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Newborn Survival and MaternalHealth: a key to child survival

Zulfiqar A. BhuttaHusein Lalji Dewraj Professor & Chairman

Department of Paediatrics & Child HealthAga Khan University

Karachi, Pakistan


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Fate has allowed humanity such a pitifully meagre coverlet that in

pulling it over one part of the world, another has to be left bare

Rabindranath Tagore


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Inequity in maternal and newborn healthThe health of the mother and newborn is inseparable


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0

20

40

60

80

100

1983 2000 1983 2000

Post-neonatal mortality

Late neonatal mortality

Early neonatal mortality

Developing Regions

Developed Regions

Source: RHR/WHO, 2003

Deaths among infants under 7 days are decreasing

more slowly than among older infants


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Where do 4 million newborns die?

1.5 million (38%

of all newborn

deaths) occur in

4 countries of

South Asia


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Referral HospitalTertiaryUniversity Hospital

SecondaryDistrict General Hospital

Sub-district Hospitals

PrimaryRural Health Center

Village Health Units

50-60%

35-40%

5-10%


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When do they die?Up to 50%

of neonatal

deaths are inthe first 24 hours

75% of neonataldeaths are in

the first week

3 million deaths


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Spectrum of Asphyxia outcomes

Neonatalencephalopathy(mild/ mod / severe)

Neonatal death as aconsequence of NE

Neurologicaldisability as acomplication ofneonatalencephalopathy


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Intra-partum Stillbirths

an extension of Asphyxia deaths?

0

20

40

60

80

100

120

140

160

Hala Matiari Kot Diji All

Macerated (LCM)Macerated (Normal)

Fresh (LCM)

Fresh (Intra-partum)

Unclassified


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Newborn Deaths from Asphyxia:

the tip of an iceberg

0.9 million asphyxia deaths

1-2 million suffer medium to

longterm impairment

Stillbirths from

intrapartum hypoxia

(~ 1 million deaths)


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4 million newborn deathsWhy?almost all are due to preventable conditions

Two thirds of all neonatal deaths are in LBW infants


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Insufficient Health

Services & Unhealthy

Environment

Maternal & Newborn illness

Insufficient

Household

Food Security

Resources & Control

Human, Economic & Organisational

Political, social and economic structures

Malnutrition Disease

BasicDeterminants

Immediatecauses

Underlying

causes

Inadequate Education

Political and Ideological Superstructure

Economic Structure

Manifestations

Care for women

Breastfeeding/Feeding;

Psychosocial Care;

Hygiene Practices;

Home Health Practices


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Three dimensions of poverty

Poverty of means and access

Poverty of Hope!

Poverty of Imagination


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REASONS FOR NOT SEEKING CARE (n=31)

13%

3%

6%

16%

23%

33%

6%

BABY NOT CONSIDERED ILL ENOUGH TO SEEK CARE

MONEY UNAVAILABLE

TRANSPORTATION UNAVAILABLE

POOR OPINION/PREVIOUS NEGATIVE EXPERIENCE OF HEALTH SYSTEM

FATALISM (BELIEF THAT CHILD WILL DIE ANYWAY)

NO PERMISSION FROM HUSBAND/IN LAWS/NOBODY AT HOME TO TAKE CARE OF OTHER CHILDREN

DIED TOO SOON AFTER BIRTH

39%Fatalism

Past experience

30%Empowerment

Support structures


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What can be done?


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Effective interventions for Newborn Care

Lancet Series on Newborn Survival

Paper 2 (2005)

16 interventions identified withadequate evidence of effect onneonatal deaths (e.g., tetanus toxoidimmunization, clean delivery, obstetric

care, breastfeeding, antibiotics forinfections)

All are highly cost-effectiveespecially if packaged and

delivered within otherprogrammes (e.g., maternal and childhealth)


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Effective interventions for Newborn Care

Lancet Series on Newborn Survival

Paper 2 (2005)

16 interventions identified withadequate evidence of effect onneonatal deaths (e.g., tetanus toxoidimmunization, clean delivery, obstetric

care, breastfeeding, antibiotics forinfections)

