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Addressing the Challenge of Neonatal Mortality
Simon Cousens
Millennium Development Goal 4
Reduce by two-thirds, between 1990 and 2015, the under 5 mortality rate
Millennium Development Goal 4
Source: Levels and trends in Child Mortality. Report 2011. Estimates developed by the Inter-agency Group for Mortality Estimation.
29
025
5075
100
Und
er 5
mor
talit
y ra
te
1990 1995 2000 2005 2010 2015Year
Millennium Development Goal 4
Sources: Levels and trends in Child Mortality. Report 2011. Estimates developed by the Inter-agency Group for Mortality Estimation. Oestergaard et al. PLoS Med. 2011 8:e1001080
29
025
5075
100
Mor
talit
y ra
te
1990 1995 2000 2005 2010 2015Year
U5MR NMR
Geographical distribution of neonatal mortality in 2009
Source: Oestergaard et al. PLoS Med. 2011 8:e1001080
Region NMR % of neonatal deaths
High income 3.6 1.4%
sub-Saharan Africa 35.9 34%
South East Asia 30.7 36%
Neonatal mortality rates in England and Wales
Source: ONS mortality statistics (www.statistics.gov.uk)
010
2030
40M
orta
lity
per
1000
live
birt
hs
1920 1940 1960 1980 2000Year
Early neonatal mortality Late neonatal mortality
Community-based care: a seminal paper from India
Bang et al. Lancet 1999. 354: 1955-1961
Implemented a home care package in a rural setting with high NMR
Trained village health workers to perform home visits, to promote breastfeeding and thermal management, in simple techniques to manage birth asphyxia, and to treat infections
Source: Bang et al. Lancet 1999. 354: 1955-1961
Treatment of sepsis
c. 60% reduction in NMR
Community-based care: a seminal paper from India
The Lancet Neonatal Survival Series (2005)
Editors: JE Lawn and S Cousens
Source: Lancet 2005. 365:977-988
Developed a model to estimate how many neonatal deaths could be prevented by increasing coverage of a package of relatively simple, cost-effective interventions
Estimated that 36-67% of neonatal deaths in 75 high mortality countries could be averted by high coverage (90%) with 16 interventions
Only about half of this reduction was through community-based care
Lives Saved Tool (LiST)Freely available software tool for programme plannershttp://www.futuresinstitute.org/pages/Spectrum.aspx
Two recent studies:
The Hala Trial, Pakistan
Lancet 2011. 377: 403-412
Intervention:Lady Health Workers (LHWs) trained in preventive newborn careDais (TBAs) trained in basic newborn careCommunities encouraged to establish Community Health Committees
Lancet 2011. 377: 403-412
The Hala Trial, Pakistan
16 clusters randomised:Approximately 23,000 live births identified over a 30 month period
Primary outcome: all-cause neonatal mortality
The Hala Trial, Pakistan
Intervention clusters
Control clusters
Risk ratio(95% c.i.)
NMR 43.0 49.1 0.85 (0.76, 0.96) P=0.02
Trial differed from other community-based trials in region in that intervention principally delivered through government health system rather than workers employed by research team.
lower intervention coverage than has been reported in other trials smaller mortality impact
Despite limitations, encouraging that public sector programme promoting preventive care can produce health benefits
Cord care
WHO recommends dry cord care BUT in a Cochrane review from 2004
all 21 trials were conducted in hospitalsall but one in high income settingsno systemic infections or deaths in any of the trials
Source: Zupan et al. Cohrane Database Syst Rev 2004. 3: CD001057
Cord care
A subsequent community-based trial of topical chlorhexidine in Nepal reported:
a 75% reduction in severe omphalitisa 24% reduction in neonatal mortality
compared with dry cord care
Source: Mullany et al. Lancet 2006. 367:910-918
Chlorhexidine trial, Pakistan
Lancet 2012. 379:1029-1036
Chlorhexidine trial, Pakistan
187 clusters randomly allocated in 2x2 factorial design2 interventions
Chlorhexidine (daily for 2 weeks) vs dry cord careHandwashing promotion vs no handwashing promotion
Interventions delivered through Dais Facility births excluded9741 livebirths enrolled over 18 months
Chlorhexidine trial, Pakistan
Neonatal mortality Neonatal deaths (NMR)
Risk ratio (95% c.i.)
P
No handwashing promotion
147 (29.1) 1.0
Handwashing promotion 140 (29.9) 1.08 (0.79, 1.48)
0.62
Dry cord care 176 (36.1) 1.0
Chlorhexidine 111 (22.8) 0.62(0.45, 0.85)
0.003
Chlorhexidine
“We could argue that more research is needed—questions certainly exist about the duration and timing of application and about external validity. Evidence from high-mortality populations in Africa would be useful. Nevertheless, to demand more evidence of effectiveness might be to repeat an old public health debate: if the need is clear, the possibilities attractive, and the risk low, how much evidence is necessary before we act on plausible findings?”Osrin and Hill. Commentary. Lancet 2012. 379:984-986.
The challenge of neonatal mortality: what needs to be done?
Effective interventions are available: how do we make sure they reach mother’s and newborns?
Improve the quality and quantity of data available to:
assist rational policy makingMonitor progress
Acknowledgements
Joy Lawn, Zulfiqar Bhutta, Gary Darmstadt, Hannah Blencowe, Susana Scott, Neff Walker, Mikkel Oestergaard, Colin Mathers and many others