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tribal only referral) districts 30% NMR Reduction51% NMR Reduction 34% NMR Reduction 54% NMR Reduction in pilot areas(Unpublished) Baqui.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!