Transcript Maternal and Child Health: a global perspective

Newborn Survival and Maternal
Health: a key to child survival
Zulfiqar A. Bhutta
Husein Lalji Dewraj Professor & Chairman
Department of Paediatrics & Child Health
Aga Khan University
Karachi, Pakistan
“ Fate has allowed humanity such a pitifully meagre coverlet that in
pulling it over one part of the world, another has to be left bare … ”
Rabindranath Tagore
and
newborn
health
TheInequity
health of in
thematernal
mother and
newborn
is inseparable
Deaths among infants under 7 days are decreasing
more slowly than among older infants
100
Developing Regions
Post-neonatal mortality
80
Late neonatal mortality
Early neonatal mortality
60
40
Developed Regions
20
0
1983
Source: RHR/WHO, 2003
2000
1983
2000
Where do 4 million newborns die?
1.5 million (38%
of all newborn
deaths) occur in
4 countries of
South Asia
Tertiary
Referral Hospital
University Hospital
Secondary
District General Hospital
Sub-district Hospitals
35-40%
Primary
Rural Health Center
Village Health Units
50-60%
5-10%
When do they die?
Up to 50%
of neonatal
deaths are in
the first 24 hours
75% of neonatal
deaths are in
the first week –
3 million deaths
Spectrum of Asphyxia outcomes
•
Neonatal
encephalopathy
(mild/ mod / severe)
•
Neonatal death as a
consequence of NE
•
Neurological
disability as a
complication of
neonatal
encephalopathy
Intra-partum Stillbirths
an extension of Asphyxia deaths?
160
140
120
100
Macerated (LCM)
Macerated (Normal)
Fresh (LCM)
Fresh (Intra-partum)
Unclassified
80
60
40
20
0
Hala
Matiari
Kot Diji
All
Newborn Deaths from Asphyxia:
the tip of an iceberg
0.9 million asphyxia deaths
1-2 million suffer medium to
long–term impairment
Stillbirths from
intrapartum hypoxia
(~ 1 million deaths)
4 million newborn deaths – Why?
almost all are due to preventable conditions
Two thirds of all neonatal deaths are in LBW infants
Maternal & Newborn illness
Disease
Malnutrition
Insufficient
Household
Food Security
Care for women
Breastfeeding/Feeding;
Psychosocial Care;
Hygiene Practices;
Home Health Practices
Insufficient Health
Services & Unhealthy
Environment
Manifestations
Immediate
causes
Underlying
causes
Inadequate Education
Resources & Control
Human, Economic & Organisational
Political and Ideological Superstructure
Economic Structure
Political, social and economic structures
Basic
Determinants
Three dimensions of poverty
• Poverty of means and access
• Poverty of Hope!
• Poverty of Imagination
REASONS FOR NOT SEEKING CARE (n=31)
6%
13%
30%
Empowerment
Support structures
3%
6%
33%
16%
39%
Fatalism
Past experience
23%
BABY NOT CONSIDERED ILL ENOUGH TO SEEK CARE
MONEY UNAVAILABLE
TRANSPORTATION UNAVAILABLE
POOR OPINION/PREVIOUS NEGATIVE EXPERIENCE OF HEALTH SYSTEM
FATALISM (BELIEF THAT CHILD WILL DIE ANYWAY)
NO PERMISSION FROM HUSBAND/IN LAWS/NOBODY AT HOME TO TAKE CARE OF OTHER CHILDREN
DIED TOO SOON AFTER BIRTH
What can be done?
