Transcript Slide 1

Newborn health packages
and priorities to save lives
NOW
Ms Kate Kerber
Dr Joy Lawn
Saving Newborn Lives / Save the Children-US
Funded by The Bill & Melinda Gates Foundation
GHANA ACADEMY OF
ARTS AND SCIENCES
Promoting Excellence in Knowledge
Outline
•
Description of the problem
•
Delivery in the real world
•
•
•
Solutions for the 3 main causes of death:
infections, preterm, intrapartum-related
Integrated MNCH packages
Development of new or adapted
interventions to reduce the cost, increase
effect, improve deliverability of newborn care
•
Discovery New science around the
mechanisms and causes of neonatal illness
DESCRIPTION
Where, When and
Why do African
Newborns Die?
Where do 1.2 million African
newborns die?
More than 18 million births at home each year in Africa
Most deaths also occur at home - unnamed and uncounted
Affects data availability but also the priority given
Over one quarter of under-five deaths in Africa are newborns
900,000 stillbirths still largely missing
When do African newborns die?
Up to 50%
of neonatal
deaths are in
the first 24 hours
10
Daily risk of death per 1000 survivors
.
12
Birth and first week is key:
when most babies die yet
when coverage of care is lowest for
mothers and babies
8
6
75% of neonatal
deaths are in
4
the first week
2
0
0
5
10
Source: Lawn JE, Kerber K Daily risk of death in Africa during first month
of life based on analysis of 19 DHS datasets (2000 to 2004) with 5,476
neonatal deaths
15
Day of life
20
25
30
Why do African newborns die?
Other, 7%
Congenital, 6%
Sepsis/
pneumonia,
28%
Infections
Asphyxia, 24%
39%
Tetanus, 6%
3 causes
account for 88%
of neonatal
deaths
Diarrhoea, 4%
Preterm, 25%
Source: Opportunities for Africa’s Newborns, 2006. Based on vital registration for one country and updated modelling using the
CHERG neonatal methods for 45 African countries using 2004 birth cohort, deaths and predictor variables.
Paradoxical opportunity at highest mortality rates
Infections
~50% of
neonatal
deaths
when NMR
is over 45
per 1000
Infections
~ 15% of
neonatal
deaths
when NMR
is less
than 15
per 1000
46%rate
| =52%
| 88%
| 99% reduction
Higher mortality
faster
possible
Median coverage of skilled attendance
and greater effect on inequity
Source: Lawn JE, Cousens SN, Zupan J Lancet 2005. based on cause specific mortality data and estimates for 192 countries
DELIVERY
of solutions for
neonatal sepsis
THE BURDEN
• ~370,000 neonatal deaths in Africa each year, plus
~70,000 due to neonatal tetanus
• Many of the deaths are among preterm babies
• Acute morbidity and long term disability - no systematic
estimates yet
Coverage and constraints
–neonatal infections
Prevention
• Antenatal care: Coverage high but quality gap high
• Intrapartum and postnatal care: hygienic care at
birth lacking, some harmful practices around cord
care, early and exclusive breastfeeding low
Case management
• Physical, cultural barriers to accessing early care
• 39/68 Countdown countries have adapted IM‘N’CI
• Lack of capacity (staff, drugs, supplies)
• Policy barriers for what to give, where and by
whom, e.g. “gold standard” antibiotic regimen which
may block community-based treatment
Urgent need for alternative antibiotic regimen / delivery strategy
Scaling up sepsis case management
– research questions
• Are shorter course or switch course
antibiotics, or oral-only antibiotic regimens
effective? New multi-site study in Pakistan,
Bangladesh but no African site.
• Can we develop an algorithm to screen
newborns needing antibiotic treatment
when identified through active surveillance?
• What are the optimal, locally adapted
delivery approaches for newborn infection
management as part of community-based
packages?
