misuse of antibiotics. Contributing factors to this rapidly growing problem are antibiotic prescriptions for patient needs that do not require them and failure to complete antibiotic courses, as prescribed.

AMR and Newborn Health

For neonates, the risk is much more vital for AMR. Neonates are particularly prone to developing infections due to their rather weak immune systems. Neonatal sepsis, severe bacterial infection, is one of the leading causes of neonate deaths and it often manifests complications when it is because of drug-resistant pathogens.

According to Dr. Apoorva Taduri, Consultant Neonatologist, "Neonatal sepsis accounts for a significant proportion of neonatal deaths, and AMR is making it worse. MDR pathogens cause around 30% of neonatal sepsis mortality globally.

Maternal health and care are also factors influencing AMR in neonates. Over-prescription of antibiotics during pregnancy increases the risk of neonatal sepsis and the development of multi-drug-resistant pathogens in newborns. This calls for prudent use of antibiotics during pregnancy and at the time of delivery. In fact, studies indicate that indiscriminate use of antibiotics in mothers has a direct impact on neonatal health, which may eventually lead to resistant infections in newborns.

One of the major issues is that the drug-resistant bacteria are causing an increasing number of healthcare-associated infections in the neonatal care settings, which include NICUs. Infections by such bacteria prove to be challenging to treat; they require more advanced, expensive interventions, and the period of risk of mortality and morbidity is extended.

Counteracting AMR in Neonatal Care

To combat AMR and reduce neonatal mortality a multifaceted approach is necessary. Dr. Taduri emphasizes the continuation of the strategies outlined by the Indian Newborn Action Plan (INAP), specifically in reducing neonatal sepsis and improving infection control. However, to combat AMR more must be done to ensure proper use of antibiotics in both maternal and neonatal care settings.

Key strategies for reducing AMR in neonatal care are:

1. Improving Infection Prevention Practice: This implies, therefore, that more efforts would be made regarding stricter hospital hygiene standards, strict equipment sterilization after its usage and even maintaining adequate hand hygiene. Enhanced infection control practices greatly impact minimizing AMR pathogens distribution.

2. Antibiotic Stewardship- Teaching the healthcare providers how not to use antibiotics is a crucial thing in preventing overuse prescription. Antibiotic stewardship programs are designed to promote use of antibiotics only when truly required; appropriate drug, dose and length of treatment should be taken.

3. Improved access to WASH: Access to clean water and sanitation is a fundamental aspect of preventing infections in mothers and newborns. WASH interventions such as clean birthing practices, can reduce the risk of neonatal sepsis due to unsanitary conditions.

4. Maternal Health Strengthening: Proper maternal care, such as proper vaccination, antenatal steroids, and supplementation of micronutrients, can reduce the risk of prematurity and neonatal infection. Prevention of infection in mothers is the first step towards prevention of infection in newborns.

5. Early Diagnosis and Treatment: Early identification and treatment of neonatal infections are very important. This includes proper screening for sepsis and the use of appropriate antibiotics based on the local resistance patterns. It also involves ensuring that infants receive adequate neonatal care, such as those provided in Special Newborn Care Units (SNCUs).

The rise of antimicrobial resistance is a global health challenge that requires urgent action. Combating AMR requires a coordinated effort from governments, healthcare systems and communities worldwide. In neonatal care, addressing AMR is essential to further reducing neonatal mortality rates and ensuring that every newborn has the opportunity to thrive.

As Dr. Taduri concludes, "While we have made substantial progress in reducing neonatal mortality, the emerging risk of antimicrobial resistance creates a major challenge for our efforts. Combating AMR requires a global collective effort, with priorities on infection prevention, responsible use of antibiotics, and enhancement of healthcare practices to ensure a healthier future for all newborns."

Dr Apoorva Taduri is a Consultant Neonatologist at Fernandez Hospital

When 36-year-old mom Angela Sanford, from Fort Mill, SC, went for an appointment for a Pap smear five years after she had her first child in 2008, her nurse midwife, who she has never seen before asked her a question she did not expect. "Who stitched you up after your first birth?"

Speaking to Healthline, Sanford shared that she just started crying when the nurse said, "This is not right." Sanford said that this was the first time she ever heard the term 'husband stitch'. Sanford was told that her stich was "too tight" by the hospitalist who managed her after her first delivery.

