Claudia S. Morrissey MD MPHClaudia S. Morrissey MD MPH
Allisyn Moran PhD MHS Allisyn Moran PhD MHS
Saving Newborn LivesSaving Newborn Lives
What’s New for Newborns?
CORE 14 October CORE 14 October 20112011
Outline
I. Newborn Survival: A Decade of Progress
II. Evidence as a Driver of Progress
III.Measuring Progress
Newborn Survival: A Decade ofProgress
Biggest News for Newborns
Deaths are going down!
3.1 Million deaths in 2010
28% decline in 2 decades
358,000 maternal deaths
34% decline
Sources: UNICEF. Levels and Trends in Child Mortality: 2011 Report. NY: UNICEF; 2011. WHO. Trends in Maternal Mortality: 1990 to 2008. WHO; 2010
Global progress to MDG 4
MDG 4 target (32)
Ref: Lawn, Kerber et al BJOG 2009 updated with data for 2008 from UN Child Mortality Group, WHO//CHERG and IHME (Rajaratnam J eta l 2010)
3.1 million neonatal deaths, 41% of under 5 deaths Links closely with maternal health and MDG 5
USA NMR is 4
A low-cost intervention that worked
12/1999:
• The Lancet publishes, “Effect ofhome-based neonatal care andmanagement of sepsis on neonatal mortality: field trial in rural India”
• Home-based neonatal care reduced neonatal and infant mortality by nearly 50% among a malnourished, illiterate, rural study population
A global commitment to act
9/2000:
• 8 UN Millennium Development Goals are endorsed by the majority of the world’s governments
• MDG 4: Reduce by 2/3rds the mortality rate among children < 5
A funder for newborn health initiatives
Fall/1999:
• The Gates Foundation puts out an RFA focused on decreasing neonatal mortality and morbidity
WHERE? Neonatal & maternal deaths
Ranking for numbers of neonatal deaths
Ranking for numbers of maternal
deaths
India 1 1
Nigeria 2 2
Pakistan 3 8
China 4 13
DR Congo 5 3
Ethiopia 6 5
Bangladesh 7 6
Indonesia 8 7
Afghanistan 9 4
Tanzania 10 9
2.4 million neonatal deaths
Approx 67% of global total
340,000 maternal deaths
Approx 65% of global total
Ref: Lawn JE et al BJOG sept 2009. Data sources: Estimates of maternal (2005) and neonatal (2008) deaths from WHO. Updated June 2010
Countries with the highest numbers of neonatal deaths are similar to those with high maternal deaths
• In sub Saharan Africa and South Asia:
– more than half of births
– the majority of neonatal deaths
Where: At home
Where: Among poorest
Source: Countdown to 2015 Nigeria Country profile (2010); analysis by Joy Lawn
If all families in Nigeria got the same care as the richest families…
• NMR would be halved
• 127,000 newborns would be saved
WHEN? The first days are critical
Up to 50% of neonatal
deaths occur in the first 24 hours
Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths)
75% of neonatal deaths occur in
the first week
WHY? Causes of newborn deaths
Three killers
account for 81% of
all neonatal deaths
3.1 million
Source: CHERG/WHO 2010. Estimates for 193 countries for 2008. Black R et al Lancet 2010 UNICEF, State of the World's Children, 2011.