All are highly cost-effectiveespecially if packaged and

delivered within otherprogrammes (e.g., maternal and childhealth)


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Referral HospitalTertiaryUniversity Hospital

SecondaryDistrict General Hospital

Taluka Hospital

PrimaryRural Health Center

Basic Health Units

Clinical or Facility-based care

Outreach

Family and

Community

Packages


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Intervention PackagesSkilled obstetric and immediate newborn care

including resuscitation

Emergency obstetric care to manage

complications such as obstructed labour and

hemorrhage

Antibiotics for preterm rupture of membranes#

Corticosteroids for preterm labour#

Emergency newborn care for illness,

especially sepsis management and

care of very low birth weight babies

C

linical

care

Folic

acid #

Counseling and preparation

for newborn care and

breastfeeding, emergency

preparedness

Healthy home care including

breastfeeding promotion,hygienic

cord/skin care, thermal care, promoting

demand for quality care

Extra care of low birth weight babies

Case management for pneumonia

Family-

community

Clean home

delivery

Simple early

newborn care15 - 32%

4-visit antenatal package

includingtetanus immunisation,

detection & management of

syphilis, other infections, pre-

eclampsia, etcMalaria intermittent

presumptive therapy*

Detection and treatment

of bacteriuria#

Outre

ach

servi

ces

Postnatal care to support healthy

practices

Early detection and referral of

complications6 - 9%

23 - 50%

NMR

effect

InfancyNeonatal periodPre- pregnancy Pregnancy Birth

Administering basic community-basedintervention packages at full coverage

can save ~ 37% of all newborn deaths!


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Coverage rates are low!

How can these be scaled-up much faster?


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Know .Do gapDont know.Dont do gap


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Analysis of systematic reviews for maternal

and newborn health interventions

72

19

713

3 1

98

39

2

Antenatal Intrapartum Post-natal

Developing Countries Community/Primary Care settings Effectiveness trials

Bh utta et al (Pediatr ic s & GFHR 2005)


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30% reduction in neonatal mortality!

Major impact on maternal mortality!


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Shivgarh (India) Trial

Community Mobilization and Behavior Change Communication

1. Birth preparedness foressential newborn care

2. Clean delivery, cord and skincare

3. Immediate wiping, drying andkeeping the baby warm

4. Skin-to-Skin Care

5. Promotion of immediate andexclusive breastfeeding

6. Recognition and managementof hypothermia


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Shivgarh (India) Trial

Community Mobilization and Behavior Change Communication

1. Birth preparedness foressential newborn care

2. Clean delivery, cord and skincare

3. Immediate wiping, drying andkeeping the baby warm

4. Skin-to-Skin Care

5. Promotion of immediate andexclusive breastfeeding

6. Recognition and managementof hypothermia

0

20

40

60

80

100

120

Control Intervention 1 Intervention 2

Perinatal Mortality Rate Neonatal Mortality Rate


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Hala Project

Phase 2 Pilot

(2003-2004)

8 clusters

317 villages

43000 households

284,000 population


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Community organization

& mobilization

Improved Primary Maternal,

Perinatal & Newborn Care

Improved Referral Pathways &Clinical Care

(Common in all areas)(through Lady Health Workers)


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Perinatal mortality trends

(Hala, Pakistan)

0

10

20

30

40

50

60

70

Control area (2002-3) Intervention area (2002-3)

Stillbirth rate Early neonatal mortality Late neonatal mortality


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Perinatal mortality trends

(Hala, Pakistan)

0

10

20

30

40

50

60

70

Control area (2003-4) Intervention area (2003-4)

Stillbirth rate Early neonatal mortality Late neonatal mortality


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Conclusions

Improving newborn health and care is critical toattaining the MDG targets for child survival

To do so would require concerted efforts to improvematernal care, outreach and provide innovative

models of community support and education Emerging data from demonstration projects in health

system settings indicate that this is doable and canbe scaled up using affordable models of care

Community engagement and ownership is a criticalelement in successful intervention models formaternal and newborn care


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Participatory development

Democratization of public health

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