This document discusses neonatal mortality measurement and summarizes recent developments. It covers: 1) Neonatal mortality rates can now be estimated annually through improved surveys, though data reliability remains a concern. Pregnancy history modules may better capture neonatal deaths. 2) Estimates of neonatal causes of death have been improved through increased country data, especially for large countries like India and China. Rates of infections and tetanus appear to be declining in some areas. 3) Surveys can be improved by modifying questions to better capture neonatal mortality and stillbirths, and through follow up verbal autopsies to obtain cause of death data for over 75% of neonatal deaths dependent on surveys.

1. Neonatal Mortality Measurement – what’s new? Joy Lawn Saving Newborn Lives / Save the Children

2. Outline Neonatal mortality rates Neonatal cause of death Improving neonatal mortality data in surveys With thanks to Colin Mathers et al at WHO and to Simon Cousens in CHERG

3. Availability of mortality estimates MICS surveys can estimate NMR but not powered to do so unless sample size is increased eg Malawi 2006 Child mortality Neonatal mortality Sources Vital registration, censuses, DHS, MICS, other surveys Vital registration, censuses, DHS, (MICS), other surveys Frequency of estimation Every year Every 10 years? (1996 for 1995, 2006 for 2000) Frequency of publication (SOWC) Every year In SOWC since 2007 but using 2000 estimates Methods transparency Expert review group, Increasingly transparent inputs and methods Previously no expert review Limited detail on methods

4. Led by WHO Dept of Information Evidence and Research, in with Child Health Epidemiology Reference Group (CHERG ) Expected annual cycle linked to UN child mortality estimates Methods have had expert review and adapt from: Previous WHO Making Pregnancy Safer methods (WHO 2006) IHME methods (Murray et al) 2007 Inputs include: Vital Registration data Survey data Regression model based on U5MR UN country estimates for 2008 New NMR estimates for 2008 Oestergen, Mathers et al WHO – work in progress Results to be released in World Statistics Report - May 2010 Separate methods paper and detailed results in preparation

5. Progress to MDG 4 for child survival Source: Graph Lawn JE et al 4 million neonatal deaths- where? When? Why? Lancet 2005. Data updated 2009 for progress until 2008 using UN data 3.59 million neonatal deaths each year around 42% of under-5 deaths 2004 2008 28 Target for MDG-4 (32)

6. 2. NEONATAL CAUSE OF DEATH

7. Invisible deaths…. Global estimates of causes of death for children under the age of 5 years country data in puts and Diarrhoea 20% Perinatal causes 22% Source: WHO and UNICEF under-5 causes of death estimates 2004 12% Other 29% HIV/AIDS 4% Malaria 8% Measles 5% ARI Malnutrition 54% Asphyxia Preterm Injuries Other Neonatal sepsis/ pneumonia Neonatal tetanus Congenital

8. Estimates of causes of neonatal death (year 2000) Lawn et al, Lancet 2005 WHO WHR 2005 Detailed methods: Lawn et al, IJE 2006 Bryce et al, Lancet 2005

9. Estimates of causes of neonatal death (year 2004) Countdown report 2008 – National level estimates New Countdown report to be released at Women Deliver and Countdown meeting June 2010

10. Sub-national estimates for cause of death eg Nigeria Neonatal tetanus nationally estimated at 8% and Northern zones at 17% Source: Saving Newborn Lives in Nigeria. FMOH Jan 2009 Estimates for 2005 by CHERG neonatal group

11. Neonatal cause of death for year 2008 Advancing the estimates MORE data inputs Vital registration up to mid 2009 Previously 46 countries – now 72 countries Total of ~130,000 neonatal deaths ( 4% of all neonatal deaths) Study datasets Revised systematic searches (>6,000 abstracts) and unpublished datasets Now 71 datasets, 23,638 deaths China and India – huge national datasets used instead of estimates 2. MORE detail for cause of death categories MORE detail by time for first week of life Source: Lawn JE, Cousens SN, Adler A, Ozi S for the CHERG neonatal group. DO NOT CITE Results to be released in World Statistics Report May 2010 Expected annual cycle – also in SOWC and Countdown Separate methods paper and detailed results in preparation

12. Causes of death in the neonatal period for 193 countries (2000-2008) Note not final : India and China own data yet to be added Source: Lawn JE, Cousens SN, Adler A, Ozi S for the CHERG neonatal group. DO NOT CITE Cause of death 2000 2004 2008 “ Asphyxia” 0.91 (23%) 0.91 (24%) 0.84 (24%) Congenital 0.30 ( 7%) 0.31 ( 8%) 0.33 ( 9%) Infection Sepsis Pneumonia 1.04 (26%) 0.94 (25%) 0.89 (25%) 0.55 0.33 Preterm 1.12 (28%) 1.23 (33%) 1.19 (33%) Diarrhoea 0.11 ( 3%) 0.07 ( 2%) 0.06 ( 2%) Tetanus 0.26 ( 6%) 0.10 ( 2.7%) 0.09 ( 2.5%) Other 0.26 ( 6%) 0.19 ( 4.9%) 0.19 ( 5.3%) Total 4.00 million 3.75 million 3.59 million

13. Beyond survival…. 3.2 million stillbirths. (Stanton, Lawn et al) ?? babies with major neonatal morbidity (birth asphyxia, preterm birth, infections, congenital, jaundice) 3.6 million neonatal deaths ?? Children/adults with poor development or disability due to fetal/neonatal ill-health 20 million LBW babies Up coming work from CHERG/Global Burden of Disease Estimates for morbidity and disability Also preterm birth and/or IUGR as a risk factor

14. 3. IMPROVING NEONATAL DATA IN SURVEYS

15. Survey data for neonatal mortality measurement Neonatal mortality data Module options Indirect question and Brass methodology (MICS) Birth history Pregnancy history Modifications (eg truncated pregnancy history) Neonatal cause of death data Follow up after survey with Verbal Autopsy Mortality data for 75% of neonatal deaths is dependent on household surveys Remarkably little evaluation… Stillbirths

16. Neonatal death data in DHS Heaping on certain days Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths) Heaping index for deaths on days 7, 14, 21 and 30/31 Age heaping on day 7 may reduce the early NMR Age heaping on day 30/31 may reduce the overall NMR

17. Age heaping index in 106 DHS surveys (Hill et al 2006) Source: Hill K et al 2006, Neonatal mortality in the developing world There seems to be regional variation – is this cultural or due to training of the interviewers?

18. (Maharashtra, India, Bang et al., 2002) NHFS II – 5 year recall SRS – ongoing data collection by local part-time enumerator with 6- monthly supervision visits Are deaths misclassified to another day or missing especially in retrospective surveys? Prospective surveillance NFHS II (recall) SRS NMR 51 32 (-38%) 29 (-43%) Postneonatal IMR 18 12 (-33%) 20 (+14%) Child (1-4) MR 14 15 (+ 6%) 14 (- 4%)

19. Conclusions Neonatal mortality measurement Annual NMR estimates likely altho process still not fully institutionalised... Data reliability is under-researched and concerns remain re underestimation in DHS/MICS Pregnancy history module would be expected to improve the neonatal death capture and also count stillbirths Neonatal cause of death Advances in country based neonatal estimates using programmatic cause categories Increasing data especially for large countries (India, China) Increasing comparability - 3 time points with consistent methods (2000, 2004 and 2008) and now should be annual Trends - definite reduction in neonatal tetanus and apparent reductions in infections in some regions/countries

20. Thank you!