Almost all deaths are due to preventable conditions
Evidence: a Driver of Progress
Skilled obstetric and immediate newborn care including resuscitation
Emergency obstetric care to manage complications such as obstructed labor and hemorrhage
Antibiotics for preterm rupture of membranes#
Corticosteroids for preterm labor#
Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies
Clin
ical
ca
re
Folic acid #
Counseling and preparation for newborn care and breastfeeding, emergency preparedness
Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care
Extra care of low birth weight babies
Case management for pneumonia
Fam
ily-c
omm
unity Clean home delivery
Simple early newborn care
4-visit antenatal package including tetanus immunization,detection & management of syphilis, other infections, pre-eclampsia, etc
Malaria intermittent presumptive therapy*
Detection and treatment of bacteriuria#
Out
rea
ch
serv
ices
Postnatal care to support healthy practices
Early detection and referral of complications
InfancyNeonatal periodPre- pregnancy PregnancyBirth
Antenatal
7-14%
Reduction
of NMR
Intrapartum
19-34%
Reduction
of NMR
Postnatal
10-27%
Reduction
of NMR
Intervention PackagesSource: Lancet Neonatal Survival Series, 2005
Preventive
Community-based newborn care packages
Preventive + referral
Preventive + management
Generate New Evidence: SNL 1Prevention +
Management in India
Prevention + Management in
Bangladesh
Prevention alone in India
Prevention + Referral using Government
model in Pakistan
Ankur 2001-2005
Home-based newborn care
(HBNC) replicated in 7 rural, urban
and tribal districts
51% NMR Reduction
Projahnmo 2001-2006
HBNC replicated in Sylhet district
34% NMR Reduction
Shivgarh 2003-2006
HBNC with community
mobilization and BCC only
54% NMR Reduction
Hala2003-2005
HBNC through existing CHW
system (preventative
care w/referral)
28% NMR Reduction in pilot
areasThe 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 for Joint Statement on PNC
Home Visits
Evidence for Joint Statement on PNC
Home Visits
SNL 2 Research: OverviewEfficacy Integration
community level
Integration 1st
level facility
Costing
Top
ic
CHX to the cord Simplified
Antibiotic
regimen
Long term effects
of newborn
resuscitation
Packages of interventions
delivered at home
ENC or PNC
integration
Intervention costs
(to take to scale)
Coverage and practices (all) Cost (all);
NMR (subset) CEA (subset)
Cou
ntri
es
Bangladesh Pakistan Indonesia Bangladesh, Ethiopia, Ghana,
Malawi, Mozambique, Mali,
Nepal, Pakistan, S. Africa,
Tanzania, Uganda
Indonesia (Garut),
Vietnam, Bolivia,
Guatemala
Ethiopia, Ghana,
Indonesia (Garut),
Malawi, Mali, S. Africa,
Tanzania, Uganda,
Pakistan, Nepal
Coverage and practices
Effectiveness/
Equivalence
Out
com
es
Omphalitis, NMR Treatment
failure
Developmental
outcomes
(morbidity)
28 Research Studies: Cluster RCT (9), RCT (1), OR (12), Cohort (1), Policy (5)
Regions: Asia (10), Africa (11), LAC (2), Global (5)
SNL 2 Research ExamplesInfection
Management RCT in
Pakistan
Postnatal Care Package OR in
Bangladesh
Integration of newborn care RCT in Uganda
MNC & HIV Care RCT in South Africa
Simplified Antibiotic Trial
Testing if simplified antibiotic
regimens are effective
treatment for sepsis
Treatment failure
To modify global policy
PNC Operations Research
Testing existing cadres providing
home visits to improve practices
Coverage & Practices
To inform MOH & partners how to deliver PNC in
existing system and scale up
UNEST
Testing community-based package using volunteers linked to the health system
Coverage & Practices
To inform MOH how to scale up newborn care through health extension volunteers
GOODSTART
Testing govrn’t CHWs providing
peer counseling at home to improve
practices
NMR, Coverage & Practices
First study looking at integration of
HIV/AIDS and ENC/PNC packages by CHWs and urban
poor
Ou
tcom
es
Descri
pti
on
Infl
uen
ce
What s New to Address the 3 Killers?
In low resource settings:
• Birth asphyxia: Helping Babies Breathe
• LBW/Preterm: Community KMC
• Infection: Community case management
Source: Wall et al. Int J Gyn and Obstetr 2009; 107: s47-s64.
Birth Asphyxia
Birth Asphyxia: Impact of training facility providers in neonatal resuscitation
• Training nurses, midwives, doctors in neonatal resuscitation– Meta-analysis of 6
before-after studies – All studies from middle-
low-income countries– Results: 30% reduction
in intrapartum neonatal deaths (range: 17% - 43%)
Source: Wall et al. Int J Obstetr Gynaecol 2009;107:S47-64
Birth asphyxia – Helping Babies BreatheSM
Simple color-coded Algorithm
• Drying and wrapping
• Assess breathing – if not breathing then,
• Clear airway and stimulate – if not breathing then,
• Ventilate until breathing (or no response after 10 – 15 min)
Developed by: American Academy of Pediatrics with Save the Children, USAID, ACCESS,
NICHD,WHO, & UNICEF
Evidence for Preterm/Low Birthweight Babies
• Facility-based Kangaroo Mother Care proven to reduce deaths in stable preterm newborns by 50%
Sources: Lawn et al (2010) ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications. Int J Epidemiol: i1–i10.
Cochrane Database of Systemic Reviews 2011, Conde-Agudelo A et al
“Compared with conventional neonatal care, KMC was found to reduce mortality at discharge.”
KMC reduced severe infections, hypothermia, severe illness, and length of hospital stay
KMC: What’s the evidence?
