Surviving the First Month of Life Lily Kak, USAID Indira Narayanan, BASICS Mini-University, George Washington University October 27, 2006
Dec 17, 2015
Surviving the First Month of Life
Lily Kak, USAIDIndira Narayanan, BASICS
Mini-University, George Washington UniversityOctober 27, 2006
Four Million Newborn Deaths: Where?
99% of newborn deaths are in low/middle income countries 66% in Africa and Southeast Asia
Stagnating Trends in Neonatal Mortality
0
5
10
15
20
25
30
35
40
45
50
1990 1995 2000 2003
De
ath
s p
er
1,0
00
liv
e b
irth
s
Global
Sub-Saharan Africa
Asia and Middle East
Latin America and Caribbean
Source: DHS and RHS estimates for countries receiving USAID support Number of countries: Global-35; ANE -8; Africa – 17; LAC: 9
Millennium Development Goal 4 can only be achieved if neonatal deaths are addressed
050
100
150
Glo
bal
mo
rtal
ity
pe
r 10
00
bir
ths
1960 1980 2000 2020Year
Under-5 mortality rate
Present trend
MDG
1-60 mo. mortality
< 1 mo. mortality (NMR)
Neonatal Deaths and the Millennium Development Goals
Source: Neonatal Lancet, 2005
Coverage of Newborn Care During the Most Critical Period
75% of neonatal deaths are in
the 7 days
Only 50% of deliveries
are attended by
skilled birth attendants
Up to 50% of neonatal
deaths are in the first 24 hours
Only 21% receive
postnatal care
within 7 days
Newborn Care in Sub-Saharan Africa: the Weakest Link
69
42
9
7565
010203040
50607080
Any a
nten
atal
care
Skille
d birt
h atte
ndan
t
Newbor
n ca
re <
3 d
ays,
NIB
*BCG
DPT3
%
NIB: Non-Institutional BirthSource of data: 1999-2005 DHS; State of the World’s Children, 2006
• The Lancet Child and Neonatal Survival Series identified newborn survival as a priority, lacking information and action
• The World Health Report advocates the repositioning of MCH as MNCH (maternal, newborn and child health)
Newborn Health: No longer Falling Through the Cracks
The World Health Report 2005
Make every mother and child count
Infection36%
Sepsis/PneumoniaTetanusDiarrhea
Asphyxia23%
Other7%
Complications of Prematurity
27%
Cong. Anom
7%
Low birth weight is a significantcontributor in 60–80% of neonatal deaths.
Adapted from Lancet 2005
Major Causes of Neonatal Mortality
•Tetanus Toxoid Immunization of Mother•Clean Delivery•Cord Care•Early & Exclusive Breastfeeding•Antibiotics for mother and baby
•Warming •Resuscitation•Skilled Birth Attendants
•Syphilis Control •Folate Supplementation
Malaria ControlAntenatal CorticosteriodTreatment of bacteriuria
•Kangaroo Mother Care•Birth Spacing•Maternal Nutrition
Evidence Based Interventions for
Context-Specific Package
Intermittent presumptive treatment
for malaria
Prevention of Mother-to-Child Transmission
of HIV
Syphilis detection and treatmentIodine
Essential Maternal & Newborn Care
USAID October, 2006
Other Essential Interventions
ProphylacticEye care
Adequate nutrition
Family planning
Immunization
Special care for LBW
EmergencyObstetric and Newborn Care
Iron and folate
Minimum activities: FacilityANC
•Birth preparedness•Tetanus toxoid
Safe Birth with Skilled Attendance
•Partograph•Infection prevention•Active mgt of 3rd stage of labor•Newborn resuscitation
Postpartum•Cord care•Thermal care•Immediate & excl breastfeeding•Infection Treatment
Minimum activities: Community
ANC•Birth preparedness•Tetanus Toxoid
Safe Birth •Clean delivery•Referral link for obstetric& newborn complications
