06 reducing perinatal & neonatal mortality

REDUCING PERINATAL AND NEONATAL

MORTALITY

REDUCING PERINATAL AND NEONATAL

MORTALITY

Dr R Soerjo Hadijono SpOG(K), DTRM&B(Ch)

Jaringan Nasional Pelatihan Klinik Kesehatan ReproduksiSub Bagian Obginsos Bagian Obgin FK Undip – RSUP Dr Kariadi

Semarang

Dr R Soerjo Hadijono SpOG(K), DTRM&B(Ch)

Jaringan Nasional Pelatihan Klinik Kesehatan ReproduksiSub Bagian Obginsos Bagian Obgin FK Undip – RSUP Dr Kariadi

Semarang

● Over 9 million deaths occur each year in the perinatal and neonatal periods;

● 98% of these deaths take place in the developing world;

● Most of these deaths are caused by infectious diseases; pregnancy-related complications; or delivery-related complications.

● Over 9 million deaths occur each year in the perinatal and neonatal periods;

● 98% of these deaths take place in the developing world;

● Most of these deaths are caused by infectious diseases; pregnancy-related complications; or delivery-related complications.

In most of the world, under-5 year and infant (under-1 year) mortality rates have declined substantially in the past three

decades.

In most of the world, under-5 year and infant (under-1 year) mortality rates have declined substantially in the past three

decades.

● Neonatal mortality has declined less rapidly than other child mortality;

● Neonatal deaths now account for 40 -70% of all infant mortality;

● Neonatal mortality has declined less rapidly than other child mortality;

● Neonatal deaths now account for 40 -70% of all infant mortality;

1975 1980 1985 1990 1995

Infant Mortality

Neonatal Mortality

Comparison of Infant and Neonatal Mortality Decline in

Nepal 1975-1995

1975 1980 1985 1990 1995

Infant Mortality

Neonatal Mortality

Turkey 1975-1995

1975 1980 1985 1990 1995

Infant Mortality

Neonatal Mortality

Egypt 1975-1995

1975 1980 1985 1990 1995

Infant Mortality

Neonatal Mortality

Ghana 1975-1995

1975 1980 1985 1990 1995

Infant Mortality

Neonatal Mortality

Peru 1975-1995

To further reduce child mortality, a new focus of

programs will have to be on reducing neonatal deaths,

particularly those in the first week of life.

To further reduce child mortality, a new focus of

programs will have to be on reducing neonatal deaths,

particularly those in the first week of life.

Medium-Term Trends in Neonatal Mortality in Asia

Medium-Term Trends in Neonatal Mortality in Latin

America

Medium-Term Trends in Neonatal Mortality in Latin

America

1975 1980 1985 1990 19950

Yemen Morocco

EgyptTunisia

Jordan

Medium-Term Trends in Neonatal Mortality

in the Middle East and North Africa

1975 1980 1985 1990 1995 0

Nigeria

Ghana Senegal

Cameroon

in Sub-Saharan Africa

Infant Mortality Rate

0 50 100 150 .5

burcam

malmli

pakper

sensen

sritha

uga zam

Early Neonatal Deaths as a Proportion of Neonatal Mortality in Developing

Countries

Early Neonatal Deaths as a Proportion of Neonatal Mortality in Developing

Countries

Antepartum Hemorrhage

Intrauterine Growth

RetardationFetal

Abnormality

Infection

Preterm Birth

Direct Causes of Perinatal Mortality

in Tygerberg, South Africa

Direct Causes of Perinatal Mortality

in Tygerberg, South Africa

Obstructed Labor

Other Indirect 20%

Hemorrhage25%

Sepsis14%

Hypertension13%

Unsafe Abortion

Other Direct8%

Joint WHO-UNICEF-UNFPA-WB statement

Causes of Perinatal Mortality

Neonatal Tetanus

Asphyxia21%

Injuries11% Congential

abnormalities11%

Sepsis7%

Prematurity10%

Other5%

Diarrhea2%

Pneumonia19%

WHO Mother and Baby Package, 1993

Direct Causes of Neonatal Mortality

Stoll, BJ. The global impact of infection, in Clin Perinatol 1997; 24:1-21.(14)

