What's New for Newborns_Claudia Morrissey & Allyison Moran_10.14.11
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  • 4.6 M in 1990 Mmratio declined 34%
  • Institute for Health Metrics and Evaluation Why? set the stage. At the end of the last century, 3 independent events occurred that converged to create a Perfect storm , if you will, for newborn survival.
  • Dec 1999, Abhay Bang published the results from the SEARCH project in Gadchiroli, India in the Lancet. There was a nearly 50% reduction in NMR when package of newborn preventive and curative care services, including management of newborn sepsis, was provide in the home by frontline workers. These finding ran counter to conventional wisdom that held that little could be done given to save newborns in low-resource settings: the investments needed to establish NICUs and to train sub-specialist staff were out of reach. I remember being at a meeting at Johns Hopkins in 1999 when Dr. Bang presented his preliminary findings. You could have heard a pin drop in that room. The second event in this perfect storm was
  • Commitments and pledges were made.
  • Save the Children developed a proposal based on new findings from SEARCH and in 2000 Saving Newborn Lives became the “flagship” project for addressing newborn mortality and morbidity in low-resource settings Celebratory moment yet sobering that there continue to be so many needless deaths.
  • Worldwide over 60 million births take place at home without the help of a skilled attendant. This can range from 94% in Ethiopia to less that 30% in Malawi where they have “outlawed” deliveries that are not attended by skilled practitioners (MDs, nurses, midwives).
  • Among the poorest and most vulnerable Coverage of life-saving interventions is highly inequitable Graph produced by Countdown 2015. On the left you will see a graph of coverage of 8 essential maternal newborn interventions by wealth quintile. The poorest quintile has only 20% coverage while the wealthiest has70% coverage. So…… If all…
  • Back in 2000, it was not clear how to impact on newborn survival. What inspired Save the Children and the Gates Foundation to try was the experience of Dr. Abhay Bang in Gadchiroli India where he reduced mortality among newborns by 61%. But there was still a tremendous need for understanding how he got the results he did. So a focus of SNL’s work has been to work with research partners to generate new evidence.
  • This is a busy slide based on data from the Lance Neonatal Survival Series, 2005 What it depicts is a breakdown of evidence-based interventions according to how they are delivered. The categories are clinical care, those that can be provided in outreach settings, and those that focus on actions by families and at the community level. Across the bottom we see the interventions positioned along a time line from pre-pregnancy to infancy. We can then create intervention packages along the timeline, divided into those delivered in the antenatal, intrapartum and postnatal periods, and ascribe the amount of reduction that can be achieved by the packages. What becomes clear, is that the most important times we can intervene to impact newborn deaths are the intrapartum and postnatal periods. So we now understand to reach MDG 4 we will have to focus more attention and resources on reducing newborn deaths. We know what these babies are dying from. We have data suggesting when to deliver key interventions. And we can then ask, How are we doing?
  • Preventive packages: To improve newborn practices and care seeking Behavior change communication Community mobilization/empowerment to improve newborn practices Preventive + management packages: Behavior change (home visits, community mobilization) Home-based assessment of newborn Home-based management of complications (eg, infection
  • A core component of SNL’s work has been to drive the generation of new evidence of what works to improve newborn survival. Overview of SNL 1 Research: Adapted and tested interventions and models in different settings Improved SOTA approaches to reduce mortality from 3 major killers
  • Building on learning from SNL1, SNL 2 generates evidence to leverage impact at scale by: Addressing the priority ‘what’ and ‘how’ questions of importance to national stakeholders (eg, MOH). Implementation research with partners involved in national scale up. Research to show how newborn health can be integrated with existing programs/systems already at scale or going to scale.
