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