Need for health systems / policy research to address existing
preventive home practices and evaluation, costing for facility
Source: Bahl et interventions
al Pediatr Infect Dis J. 2009
Suppl):S43-8.
andJan;28(1
quality
improvement (PIDJ 2009)
DELIVERY
of solutions for preterm birth
complications
THE BURDEN
• ~290,000 neonatal deaths in Africa each year
• Preterm babies are also at greater risk of death due to
infections
• Acute morbidity and long term disability - no systematic
estimates yet
Priorities for reducing
preterm deaths
• No effective primary prevention of preterm
labour, some effect through addressing
malaria and other maternal infections during
pregnancy
• Antenatal steroids
• Extra care of preterm babies including clean,
safe delivery, support for breastfeeding and
thermal care, and Kangaroo Mother Care
• Early treatment and care for complications
such as breathing problems, and infections
The average baby born 28-31 weeks gestation
in USA costs $95,000 in medical care in first year:
More than 10x average African per capita income
Coverage and constraints
– preterm complications
Prevention
• Large gains in coverage for malaria IPTp but effect small
• Antenatal steroids – major effect but very low coverage
• Traditional practices can be barriers to improved simple
care – thermal care and immediate, exclusive
breastfeeding
Case management
• Kangaroo Mother Care – new meta-analysis revealing
large mortality effect, BUT:
• Coverage is low - often only available at referral
centres
• Lack of knowledge and acceptance by hospital/
admin staff
• Lack of capacity - trained staff, supervision
Knowledge ≠ implementation
Newspaper headline August 2007
Kangaroo Mother Care
Effective, low cost care
for preterm babies
(Cochrane review)
Scaling up KMC
– research questions
• Services closer to home
– Some governments would like to expand KMC to district
hospitals and health centres (e.g. Malawi, Tanzania, Mali)
– Evidence for community initiation/continuation of KMC?
• Novel approaches to counteract staff shortages in
facility (e.g. task shifting and use of patient attendants)
• Training and tracking
–
–
–
–
Shorter, integrated off-site training
1-2 day workshops for district officials, implementers
On-site facilitation and support
Consistent indicators and measuring scale up
Large scale implementation is possible, with training either on site
or at centre of excellence, but facilitation/mentoring is crucial
DELIVERY
of solutions for intrapartumrelated neonatal deaths
(“birth asphyxia”)
THE BURDEN
• ~290,000 neonatal deaths in Africa each year
• +18 million home births
• Acute morbidity and long term disability - no systematic
estimates yet
“Birth Asphyxia” language
• “Asphyxia” is imprecise and poorly
defined - recommended term is
intrapartum-related neonatal
deaths and refers to neonatal
deaths in term babies with
evidence of intrapartum injury
• Most of the evidence relates to “not
breathing at birth” – new metaanalysis suggests possible 35%
reduction in mortality for babies not
breathing at birth (Lee, Lawn et al,
unpublished)
Priorities for reducing
intrapartum-related deaths
Prevention
•
•
•
Prevention through antenatal care including
management of pre-eclampsia and multiple
pregnancy
Skilled care at birth
Basic and comprehensive emergency
obstetric care
Case management
•
•
Resuscitation
Care of babies with neonatal encephalopathy
Intrapartum-related neonatal deaths
- coverage and constraints
Prevention
• Antenatal care
– Quality gap, e.g. identifying abnormal lie, and
early booking
– Birth preparedness and danger signs
• Intrapartum care: community empowerment
and financial schemes to improve skilled care
coverage, task shifting
Case management
• Even where more births are in health facilities,
neonatal resuscitation may be low
• Lack of capacity (competent staff)
• Lack of supplies especially bag and mask
Basic newborn resuscitation is life saving and feasible,
less than 1% need advanced resuscitation
Neonatal resuscitation
• People
– Competency training, refresher
courses, supervision
– Task shifting to community: Promising,
but more evaluation required
• Devices
– Bag and mask
– Suction devices
– Training mannequins
Helping Babies Breathe training,
Tanzania
• Post-resuscitation care
– Pulse oximeters
– Oxygen condensers
New Laerdal “NeoNathalie”
is 80% lower cost
Source: Joy Lawn, American Academy of Pediatrics, 2009
DELIVERY
of integrated MNCH
packages to reduce
neonatal deaths
LIVES
Reaching 90% of women and babies with
16 proven interventions delivered through health
packages could reduce neonatal mortality by up
to 67% saving up to 800,000 lives per year.
COST
Potential neonatal lives saved and
additional cost of health system packages
Additional cost of providing these interventions is
US$1 billion annually or US$1.30 per capita. Twothirds of this cost will also benefit mothers and
older children.
Approximately one-third of newborn deaths could be
prevented just through achievable coverage increases of
context-specific interventions in two years,
the main question is HOW to deliver.