Infection Number ofCases

Case Fatality Rate (%) Number ofDeaths

Acute RespiratoryInfections

2,500,000 30 750,000

Neonatal Tetanus 438,000 85 372,000Sepsis 750,000 40 300,000Diarrhea 25,000,000 .6 150,000Meningitis 126,000 40 50,400

Estimated Global Burden of Disease of

Major Neonatal Infections

Estimated Global Burden of Disease of

Major Neonatal Infections

Estimated Global Burden of Disease of Major Neonatal

Infections

Estimated Global Burden of Disease of Major Neonatal

Infections

InfectionNumber of

casesCase Fatality

Rate (%)Number

of Deaths

Acute Respiratory InfectionNeonatal TetanusSepsisDiarrheaMeningitis

2,500,000

438,000750,000

25,000,000126,000

85400.640

750,000

372,000300,000150,00050,400

InterventionsInterventions

● Prior to or During Pregnancy● During Delivery● After Delivery

Interventions Prior to or During Pregnancy

● Nutritional Interventions● Malaria Prophylaxis● Maternal Immunization

BMJ 1997 Sept 27;315(7111):786-90

Nutritional Interventions I

● Low birthweight by 35%● Stillbirths by 55%● Perinatal deaths by 49%● Neonatal deaths by 40%

Ceesay et al supplemented pregnant women in The Gambia with 900 additional calories per day, and reduced:

Atukorala TM et al AJCN 1995 Aug;60(2):286-92

Nutritional Interventions II

● Low birthweight by 50%● Perinatal deaths by 45%

In Sri Lanka, iron supplementation along with antihelminthic therapy reduced:

Malaria - Effects on Perinatal and Neonatal

Mortality

Malaria - Effects on Perinatal and Neonatal

Mortality● In 1994, 45 million pregnant women

were living in malarious areas, with over 23 million in Sub-Saharan Africa;

● Malaria may cause up to 30% of preventable low birth weight, and 3-5% of neonatal mortality in highly endemic areas, and

● Malaria is also associated with an increased risk of spontaneous abortions and stillbirths

● In 1994, 45 million pregnant women were living in malarious areas, with over 23 million in Sub-Saharan Africa;

● Malaria may cause up to 30% of preventable low birth weight, and 3-5% of neonatal mortality in highly endemic areas, and

● Malaria is also associated with an increased risk of spontaneous abortions and stillbirths

Shulman CE et al, Lancet 1999 Feb 20; 353(9153):632-6

Malaria ProphylaxisMalaria Prophylaxis

● Perinatal deaths by 22%● Neonatal deaths by 38%

In Kilifi District, Kenya, an area of high malaria transmission, Shulman et al presumptively treated pregnant women with Fansidar which reduced:

Black RE et al Bull WHO 1980 58:927-930 & Shahid et al, Lancet 1995;346(8985):1252-7.

Maternal ImmunizationMaternal Immunization

● Maternal immunization with tetanus toxoid reduced neonatal mortality (from days 4 to 14) from 30/1000 to 10/1000, and reduced deaths for three years after vaccination.

● Maternal immunization with pneumococcus produced antibody levels in infants twice that of infants of unimmunized mothers.

● Maternal immunization with tetanus toxoid reduced neonatal mortality (from days 4 to 14) from 30/1000 to 10/1000, and reduced deaths for three years after vaccination.

● Maternal immunization with pneumococcus produced antibody levels in infants twice that of infants of unimmunized mothers.

