Hearing the Unheard Cry: Pillars To Improve Newborn Survival

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)

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 Source: Lawn JE et al Lancet 2005 0 50 100 150 Mortality per 1000 births (global av) 1960 1980 2000 2020 Year Under-5 mortality rate Late neonatal mortality Early neonatal mortality Target for MDG-4

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 neonatal deaths 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)

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

Evidence-based interventions to reduce neonatal deaths Childhood Neonatal period Pre- pregnancy Pregnancy Birth Source: 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
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 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

GAP 1 GAP 2 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 3 rd year
Source: 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 mos
Source: 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 yrs
Source: Bhutta et al. Bulletin World Health Organ 2008;86:452-9

Content and timing of home visits: A summary of the evidence 30%
Prenatal counselling
Postnatal visits (newborn assessment, counselling, referral if needed)
Prenatal, Days 1, 3, 7, 14 and 28 Lady Health Worker (government paid) Hala (Pakistan) Source: Bhutta. Bull World Health Organ 2008 54%
Postnatal visits (counselling)
Prenatal, Days 1 and 3 Community health worker (paid), changed to community volunteers Shivgarh (India) Source: Kumar et al. Lancet 2008 34%
Postnatal visits (newborn assessment, counselling)
Treatment of newborn infection (if refused referral)
Prenatal, Days 1, 3, and 7 Community health worker (paid) Projahnmo (Bangladesh) Source: Baqui et al. Lancet 2008 51%
Care at birth (resuscitation)
Postnatal visits (care & counselling)
Infection management
LBW care (extra visits)
Prenatal, Delivery, Days 1, 2, 3, 5, 7, 14, 21 and 28 Community health worker (paid, plus performance incentives) ANKUR (India) Source: Bang et al. Unpublished 61%
Care at birth (resuscitation)
Postnatal visit (care & counselling)
Infection management
LBW care (extra visits)
Prenatal, Delivery, Days 1, 2, 3, 5, 7, 14, 21 and 28 Community health worker (paid. Plus performance incentives) SEARCH (India) Source: Bang et al. Lancet 1999 ↓ NMR Content of home visits Home visits for newborn care on Provider Study

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: 1 st visit within 24 hours; additional visit on day 3 (or after hospital discharge); if possible on day 7.

Thank you!

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Hearing the Unheard Cry: Pillars To Improve Newborn Survival

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