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Global Network for Women’s and Children’s Health Research
Resuscitation: How to Save One Million Lives Per Year
Albert Manasyan, MD; Wally Carlo, MD and the FIRST BREATH Study GroupFor the Global Network for Women’s and
Children’s Health Research
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Stillbirth and Neonatal Deaths Per Year
• 98% of all stillbirths and neonatal deaths occur in developing countries
~ 2.6 million stillbirths ~ 3.5 million neonatal deaths
• Preterm 1.0 mil• Birth asphyxia 0.8 mil• Sepsis 0.5 mil• Other 1.2 mil
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Background: Essential Newborn Care
• The WHO developed Essential Newborn Care (ENC) course sets minimum standards for training birth attendants in neonatal care including:• Basic resuscitation• Universal precautions• Routine neonatal care • Thermoregulation• Breastfeeding• Kangaroo mother (skin-to-skin) care• Care of the small baby• Danger signs
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First Breath Protocols
The First Breath protocols were designed to address the impact of Essential Newborn Care (ENC) on perinatal mortality:
•First Breath: Clinic Study•First Breath: Common Protocol
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Comparison of First Breath Protocols
First Breath:
Clinic Study
First Breath:
Common Protocol
Setting Institution-based
(first level health clinics)
Community-based
Birth Attendants Formally-trained midwives
All birth attendants including MDs, RNs, MWs, TBAs
Outcomes Early neonatal mortality (7 days), stillbirths, perinatal mortality
Early neonatal mortality (7 days), stillbirths, perinatal mortality
Timeline 2004 – 2006 2007 – 2008
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First Breath: Clinic Study
Design: Pre-Post controlled study with active baseline data collection
Setting: Level 1 health delivery centers in Zambia
Interventions: WHO ENC (including resuscitation training) and NRP
Patients: 71,689 low risk newborns
Carlo W et al. Pediatrics 126:e1064-71, 2010.
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First Breath: Clinic Study
Results Pre-ENC Post-ENC p value
All cause 7-day mortality/1000 11.5 6.8 p<0.001
Perinatal mortality/1000 18.3 12.9 p=0.002
Mortality due to asphyxia/1000 3.4 1.9 p=0.02
Mortality due to infection/1000 2.2 0.8 p=0.02
Mortality < 1500/1000gr 576 407 p=0.049
SB rate/1000 4.9 4.9 NS
Carlo W et al. Pediatrics 126:e1064-71, 2010.
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Delivery by Birth Attendant
TBA37%
Physician16%
Nurse/Midwife 28%
Family members 19%
Carlo et al. N Engl J Med. 362:614-23, 2010.Carlo et al. N Engl J Med. 362:614-23, 2010.
Birth Attendant Home10%
Home 56% Hospital 25%
Clinic 9%
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First Breath: Common Protocol
1. Population-based prospective study
2. 96 communities in 6 countries (7 clinical sites) in South America, Africa, and Asia
3. 3,676 birth attendants trained in data collection and clinical measures (fetal heart rate monitoring, Apgar scoring etc.)
4. Active baseline data collection
5. Training in ENC
6. Post-ENC data collection
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First Breath: Common Protocol
0.69 (0.54 ,0.88)15.923.0Stillbirth
RR (CI)Post-ENCRate/1000
Pre-ENCRate/1000
Results
0.99 (0.81, 1.22)23.223.4All cause 7-day mortality
0.85 (0.70, 1.02)38.945.9Perinatal mortality
Carlo et al. N Engl J Med. 362:614-23, 2010.Carlo et al. N Engl J Med. 362:614-23, 2010.
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Pre-Post ENC Perinatal Mortality Rates by Birth Attendant
Per
inat
al M
orta
lity
**
Family/ UnattendedTraditional Birth AttendantNurse/MidwifePhysicianAll Birth Attendants
Carlo et al. N Engl J Med. 362:614-23, 2010.Carlo et al. N Engl J Med. 362:614-23, 2010.
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Methods: Cost Analysis
• Cost-effectiveness was calculated as follows:
Cost per life saved = Cost
Reduction in death
• Cost per disability-adjusted life years (DALY) was calculated as follows:
Cost per DALY = Cost per life saved
Life expectancy
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Results: DALY
Cost per DALY = Cost per life saved
Life expectancy
Cost per DALY = $208
39.7 years
Cost per DALY = $5.24
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Final Conclusions
1. WHO ENC training of midwives in first level centers reduced neonatal mortality by ~10/1000
2. This intervention was very cost-effective in first level facilities ($5 per DALY)
3. In communities, ENC reduced fresh stillbirths and perinatal mortality without increasing neonatal mortality
4. Survivors of birth asphyxia have low rates of impairment
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Acknowledgement
Support for this project from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), part of the National Institutes of Health within the U.S. Department of Health and Human Services, and the Bill and Melinda Gates Foundation