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  

     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?

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    

SEARCH: Community interventions save NB lives-2

NMR  reduced  by  62%  (in  3rd  year  (Bang,  Lancet  1999)  

Evidence:  CB  interven4ons  reduce  newborn  deaths  

Replication of SEARCH in India

Replication in Bangladesh

Preventative care alone in India

Government model in Pakistan

Ankur 2001-2005

Home-based newborn

care (HBNC) replicated in 7 rural,

urban and tribal districts

51% NMR Reduction (Unpublished)

Projahnmo 2001-2006

HBNC replicated in

Sylhet district

34% NMR Reduction Baqui. Lancet 2008

Shivgarh 2003-2006

HBNC with community

mobilization and BCC only

54% NMR Reduction Kumar. Lancet 2008

, Hala 2003-2005

HBNC through

existing CHW system (preventative care w/

referral)

30% NMR Reduction in pilot areas

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.

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)  

   

Evidence:    Impact  of  program  implementa9on  of  JS  

Projahnmo 2 (Bangladesh)

Hala 2 (Pakistan)

Haryana (India)

Newhints (Ghana)

Mirzapur: Replication of Projahnmo 1

CHW pregnancy and 2 postnatal home visits; referral

13% NMR Reduction (NS) Darmstadt. PLoS One 2010

Replicaion & scale up of Hala 1

Lady Health Worker home visits and community group counseling; referral

15% NMR Reduction Bhutta. Lancet 2011; 377

IMNCI program in rural India district

CHW home visits; physicians and nurses trained in IMNCI

9% NMR Reduction (NS) Bhandari. BMJ 2012

Replication of Asia CHW home visit package Volunteer CHWs counseling at home visits; referral 8% NMR Reduction (NS) Kirkwood. Lancet 2013

Meta-analysis suggests 12% reduction in NMR when CHW home visiting is implemented in actual programs .

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

Deaths due to Preterm Birth: How to prevent

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

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.  

 

•  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

Simplified  Resuscita9on  :    Helping  Babies  Breathe    

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

Chlorhexidine Impact on All-Cause Neonatal Mortality

MORTALITY: Any CHX vs. No CHX

Study

Overall 0.77 (0.63, 0.94)

RR (95% CI) RR (95% CI)

1 .5 .75 1.2

Nepal 0.76 (0.58, 1.00)

Bangladesh 0.88 (0.74, 1.04)

Pakistan 0.62 (0.45, 0.85)

MORTALITY: Any CHX vs. No CHX

23% reduction in mortality among those receiving

intervention

In  press.  

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

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

Packaging Evidence: Focus on Major Killers and Evidence-Based Intervention Packages

 

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)

3  main  causes  of  neonatal  death:  •           Asphyxia  •           Prematurity/Low  birth  weight  •           Infec9on    

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)

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.

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