Also Read: US CDC Warns Of New Immune-Evasive COVID Variant In 23 Countries

“He gave you what some people call a husband stitch,” Sanford recalled the midwife telling her.

“I couldn’t connect in my mind why it would be called that. My midwife said, ‘They think that some men find it more pleasurable,’” she recalled. “My husband has been worried about me and fearful of hurting me. He would never have asked for this.”

A 'Husband Stich' - What Is It?

During vaginal delivery, a woman undergoes perineal tears or vaginal lacerations which means tears between the vaginal opening and anus. This causes pain, and requires stitches for grades two and higher. It also takes 4 to 6 weeks to heal. Women can experience from first to fourth degree tears.

Sometimes, a surgical incision is made in the perineum during childbirth to enlarge the vaginal opening, this is called an episiotomy. However, it is not medically necessary or a routine procedure, unless it is a case of emergency.

Stiches are required in such cases that dissolves on its own. However, a 'husband stitch', also known as "daddy stitch" is an unethical practice where an extra stitch is given during the repair process that 'tightens the vagina' to increase sexual pleasure for a male partner. While it is considered a medical malpractice, it is still done to women after vaginal delivery.

Many women face difficulty after the extra stich is given to them. In Sanford's case, she felt "excruciating" pain during sex afterwards.

Read: Romanticization And The Silent Dismissal Of Women’s Pain

When Objectifying Women's Bodies Is Made A Medical Practice

Stephanie Tillman, CNM, a certified nurse midwife at the University of Illinois at Chicago and blogger at The Feminist Midwife told Healthline: “The fact that there is even a practice called the husband stitch is a perfect example of the intersection of the objectification of women’s bodies and healthcare. As much as we try to remove the sexualization of women from appropriate obstetric care, of course the patriarchy is going to find its way in there."

Harkins, 37, said that she "kind of" laughed it off when an "old, crusty Army doctor" overstitched her so she could give her husband more pleasure. In many cases, doctors do it as a routine practice without even being told by anyone. “I couldn’t even process [it], but I kind of laughed, like what else do you do when someone says that? I had just had a baby. I didn’t think much about it because the whole birth experience was so traumatizing, but now that I think about it differently, the implications of that are just crazy.”

Episiotomy Is An Excuse For 'Husband Stitch'

Dr Robert Barbieri, chair of obstetrics and gynecology and reproductive biology at Brigham and Women’s Hospital in Boston, told the Huffington Post that doctors were taught in the 50s and 60s that "routine episiotomy was good for women".

“What they thought is that if they did a routine episiotomy, they’d have a chance to repair it and that during the repair, they could actually create a better perineum than if they hadn’t done it. The idea [was] that we could ‘tighten things up,’” explains doctor.

However, a 2005 systematic review in the Journal of the American Medical Association found no benefit to routine episiotomy use. A 2017 Cochrane review “could not identify any benefits of routine episiotomy for the baby or the mother.” In 2016, the American College of Obstetricians and Gynecologists (ACOG) recommended that clinicians “prevent and manage” delivery lacerations through strategies like massage and warm compresses rather than making cuts on the perineum. Yet, this practice still continues inside the labor rooms.

While you may be buying fast-fashion clothes that are easy on your pocket and also give your children trendy looks, a new study highlights the risk of being laced with a highly toxic ingredient: lead.

The preliminary research, based on lab tests of several shirts from different retailers in the US, found that all the samples exceeded the country’s federal regulatory lead limits.

The US Consumer Product Safety Commission currently has a 100 parts per million (ppm) lead limit for children's products like toys and clothing.

"I started to see many articles about lead in clothing from fast fashion, and I realized not too many parents knew about the issue," said Kamila Deavers, principal investigator of the study, at Marian University in the US.

Deavers began the study after her young daughter’s lab reports showed elevated levels of lead in her blood from toy coatings.

How was study conducted?

The team tested 11 shirts that spanned the rainbow—red, pink, orange, yellow, gray, and blue. All brightly colored fabrics, particularly reds and yellows, showed higher levels of lead compared to more muted tones.

