counting every stillbirth, maternal and newborn death … · counting every stillbirth, maternal...

Counting every stillbirth, maternal

and newborn death and making

them count:

INDEPTH INTERNATIONAL

SCIENTIFIC CONFERENCE

2013

INDEPTHSCIENTIFIC CONFERENCE

them count: opportunities for the INDEPTH Network

By Peter Waiswa

Makerere University School of Public Health

Iganga-Mayuge HDSS

Newborn Working Group Leader

Acknowledgement

• Prof Joy Lawn – LSHTM and Save the Children,

USA

• Kate Kerber – Save the Children, USA



2013


Outline

1. Background on working group

2. Why are 3 million newborns dying

each year?

3. What are the major priorities for



2013



addressing this burden?

4. What is the potential role for the

INDEPTH newborn working group?

The Maternal and Newborn WG

Goal: To provide evidence to inform

policy and programs for newborn

survival in low and middle income

countries.

Objectives:

•Develop and implement a newborn



2013


•Develop and implement a newborn

research agenda

•Track pregnancies and their outcomes

for the mother and foetus and provide

actual data driven evidence

Update on working group• Born 2010 with 10 initial HDSS

centres

• In July 2013 Ho, Ghana workshopwe had 22 sites

• About 18 sites have sent us theirmaternal and newborn data formanuscripts being written



2013


maternal and newborn data formanuscripts being written

• INDEPTH guidelines requirepregnancy tracking for all sitesmeaning all sites should bemembers

Outline



each year?




2013






No woman should die giving birth

No child conceived or born to die



2013


2.9 million die280,000 die 3 million die2.6 million die

3.5 million within a few days of birth

10 million deaths

Global progress for reducing maternal, newborn and

child deaths has accelerated with the MDGs

Average rate

reduction

1990-2010

Maternal mortality ratio 4.2%

Children aged 1- 59 months 2.5%

Neonatal mortality 1.8%



2013


Source: Lawn J,E. et al. 2012. Newborn survival: a multi-country analysis of a decade of change. Health Policy and Planning.

27(Suppl. 3): iii6-ii28. Data sources: UNICEF 2011 www.childinfo.org , UN MMR estimates 2012

Neonatal mortality (newborn, first 4 weeks after birth)

1.8%

Stillbirths

(last 3 months of pregnancy)

1.0%

(1995-2009)

At least 30%

slower for

newborn survival

8

60

70

80

90

100

U5M current trajectory: ARR 2.5%

• MDG 4 achieved in 2035

• 4 million deaths annually in 2035U5M ARR 5.2%

• 2 million deaths by 2035

• Every country reaches

20/1000 Many countries

below 15/10006 m deaths in 2011

Absolute target by 2035 for A Promise Renewed

Under 5 mortality = 20/1000Mortality rate (per

1,000 live births)

9.6 mm deaths

in 2000



2013


0

10

20

30

40

50

1990 1995 2000 2005 2010 2015 2020 2025 2030 2035

MDG 4

Source: UNICEF State of the World’s Children 2012; The UN Inter-agency Group for Child Mortality Estimation, Levels and Trends in Child Mortality: Report

2011, 2011; Team analysis from 2035 onward based on straight-line ARR reduction from UNICEF numbers 1990-2035

NMR current trajectory

of ARR 2.2%

9Unless we achieve major acceleration for newborn survival, we cannot

reach our goal for ending preventable child deaths by 2035

Unless we achieve major acceleration for newborn survival, we cannot

reach our goal for ending preventable child deaths by 2035

30

35

40

45

50

Ne

on

ata

l mo

rta

lity

ra

te (

pe

r 1

,00

0 l

ive

bir

ths)

Years needed for each region to reach current industrialized region NMR (=3) based on

regional average rate of reduction (ARR) from 2000-2011

Latin America/Caribbean

Year: 2039

CEE/CIS

Year: 2039

East Asia/Pacific

Year: 2038

When will every newborn have the same survival chance as

those in the richest countries?

Over 100 YEARS FOR SOUTH

ASIAN AND AFRICAN

NEWBORNS… Three times longer than the

same change took rich countries

a century before,

despite new interventions

Over 100 YEARS FOR SOUTH

ASIAN AND AFRICAN

NEWBORNS… Three times longer than the

same change took rich countries

a century before,

despite new interventions



2013


0

5

10

15

20

25

1990 2000 2010 2020 2030 2040 2050 2060 2070 2080 2090 2100 2110 2120 2130 2140 2150 2160

Ne

on

ata

l mo

rta

lity

ra

te (

pe

r 1

,00

0 l

ive

bir

ths)

Sub-Saharan Africa

Year: 2155

South Asia

Year: 2125

Middle East/North Africa

Year: 2082

despite new interventionsdespite new interventions

1

0

Do stillbirths count? Country variation in stillbirth rates

10 countries account for

66% of the world’s

stillbirths – and also 66%

of neonatal deaths and

over 60% of maternal

deaths

~1 million third

trimester stillbirths

each year

If high-income

country stillbirth



2013

INDEPTHSCIENTIFIC CONFERENCESource: Lawn JE, Blencowe H, Pattinson R, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: Where? When? Why? How to

make the data count? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62187-3.