Effective interventions for Newborn Care
Lancet Series on Newborn Survival
Paper 2 (2005)
•
16 interventions identified with
adequate evidence of effect on
neonatal deaths (e.g., tetanus toxoid
immunization, clean delivery, obstetric
care, breastfeeding, antibiotics for
infections)
•
All are highly cost-effective
especially if packaged and
delivered within other
programmes (e.g., maternal and child
health)
Effective interventions for Newborn Care
Lancet Series on Newborn Survival
Paper 2 (2005)
•
16 interventions identified with
adequate evidence of effect on
neonatal deaths (e.g., tetanus toxoid
immunization, clean delivery, obstetric
care, breastfeeding, antibiotics for
infections)
•
All are highly cost-effective
especially if packaged and
delivered within other
programmes (e.g., maternal and child
health)
Tertiary
University Hospital
Referral Hospital
Secondary
District General Hospital
Taluka Hospital
Clinical or Facility-based care
Primary
Rural Health CenterOutreach
Basic Health Units
Family and
Community
Packages
Intervention Packages
Clinical
care
Skilled obstetric and immediate newborn care
including resuscitation
Emergency obstetric care to manage
complications such as obstructed labour and
hemorrhage
Emergency newborn care for illness,
especially sepsis management and
care of very low birth weight babies
23 - 50%
NMR
effect
Outreach
services
Antibiotics for preterm rupture of membranes#
Corticosteroids for preterm labour#
4-visit antenatal package
including
Postnatal care to support healthy
practices
tetanus immunisation,
detection & management of
syphilis, other infections, preeclampsia, etc
Early detection and referral of
complications
Administering basic
community-based
6 - 9%
Malaria intermittent
intervention
presumptive therapy* packages at full coverage
and treatment
canDetection
save
~ 37% of all newborn deaths!
of bacteriuria
Familycommunity
#
Folic
acid #
Counseling and preparation
for newborn care and
breastfeeding, emergency
preparedness
Clean home
delivery
Simple early
newborn care
Healthy home care including
breastfeeding promotion, hygienic
cord/skin care, thermal care, promoting
demand for quality care
15 - 32%
Extra care of low birth weight babies
Case management for pneumonia
Pre- pregnancy
Pregnancy
Neonatal period
Birth
Infancy
Coverage rates are low!
How can these be scaled-up much faster?
Know
….Do gap
Don’t
know….Don’t
do gap
Analysis of systematic reviews for maternal
and newborn health interventions
Developing Countries
Community/Primary Care settings
Effectiveness trials
98
72
39
19
13
7
Antenatal
3
1
Intrapartum
2
Post-natal
Bhutta et al (Pediatrics & GFHR 2005)
30% reduction in neonatal mortality!
Major impact on maternal mortality!
Shivgarh (India) Trial
Community Mobilization and Behavior Change Communication
1.
Birth preparedness for
essential newborn care
2.
Clean delivery, cord and skin
care
3.
Immediate wiping, drying and
keeping the baby warm
4.
Skin-to-Skin Care
5.
Promotion of immediate and
exclusive breastfeeding
6.
Recognition and management
of hypothermia
Shivgarh (India) Trial
Community Mobilization and Behavior Change Communication
1.
Birth preparedness for
essential newborn care
Perinatal Mortality Rate
Neonatal Mortality Rate
120
2.
3.
Clean delivery, cord and skin
care
Immediate wiping, drying and
keeping the baby warm
100
80
60
4.
Skin-to-Skin Care
5.
Promotion of immediate and
exclusive breastfeeding
6.
Recognition and management
of hypothermia
40
20
0
Control
Intervention 1
Intervention 2
Hala Project
Phase 2 Pilot
(2003-2004)
8 clusters
317 villages
43000 households
284,000 population
Community organization
& mobilization
Improved Primary Maternal,
Perinatal & Newborn Care
(through Lady Health Workers)
Improved Referral Pathways &
Clinical Care
(Common in all areas)
Perinatal mortality trends
(Hala, Pakistan)
Stillbirth rate
Early neonatal mortality
Late neonatal mortality
70
60
50
40
30
20
10
0
Control area (2002-3)
Intervention area (2002-3)
Perinatal mortality trends
(Hala, Pakistan)
Stillbirth rate
Early neonatal mortality
Late neonatal mortality
70
60
50
40
30
20
10
0
Control area (2003-4)
Intervention area (2003-4)
Conclusions
• Improving newborn health and care is critical to
attaining the MDG targets for child survival
• To do so would require concerted efforts to improve
maternal care, outreach and provide innovative
models of community support and education
• Emerging data from demonstration projects in health
system settings indicate that this is doable and can
be scaled up using affordable models of care
• Community engagement and ownership is a critical
element in successful intervention models for
maternal and newborn care
Participatory development
Democratization of public health