Download - Neonatal mortality measurement what's new
Neonatal Mortality Measurement – what’s new?
Joy Lawn Saving Newborn Lives / Save the Children
Outline1. Neonatal mortality rates
2. Neonatal cause of death
3. Improving neonatal mortality data in surveys
With thanks to Colin Mathers et al at WHO and to Simon Cousens in CHERG
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
MICS surveys can estimate NMR but not powered to do so unless sample size is increased eg Malawi 2006
Availability of mortality estimates
• 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 2010Separate methods paper and detailed results in preparation
Target for MDG-4(32)
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
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2. NEONATAL CAUSE OF DEATH
country data in puts and
Invisible deaths….Global estimates of causes of death for children under the age of 5 years
Diarrhoea
20%
12%
Other 29%
HIV/AIDS
4%
Malaria
8%
Measles
5%
ARI
Malnutrition
54%
Perinatalcauses
22%
Asphyxia
Preterm
Injuries
Other
Source: WHO and UNICEF under-5 causes of death estimates 2004
Neonatal sepsis/ pneumonia
Neonatal tetanus
Congenital
Estimates of causes of neonatal death (year 2000)
Lawn et al, Lancet 2005
WHO WHR 2005Detailed methods: Lawn et al, IJE 2006
Bryce et al, Lancet 2005
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
Sub-national estimates for cause of deatheg Nigeria
Neonatal tetanus nationally estimated at 8% and Northern zones at 17%
Source: Saving Newborn Lives in Nigeria. FMOH Jan 2009Estimates for 2005 by CHERG neonatal group
1. 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 datasetsNow 71 datasets, 23,638 deaths China and India – huge national datasets used instead of estimates
2. MORE detail for cause of death categories
3. MORE detail by time for first week of life
Neonatal cause of death for year 2008Advancing the estimates
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 2010Expected annual cycle – also in SOWC and Countdown
Separate methods paper and detailed results in preparation
Causes of death in the neonatal period for 193 countries (2000-2008)
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%)0.550.33
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
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
3.2 million stillbirths.
(Stanton, Lawn et al)
Beyond survival….
?? 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
3. IMPROVING NEONATAL DATA IN SURVEYS
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
Survey data for neonatal mortality measurement
Mortality data for 75% of neonatal deaths is dependent on household surveysRemarkably little evaluation…
Stillbirths
Neonatal death data in DHSHeaping 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 30/31Age heaping on day 7 may reduce the early NMR
Age heaping on day 30/31 may reduce the overall NMR
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?
(Maharashtra, India, Bang et al., 2002)
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%)
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?
1. 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
2. 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
Conclusions
Thank you!