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Newborn survival and perinatal health in resource-constrained settings in Asia and the Pacific: Applying Global Evidence to Priorities Beyond 2015

Newborn survival and perinatal health in resource-constrained settings in Asia and the Pacific: Applying Global Evidence to Priorities Beyond 2015
12 April 2013

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    Steve Wall, Saving Newborn Lives Steve Wall, Saving Newborn Lives Presentation Transcript

    • Save the Children – Saving Newborn Lives Lessons  learned:  low-­‐cost  feasible  interven4ons  for  newborn  survival  and  how   to  integrate  them  into  programs    Stephen  Wall   Melbourne  Australia   April  12,  2013  
    •      Outline   I.  Do community-based newborn health packages work? II.  What specific high impact interventions are effective and feasible in low income settings? III.  What should be the research agenda for future newborn survival and health?
    • SEARCH: Community interventions save NB livesHBNC  package:     Ø CHW  pregnancy   surveillance,  2    ANC   counseling  visits   Ø Delivery  care  (including   neo  resus)  by  trained   TBA  &  CHW   Ø 8  postnatal  visits  by   CHW   Ø Extra  CHW  visits  &  care   of  <2kg  babies   Ø CHW  dx  &  tx  of  sepsis:   oral  cotrimoxazole  +  IM   gentamicin    
    • SEARCH: Community interventions save NB lives-2NMR  reduced  by  62%  (in  3rd  year  (Bang,  Lancet  1999)  
    • Evidence:  CB  interven4ons  reduce  newborn  deaths   Replication of Replication in Preventative care Government model SEARCH in India Bangladesh alone in India in Pakistan Ankur Projahnmo Shivgarh , Hala 2001-2005 2001-2006 2003-2006 2003-2005Home-based newborn HBNC replicated in HBNC with HBNC through care (HBNC) Sylhet district community existing CHW system replicated in 7 rural, mobilization and BCC (preventative care w/ urban and tribal only referral) districts 30% NMR Reduction51% NMR Reduction 34% NMR Reduction 54% NMR Reduction in pilot areas(Unpublished) Baqui. Lancet 2008 Kumar. Lancet 2008 Bhutta. Bull WHO. 2008 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 to policyPosi9ves  Ø Spurred  many  countries   and  donors  to  take  ac4on   for  newborn  survival   Ø Country  policies   Ø Programs   (government  &  NGO)  Nega9ves  Ø  Based  on  “efficacy”   instead  of  “effec4veness”   evidence  Ø  Li_le  a_en4on  to  mother  Ø  No  implementa4on  tools   (eg,  training,  supervision,   monitoring  systems,   logis4cs  management)    
    • Evidence:    Impact  of  program  implementa9on  of  JS   Projahnmo 2 Hala 2 Haryana Newhints (Bangladesh) (Pakistan) (India) (Ghana)Mirzapur: Replicaion & scale up IMNCI program in Replication of AsiaReplication of of Hala 1 rural India district CHW home visitProjahnmo 1 package Lady Health Worker CHW home visits;CHW pregnancy and home visits and physicians and nurses Volunteer CHWs2 postnatal home community group trained in IMNCI counseling at homevisits; referral counseling; referral visits; referral13% NMR Reduction 15% NMR Reduction 9% NMR Reduction 8% NMR Reduction(NS) (NS) (NS)Darmstadt. PLoS One Bhutta. Lancet 2011; Bhandari. BMJ 2012 Kirkwood. Lancet2010 377 2013 Meta-analysis suggests 12% reduction in NMR when CHW home visiting is implemented in actual programs .
    • Deaths due to Preterm Birth: How to preventCorticosteroids (in preterm labor) – to prevent lung disease/death –  Mothers in preterm labor or medically indicated preterm delivery (eg, pre-eclampsia) –  Effectiveness •  LiST review: in MIC, 53% reduction in preterm mortality in MIC, 37% morbidity reduction (Source: Lawn et al. Int J Epi 39 (2010); i144. –  Coverage: <10% in LIC-MIC –  Achieving high coverage (first level health facilities, district hospitals) would avert 500,000 newborn deaths per year
    • Preterm Birth: ManagementFacility-based KMC for LBW newborn•  In LIC-MIC, 51% reduction in neonatal mortality for babies less than 2kg•  Source: Lawn et al. Int J Epi 2010.•  Major reduction in morbidities among LBW newborns (eg, pneumonia, low weight gain, length of hospital stay) –  Source: Conde-Agudelo et al. Cochrane Reviews 2003•  Coverage in LIC remains low