  • For some babies, special care is needed to address babies with complications: For BA, HBB: To increase quality and coverage of neonatal resuscitation at first-level facilities by front-line health workers The HBB curriculum was developed by the American Academy of Pediatrics and is currently be rolled out across the developing world. Any pediatricians here? Are you involved in the HBB roll-out? CCM of infection based on Dr. Bang’s work and on results from the Projahnmo project in Bangladesh funded through SNL showing significant reductions in newborn deaths from sepsis. And for preterm/ LBW infants, Kangaroo Mother Care
  • There is also now a new Cochrane Review from 2011 on facility-based KMC that suggests benefits from KMC
  • Previous Cochrane review from 2003 had not shown a significant mortality benefit. But numbers were small, studies had different outcomes, and the interventions started at different points. The review was updated 3/2011: Conde-Agudelo A, Belizán JM,Diaz-Rossello J. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD002771. DOI: 10.1002/14651858.CD002771.pub2 Compared with conventional neonatal care, KMC was found to reduce mortality at discharge or 40 - 41 weeks’ postmenstrual age and at latest follow up. Typical RR .60 Also reduced: severe infection/sepsis, nosocomial infection/sepsis, hypothermia, severe illness, lower respiratory tract disease, length of hospital stay. In addition, KMC increased: weight, head circumference, and length gains frequency and duration of breastfeeding mother satisfaction with method of infant care some measures of maternal-infant attachment Profound results for such a simple intervention.
  • MCHIP Ethiopia is conducting a study – also as shown in this poster, it is being implemented in Malawi
  • The evidence on impact of clean delivery practices was considered of low quality given that Randomized Controlled Trials are not possible—we can’t randomize some mothers to experience dirty deliveries; clearly would be unethical. 30 published studies show that clean birth practices reduce neonatal mortality & morbidity from infection‐related causes, including tetanus. In 3 studies (1 RCT), a reduction in maternal sepsis was found. Although evidence is weak, the GRADE recommendation for clean practices at birth is strong as this is an accepted standard. Evidence from 3 studies including 1 RCT supports the role of CBKs in promoting clean birth practices, although in all cases there were co‐interventions. None of the studies in either review reported any adverse effects from interventions including a CBK, however, none explicitly stated that they had looked for negative effects.
  • Because infections present themselves not on the day of birth that in the days after, and families don’t always recognize the baby as sick until the infectin is very severe and typically don’t seek care for illnesses in very young babies, a community-based intervention is needed. Typically management of infections is part of a series of home-based postnatal care visits. June 2011 – Journal of health Population and Nutrition.
  • Need to Highlight SNL’s Role in this process 2) Can mention Situation Analysis result examples: Launch Tz sit analysis – Dept of Planning there and sent template to all districts for financial planning to include KMC and resus that year – need for technical support to continue to move forward – included in district budgets Every Death counts in South Africa led to Lancet South Africa series – led to agenda for new MOH
  • While the knowledge of what works is increasing, it only matters if it is applied on a wide scale. Critical to that is knowing how widely these interventions are being implemented.
  • The goal is to reduce mortality This required changing behaviors and use of services at scale This requires as an intermediate measure ensuring that health systems have integrated effective newborn health interventions The boxes at the bottom are how we see our inputs into the process. The box on the right is the most critical. Etc. This framework guides SNL’s evaluation strategy
  • Agreement on measurement of PNC coverage and content, newborn behaviors/practices, and facility care – national level – DHS and MICS4 and SPA and optional DHS newborn module Agreement on indicators to include on newborn at sub-national levels – ongoing process – looking at SNL data as well as other partners Next meeting – Oct 17, 18 – Todd Nitkin is member of group -
  • At least two newborn danger signs – including:
  • Kidal region with 4 districts not yet reached I clarified some questions on the Mali training tracker tool and asked the team to separate out the communes of Bamako as districts as this was confusing us (the previous listed 53 districts yet the 6 communes of Bamako are included when we say 59 districts).  In terms of interpreting the information, I have also received further clarity.   UNICEF has provided the funding for training and equipment for essential newborn care which has led to 2,042 health providers trained in 83% (880/1059) of Mali’s health areas.  Specifically Regional trainers trained in 8 out of 8 Regions District level staff trained in 49 out of 59 districts (83%) CSCom staff trained in 39 out of 59 districts nationally (8 regions) or 39 out of 44 districts (6 regions) originally targeted by SNL at the start of SNL2 (89%).    (Note:  to count the 39, I included on the districts where more than 10 people have been trained within a district because the smaller numbers from 1-4 are usually the district level trainers)
  • This slide shows the quantity of data were are currently collecting from our countries. Some of the results we expect to report on are coming from less rigorous research so we look forward in next year or so to perform a lot of analysis!