Interventions During Delivery

● Prevention and Management of Delivery Complications

● Resuscitation of the newborn

● Prevention and Management of Delivery Complications

● Resuscitation of the newborn

Yan et al. Int J Gynaecol Obstet 1989 Sep;30(1):23-6

Prevention and Management of Delivery

Complications

Prevention and Management of Delivery

Complications

● Training a community member to recognize early warning signs of pregnancy problems, and refer the woman to a township doctor;

● Improvements in transportation services for referral;

● Education campaigns specifically targeted at newly married couples and their families, and the general public through television and radio messages

● Training a community member to recognize early warning signs of pregnancy problems, and refer the woman to a township doctor;

● Improvements in transportation services for referral;

● Education campaigns specifically targeted at newly married couples and their families, and the general public through television and radio messages

A study in Shunyi, China reduced perinatal mortality by 34% and early neonatal mortality by 25% by implementing the following interventions:

Resuscitation of the newborn

● Asphyxia due to prolonged labor or small infant size continues to claim the lives of nearly 1 million neonates each year.

● Infants born at home are those at greatest risk.

● Midwives and community health workers must be authorized and trained to give bag and mask resuscitation to newborns.

● Complex interventions such as intubation, chest compression and drugs are rarely needed.

● Asphyxia due to prolonged labor or small infant size continues to claim the lives of nearly 1 million neonates each year.

● Infants born at home are those at greatest risk.

● Midwives and community health workers must be authorized and trained to give bag and mask resuscitation to newborns.

● Complex interventions such as intubation, chest compression and drugs are rarely needed.

Interventions After Delivery

● Kangaroo Care Method● Breastfeeding and Nutritional

Support● Prevention and Management of

Infections

● Kangaroo Care Method● Breastfeeding and Nutritional

Support● Prevention and Management of

Infections

Bergman & Jurisoo Trop Doct 1994;24(2):57-60 & Kambarami et al. Ann Trop Paediatr 1998 Jun;18(2):81-6.

Kangaroo Care MethodKangaroo Care Method

In Zimbabwe, Kangaroo Care babies had:

● Improved survival● Faster growth;● A higher median weight and hospital

discharge weight;● A lower frequency of illness, and● A lower median duration of hospital

In Zimbabwe, Kangaroo Care babies had:

● Improved survival● Faster growth;● A higher median weight and hospital

discharge weight;● A lower frequency of illness, and● A lower median duration of hospital

Breastfeeding and Nutritional SupportBreastfeeding and Nutritional Support

● Breastfeeding protects against late neonatal deaths (from 8 - 28 days) which are primarily due to infections, such as sepsis, ARI, meningitis, umbilical infection (omphalitis), and diarrhea.

Breastmilk Only Breastmilk + Formula No Breastmilk

Victora et al Lancet 1987;Aug;8:319-21

Relative Risk for Mortality (0-1 Month) by Breastfeeding,

Pelotas, Brazil

Relative Risk for Mortality (0-1 Month) by Breastfeeding,

Pelotas, Brazil

Prevention and Management of Infections

● To protect immature epithelial barriers from infection, a topical emollient such a Aquaphor may be applied to the skin of pre-term infants.

● In clinical trials, Aquaphor reduced positive blood and cerebrospinal fluid cultures to 3.3% (controls = 26.7%).

● Studies are currently in progress to examine the safety and efficacy of inexpensive and locally available vegetable oil substitutes for use in the developing world.

● To protect immature epithelial barriers from infection, a topical emollient such a Aquaphor may be applied to the skin of pre-term infants.

● In clinical trials, Aquaphor reduced positive blood and cerebrospinal fluid cultures to 3.3% (controls = 26.7%).

● Studies are currently in progress to examine the safety and efficacy of inexpensive and locally available vegetable oil substitutes for use in the developing world.