Source: Darmstadt et al Saving Newborn Lives in Asia and Africa: cost and impact of phased scale-up of interventions. HPP. Feb 2008
Single interventions with some evidence
of benefit for neonatal outcomes
Source: Hawes R et al Impact of packaged interventions on neonatal health: a review of the evidence. HPP. May 2007
Newborn lives saved at 90% coverage of packages
EMERGENCY NEWBORN CARE
- Integrated management of childhood illness
(IMNCI)
Clinical
CHILDBIRTH CARE
–Emergency obstetric care
26-51%
NMR
reduction
–Skilled obstetric care and immediate newborn care
(hygiene, warmth, breastfeeding) and resuscitation,
PMTCT
Antenatal
–Focused 4-visit ANC,
including:care
•hypertension/preeclampsia 8%
management
•tetanus immunisation
•syphilis/STI
(6–9%)
management
reduction
•IPTp
and ITN for malaria
•PMTCT
HIV/AIDS
inforNMR
Family/community
Outreach/outpatient
ANTENATAL CARE
10-30%
NMR
reduction
14-32%
NMR
reduction
Pre-pregnancy
–Knowledge newborn
care and breastfeeding
–Emergency
preparedness
Childbirth
care
27%
(18-35%)
reduction
in NMR
–Where skilled care is not
available, clean delivery
and immediate newborn
care including hygiene,
warmth and early initiation
of breastfeeding
–Extra care of preterm babies including
kangaroo mother care
–Emergency care of sick newborns
POSTNATAL CARE
Postnatal
care
–Early detection
and referral of
complications
29%
–Extra care of LBW babies
–PMTCT
for HIV
(17-39%)
reduction
in NMR
–Promotion of healthy behaviours
–Healthy home care including: promotion of
exclusive breastfeeding, hygienic cord/skin
care, warmth, danger sign recognition and
careseeking for illness
–Where referral is not available consider case
management for pneumonia, neonatal sepsis
Pregnancy
Source: Lawn JE DCP chapter adapted for Lancet neonatal series executive summary
Birth
Newborn/postnatal
Childhood
Clinical
Reality for integrated service delivery
REPRODUCTIVE
CHILDBIRTH CARE
- Post-abortion
care, TOP where
legal
–Emergency obstetric care
- STI case mx
EMERGENCY NEWBORN AND CHILD CARE
- Hospital care of childhood illness and children
HIV using Integrated
management
of Childhood
Sick
baby and
Emergency obstetric with
Illness principles (IMNCI)
–Skilled obstetric care and immediate newborn
childincluding
care kangaroo
in
and neonatal
carecare of preterm babies
care (hygiene, warmth, breastfeeding)
and
–Extra
resuscitation
hospital
mother care
–Emergency care of sick newborns
Family/community
Outreach/outpatient
–PMTCT
Family
REPRODUCTIVE
HEALTH
CARE
planning
- Family planning
ANTENATAL CARE
Childbirth
Adol- Antenatal
- IPTp and ITN for
Skilled
Antenatal
malaria
care
care
escent
attendance
care
- PMTCT for
- Folic acid
health
HIV/AIDS
- Prevention &
management of STI
& HIV
FAMILY AND COMMUNITY
–Knowledge
newborn care and
breastfeeding
school
–-Education
programs
–Emergency
preparedness
–Prevention of
HIV and STIs
Intersectoral
Pre-pregnancy
CHILD HEALTH CARE
–Promotion of healthy
behaviours
–Immunisations, nutrition eg
Vit A and growth monitoring
–Early detection
/referral of illness
–Malaria ITN
PMTCT of HIV
- 4-visit focused
package
–Adolescent and
Adolpre-pregnancy
nutrition
escent &
POSTNATAL CARE
–Where skilled care is
not available, clean
delivery and immediate
newborn care including
hygiene, warmth and
early initiation of
breastfeeding
Postnatal
Routine
–Extracare
care of LBW
Postnatal
babies
care
–PMTCT for HIV
Child health
care
–Care of children with HIV
including cotrimoxazole
IMCI
–First level assessment and
care of childhood illness (IMCI)
Healthy home care including:
-newborn home care of babies (hygiene, warmth), - nutrition including exclusive breastfeeding and
appropriate complementary feeding
- seeking appropriate preventive care
–danger sign recognition and careseeking for illness
–Oral rehydration salts for prevention of diarrhoea
–Where referral is not available consider case
management for pneumonia malaria, neonatal sepsis
Malaria programmes
Nutrition programmes
Behaviour change and community mobilisation,
community IMCI
Improved living conditions – Housing, water and sanitation, nutrition
Education and empowerment
Pregnancy
Source: Lawn JE DCP chapter adapted for Lancet neonatal series executive summary
Birth
Newborn/postnatal
Childhood
Priorities for DELIVERY research
for health system packages
1. Routine postnatal care for mother and baby
2. Treating neonatal infections (and maternal postnatal
complications) especially where referral is not possible
3. Extra care of preterm babies in the community, and linking to
improved facility care, KMC
4. Integrated service delivery in practice, e.g. in settings with
high HIV/AIDS prevalence through PMTCT and early
feeding support
5. Improved facility-based care, especially improved neonatal
care at district hospital level
Priority for implementation research:
Answering HOW and WHO and WHERE questions
Integrated postnatal care – where and when?
