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 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?
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 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PakistanAnkur2001-2005Home-based newborncare (HBNC)replicated in 7 rural,urban and tribaldistricts51% NMR Reduction(Unpublished)Projahnmo2001-2006HBNC replicated inSylhet district34% NMR ReductionBaqui.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.
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(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 .
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
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
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.
• 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
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
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.
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
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
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
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)
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.
Much to learn and share. . . to save newborn lives.Thanks!