Hearing the Unheard Cry: Pillars To Improve Newborn Survival

Stephen Wall, MD MS MSW Saving Newborn Lives Save the Children/USA

April 28, 2010

Outline

• Global situation of newborn health• Strategies to improve newborn survival

– Increasing availability/access to interventions: Community health worker home visits (Steve Wall)

– Improving demand and use of interventions: Community mobilization for newborn health (Joseph DeGraft Johnson)

– Improving quality of interventions: providing newborn resuscitation in low resource settings (Susan Niermeyer, Tore Laerdal)

– Using partnerships to scale up interventions: Global Development Alliances for neonatal resuscitation & handwashing (Lily Kak)

050

100

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Mo

rtal

ity

per

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irth

s (g

lob

al a

v)

1960 1980 2000 2020Year

Neonatal deaths and the Millennium

Development Goals

Almost 40% of under 5 deaths are neonatal – almost 4 million a year

MDG- 4 can only be achieved if neonatal deaths – especially early neonatal deaths – are addressed

Under-5 mortality rate

Late neonatal mortality

Early neonatal mortality

Target for

MDG-4

Source: Lawn JE et al Lancet 2005

Where are babies born and where do newborns die?

• Approximately half of all childbirths are in settings without a skilled birth attendant

• More than three-quarters of neonatal deaths occur in settings without skilled care, most at home

When do neonatal deaths occur?Up to 50%

of neonataldeaths are in

the first 24 hours

75% of neonatal deaths are in

the first week – approximately 3 million deaths

Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths)

Risk of stillbirth, newborn, maternal mortality: WHEN?

Sources: Maternal deaths: from WHO/UNICEF/UNFPA 2000 estimates. Child deaths from UNICEF estimates for 2000, Neonatal deaths from WHO RHR estimates 2004. Stillbirths from WHO in SOWC 2001. Denominator used is the number of live births from UNICEF, adjusted to all births by adding the 4 million stillbirths. Timing of maternal deaths is based on Li XF et al, 1996 after subtraction of 13% estimated to be related to unsafe abortion, assuming these are prior to the last trimester (WHO 1997). Percent of stillbirths that are intrapartum from Lawn JE et al (WHO Bull June 2005)). Child deaths, percentage early neonatal, neonatal, months 2-12 and years 2-4.99 based on WHO and UNICEF estimated rates for 2000. Percentage of deaths on day 1 based on 2 inputs; DHS data (34 most recent surveys, 10,041 NNDs, median year 2000). Study input of 28 studies (NNDs 7369, median year 1991)

0

2

4

6

8

10

12

14

16

Last 3 monthsof pregnancy

During childbirth First day Day 2 to 6.99 Day 7 to 27.99 Month 2 to 12 Year 2 to 4.99

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ild m

ort

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pe

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0)

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20

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120

140

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Ma

tern

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0)

Daily risk of stillbirth per 1000 total births

Daily risk of child death per 1000live births

Daily risk of maternal death per 100,000 births

Direct causes of 3.72 million neonatal deaths

- almost all are due to preventable conditions

Source: Lawn JE, Cousens SN, Zupan J Lancet 2005.

60 to 90% of neonatal deaths are in low birth weight babies, mostly preterm

Focused 4-visit antenatal package including • tetanus immunisation,• detection & management of HIV, syphilis, other infections, • pre-eclampsia, etc

Malaria intermittent presumptive therapy*

Detection and treatment of bacteriuria#

Outreach/Outpatient

Postnatal care to support healthy practices

Early detection and referral of complications

Folic acid #

Family Plann-ing

Evidence-based interventions to reduce neonatal deaths

Skilled obstetric and immediate newborn care (hygiene, warmth, breastfeeding) & resuscitation

Emergency obstetric care to manage complications such as obstructed labour and hemorrhage

Antibiotics for preterm rupture of membranes#

Corticosteroids for preterm labour#

Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies including Kangaroo Mother Care

Clinical care

Counseling and preparation for newborn care and breastfeeding, emergency preparedness

Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care

Extra care of low birth weight babies

Case management for pneumonia

Family-community

Clean delivery by traditional birth attendant (if no skilled attendant is available)