  • 1. What’s New for Newborns? Claudia S. Morrissey MD MPH Allisyn Moran PhD MHS Saving Newborn Lives CORE 14 October 2011
  • 2. Outline
    • Newborn Survival: A Decade of Progress
    • Evidence as a Driver of Progress
    • Measuring Progress
  • 3. Newborn Survival: A Decade of Progress
  • 4. Biggest News for Newborns
    • Deaths are going down!
      • 3.1 Million deaths in 2010
      • 28% decline in 2 decades
      • 358,000 maternal deaths
      • 34% decline
    Sources: UNICEF. Levels and Trends in Child Mortality: 2011 Report. NY: UNICEF; 2011. WHO. Trends in Maternal Mortality: 1990 to 2008. WHO; 2010
  • 5. Global progress to MDG 4 MDG 4 target (32) Ref: Lawn, Kerber et al BJOG 2009 updated with data for 2008 from UN Child Mortality Group, WHO//CHERG and IHME (Rajaratnam J eta l 2010) 3.1 million neonatal deaths, 41% of under 5 deaths Links closely with maternal health and MDG 5 USA NMR is 4
  • 6. A low-cost intervention that worked
    • 12/1999:
    • The Lancet publishes, “Effect of
    • home-based neonatal care and
    • management of sepsis on neonatal mortality: field trial in rural India ”
    • Home-based neonatal care reduced neonatal and infant mortality by nearly 50% among a malnourished, illiterate, rural study population
  • 7. A global commitment to act
    • 9/2000:
    • 8 UN Millennium Development Goals are endorsed by the majority of the world’s governments
    • MDG 4: Reduce by 2/3rds the mortality rate among children < 5
  • 8. A funder for newborn health initiatives
    • Fall/1999:
    • The Gates Foundation puts out an RFA focused on decreasing neonatal mortality and morbidity
  • 9. WHERE? Neonatal & maternal deaths 2.4 million neonatal deaths Approx 67% of global total 340,000 maternal deaths Approx 65% of global total Ref: Lawn JE et al BJOG sept 2009. Data sources: Estimates of maternal (2005) and neonatal (2008) deaths from WHO. Updated June 2010 Countries with the highest numbers of neonatal deaths are similar to those with high maternal deaths Ranking for numbers of neonatal deaths Ranking for numbers of maternal deaths India 1 1 Nigeria 2 2 Pakistan 3 8 China 4 13 DR Congo 5 3 Ethiopia 6 5 Bangladesh 7 6 Indonesia 8 7 Afghanistan 9 4 Tanzania 10 9
  • 10.
    • In sub Saharan Africa and South Asia:
      • more than half of births
      • the majority of neonatal deaths
    Where: At home
  • 11. Where: Among poorest Source: Countdown to 2015 Nigeria Country profile (2010); analysis by Joy Lawn
    • If all families in Nigeria got the same care as the richest families…
    • NMR would be halved
    • 127,000 newborns would be saved
  • 12. WHEN? The first days are critical Up to 50% of neonatal deaths occur in the first 24 hours Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths) 75% of neonatal deaths occur in the first week
  • 13. WHY? Causes of newborn deaths Three killers account for 81% of all neonatal deaths 3.1 million Source: CHERG/WHO 2010. Estimates for 193 countries for 2008. Black R et al Lancet 2010 UNICEF, State of the World's Children, 2011. Almost all deaths are due to preventable conditions
  • 14. Evidence: a Driver of Progress
  • 15. Intervention Packages Source: Lancet Neonatal Survival Series, 2005 Skilled obstetric and immediate newborn care including resuscitation Emergency obstetric care to manage complications such as obstructed labor and hemorrhage Antibiotics for preterm rupture of membranes # Corticosteroids for preterm labor # Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies Clinical care Folic acid # 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 home delivery Simple early newborn care 4-visit antenatal package including tetanus immunization, detection & management of syphilis, other infections, pre-eclampsia, etc Malaria intermittent presumptive therapy* Detection and treatment of bacteriuria # Outreach services Postnatal care to support healthy practices Early detection and referral of complications Infancy Neonatal period Pre- pregnancy Pregnancy Birth Antenatal 7-14% Reduction of NMR Intrapartum 19-34% Reduction of NMR Postnatal 10-27% Reduction of NMR