Sepsis52%

Asphyxia20%

Prematurity15%

Other13%

A Bang, Personal Communication

Primary Causes of Neonatal Deaths in the

Community

Primary Causes of Neonatal Deaths in the

Community

Sepsis22%

Asphyxia26%Prematurity

Other12%

Congenital abnormality

Report on the Neonatal-Perinatal Database, 1995. New Delhi

Primary Causes of Death in Hospital-Borne Neonates

Implications for Research and Programs

● Community and Health System Barriers

● Adapting IMCI to the Neonatal Period

● Community-Based Neonatal Care in India

● Community and Health System Barriers

● Adapting IMCI to the Neonatal Period

● Community-Based Neonatal Care in India

Community and Health System Barriers

● A study in Guatemala of perinatal and neonatal deaths by McDermott and colleagues showed that 83% of mothers sought care, but most received care only from TBAs.

● In neonatal deaths, hypothermia was noted in 89%, the umbilical cord was cut with scissors in 86%, and nothing was applied to the cord wound in 53%.

● A study in Guatemala of perinatal and neonatal deaths by McDermott and colleagues showed that 83% of mothers sought care, but most received care only from TBAs.

● In neonatal deaths, hypothermia was noted in 89%, the umbilical cord was cut with scissors in 86%, and nothing was applied to the cord wound in 53%.

ArgentinaBrazilBoliviaColombiaEcuadorParaguayPeruVenezuela

EgyptIranMoroccoPakistanSudanSyriaTurkeyYemen

Status of implementation

Dominican Rep.El SalvadorHaitiHondurasNicaragua

Discussions had started in at least another 8 countries

ArmeniaAzerbaijanBelarusGeorgiaKazakhstan

KyrgyzstanMoldovaTadjikistanTurkmenistanUzbekistan

BangladeshBhutanCambodiaChinaIndiaIndonesiaLaosMyanmarNepalPhilippinesViet Nam

Expansion (12 countries)

Early implementation (31 countries)

Introduction (20 countries)

*Based on information available in June 1999

BeninBotswanaCote d'IvoireEritreaEthiopiaGhanaKenyaMadagascarMalawiMaliMozambique

NamibiaNigerNigeriaSenegalSouth AfricaTanzania, U.R.TogoUgandaZambiaZimbabwe

Implementation of IMCI (June 1999)*Implementation of IMCI (June 1999)*

Neonatal Health Interventions I

During Pregnancy

Neonatal Health Interventions I

During Pregnancy● Preparedness and counselling on

safe childbirth;● Treatment of maternal complications; ● Infection control in endemic areas

(malaria, syphilis and hookworm); ● Control of nutritional deficiencies ● Immunizing the mother with tetanus

toxoid; ● Avoiding harmful substances.

● Preparedness and counselling on safe childbirth;

● Treatment of maternal complications; ● Infection control in endemic areas

(malaria, syphilis and hookworm); ● Control of nutritional deficiencies ● Immunizing the mother with tetanus

toxoid; ● Avoiding harmful substances.

Neonatal Health Interventions II During

Childbirth

Neonatal Health Interventions II During

Childbirth● Safe and clean delivery; ● Effectively managed pregnancy

complications, and ● referral for essential obstetric

● Safe and clean delivery; ● Effectively managed pregnancy

complications, and ● referral for essential obstetric

Neonatal Health Interventions III For the

Newborn

Neonatal Health Interventions III For the

Newborn● Routine care and vigilance for all newborns,

during from 6-12 hours after birth; ● Special care for preterm and/or low birth

weight infants, including Kangaroo Care; ● Identification and treatment of infections; ● Support for mothers on providing newborn

care, and on recognizing danger signs and taking appropriate action;

● Immunization, and ● Prevention of vertical HIV/AIDS

transmission

● Routine care and vigilance for all newborns, during from 6-12 hours after birth;

● Special care for preterm and/or low birth weight infants, including Kangaroo Care;

● Identification and treatment of infections; ● Support for mothers on providing newborn

care, and on recognizing danger signs and taking appropriate action;

