Newborn survival and perinatal health in resource-constrained settings in Asia and the Pacific: Applying Global Evidence to Priorities Beyond 2015 12 April 2013

1. Save the Children –
Saving Newborn Lives
Lessons
learned:
low-­‐cost
feasible
interven4ons
for
newborn
survival
and
how
to
integrate
them
into
programs
Stephen
Wall
Melbourne
Australia
April
12,
2013

2.
Outline
I. Do community-based newborn health
packages work?
II. What specific high impact interventions are
effective and feasible in low income settings?
III. What should be the research agenda for
future newborn survival and health?

3. SEARCH: Community interventions save NB lives
HBNC
package:
Ø CHW
pregnancy
surveillance,
2
ANC
counseling
visits
Ø Delivery
care
(including
neo
resus)
by
trained
TBA
&
CHW
Ø 8
postnatal
visits
by
CHW
Ø Extra
CHW
visits
&
care
of
<2kg
babies
Ø CHW
dx
&
tx
of
sepsis:
oral
cotrimoxazole
+
IM
gentamicin

4. SEARCH: Community interventions save NB lives-2
NMR
reduced
by
62%
(in
3rd
year
(Bang,
Lancet
1999)

5. Evidence:
CB
interven4ons
reduce
newborn
deaths
Replication of Replication in Preventative care Government model
SEARCH in India Bangladesh alone in India in Pakistan
Ankur Projahnmo Shivgarh , Hala
2001-2005 2001-2006 2003-2006 2003-2005
Home-based newborn HBNC replicated in HBNC with HBNC through
care (HBNC) Sylhet district community existing CHW system
replicated in 7 rural, mobilization and BCC (preventative care w/
urban and tribal only referral)
districts
30% NMR Reduction
51% NMR Reduction 34% NMR Reduction 54% NMR Reduction in pilot areas
(Unpublished) Baqui. Lancet 2008 Kumar. Lancet 2008 Bhutta. Bull WHO.
2008
The 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.

6. Evidence to policy
Posi9ves
Ø Spurred
many
countries
and
donors
to
take
ac4on
for
newborn
survival
Ø Country
policies
Ø Programs
(government
&
NGO)
Nega9ves
Ø Based
on
“efficacy”
instead
of
“effec4veness”
evidence
Ø Li_le
a_en4on
to
mother
Ø No
implementa4on
tools
(eg,
training,
supervision,
monitoring
systems,
logis4cs
management)

7. Evidence:
Impact
of
program
implementa9on
of
JS
Projahnmo 2 Hala 2 Haryana Newhints
(Bangladesh) (Pakistan) (India) (Ghana)
Mirzapur: Replicaion & scale up IMNCI program in Replication of Asia
Replication of of Hala 1 rural India district CHW home visit
Projahnmo 1 package
Lady Health Worker CHW home visits;
CHW pregnancy and home visits and physicians and nurses Volunteer CHWs
2 postnatal home community group trained in IMNCI counseling at home
visits; referral counseling; referral visits; referral
13% NMR Reduction 15% NMR Reduction 9% NMR Reduction 8% NMR Reduction
(NS) (NS) (NS)
Darmstadt. PLoS One Bhutta. Lancet 2011; Bhandari. BMJ 2012 Kirkwood. Lancet
2010 377 2013
Meta-analysis suggests 12% reduction in NMR when CHW
home visiting is implemented in actual programs .

8. Deaths due to Preterm Birth: How to prevent
Corticosteroids (in preterm labor) – to prevent
lung disease/death
– Mothers in preterm labor or medically indicated
preterm delivery (eg, pre-eclampsia)
– Effectiveness
• LiST review: in MIC, 53% reduction in preterm
mortality in MIC, 37% morbidity reduction
(Source: Lawn et al. Int J Epi 39 (2010); i144.
– Coverage: <10% in LIC-MIC
– Achieving high coverage (first level health facilities,
district hospitals) would avert 500,000 newborn
deaths per year

9. Preterm Birth: Management
Facility-based KMC for LBW newborn
• In LIC-MIC, 51% reduction in neonatal mortality for
babies less than 2kg
• Source: Lawn et al. Int J Epi 2010.
• Major reduction in morbidities among LBW
newborns (eg, pneumonia, low weight gain, length of
hospital stay)
– Source: Conde-Agudelo et al. Cochrane Reviews 2003
• Coverage in LIC remains low

10. Birth
Asphyxia
–
Neonatal
Resuscita9on
Can
neonatal
resuscita4on
be
effec4vely
provided
in
low
resource
se`ngs?
• Indonesia:
40%
reduc4on
in
overall
crude
all-­‐cause
NMR
by
including
neo
resus
training,
simple
resus
device,
and
suppor4ve
supervision
for
community
midwife
training
Source:
Wall
et
al.
Int
J
Gynel
Obstet
107
(2009);
S47.