  • 16. Preventive Community-based newborn care packages Preventive + referral Preventive + management
  • 17. Generate New Evidence: SNL 1 The 36 research studies supported under SNL 1 built awareness that simple solutions for 3 killers could be feasibly delivered and have impact in low resource settings. Evidence for Joint Statement on PNC Home Visits Evidence for Joint Statement on PNC Home Visits Prevention + Management in India Prevention + Management in Bangladesh Prevention alone in India Prevention + Referral using Government model in Pakistan Ankur 2001-2005 Home-based newborn care (HBNC) replicated in 7 rural, urban and tribal districts 51% NMR Reduction Projahnmo 2001-2006 HBNC replicated in Sylhet district 34% NMR Reduction Shivgarh 2003-2006 HBNC with community mobilization and BCC only 54% NMR Reduction Hala 2003-2005 HBNC through existing CHW system (preventative care w/referral) 28% NMR Reduction in pilot areas
  • 18. SNL 2 Research: Overview
    • 28 Research Studies:
    • Cluster RCT (9), RCT (1), OR (12), Cohort (1), Policy (5)
    • Regions:
    • Asia (10), Africa (11), LAC (2), Global (5)
  • 19. SNL 2 Research Examples Outcomes Description Influence Infection Management RCT in Pakistan Postnatal Care Package OR in Bangladesh Integration of newborn care RCT in Uganda MNC & HIV Care RCT in South Africa Simplified Antibiotic Trial Testing if simplified antibiotic regimens are effective treatment for sepsis Treatment failure To modify global policy PNC Operations Research Testing existing cadres providing home visits to improve practices Coverage & Practices To inform MOH & partners how to deliver PNC in existing system and scale up UNEST Testing community-based package using volunteers linked to the health system Coverage & Practices To inform MOH how to scale up newborn care through health extension volunteers GOODSTART Testing govrn’t CHWs providing peer counseling at home to improve practices NMR, Coverage & Practices First study looking at integration of HIV/AIDS and ENC/PNC packages by CHWs and urban poor
  • 20. What s New to Address the 3 Killers?
    • In low resource settings:
    • Birth asphyxia:
    • Helping Babies Breathe
    • LBW/Preterm: Community KMC
    • Infection:
    • Community case management
  • 21. Source: Wall et al. Int J Gyn and Obstetr 2009; 107: s47-s64. Birth Asphyxia
  • 22. Birth Asphyxia: Impact of training facility providers in neonatal resuscitation
    • Training nurses, midwives, doctors in neonatal resuscitation
      • Meta-analysis of 6 before-after studies
      • All studies from middle-low-income countries
      • Results: 30% reduction in intrapartum neonatal deaths (range: 17% - 43%)
    Source: Wall et al. Int J Obstetr Gynaecol 2009;107:S47-64
  • 23. Birth asphyxia – Helping Babies Breathe SM
    • Simple color-coded Algorithm
    • Drying and wrapping
    • Assess breathing – if not breathing then,
    • Clear airway and stimulate – if not breathing then,
    • Ventilate until breathing (or no response after 10 – 15 min)
      • Developed by:
      • American Academy of Pediatrics with
      • Save the Children, USAID, ACCESS, NICHD,
      • WHO, & UNICEF
  • 24. Evidence for Preterm/Low Birthweight Babies
    • Facility-based Kangaroo Mother Care proven to reduce deaths in stable preterm newborns by 50%
    Sources: Lawn et al (2010) ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications. Int J Epidemiol: i1–i10.