Preterm/LBW: Community KMC
• Large reduction (54%) in NMR of package including skin-to-skin care for all babies
Source: Kumar et al. Lancet 2008
• Suggestion of mortality reduction for <2kg newborns
Source: Sloan et al. Pediatrics 2008
• Program feasibility in Nepal Source: Access, 2008
Prevention of infections
Chlorhexidine to cord Evidence:– Nepal
Mullany et al. Lancet 2006
– BangladeshAl Arifeen, in press
– Pakistan Bhutta, in press
– Recent pooled analysis: chlorhexidine vs no chlorhexidine: 23% reduction in all cause mortality
Chlorhexidine Working Group, in press
– 2 Ongoing trials in Africa
Prevention of Infections
Clean Birth Practices
• 30 published studies confirm benefit for babies
• 3 studies suggest benefit for mothers
• GRADE recommendation: strong
• 3 studies support the role of CBKs
• No adverse effects
Source: Clean Birth Kit Working Group
Management of Infections
• Community case management of neonatal pneumonia – 27% reduction in all-cause neonatal mortality
Source: Sazawal and Black. Lancet Inf Dis 2003;3:547056
• CHW identification and management of sepsis (injectables, oral/injectables)– SEARCH: (India) Sepsis CFR declined from 16.6% to
6.9%Source: Bang et al. J Perinatol suppl 2005
– Projahnmo (Bangladesh): Sepsis CFR 4.4% in CHW treated
Source: Baqui et al. PIDJ 2009
– MINI (Nepal): Sepsis CFR 1.5% in those given cotrimoxazole by FCHVs and gent by CHWs at peripheral health centers (compared to 5.3% not treated)
Source: Khanal et al, JHPN 2011
Management of Infections
• Simplified Antibiotic Therapy Trial
– Are simplified antibiotic regimens equivalent to WHO “gold standard” (14 injections)? - ongoing• Common protocol
– Asia: Pakistan (SNL), Bangladesh (USAID)– Africa: Nigeria, Kenya, DRC (WHO)
Translating Research & Data for Action
RegionalOpportunities for Africa’s Newborns
ASADI Science in Action
LAC Alliance
GlobalCountdown to 2015
CHERG
LiST
UN Jt. Statement
NationalSituation Analysis (15)
Data Profiles
III. Measuring Progress
Overview
• SNL Evaluation Strategy• Newborn Indicators TWG• Preliminary Findings• Lessons Learned
SNL Pathway to Scale
SNL Evaluation Strategy
SNL has a comprehensive evaluation strategy for programs and implementation research:
• 39 core indicators collected at national and sub-national levels
• NMR, Coverage, Behaviors, Practices• Availability of equipment, supplies, drugs• Quality of care• Demand for services
• Document SNL contribution to Scale Up
• Scale up Readiness Benchmarks• Policy timeline• Implementation tracker• Funding for newborn health
• Secondary analyses to answer key implementation questions
Newborn Indicators Technical Working Group
• Representation from:– SNL, MICS, DHS, USAID, UNICEF, WHO, CORE
group
• Objectives– Ensure consistent use of newborn health
indicators– Provide in-depth instruments on newborn care– Advance the state-of-the-art in newborn care
measurement by identifying priorities and opportunities to validate indicators
Country Design Dates Sample size
Bangladesh (GO)
Pre/Post
Intervention / Comparison
Baseline: 2008Endline: 2010
Baseline: 788Endline: 794
Nepal Pre/Post Baseline: 2008Endline: 2011
Baseline: 630Endline: 630
Indonesia Pre/Post Baseline: 2007/8Endline: 2011
Baseline: 400Endline: 400
Vietnam Pre/Post
Intervention / Comparison
Baseline: 2007Endline: 2011
Baseline: 1,073Endline: 1,050
Malawi Pre/Post Baseline: 2007Endline: 2011
Baseline: 903Endline: 900
SNL Household Surveys
Preliminary Findings from SNL Household Surveys
Skilled Birth Attendance
0102030405060708090
100
Bangladesh Nepal Indonesia Malawi
Baseline
Endline
*
*
*
*
*Statistically significant at p<.05
Immediate Breastfeeding (within 1 hour of birth)
0102030405060708090
100
Bangladesh Nepal Indonesia Vietnam
Baseline
Endline
*
*
*
*
*Statistically significant at p<.05
Delayed Bathing (≥6 hours after birth)
0102030405060708090
100
Bangladesh(non-facility births
only)
Nepal Indonesia Malawi
Baseline
Endline
*
*
**
*Statistically significant at p<.05
Knowledge of Newborn Danger Signs
0102030405060708090
100
Bangladesh Indonesia Vietnam Malawi
Baseline
Endline*
*
*
*
