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It is the neonatal period that poses the most significant threat to the health and survival of children across the globe. In 2021 the neonatal period accounted for about 47 percent of all deaths to children under the age of five. The international neonatal death rate was 17 per 1,000 live births with most of those deaths occurring in low and very low-income countries. The highest neonatal death rates were found in sub-Saharan African and South Asian countries (UNICEF, 2021).

The commitment to lowering the neonatal mortality and morbidity rate has long been a central part of almost all global health discussions. Political commitments to and resource allocations aimed at lowering the neonatal death rate transcend political parties and ideologies as well as national boundaries. For example, as recently as 2015 an array of expert leaders from across the globe committed to lowering the global neonatal mortality rate to 12 deaths per 1000 live births by 2030. The strategies to lower neonatal mortality are vast but one of the most effective ways is to have a trained/well-educated neonatal nurse.

COVID has exacerbated inequities and inequalities, broken community, social, economic, familial, and health care systems as well as the healthcare workforce, as it also exposed all too often hidden long standing structural injustices and gaps in housing, nutrition, education, workforce opportunities, and economic conditions, as well as in health care access and options.

It is fair to say that when it comes to the health care workforce generally and the nursing workforce specifically the pandemic has exacerbated the gaps within the labor sector, and it broke, or at least dramatically shattered, the stability and strength of the global health care workforce. The pandemic has also exposed the need for a highly trained specialized nursing workforce.

The Council of International Neonatal Nurses, Inc. (COINN), and other nursing organizations, for decades have been repeating the mantra that specialized training and education for nurses who care for the small and sick newborn is necessary condition to enable these vulnerable newborns to survive and thrive. While acknowledging the need for such training and education for all nurses and all subspecialties, in this brief we call special attention to not only the need but the justification for why specialized neonatal training and education must be a priority for all nations.

An array of challenges, barriers, and opportunities for providing the highest quality neonatal care exists and these vary by country and region. There is no silver bullet, or one size fits all solution to ensuring that all neonatal nurses are provided the training and education needed to ensure that all small and sick newborns are provided the quality of care required to survive and thrive.

However, there are two interconnected issues that require policy intervention and that lend themselves to solutions that are applicable across national and regional borders. The first, recognizing that outcomes are tied to workforce capacity and capabilities, is to acknowledge the need for specialized nursing training. The second is to design a model for how specialized nursing education and training is funded and supported by governments.


Why do neonates matter? This may seem like a ridiculous question but if there is no investment in fundamental workable strategies to decrease neonatal mortality then one has to ask the question: do neonates matter? They matter not only because it is the right thing for a society to protect its most vulnerable members, because neonates are the future workforce in a country. They provide stability to an economy in the long run.

Why must neonatal nurses be specialized and why do they need and deserve resources? Quite simply, nurses who care for small and sick newborns require special knowledge and skills. These patients are not small children or adults. They represent a population with health care needs requiring skills beyond generalist nursing education. The neonatal period is unique. It is a period where nurses need to know how the developing body will affect the care of that specific neonate. For example, a 38-week infant with respiratory distress has retractions, nasal flaring and an oxygen requirement similar to a 30-week gestation infant. Yet the reason for the same symptoms is crucial for treatment. At 30 weeks there is a surfactant deficiency at 38 weeks it may be related to retained fluid from delivery or infection. Without specialized training a nurse will approach each infant in the same way and delay the appropriately life-saving treatment. Similarly, a full-term infant that weighs 3 kg will not have the same problems as a full-term infant that weighs only 2 kg. The small gestation infant will have increased risk of metabolic problems and thermoregulation. Without education on the small for gestation infant the nurse would not have the knowledge to anticipate and identify potential issues. Equally the large for gestation infant, born greater than 4 kg is often applauded for their size. Yet a large for gestational age infant can be premature and have problems with glucose, respiratory distress, and poor feeding. These three incidents are just a few of the unique neonatal issues that nurses deal with in neonatal units daily. Without specialized education and training nurses will not know how to address these, and other, unique conditions, not be able to provide required crucial care, and potentially cause severe harm to their patient, i.e., the neonate in need of specialized care. these unique things and

As the WHO HRH Roadmap suggests decreasing neonatal mortality and morbidity, we must upgrade the existing workforce and develop a new cadre of nurses prepared to meet the needs of the small and sick newborn (WHO, 2020).


  1. Secure funding to support specialized neonatal nursing care must be available.

  2. Staffing ratios must be tied to acuity and number of small and sick newborns and not to the shift worked.

  3. Staffing for a neonatal unit must always be at a level which allows nurses to provide appropriate levels of care to all patients, even if the unit is at full occupancy capacity.

  4. Development of a metric that accounts for the number of patients must emphasize the acuity of the small and sick newborn population.

  5. Nurses with specialized neonatal knowledge must not be rotated out of the units caring for the small and sick newborns.

  6. If nurses are rotated into neonatal units, they must first undergo cross-training on the care of the small and sick newborns.


World Health Organization. (WHO). (2020). WHO Launches New Roadmap on Human Resource Strategies to Ensure That Newborns Survive and Thrive.


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