Simple early newborn care

Childhood Neonatal periodPre- pregnancy PregnancyBirthSource: Lawn et al. DCP chapter adapted for Lancet neonatal series executive summary, plus impact by level and time period based on Darmstadt et al 2005

GAP1

GAP2

Where are actions needed? Covering the gaps

Source: Lancet Countdown Coverage writing group, Lancet Countdown special issue, 2008

Evidence for newborn care ‘packages’ with CHW home

visits

India• SEARCH (India)

– CHW antenatal and postnatal home visit counseling

– CHW attendance at delivery (with TBA): resuscitation; home care of LBW

– CHW identification and management of newborn sepsis & pneumonia (IM Gentamicin + Cotrimoxazole)

– 61% reduction in NMR in 3rd yearSource: Bang et al. Lancet 1999; 354:1955-

61

• Ankur (India)– SEARCH replication by 7 NGOs – 51% reduction in NMR after 2 years

• Source: Bang. Unpublished. Presented at ANE Meeting, Bangkok, 2009

Bangladesh• Projahnmo (Bangladesh)

– CHW antenatal and postnatal home visit counseling

– Assessment of newborns, referral for signs of illness

– If referral not successful, CHW offered/provided home-based infection management (IM Penicillin + IM Gentamicin)

– 34% reduction in NMR Source: Baqui et al. Lancet 2008;371;1936-44

– Important observational findings:• First postnatal home visit in 48 hours was

associated with significant 2/3 reduction in NMR. Source: Baqui et al. BMJ 2009;

India

• Shivgarh (India)– Community mobilization/BCC by

CHWs – birth preparedness, hygiene, breastfeeding, thermal care (skin to skin), cord care

– 54% reduction in NMR in 18 mosSource: Kumar et al. Lancet

2008;372:1151-62

Pakistan

• Hala (Pakistan)– Existing government cadre: Lady Health Workers– Community mobilization: male and female groups– Antenatal and postnatal home visits for

counseling and newborn assessment• Referral of complications to (modestly

strengthened) health facilities

– 30% reduction in NMR in 2 yrsSource: Bhutta et al. Bulletin World Health Organ 2008;86:452-9

Content and timing of home visits: A summary of the evidence

Study Provider Home visits for newborn care on

Content of home visits↓NMR

SEARCH(India)

Source: Bang et al. Lancet 1999

Community health worker (paid. Plus performance incentives)

Prenatal, Delivery, Days 1, 2, 3, 5, 7, 14, 21 and 28

•Prenatal counselling•Care at birth (resuscitation) •Postnatal visit (care & counselling)•Infection management•LBW care (extra visits)

61%

ANKUR (India)

Source: Bang et al. Unpublished

Community health worker (paid, plus performance incentives)

Prenatal, Delivery, Days 1, 2, 3, 5, 7, 14, 21 and 28

•Prenatal counselling•Care at birth (resuscitation) •Postnatal visits (care & counselling)•Infection management•LBW care (extra visits)

51%

Projahnmo (Bangladesh)

Source: Baqui et al. Lancet 2008

Community health worker (paid) Prenatal, Days 1, 3, and 7 •Prenatal counselling•Postnatal visits (newborn assessment, counselling)•Treatment of newborn infection (if refused referral)

34%

Shivgarh (India)

Source: Kumar et al. Lancet 2008

Community health worker (paid), changed to community volunteers

Prenatal, Days 1 and 3 •Prenatal counselling•Postnatal visits (counselling)

54%

Hala (Pakistan)

Source: Bhutta. Bull World Health Organ 2008

Lady Health Worker (government paid)

Prenatal, Days 1, 3, 7, 14 and 28 •Prenatal counselling•Postnatal visits (newborn assessment, counselling, referral if needed)

30%

Evidence to Policy

UN Joint Statement key messages

• Effective newborn care must be provided immediately, in first hours and first week.

• Provide postnatal home visit where access to facility-based skilled care is limited.

UN Joint Statement key messages

• Home visit content for home births should include check ups and counseling (eg, BF, cord care, thermal care, danger signs).

• Home visits should be as soon as possible. Proposed schedule: 1st visit within 24 hours; additional visit on day 3 (or after hospital discharge); if possible on day 7.

Thank you!

Healthy Newborn Network

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