Postpartum•Cord care•Thermal Care•Immediate & excl Breastfeeding•Infection recognition & referral/treatment
Saksham LOGO
A community based and community drivenessential newborn care program
Shivgarh, India
Source: Global Research Activities, Johns Hopkins University
Neonatal Mortality Rate, Shivgarh, India
42
84
0
10
20
30
40
50
60
70
80
90
Project Comparison
Mortality per 1,000 live
births
Source: Global Research Activities, Johns Hopkins University
ProjahnmoProjahnmo
Pro
j ah
nm
o…
Sylhet, Bangladesh
A community based essential newborn care program
Source: Global Research Activities, Johns Hopkins University
20
25
30
35
40
45
50
55
Baseline J -J '03 J -D '03 J -J '04 J -D '04 J -J '05 J -D '5
Mor
talit
y Rat
e/ 1
,000
live
birth
s
Home Care Comparison
Significant reduction in neonatal mortality with home-based care
Neonatal Mortality RatesSylhet, Bangladesh
Pro
j ah
nm
o…
Source: A Community-based Effectiveness Trial to Improve Newborn Health in Sylhet District of Bangladesh, GRA/JHU, 2006
USAID’s Global Priorities
• Introduce and expand community-based essential newborn care globally
• Focus on major killers to reduce mortality: low birth weight, infections, asphyxia
Globally, 60-80% Neonatal Deaths occur Globally, 60-80% Neonatal Deaths occur in Babies below 2500 Gm (LBW)in Babies below 2500 Gm (LBW)
Other7%
Preterm27%
Asphyxia23%
Congenital 7%
Sepsis/ pneumoni
a26%
Diarrhoea3%
Tetanus7%
LBW
LBW
Based on Vital Registration data for 45 countries (N = 96797). and modeled estimates for 146 countries (N = 13,685) - Lawn JE, Cousens SN. Zupan J, Lancet 2005
Management of Low Birth Weight
Low Birth Weight Infants
c
• Global burden: 21 million,
96% in developing countries
• Global incidence: 16%
Distribution of 21 million LBW
India40%
Bangladesh6%
Pakistan4%
Rest SA4%
WHO, UNICEF. Country, regional and global estimates. 2004
The priority from a public health point of view is the group of larger / more mature LBW infants Currently, there is more evidence and experience on management than prevention of LBW infants
2000-2499 g77%
1500-1999 g19%
<1500 g4%
35-36 wk70%
33-34 wk17%
<33 wk13%
Bang 2005
Priority Intervention
Outcome of LBW babies with extra care at first referral level facility
Category n Died/referred Discharged
<1500g 101 28% 72%
1501-1999g 264 7% 93%
2000-2499g 1744 1% 99%
All LBW 2109 3% 97%
Paul VK- Ballafgarh Hospital (1994-1999)
With intervention, 95% LBW survived
11.3
33.3
5
10.2
0
5
10
15
20
25
30
35
LBW Preterm
Mo
rtal
ity
(%)
Baseline Post-intervention Bang 2005
Outcome with Extra Care at Community Level
Extra Care for LBW Babies
• Extra focus on essential newborn care especially– Temperature maintenance– Prevention of infection – More frequent breastfeeding and/or use of breast
milk• Kangaroo Mother Care - major components
– Skin to skin contact
– Position
– Nutrition
– Support to mother and baby
– Discharge & follow-up policy
• Baby wears only a diaper (cap and socks where needed)
• Placed vertically in between the mother’s breasts
• Wrapped firmly / securely on to the mother’s chest
• Can also be carried out by other family members
Kangaroo Mother Care (KMC)
• Thermal control—mother’s temperature adjusts for baby
• Vital signs better—breathing more regular—less ‘periodic breathing’; less apnea
• Less crying—less stress—even in term babies after delivery—salivary cortisol twice as high in control infants with standard care than with skin-to-skin contact 1 hr. post birth.
