Uruguay, 11 April 2018 (PAHO/WHO) -  In 1997, 16.8 of every 1,000 infants born alive died before the age of 1. By 2017, that number had declined more than 60%, to 6.6. Better care and improved coordination between levels of care were keys to achieving these results and saving lives.

A mother gazes at her daughter in the incubator, talks to her, caresses her hands. She says the baby girl "gets crazy" when it's time to hold her in her arms. The baby is premature, born before 39 weeks, but she is receiving the care she needs at the Newborn Services ward at the Pereira Rossell Hospital Center in Montevideo, Uruguay.

Newborn in incubator

At Pereira Rossell, about 12% of the 7,000 babies born on average each year require intensive, intermediate or minimum care. Those 7,000 births represent 16% of all deliveries in the country (in 2017, there were 43,014 nationally). Prematurity is the leading cause of death in children under 5 at the global level, and access to good medical care greatly increases their chances of survival.

In 2017, Uruguay reached a historic low for infant mortality, with a rate of 6.6 deaths per 1,000 live births. The number reflects a downward trend that began 20 years earlier. "Being among the group of countries with rates between 5 and 7 per 1,000 is a huge achievement," said Daniel Borbonet, head of Pereira Rossell's Newborn Services.

In Latin America, average infant mortality is 16 deaths per 1,000 live births, and Uruguay's rate of 6.6 puts it among the region's countries with the lowest rates-lower than Brazil, Mexico, Colombia and Argentina, although higher than Chile, the United States, Canada and Cuba. Overall, Latin American countries-with support from the Pan American Health Organization (PAHO) and other partners-reduced infant mortality by more than half between 1990 and 2010.

More investment, better networking

Borbonet, who has over 30 years' experience working and teaching in neonatology, says Uruguay's achievements in this area are the result of public investments in health and a policy adopted in 2008 by the National Integrated Health System (SNIS) that directs to "complement and support the different levels of care" and not foment competition between them.

"In the past, babies would come to Pereira Rossell-a tertiary-care hospital-who did not that level of care. Today these cases are treated at first-level health centers in their own regions," said Borbonet, adding that decentralization has also reduced inequities in care between health centers in Uruguay's capital and those in other departments.

Networking between hospitals and health centers follows PAHO recommendations for how to overcome fragmentation of health services, which results in problems with access, low quality and inefficient use of resources. This year, as part of the World Health Day Campaign for "Universal Health: Everyone, Everywhere," PAHO called for breaking down barriers to accessing care, including institutional barriers.

Pereira Rossell's neonatal service has become synonymous with quality. Borbonet notes approvingly that "it is better than many private places," adding that many of the babies born there today might not have survived a few years ago. Moreover, "premature babies born today are less prone to blindness, retinopathy, hearing loss, and neurodevelopmental problems," he said.

A committed health team

Teamwork is key, as is the role of nurses. "So much life happens here, which makes it a very rewarding job," said nurse Adriana García, whose emotion and passion for her work are contagious. It's also important that mothers and fathers are engaged and proactive, and that health teams maintain direct and ongoing communication with them.

Teamwork is key, as is the role of nurses

"Parents are not just visitors; they are integral members of a child's health care team," said Borbonet. "They do not need permission to enter or leave the intensive care center. We, the health team, are the ones who should ask permission to give any kind of care."

For Soledad Núñez, head of neonatal nursing, there is "a synergy created between baby, parents and caregivers. When that synergy becomes effective, of quality, that's when we see good results."

Nuñez words bring a smile to Santiago, a rural laborer from an area far from the capital, as he caresses and sings to his little girl, Amber.

Studying each case

Despite all this progress, in 2017, 38 children under 1 died at the Pereira Rossell Hospital Center. "Today we study the cases of every child who does not survive," said Borbonet, who also heads the Department of Neonatology at the School of Medicine of the University of the Republic.

Borbonet, who has over 30 years' experience working and teaching in neonatology

"We know by heart what happened and why it happened, what we might have done and didn't do, or even if when did everything possible, the result was the same. That's what it's about: auditing, evaluating and discussing," he said.

Pereira Rossell's Newborn Services trains "doctors, nurses, technicians, midwives, obstetricians - all the perinatal personnel- that will end up working in public hospitals and private clinics," said Borbonet. He adds that it is a plus to be able to discuss cases with the university's medical faculty, no to try to place blame but rather to look for solutions.

Borbonet is not satisfied with the fact that Uruguay's infant mortality rate now at a low 6.6 per 1,000 live births. "We need to go abroad and see other models of care, learn how other countries have managed to reduce their rates to as low as 3 per 1,000," he said. What he already knows is that timely, quality care that is well organized in networks and based on evidence is essential to prevent complications and save children in their first year of life.