*Statistically significant at p<.05
Preliminary Findings from Scale up Readiness
Benchmarks
Scale Up Readiness Benchmarks
• Focus on “readiness” to implement newborn programs at scale
• Benchmarks revised based on:– Technical input from experts– Consultation meeting in April 2011 – Data collection and analysis
• Ongoing verification of benchmarks
Scale up Readiness Benchmarks
0 5 10 15 20 25
Bangladesh
Bolivia
Ethiopia
Malawi
Mali
Nepal
Pakistan
Tanzania
Uganda
Countr
y
Number of Benchmarks
Achieved
In progress
Not begun
Missing
SNL Countries 2000
Scale up Readiness Benchmarks
0 5 10 15 20 25
Bangladesh
Bolivia
Ethiopia
Malawi
Mali
Nepal
Pakistan
Tanzania
Uganda
Countr
y
Number of Benchmarks
Achieved
In progress
Not begun
Missing
SNL Countries 2005
Scale up Readiness Benchmarks
0 5 10 15 20 25
Bangladesh
Bolivia
Ethiopia
Malawi
Mali
Nepal
Pakistan
Tanzania
Uganda
Countr
y
Number of Benchmarks
Achieved
In progress
Not begun
Missing
SNL Countries 2010
• Nationally endorsed Essential Newborn Care Package– SNL developed during SNL1; supported
implementation under SNL2 with Government, UNICEF
• Package rolled out at CSCom level in 6 of 8 regions and 39 of 59 districts (66%) and by MOH, support from SC and UNICEF– Regional trainers in all 8 regions – Trainers in 49 out 59 districts (83%) poised to
train facilities
• Total of 2042 facility-based health workers have been trained nationwide
Implementation Tracker - Mali
Segou Region
Lessons Learned
• Challenges of working within existing health systems
– Malawi HSAs
• Need for flexibility of newborn intervention packages with rapidly changing context
– Increasing facility delivery– Incentive schemes
• Need to understand the relationship between coverage and quality
– What happens during home visits?– How does quality differ by place of delivery?
• Progress in readiness to implement at scale in all SNL countries
Thank you!
Visit the Healthy Newborn Networkwww.healthynewbornnetwork.org
SNL Evaluation: Baselines & Endlines
• Baseline assessments:– 14 household surveys – 6 health facility assessments
• Adequacy surveys:– 2 in 2011and 2012 (Tanzania, Ethiopia)
• Endline assessments:– 10 household surveys
• 3 in 2010 (Bangladesh, Bolivia, Guatemala)• 5 in 2011 (Nepal, Malawi, Uganda, Indonesia, Vietnam)• 1 in 2012 (Tanzania – if funding secured)• 1 in 2013 (Ethiopia)
– 5 health facility assessments• 2011(Nepal, Malawi, Uganda, Mali, Vietnam)
Core indicators collected via baseline and endline evaluations:
Country
Design Components Dates Sample size
Mali Endline only
•Inventory of essential equipment/supplies
•Provider knowledge/skills
•Client exit interview
2011 Hospitals: 4First level facility:
40Providers: 90Clients: 280
Vietnam Pre/Post •Provider knowledge/skills in neonatal resuscitation
Baseline: 2007Endline:
2011
Providers at Baseline: 76Providers at
Endline: 86
SNL Health Facility Assessments
Follow up of resuscitated newborns in Indonesia using Bayleys scales (in press)
Methods: Infants between 24 and 36 months assessed according to the Bayley Scales of Infant and Toddler Development III adapted for Indonesia
8.1
6
3.8
8.1
4.9
0.80
5
10
15
20
25
No asphyxia Resuscitated bymidwives
Resuscitated in thehospital
Mild
Moderate/ Severe
Cog
nitiv
e im
pairm
ent
13.9
10.53.8
5.6
2.81.2
0
5
10
15
20
25
No asphyxia Resuscitated by
midwives
Resuscitated in
the hospital
Mild
Moderate
Lang
uage
19.4
11.6
15.8
2.81.11.9
0
5
10
15
20
25
No asphyxia Resuscitated bymidwives
Resuscitated in thehospital
Mild
Moderate/Severe
Mot
or
23.7
28.227.2
13.2
7.88.8
0
5
10
15
20
25
30
35
40
45
50
No asphyxia Resuscitated bymidwives
Resuscitated in thehospital
Mild
Moderate/Severe
34.2
24.927.2
18.4
28.8
22.2
0
5
10
15
20
25
30
35
40
45
50
No asphyxia Resuscitated by
midwives
Resuscitated in
the hospital
Mild
Moderate/Severe
Ada
ptiv
e be
h.
Results• Moderate/severe cognitive
impairment higher in midwife-resuscitated newborns vs. non-asphyxiated newborns
• Rate of moderate/severe impairment twice as high among hospital-resuscitated newborns vs. midwife-resuscitated newborns
Soc
ial
No statistical diffe
rence