1. India

2. Pakistan

3. Nigeria

4. China

5. Bangladesh

6. Dem Rep Congo

7. Ethiopia

8. Indonesia

9. Tanzania

10. Afghanistan

country stillbirth

definitions (second

and third trimester)

are used, this

number may be

40% higher

98% of stillbirths occur in low-income and middle-income countries –

more than two thirds are in rural families.

43%

Neonatal cause of death

We now know the causes and timing3 main killers of

newborns are known

and addressable :

1. Preterm birth

complications

2. Intrapartum-

related



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43%

Source :CHERG and WHO, Liu et al. 2012. Global, regional and national causes of child mortality in 2000-2010.The Lancet.

DOI:10.1016/SO140-60560-1.

1

related

3. Severe infections

One-third of newborn deaths take place on the

day of birth

Outline



each year?




2013






Newborn survival solutions:

3 x 2 +11. Preterm complications

1. Prevention of complications: Management of preterm labour and ACS

2. Management: KMC, preterm care

2. Severe infections: pneumonia/sepsis/meningitis/tetanus

1. Prevention: tetanus toxoid immunization, clean delivery, cord care including chlorhexidine, handwashing, breastfeeding, hygiene promotion

2. Management: antibiotics, supportive care



2013


2. Management: antibiotics, supportive care

3. Intrapartum-related complications

1. Prevention: Quality obstetric care and labour monitoring

2. Management: Stimulation/resuscitation if not breathing at birth

+1 Essential newborn care

• Hygiene, warmth, immediate/exclusive breastfeeding

• Demand gaps at household level

• Supply gaps at health facility level

Data gaps for stillbirths and

maternal and newborn deathsData collection gap

• Most deaths are uncounted, up to half occur

at home

• Globally 75% of child death data comes from

Demographic & Health Survey data –

unreliable for stillbirth rates



2013


unreliable for stillbirth rates

Data consistency gap

• Definition confusion

• Multiple cause of death classification systems

• Lack of consistency in attributing cause of

death

• Rate and cause estimates not routinely being

done

Outline



each year?




2013





INDEPTH newborn working

group?

Pregnancy surveillance • Early registration

• Gestational age: SGA and preterm birth

• SB and neonatal death misclassification

• Intrapartum SB and early NND



2013


Role for INDEPTH sites to feed in to global estimates,

help understand determinants, test and improve tools, collection

systems, encourage local use of data for planning and action

Cause of death• Standard verbal autopsy tools and hierarchies

• Underlying factors: social autopsy

Coverage of care and household behaviours

DEVELOPMENT & DELIVERY RESEARCH – testing

known interventions and packages

• Home visit package for newborn care (Iganga-

Mayuge, Kintampo, ICCDRB)

• mHealth – verbal autopsy and linked facility

mortality audit



2013


mortality audit

• Costing interventions and service delivery

DISCOVERY – basic science

• Preterm birth prevention?

Ready-to-go business case required for how

INDEPTH sites can help fill these gaps

Some of our next steps

• Standardise analysis plan across sites and reanalyse existing newborn data (Friday and Saturday this week)

• Submit publication on multi-site findings as well as individual site write-ups

• Present results



2013


• Present results• Several in and outside the country and INDEPTH Network

fora

• Engage with the global newborn health community

• Find funding

Summary

• An estimated 280000 maternal deaths, 3 million newborn deaths and 2.6 million stillbirths occur each year. We have moredata now, but INDEPTH can help make it better.

• Clear role for INDEPTH – particularly in



2013


• Clear role for INDEPTH – particularly in description and delivery research

• We invite sites and donors to come on board so we inform the world and develop solutions

Acknowledgement

• We thank the Gates funded SavingNewborn Lives Program and INDEPTHNetwork (which has funded us twice)andMRC South Africa which is funding a postconference meeting 1st and 2nd November2013

• Makerere University Iganga-Mayuge HDSS



2013


• Makerere University Iganga-Mayuge HDSS

Which coordinates the Newborn Working

Group



2013


Thank you!Thank you!

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