11. Simplified
Resuscita9on
:
Helping
Babies
Breathe
• Simple color-coded algorithm
(The Golden Minute™)
(1) Drying and wrapping/skin-to-skin
(2) Assess breathing – if not breathing
then,
(3) Clear airway and stimulate – if not
breathing then,
(4) Ventilate until breathing (or no
response after 10 – 15 min)
* Developed by American Academy of Pediatrics in
collaboration with Save the Children, USAID,
ACCESS, NICHD, WHO, & UNICEF

12. Neonatal infections -- Chlorhexidine
• Researchers hypothesized that
7.1% chlorhexidine digluconate
cleansing of the cord would
reduce neonatal mortality
compared to dry cord care.
• 3 cluster-randomized controlled
trials:
– Nepal (2006): Mullany et al. Lancet
2006:367:910
– Bangladesh (2012): Al Arifeen et al. Lancet
Feb 2012: DOI: 10.1016/S01406736(11)
61848-5
– Pakistan (2012): Soofi et al. Lancet Feb
2012: DOI: 10.1016/
S01406736(11)61877-1

13. Chlorhexidine Impact on All-Cause Neonatal Mortality
MORTALITY: Any CHX vs. No CHX
MORTALITY: Any CHX vs. No CHX
Study RR (95% CI)
23% reduction in mortality
Nepal 0.76 (0.58, 1.00)
Bangladesh 0.88 (0.74, 1.04)
Pakistan
among those receiving 0.85)
0.62 (0.45,
Overall intervention
0.77 (0.63, 0.94)
.5 .75 1 1.2
In
press.

14. Neonatal Infections – CB Management
CHW identification and management of sepsis,:
§ Simple diagnostic algorithms (pictorial)
§ Injectable or oral/injectable antibiotic regimens
– SEARCH: (India) CHW treatment of presumed newborn sepsis
reduced CFR from 16.6% to 6.9%
Source: Bang et al. J Perinatol suppl 2005
– Projahnmo (Bangladesh): Sepsis CFR 4.4% in CHW-treated
newborns with “very severe disease”
Source: Baqui et al. PIDJ 2009
– MINI (Nepal): Sepsis CFR 1.5% in CHW-treated newborns with
PSBI
Source: Khanal et al, JHPN 2011

15. Neonatal Infection -- Lessons Learned About Care Seeking
• Care seeking for newborn illness: families are
willing to bring sick newborns to health posts/
centers for treatment – requires awareness of
problem and available solution (commodities and
quality services)
• Linkage to maternal health and survival –
pervasive and deep community concern about
maternal survival communities provides
opportunity to improve newborn care practices
and care seeking

16. Packaging Evidence: Focus on Major Killers and
Evidence-Based Intervention Packages
3
main
causes
of
neonatal
death:
•
Asphyxia
•
Prematurity/Low
birth
weight
•
Infec9on
Evidence-­‐based
interven9on
packages:
• Basic
newborn
care
-­‐
Hygiene,
warmth,
breas1eeding,
cord
care
• Asphyxia:
– Preven9on:
Quality
obstetric
care
and
labor
monitoring
– Treatment:
S9mula9on/resuscita9on
(“Helping
Babies
Breathe”)
• Prematurity/low
birth
weight:
– Steroids
to
mother
during
premature
labor
– Kangaroo
Mother
Care
• Infec9on
– Preven9on:
clean
delivery,
cord
care,
handwashing,
breas1eeding;
chlorhexidine
– Detec9on
and
treatment:
an9bio9cs
(including
at
community
level)

17. Innovations – current SNL investigation
• Simplified antibiotic regimens (multi-center
studies in Asia and Africa)
§ Simple FHR monitor and mobile-based
perinatal death audit (Uganda)
§ “Upright” bag and mask resuscitation device
to enable more effective ventilation (India)

18. Conclusions
Ø There is solid evidence of what simple interventions can save
newborn lives, averting most of the world’s neonatal deaths.
Ø Intervention effectiveness requires strong implementation
(availability of services, commodities; care seeking)
Ø We must modify and adapt interventions to the (rapidly)
changing contexts – focus on referrals, quality of facility care,
linking facilities to communities, and integrating newborn and
maternal interventions and delivery strategies.
Ø As we move forward to implement, we need to learn HOW to
deliver these interventions effectively at scale.

19. Much to learn and share
. . . to save newborn lives.
Thanks!