● Immunization, and ● Prevention of vertical HIV/AIDS

transmission

Bang et al

Community-Based Neonatal Care in India

● Case fatality from sepsis from 18.5% to 2.8%

● Perinatal mortality by 71%● Neonatal mortality by 62%

● Case fatality from sepsis from 18.5% to 2.8%

● Perinatal mortality by 71%● Neonatal mortality by 62%

A study in India which trained community health workers to treat or refer women with pregnancy complications; identify sick or high-risk newborns, treat infections and administer injections, reduced:

RESEARCH AND PROGRAM PRIORITIES

Program PrioritiesProgram Priorities

● Before Birth● During Labor and Delivery● The Early Weeks of Life

Perinatal and Neonatal Program Priorities Before

Birth● Increasing the quality and scope of

syphilis screening;● Improving the diagnosis and

treatment of ascending, reproductive tract infections in pregnant women;

● Expanding maternal immunization with tetanus toxoid and pneumococcus;

● Increasing the quality and scope of syphilis screening;

● Improving the diagnosis and treatment of ascending, reproductive tract infections in pregnant women;

● Expanding maternal immunization with tetanus toxoid and pneumococcus;

Perinatal and Neonatal Program Priorities Before

Birth● Presumptive malaria prophylaxis in

routine antenatal care visits, and● Nutritional support for pregnant

women to improve birth outcomes.

● Presumptive malaria prophylaxis in routine antenatal care visits, and

● Nutritional support for pregnant women to improve birth outcomes.

Perinatal and Neonatal Program Priorities During

Labor and Delivery

● Regular re-education of health workers and birth attendants and the use of economic incentives to improve the identification and management of malpresentation and prolonged labor;

● Referral of complicated cases to health center or hospital;

● Regular re-education of health workers and birth attendants and the use of economic incentives to improve the identification and management of malpresentation and prolonged labor;

● Referral of complicated cases to health center or hospital;

Labor and Delivery

● Combating the barriers to referral compliance, including transportation of mothers and care of other children, and

● Institution of perinatal and neonatal audits at hospitals and health centers

● Combating the barriers to referral compliance, including transportation of mothers and care of other children, and

● Institution of perinatal and neonatal audits at hospitals and health centers

Perinatal and Neonatal Program Priorities In the Early Weeks of

Life● Wider use of resuscitation techniques

for asphyxiated infants;● Proper management of neonatal

sepsis and other infections;● Skin-to-skin Kangaroo Care for

preterm infants, and● Immediate and exclusive

breastfeeding for all newborns.

● Wider use of resuscitation techniques for asphyxiated infants;

● Proper management of neonatal sepsis and other infections;

● Skin-to-skin Kangaroo Care for preterm infants, and

● Immediate and exclusive breastfeeding for all newborns.

Crucial to the success of programs is:Crucial to the success of programs is:

● national ownership, and ● public-private partnerships to

ensure long-term funding

● national ownership, and ● public-private partnerships to

ensure long-term funding

A cost-effective, and efficient way

to introduce interventions would be to make additions

to already existing programs.

A cost-effective, and efficient way

to introduce interventions would be to make additions

to already existing programs.

Research PrioritiesResearch Priorities

● Neonatal Infections● IMCI● Community-Based Health

Services● Malaria Reduction● Reduction of Premature and

IUGR Births

● Neonatal Infections● IMCI● Community-Based Health

Services● Malaria Reduction● Reduction of Premature and

IUGR Births

Research Priorities for Neonatal Infections

● Community-based surveillance to identify the principal bacterial and viral agents of neonatal infections

● Determination of the antimicrobial resistance profiles of the common bacterial agents of serious infections in neonates on a regional basis, in both community and hospital settings;

● Community-based surveillance to identify the principal bacterial and viral agents of neonatal infections

● Determination of the antimicrobial resistance profiles of the common bacterial agents of serious infections in neonates on a regional basis, in both community and hospital settings;