• Better breastfeeding
• Bonding
KMC - Advantages
• Simple, effective, low cost intervention
• At facility level and at home
• Has global applications—both for advanced and developing countries. May be the only alternative in resource-poor situations
• Other practical applications:
– Just after birth for all babies (without problems needing immediate attention)
– During transport of sick & LBW babies
KMC - Conclusions
CongenitalCongenitalmalformationsmalformations
7 %7 %
Birth asphyxia Birth asphyxia & trauma& trauma
23 %23 %
Neonatal Neonatal tetanus 7%tetanus 7%
Diarrhea 3%Diarrhea 3%
Sepsis /Sepsis /Pneumonias Pneumonias 26 %26 %
7 %7 %OthersOthers
Complications ofComplications ofPrematurityPrematurity
27%27%
Low Birthweight
Infections Infections 36 %36 %
Causes of Neonatal Mortality
Neonatal Sepsis Timing of Deaths and Interventions
0
100
200
300
400
500
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Age at death (day)
Nu
mb
er o
f d
eath
s
0
20
40
60
80
100
Cu
mu
lati
ve f
req
uen
cy (
%)
Source: South Asia Newborn Health Investigators Group (Unpublished courtesy Steve Wall )
Clean delivery
Cord care
Colostrum and exclusive breastfeeding
Identify signs of illness- algorithms / Antibiotics
Types of Infections Minor Infections:
Thrush
Conjunctivitis
Skin infections
Umbilical infection ( localized)
Major Infections
Specific entities such as pneumonia, diarrhea, septicemia and meningitis difficult to diagnose in the newborn . Hence catch-all term “sepsis” is used in public health
Easy spread and rapid progression of disease
High case fatality
Specific infections such as syphilis, HIV/AIDS, Hepatitis B, tetanus, and malaria
Trotman Ann. Tropical Paediatrics 2006 and Robillard West Indian Medical Journal 2001
Timing of Infections Early onset of infection (0-3d) is usually acquired from
maternal risk factors and during delivery such as: Maternal fever Premature rupture of the membranes (>12-18-24 hr) Unhygienic delivery practices Poor cord care
Late onset of infection (4-30d) are usually acquired from the environment (most likely acquired in the home or facility - nosocomial) due to factors such as: Unhygienic newborn care practices (i.e., lack of hand
washing) Excessive invasive procedures
Neonatal Sepsis Key Components Of Prevention
• Antenatal period: – Addressing tetanus, STD, HIV/AIDS and malaria
• Delivery: – Clean delivery practices, preventive Essential
Newborn Care (ENC) –hygiene-clean cord and skin care, breastfeeding
• Postnatal period: – Preventive maternal and newborn care – clean
cord and skin care, breastfeeding
0
20
40
60
80
100
120
PreventiveENC
Preventive ENC+HBC of sick babies
Pratinidhi et al Bang et al
Fall in
NMR
23.1%
Fall in
NMR
62.2%Per
cen
tag
e
Newborn Care: Impact of Options on Mortality - Community Level
Newborn Care: Impact of Options on Mortality - Community Level
Neonatal Sepsis: Clinical Characteristics
• Newborns, notably LBW infants are at high risk for infection
• Easy spread to other organs and rapid progression of disease
• Specific diagnosis difficult in major infections – hence catch-all term “sepsis” is used
• High case fatality• Susceptible to special germs that do not affect normal
older infants• Most require injectable antibiotics• Organisms vary by region, over time and with long term
use of antibioticsAll these have public health implications
Neonatal Sepsis :Danger Signs
• Numbers vary (1st 4 or 5 most important)– refusal to feed/suck/poor feeding – inactivity/lethargy/ ‘limp limbs’– body hot/cold– Rapid breathing /difficulty in breathing
• chest in-drawing, grunting/nasal flaring
– weak/no cry– vomiting/abdominal distention – periumbilical redness/pus discharge
Based on Bang et al, BASICS country programs
• IMCI – 11-15 signs
Neonatal Sepsis:Needed Government Policies
– Availability of drugs, supplies, and equipment Need for appropriate
–Antibiotics, including required strengths –Supplies and equipment including
suitable sizes
– Quality of services at the facility
– Policies of administration of antibiotics by less qualified health workers in special situations
Neonatal Sepsis: Link with IMCI
• Conventional IMCI addresses babies older than 1 week• Now newborns included by WHO and by some countries• One prominent example is IMNCI-India
– Includes 0-6 days of age– 50% of training time on infants 0-2 months of age– Home-based care of young infants by workers added– In severe illness administration of first dose of oral
antibiotics before referral • Requires training, supervision, and suitable drugs and
supplies• Needs to be applied at facility and community level
Neonatal Sepsis: Major Infections
• Major infections:
– Early stage: Baby can accept feeds and maintain temperature with simple aids
– Late stage: Baby cannot feed and/or maintain temperature with simple aids
• Influences level of treatment
Strategies/Options Levels for Implementation
Strategy No. 1: Preventive essential newborn care + detection of danger signs + care seeking/referral
Home, community and facility; prevention key
Strategy No. 2: Strategy #1 plus treatment of minor infections and first dose of antibiotics at community / facility level before referral
Health posts/centers,
? home/community
Strategy No. 3: Strategy # 2 plus treatment with injectable antibiotics for moderate sepsis at community /facility level
Health centers and higher
Strategy No. 4: Strategy # 3 plus full treatment including intravenous fluids
Referral hospitals
Management of Neonatal Infections