NEWBORN HEALTH AND SURVIVAL

OVERVIEW & CASE STUDY

KIWOKO, UGANDAGH/HSERV 544MCH IN DEVELOPING COUNTRIES

Maneesh Batra MD, MPHJan 12, 2012

Goals Provide an overview of the current

status of Newborn Survival in the world

Place Newborn Survival within the context of Childhood Survival in the world

Provide an in-country example Highlight potential areas for

intervention to improve Newborn Survival

The Newborn Period is Risky - Pop Quiz

Each year _ million children (<5 yrs old) die~8.8 million

Each year _ million infants (<1 yr old) die~5.9 million

Each year _ million newborns (<1 mo old) die~3.6 million = 10,000 per day!

How many die within the first 24 hrs of life ?~1.8 million

Black, 2010

Millennium Development Goals

2000 UN Millennium Declaration:1. Eradicate extreme poverty and hunger2. Achieve universal primary education3. Promote gender equality and empower women4. Reduce child mortality5. Improve maternal health6. Combat HIV/AIDS, malaria and other diseases7. Ensure environmental sustainability8. Develop a global partnership for development

MDG-4 “Reduce Child Mortality by 2/3 between 1990 and 2015”

Lawn Sem Peri 2010

Is It Possible to Change This Trend?

Childhood Deaths…Where?

Black, Lancet 2010

Childhood Deaths…Why?

Black, Lancet 2010

Lawn, IJGO 2010

Half of neonatal deaths occur on day 1

Neonatal Deaths – Why?

• Physiologic adjustments and adaptation to extrauterine life:• Establish breathing• Change fetal circulation to newborn• Body temperature regulation• Feeding and digestion• Immune system development

• Recognizing illness is a challenge

• Majority of births occur at home

Neonatal Deaths – Where?

66% in 10 countries 99% in low/middle income countries Majority of deaths occur in-home, not in a

health facility

Causes of Neonatal Deaths

Lawn, Sem Peri 2010

Lawn, Sem Peri 2011

Neonatal Deaths – Why?

60-80% of neonatal deaths occur in babies with birth weight <2500g

Risk of early death: 1500-2499g, 6 times greater <1500g, 100 times greater

~3 million newborn deaths can be prevented with low-cost, low-tech interventions ~$1 per inhabitant per year! Marginal cost of adding neonatal resuscitation training and

equipment for midwives: <$0.02 per capita per year Most deaths could be prevented with simple interventions such

as: Thermoregulation Breast feeding, Kangaroo care Early treatment of infections A very small minority of patients require costly intensive care

How…

Lawn, IJGO 2010

Risk of Mortality Peaks Around Childbirth

ChildhoodNewborn/postnatalPre-pregnancy Pregnancy Birth

Maternal deaths

StillbirthsNewborn deaths

Child Deaths

Courtesy of ZA Bhutta

Kiwoko, Uganda

Case Study

Setting - Uganda

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Population: 27 million 84% rural

Languages: English, Luganda, Swahili

Literacy Rate: 69% (male), 59% (female)

Per capita GNP: $270 Fertility rate: 7.1 (5th in world) Malnourished Children: 26% Life expectancy: 42 years

Setting - Uganda

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Per Capita Govt healthcare spending: $5

NMR: 29/1000 live births Annual Neonatal Deaths 40,900

IMR: 88.3/1000 live births

U5MR: 137/1000 live births

MMR: 435/100,000 live births Annual Maternal Deaths: 6,100

Stillbirths: 31/1000 deliveries

Setting - Uganda

25Opportunities for Africa’s Newborns, 2006

21% of childhood deaths are newborns

Setting – Luwero District

Area: 5773.53 sq. km Population: 492,184 (proj. 2000)

91.1% rural Population within 5 km of a health

services unit: 53%. Doctors to Population Ratio

1:23,438 16 doctors in the district

IMR: 112/1000 live births U5MR: 150/1000 live births

Setting – Luwero District

Immunization Coverage: 46% Stunting Rate: 36% Acute Malnutrition: 7% Antenatal Care

ANC attendance rate: 75 % Delivery by trained staff: 36 %

Access to Safe Water: 42% Latrine Coverage: 54%

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Kiwoko Hospital

Kiwoko Hospital Early 1990s - Abandoned

school into a health clinic by Dr. Ian Clarke

One of 3 hospitals in the district

4 full time doctors Serves population of 500,000 Treats 25,000 people per year 1000 deliveries per year 1500 operations per year Most patients arrive by foot or

bicycle30

Kiwoko Hospital 150-250 beds 8 wards (Peds, Malnutrition, Male, Female, Surgical, TB,

Maternity, NICU) Outreach/Education

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Kiwoko Hospital - Resources

Majority of care by family members

Sporadic electricity Rain + well water Limited vaccine supply

BCG, DTP, Td, Measles, OPV Limited laboratory Limited medication supply Limited blood supply

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Kiwoko Hospital - NICU35

Built by ISIS, opened in 1999

Kiwoko Hospital - NICU36

Primary Diagnoses: LBW, Sepsis, Tetanus, Malaria, Meningitis, Asphyxia, Meconium

Aspiration, Respiratory Distress

Kiwoko Hospital - NICU

20 beds, 3 functioning incubators ½ of admissions inborn Overall Mortality 20-30% Tetanus Mortality 80-90%

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Why do babies die in Luwero?

At Home

Largely unknown magnitude and scope of problem

Barriers to seeking care Knowledge $$$$$$$$$ Impact on family unit What if the baby dies?

Critical point of intervention!39

Why do babies die in Luwero?

In the Hospital In-born

LBW Sepsis Asphyxia

Out-born Delayed presentation LBW Sepsis, Meningitis, Skin infections Tetanus ? Etiology

Majority present with non-specific signs

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World Bank 2003

Improving Newborn Outcomes

Framework Antenatal

Antenatal care Immunization Malaria treatment Maternal nutrition

Birth spacing Breast feeding

counselling

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Improving Newborn OutcomesFramework

Peripartum Skilled birth attendant Immediate newborn care Obstetric emergencies

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Improving Newborn Outcomes

Framework Postpartum

Recognition of illness Appropriate initial stabilization

Prevent hypoglycemia Maintain temperature Eye care Prevent/treat infections

Nutritional management of LBW

Availability of referral care Birth spacing

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Thanks!45