Steve Wall, Saving Newborn Lives


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Steve Wall, Saving Newborn Lives

  1. 1. 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  
  2. 2.      Outline  I.  Do community-based newborn healthpackages work?II.  What specific high impact interventions areeffective and feasible in low income settings?III. What should be the research agenda forfuture newborn survival and health?
  3. 3. 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    
  4. 4. SEARCH: Community interventions save NB lives-2NMR  reduced  by  62%  (in  3rd  year  (Bang,  Lancet  1999)  
  5. 5. Evidence:  CB  interven4ons  reduce  newborn  deaths  Replication ofSEARCH in IndiaReplication inBangladeshPreventative carealone in IndiaGovernment modelin PakistanAnkur2001-2005Home-based newborncare (HBNC)replicated in 7 rural,urban and tribaldistricts51% NMR Reduction(Unpublished)Projahnmo2001-2006HBNC replicated inSylhet district34% NMR ReductionBaqui. Lancet 2008Shivgarh2003-2006HBNC withcommunitymobilization and BCConly54% NMR ReductionKumar. Lancet 2008, Hala2003-2005HBNC throughexisting CHW system(preventative care w/referral)30% NMR Reductionin pilot areasBhutta. Bull WHO.2008The 36 research studies supported under SNL 1 builtawareness that simple solutions for 3 killers could be feasiblydelivered and have impact in low resource settings.
  6. 6. 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)    
  7. 7. Evidence:    Impact  of  program  implementa9on  of  JS  Projahnmo 2(Bangladesh)Hala 2(Pakistan)Haryana(India)Newhints(Ghana)Mirzapur:Replication ofProjahnmo 1CHW pregnancy and2 postnatal homevisits; referral13% NMR Reduction(NS)Darmstadt. PLoS One2010Replicaion & scale upof Hala 1Lady Health Workerhome visits andcommunity groupcounseling; referral15% NMR ReductionBhutta. Lancet 2011;377IMNCI program inrural India districtCHW home visits;physicians and nursestrained in IMNCI9% NMR Reduction(NS)Bhandari. BMJ 2012Replication of AsiaCHW home visitpackageVolunteer CHWscounseling at homevisits; referral8% NMR Reduction(NS)Kirkwood. Lancet2013Meta-analysis suggests 12% reduction in NMR when CHWhome visiting is implemented in actual programs .
  8. 8. Corticosteroids (in preterm labor) – to preventlung disease/death– Mothers in preterm labor or medically indicatedpreterm delivery (eg, pre-eclampsia)– Effectiveness•  LiST review: in MIC, 53% reduction in pretermmortality 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 newborndeaths per yearDeaths due to Preterm Birth: How to prevent
  9. 9. Preterm Birth: ManagementFacility-based KMC for LBW newborn•  In LIC-MIC, 51% reduction in neonatal mortality forbabies less than 2kg•  Source: Lawn et al. Int J Epi 2010.•  Major reduction in morbidities among LBWnewborns (eg, pneumonia, low weight gain, length ofhospital stay)–  Source: Conde-Agudelo et al. Cochrane Reviews 2003•  Coverage in LIC remains low
  10. 10. 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.  
  11. 11. •  Simple color-coded algorithm(The Golden Minute™)(1)  Drying and wrapping/skin-to-skin(2) Assess breathing – if not breathingthen,(3) Clear airway and stimulate – if notbreathing then,(4)Ventilate until breathing (or noresponse after 10 – 15 min)* Developed by American Academy of Pediatrics incollaboration with Save the Children, USAID,ACCESS, NICHD,WHO, & UNICEFSimplified  Resuscita9on  :    Helping  Babies  Breathe    
  12. 12. Neonatal infections -- Chlorhexidine•  Researchers hypothesized that7.1% chlorhexidine digluconatecleansing of the cord wouldreduce neonatal mortalitycompared to dry cord care.•  3 cluster-randomized controlledtrials:–  Nepal (2006): Mullany et al. Lancet2006:367:910–  Bangladesh (2012):Al Arifeen et al. LancetFeb 2012: DOI: 10.1016/S01406736(11)61848-5–  Pakistan (2012): Soofi et al. Lancet Feb2012: DOI: 10.1016/S01406736(11)61877-1
  13. 13. Chlorhexidine Impact on All-Cause Neonatal MortalityMORTALITY: Any CHX vs. No CHX StudyOverall 0.77 (0.63, 0.94)RR (95% CI)RR (95% CI)1.5 .75 1.2Nepal 0.76 (0.58, 1.00)Bangladesh 0.88 (0.74, 1.04)Pakistan 0.62 (0.45, 0.85)MORTALITY: Any CHX vs. No CHX 23% reduction in mortalityamong those receivingintervention In  press.  
  14. 14. 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 sepsisreduced CFR from 16.6% to 6.9%Source: Bang et al. J Perinatol suppl 2005–  Projahnmo (Bangladesh): Sepsis CFR 4.4% in CHW-treatednewborns with “very severe disease”Source: Baqui et al. PIDJ 2009–  MINI (Nepal): Sepsis CFR 1.5% in CHW-treated newborns withPSBISource: Khanal et al, JHPN 2011
  15. 15. Neonatal Infection -- Lessons Learned About Care Seeking•  Care seeking for newborn illness: families arewilling to bring sick newborns to health posts/centers for treatment – requires awareness ofproblem and available solution (commodities andquality services)•  Linkage to maternal health and survival –pervasive and deep community concern aboutmaternal survival communities providesopportunity to improve newborn care practicesand care seeking
  16. 16. Packaging Evidence: Focus on Major Killers andEvidence-Based Intervention Packages  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)3  main  causes  of  neonatal  death:  •           Asphyxia  •           Prematurity/Low  birth  weight  •           Infec9on    
  17. 17. Innovations – current SNL investigation•  Simplified antibiotic regimens (multi-centerstudies in Asia and Africa)§  Simple FHR monitor and mobile-basedperinatal death audit (Uganda)§  “Upright” bag and mask resuscitation deviceto enable more effective ventilation (India)
  18. 18. ConclusionsØ There is solid evidence of what simple interventions can savenewborn 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 andmaternal interventions and delivery strategies.Ø As we move forward to implement, we need to learn HOW todeliver these interventions effectively at scale.
  19. 19. Much to learn and share. . . to save newborn lives.Thanks!