    • Birth  Asphyxia  –  Neonatal  Resuscita9on    Can  neonatal  resuscita4on  be  effec4vely  provided  in  low  resource  se`ngs?    •  Indonesia:  40%  reduc4on  in   overall  crude  all-­‐cause  NMR   by  including  neo  resus   training,  simple  resus   device,  and  suppor4ve   supervision  for    community   midwife  training  Source:    Wall  et  al.  Int  J  Gynel  Obstet  107  (2009);  S47.  
    • Simplified  Resuscita9on  :    Helping  Babies  Breathe    •  Simple color-coded algorithm (The Golden Minute™) (1)  Drying and wrapping/skin-to-skin (2) Assess breathing – if not breathing then, (3) Clear airway and stimulate – if not breathing then, (4) Ventilate until breathing (or no response after 10 – 15 min)* Developed by American Academy of Pediatrics in collaboration with Save the Children, USAID, ACCESS, NICHD, WHO, & UNICEF
    • Neonatal infections -- Chlorhexidine•  Researchers hypothesized that 7.1% chlorhexidine digluconate cleansing of the cord would reduce neonatal mortality compared to dry cord care.•  3 cluster-randomized controlled trials: –  Nepal (2006): Mullany et al. Lancet 2006:367:910 –  Bangladesh (2012): Al Arifeen et al. Lancet Feb 2012: DOI: 10.1016/S01406736(11) 61848-5 –  Pakistan (2012): Soofi et al. Lancet Feb 2012: DOI: 10.1016/ S01406736(11)61877-1
    • Chlorhexidine Impact on All-Cause Neonatal Mortality MORTALITY: Any CHX vs. No CHX MORTALITY: Any CHX vs. No CHX Study RR (95% CI) 23% reduction in mortalityNepal 0.76 (0.58, 1.00)Bangladesh 0.88 (0.74, 1.04)Pakistan among those receiving 0.85) 0.62 (0.45,Overall intervention 0.77 (0.63, 0.94) .5 .75 1 1.2In  press.  
    • Neonatal Infections – CB ManagementCHW identification and management of sepsis,:§  Simple diagnostic algorithms (pictorial)§  Injectable or oral/injectable antibiotic regimens –  SEARCH: (India) CHW treatment of presumed newborn sepsis reduced CFR from 16.6% to 6.9% Source: Bang et al. J Perinatol suppl 2005 –  Projahnmo (Bangladesh): Sepsis CFR 4.4% in CHW-treated newborns with “very severe disease” Source: Baqui et al. PIDJ 2009 –  MINI (Nepal): Sepsis CFR 1.5% in CHW-treated newborns with PSBI Source: Khanal et al, JHPN 2011
    • Neonatal Infection -- Lessons Learned About Care Seeking •  Care seeking for newborn illness: families are willing to bring sick newborns to health posts/ centers for treatment – requires awareness of problem and available solution (commodities and quality services) •  Linkage to maternal health and survival – pervasive and deep community concern about maternal survival communities provides opportunity to improve newborn care practices and care seeking
    • Packaging Evidence: Focus on Major Killers and Evidence-Based Intervention Packages3  main  causes  of  neonatal  death:  •           Asphyxia  •           Prematurity/Low  birth  weight  •           Infec9on      Evidence-­‐based  interven9on  packages:  •  Basic  newborn  care  -­‐  Hygiene,  warmth,  breas1eeding,  cord  care  •  Asphyxia:     –  Preven9on:    Quality  obstetric  care  and  labor  monitoring   –  Treatment:    S9mula9on/resuscita9on  (“Helping  Babies  Breathe”)    •  Prematurity/low  birth  weight:   –  Steroids  to  mother  during  premature  labor   –  Kangaroo  Mother  Care    •  Infec9on   –  Preven9on:    clean  delivery,  cord  care,  handwashing,  breas1eeding;  chlorhexidine   –  Detec9on  and  treatment:    an9bio9cs  (including  at  community  level)
    • Innovations – current SNL investigation•  Simplified antibiotic regimens (multi-center studies in Asia and Africa)§  Simple FHR monitor and mobile-based perinatal death audit (Uganda)§  “Upright” bag and mask resuscitation device to enable more effective ventilation (India)
    • ConclusionsØ  There is solid evidence of what simple interventions can save newborn lives, averting most of the world’s neonatal deaths.Ø  Intervention effectiveness requires strong implementation (availability of services, commodities; care seeking)Ø  We must modify and adapt interventions to the (rapidly) changing contexts – focus on referrals, quality of facility care, linking facilities to communities, and integrating newborn and maternal interventions and delivery strategies.Ø  As we move forward to implement, we need to learn HOW to deliver these interventions effectively at scale.
    • Much to learn and share. . . to save newborn lives.Thanks!