  • 25. Cochrane Database of Systemic Reviews 2011, Conde-Agudelo A et al “ Compared with conventional neonatal care, KMC was found to reduce mortality at discharge.” KMC reduced severe infections, hypothermia, severe illness, and length of hospital stay KMC: What’s the evidence?
  • 26. Preterm/LBW: Community KMC
    • Large reduction (54%) in NMR of package including skin-to-skin care for all babies
    • Source: Kumar et al. Lancet 2008
    • Suggestion of mortality reduction for <2kg newborns
    • Source: Sloan et al. Pediatrics 2008
    • Program feasibility in Nepal
    • Source: Access, 2008
  • 27. Prevention of infections
    • Chlorhexidine to cord Evidence:
      • Nepal
      • Mullany et al. Lancet 2006
      • Bangladesh
      • Al Arifeen, in press
      • Pakistan
      • Bhutta, in press
      • Recent pooled analysis: chlorhexidine vs no chlorhexidine: 23% reduction in all cause mortality
      • Chlorhexidine Working Group, in press
      • 2 Ongoing trials in Africa
  • 28. Prevention of Infections
    • Clean Birth Practices
    • 30 published studies confirm benefit for babies
    • 3 studies suggest benefit for mothers
    • GRADE recommendation: strong
    • 3 studies support the role of CBKs
    • No adverse effects
    • Source: Clean Birth Kit Working Group
  • 29. Management of Infections
    • Community case management of neonatal pneumonia
    • – 27% reduction in all-cause neonatal mortality
    • Source: Sazawal and Black. Lancet Inf Dis 2003;3:547056
    • CHW identification and management of sepsis (injectables, oral/injectables)
      • SEARCH: (India) Sepsis CFR declined from 16.6% to 6.9%
      • Source: Bang et al. J Perinatol suppl 2005
      • Projahnmo (Bangladesh): Sepsis CFR 4.4% in CHW treated
      • Source: Baqui et al. PIDJ 2009
      • MINI (Nepal): Sepsis CFR 1.5% in those given cotrimoxazole by FCHVs and gent by CHWs at peripheral health centers (compared to 5.3% not treated)
      • Source: Khanal et al, JHPN 2011
  • 30. Management of Infections
    • Simplified Antibiotic Therapy Trial
      • Are simplified antibiotic regimens equivalent to WHO “gold standard” (14 injections)? - ongoing
        • Common protocol
          • Asia: Pakistan (SNL), Bangladesh (USAID)
          • Africa: Nigeria, Kenya, DRC (WHO)
  • 31. Translating Research & Data for Action Regional Opportunities for Africa’s Newborns ASADI Science in Action LAC Alliance Global Countdown to 2015 CHERG LiST UN Jt. Statement National Situation Analysis (15) Data Profiles
  • 32. III. Measuring Progress
  • 33. Overview
    • SNL Evaluation Strategy
    • Newborn Indicators TWG
    • Preliminary Findings
    • Lessons Learned
  • 34. SNL Pathway to Scale
  • 35. SNL Evaluation Strategy
    • SNL has a comprehensive evaluation strategy for programs and implementation research:
    • 39 core indicators collected at national and sub-national levels
      • NMR, Coverage, Behaviors, Practices
      • Availability of equipment, supplies, drugs
      • Quality of care
      • Demand for services
    • Document SNL contribution to Scale Up
      • Scale up Readiness Benchmarks
      • Policy timeline
      • Implementation tracker
      • Funding for newborn health
    • Secondary analyses to answer key implementation questions
  • 36. Newborn Indicators Technical Working Group
    • Representation from:
    • Objectives
      • Ensure consistent use of newborn health indicators
      • Provide in-depth instruments on newborn care
      • Advance the state-of-the-art in newborn care measurement by identifying priorities and opportunities to validate indicators
  • 37. SNL Household Surveys Country Design Dates Sample size Bangladesh (GO) Pre/Post Intervention / Comparison Baseline: 2008 Endline: 2010 Baseline: 788 Endline: 794 Nepal Pre/Post Baseline: 2008 Endline: 2011 Baseline: 630 Endline: 630 Indonesia Pre/Post Baseline: 2007/8 Endline: 2011 Baseline: 400 Endline: 400 Vietnam Pre/Post Intervention / Comparison Baseline: 2007 Endline: 2011 Baseline: 1,073 Endline: 1,050 Malawi Pre/Post Baseline: 2007 Endline: 2011 Baseline: 903 Endline: 900