"We saw that the shirts we tested were all over the allowed limit for lead of 100 ppm," said Priscila Espinoza, from Marina.

The researchers explained that some manufacturers use lead (II) acetate as an inexpensive way to help dyes stick to the materials and produce bright, long-lasting color.

Children At Greater Risk

The researchers found the risk is particularly higher among younger kids as they tend to playfully suck or chew their clothes during play.

"Even briefly chewing these fabrics could expose children to dangerous lead levels,” they found in the study, to be presented at the forthcoming meeting of the American Chemical Society.

According to the US Environmental Protection Agency (EPA), lead exposure can lead to behavior problems, brain and central nervous system damage, as well as other negative health effects in children.

The agency considers children under six years old to be most at risk from exposure. Even low levels of lead in the blood of children can result in:

• Behavior and learning problems
• Lower IQ and Hyperactivity
• Slowed growth
• Hearing Problems
• Anemia

The researchers also pointed out safer alternatives to lead-based dyeing agents that already exist. These include natural and less harmful substances such as:

• Plant-based tannins (e.g., oak bark, pomegranate peel)
• Rosemary
• Alum.

A recent systematic review published in the European Medical Journal found that racial discrimination leads to postpartum depression and low birth weight (LBW). Pregnant women of color were 40 per cent more likely to experience postpartum depression and have 170 per cent higher risk of delivering a baby with LBW.

The findings allowed the researchers to report that racial discrimination is a modifiable determinant of maternal and nenonatal health. Researchers also note that they should be integrated into perinatal research and care to reduce inequalities.

Large Review Examines Decades of Research

A large review of international studies has found that racial discrimination experienced by pregnant women may be linked to a higher risk of postpartum depression and poor birth outcomes, including babies born with low birth weight.

Researchers analysed nearly three decades of research that examined self reported experiences of racial discrimination among pregnant women or those who had previously been pregnant. The analysis included more than 20,300 research records and covered close to 1.5 million participants.

The study explored whether exposure to racial discrimination was associated with a range of maternal and newborn health outcomes. These included hypertensive disorders during pregnancy, gestational diabetes, mode of delivery, postpartum depression, fetal growth, gestational outcomes, infant mortality, and admission of newborns to neonatal intensive care units.

Among all the outcomes studied, the strongest link was found with postpartum depression. Women who reported experiencing racial discrimination had a 37 percent higher risk of developing postpartum depression compared with those who did not report such experiences.

Higher Risk of Low Birth Weight Among Affected Mothers

The analysis also found significant associations between racial discrimination and low birth weight in babies.

Women who experienced racial discrimination were found to have a 121 percent higher risk of delivering babies with low birth weight. The risk was even greater for very low birth weight babies, with the likelihood increasing by 170 percent.

However, researchers did not find clear links between racial discrimination and certain pregnancy complications. No strong association was observed with hypertensive disorders of pregnancy or gestational diabetes.

Findings related to preterm birth were mixed. Cohort studies did not show a clear association, while cross sectional studies suggested a modest 19 percent increased risk of premature birth among women who reported discrimination.

For several other outcomes studied, the available evidence remained inconsistent.

Stress and biological changes may explain the link

Researchers suggested that everyday experiences of racial discrimination may affect maternal health through multiple pathways.

Repeated exposure to discrimination can create chronic stress, which may affect both mental and physical health during pregnancy. The stress can also lead to social isolation and strained personal relationships, which may increase the risk of postpartum depression.

Biological changes triggered by prolonged stress may also affect pregnancy outcomes. Researchers noted that stress linked to discrimination could influence placental function, metabolism, and inflammatory responses in the body. These changes may contribute to restricted fetal growth and increase the risk of babies being born underweight.

Experts call for stronger public health response

The authors emphasized that healthcare systems should recognize racial discrimination as an important social stressor that can influence maternal and newborn health.

They recommend that routine prenatal care include screening for social stressors along with mental health assessments during pregnancy and after childbirth.

Currently, many clinical guidelines do not explicitly recognise racial discrimination as a potential risk factor for maternal and neonatal health.

Researchers say the evidence highlights the need for broader policy efforts that address discrimination at a structural level. Treating discrimination as a public health issue rather than an individual experience may help reduce health inequalities and improve outcomes for mothers and babies.