Evidence from Bangladesh:
Neonatal mortality rate
3 arm RCT with >10,000 births, baseline neonatal mortality rate 41 per 1000 live births
No Visit
New
consensus
statement
on
home
65
Visit
visits: mothers
and newborns to be visited
39
25 on day 3 and day
within
21 24 hours and again
16
13
9
7 if possible, by health professionals7or
appropriately trained CHW.
Day of birth
2nd day of life
3rd-6th day of life >=7th day of life
Early postnatal visits reduce newborn deaths.
A first visit within 2 days of birth may reduce deaths by 67%.
Need to test integrated, scaleable packages, especially in
Africa as the cadre and package content will vary.
Baqui A et al. Effect of timing of first postnatal care home visit on neonatal mortality in Bangladesh, BMJ 2009.
Lessons learned from newborn
health research in Asia
• Major impact is achievable through
community intervention packages
• In high NMR settings (>60), up to 50% decline can be
achieved through behaviour change / community
mobilisation, even without antibiotics or other “medical” care
HOWEVER
• Only 2 are in the public sector and several do not link to the health system
• Only 2 have cost data published and these are not comparable
THEREFORE
• Packages need adaptation and assessment in Africa
• Must consider getting to scale in the design, including comparable cost
• Operationalise links with the health system, especially in African context
Adapting, testing and costing community-based,
integrated newborn health packages in Africa
Mali
(OR)
Ethiopia
(RCT)
Uganda
UNEST (RCT)
Ghana
NEWHINTS (RCT) 1
Tanzania
INSIST (RCT)
Malawi
South Africa
Goodstart III (RCT)2
1. Co-funding with WHO, DfID
2. Co-funding with CDC and UNICEF
RCT = Randomized Control Trial
OR = Operations Research
(OR – district scale up
with MoH)
Mai Mwana (RCT)
Mozambique
(OR)
DEVELOPMENT
and DISCOVERY
research
Development and discovery:
Neonatal infections
•
Treatment switch regimens and shorter courses
•
New antibiotics, especially oral
•
Improved technology for facility care, especially
oxygen use and monitoring
•
New/improved prevention strategies (e.g.
chlorhexidine wipes)
•
Vaccines?
Source: Lawn JE, Rudan I, Ruben C. Four million newborn deaths: is the global research agenda evidence based? EHD 2008
Development and discovery:
Preterm complications
•
Use of emollients in low level care / at home
•
Antenatal steroid use – reduced cost / complexity
•
Surfactant use in low-income settings
•
CPAP, district hospital level care
•
Adapted simpler, robust technology, e.g. pulse oximeters
and syringe drivers
•
Discovery: Prevention of preterm birth
Source: Lawn JE, Rudan I, Ruben C. Four million newborn deaths: is the global research agenda evidence based? EHD 2008
Development and discovery:
intrapartum-related neonatal deaths
•
Simpler approaches and robust technology
needed:
•
•
•
•
Intrapartum care, e.g. doppler fetal heart monitors
Neonatal resuscitation
Care of babies with neonatal encephalopathy (e.g.
head cooling)
Use of cell phones/other communication
technology for emergency transport
Discovery:
• Simpler, specific identification of fetal distress
• Addressing the synergies of infection and
intrapartum hypoxic insult
Source: Lawn JE, Rudan I, Ruben C. Four million newborn deaths: is the global research agenda evidence based?
EHD 2008
Conclusion
•
Three preventable causes account for 88% of
newborn deaths in Africa.
•
Up to 800,000 newborn deaths could be
prevented if essential care reached 90% of
mothers and babies – how to deliver care to
those who need it most.
•
All types of research are required, but
systematic pipeline (D-D-D-D) addressing
priority questions would be more productive.
•
Breakthroughs in development and discovery
research could significantly accelerate progress –
science in action.