  • 38. Preliminary Findings from SNL Household Surveys
  • 39. Skilled Birth Attendance *Statistically significant at p<.05
  • 40. Immediate Breastfeeding (within 1 hour of birth) *Statistically significant at p<.05
  • 41. Delayed Bathing (≥6 hours after birth) *Statistically significant at p<.05
  • 42. Knowledge of Newborn Danger Signs *Statistically significant at p<.05
  • 43. Preliminary Findings from Scale up Readiness Benchmarks
  • 44. Scale Up Readiness Benchmarks
    • Focus on “readiness” to implement newborn programs at scale
    • Benchmarks revised based on:
      • Technical input from experts
      • Consultation meeting in April 2011
      • Data collection and analysis
    • Ongoing verification of benchmarks
  • 45. Scale up Readiness Benchmarks SNL Countries 2000
  • 46. Scale up Readiness Benchmarks SNL Countries 2005
  • 47. Scale up Readiness Benchmarks SNL Countries 2010
  • 48.
    • Nationally endorsed Essential Newborn Care Package
      • SNL developed during SNL1; supported implementation under SNL2 with Government, UNICEF
    • Package rolled out at CSCom level in 6 of 8 regions and 39 of 59 districts (66%) and by MOH, support from SC and UNICEF
      • Regional trainers in all 8 regions
      • Trainers in 49 out 59 districts (83%) poised to train facilities
    • Total of 2042 facility-based health workers have been trained nationwide
    Implementation Tracker - Mali
  • 49. Segou Region
  • 50. Lessons Learned
    • Challenges of working within existing health systems
      • Malawi HSAs
    • Need for flexibility of newborn intervention packages with rapidly changing context
      • Increasing facility delivery
      • Incentive schemes
    • Need to understand the relationship between coverage and quality
      • What happens during home visits?
      • How does quality differ by place of delivery?
    • Progress in readiness to implement at scale in all SNL countries
  • 51. Thank you! Visit the Healthy Newborn Network www.healthynewbornnetwork.org
  • 52.  
  • 53. SNL Evaluation: Baselines & Endlines
    • Baseline assessments :
      • 14 household surveys
      • 6 health facility assessments
    • Adequacy surveys:
      • 2 in 2011and 2012 (Tanzania, Ethiopia)
    • Endline assessments:
      • 10 household surveys
        • 3 in 2010 (Bangladesh, Bolivia, Guatemala)
        • 5 in 2011 (Nepal, Malawi, Uganda, Indonesia, Vietnam)
        • 1 in 2012 (Tanzania – if funding secured)
        • 1 in 2013 (Ethiopia)
      • 5 health facility assessments
        • 2011(Nepal, Malawi, Uganda, Mali, Vietnam)
    Core indicators collected via baseline and endline evaluations:
  • 54. SNL Health Facility Assessments Country Design Components Dates Sample size Mali Endline only
    • Inventory of essential equipment/supplies
    • Provider knowledge/skills
    • Client exit interview
    2011 Hospitals: 4 First level facility: 40 Providers: 90 Clients: 280 Vietnam Pre/Post
    • Provider knowledge/skills in neonatal resuscitation
    Baseline: 2007 Endline: 2011 Providers at Baseline: 76 Providers at Endline: 86
  • 55. Follow up of resuscitated newborns in Indonesia using Bayleys scales (in press)
    • Methods : Infants between 24 and 36 months assessed according to the Bayley Scales of Infant and Toddler Development III adapted for Indonesia
    Cognitive impairment Language Motor Adaptive beh.
    • Results
    • Moderate/severe cognitive impairment higher in midwife-resuscitated newborns vs. non-asphyxiated newborns
    • Rate of moderate/severe impairment twice as high among hospital-resuscitated newborns vs. midwife-resuscitated newborns
    Social No statistical difference