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

Pearl # 1

All newborns need essential newborn care

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

Pearl # 2

Kangaroo Mother Care

is for humans too!

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

Pearls for Today

1.All newborns need …

2.Kangaroo mother care is for…

Care of the sick newborn is challengingbut will improve mortality outcomes to better achieve MDG #4

Babies are worth it

We need to act NOW!