Research Priorities for Neonatal Infections

● Studies of neonatal care provided in the home by caretakers, traditional birth attendants, and community health workers, and follow cohorts of neonates for infectious outcome, and

● Case-control studies to identify the principal risk factors for neonatal infections. Risk factors to be evaluated include low birth weight; unhygienic delivery, skin and umbilical cord care; birth asphyxia; hypothermia; smoke inhalation; and feeding practices

● Studies of neonatal care provided in the home by caretakers, traditional birth attendants, and community health workers, and follow cohorts of neonates for infectious outcome, and

● Case-control studies to identify the principal risk factors for neonatal infections. Risk factors to be evaluated include low birth weight; unhygienic delivery, skin and umbilical cord care; birth asphyxia; hypothermia; smoke inhalation; and feeding practices

Research Priorities for IMCI

● Identification of historical information and clinical signs and symptoms that are most predictive of the presence of acute neonatal infection;

● Development of an algorithm for use in identifying neonatal infection, and

● Training and testing the abilities of community-health workers to use the algorithm to identify acutely infected neonates

● Identification of historical information and clinical signs and symptoms that are most predictive of the presence of acute neonatal infection;

● Development of an algorithm for use in identifying neonatal infection, and

● Training and testing the abilities of community-health workers to use the algorithm to identify acutely infected neonates

Research Priorities for Community-Based Health

Services

Services● Community-based studies to

determine existing obstetric practices, neonatal care, and health-seeking behavior for neonatal illnesses;

● Training of traditional birth attendants and community health workers to implement the package of basic neonatal care practices;

● Community-based studies to determine existing obstetric practices, neonatal care, and health-seeking behavior for neonatal illnesses;

● Training of traditional birth attendants and community health workers to implement the package of basic neonatal care practices;

Services

Services● Strategies to improve access to

emergency obstetric care, and methods to increase referral rates for complicated pregnancies, and

● Design of a package of simple practices for the routine post-delivery care of neonates born in the community.

● Strategies to improve access to emergency obstetric care, and methods to increase referral rates for complicated pregnancies, and

● Design of a package of simple practices for the routine post-delivery care of neonates born in the community.

Research Priorities to Reduce Malaria

● Efficacy studies of presumptive, intermittent treatment to prevent malaria as part of routine antenatal care in areas of high transmission;

● Design of methods for treatment of malaria during pregnancy using safe, effective and simple regimens in areas of high, medium, and low transmission;

● Efficacy studies of presumptive, intermittent treatment to prevent malaria as part of routine antenatal care in areas of high transmission;

● Design of methods for treatment of malaria during pregnancy using safe, effective and simple regimens in areas of high, medium, and low transmission;

Research Priorities to Reduce Malaria

● Evaluation of the safety and efficacy of newly available antimalarial drugs (alone or in combinations) for treatment and prevention in pregnancy, and

● Reduction of malaria exposure during pregnancy using methods such as insecticide-permeated bed nets.

● Evaluation of the safety and efficacy of newly available antimalarial drugs (alone or in combinations) for treatment and prevention in pregnancy, and

● Reduction of malaria exposure during pregnancy using methods such as insecticide-permeated bed nets.

Research Priorities to Reduce

Premature and IUGR Births

Premature and IUGR Births● Evaluation of simple methods for

detection of bacterial vaginosis, and appropriate treatment, such as comparing a once versus three-times daily treatment with metronidazole;

● Development of strategies to improve knowledge and practice of methods to prevent sexually-transmitted diseases;

● Evaluation of simple methods for detection of bacterial vaginosis, and appropriate treatment, such as comparing a once versus three-times daily treatment with metronidazole;

● Development of strategies to improve knowledge and practice of methods to prevent sexually-transmitted diseases;

Premature and IUGR Births

Premature and IUGR Births● Evaluation of the safety and efficacy

of maternal caloric supplementation for reducing low birth weight, and methods to reduce maternal anemia through the use of iron supplements, antihelminths and antimalarials, and

● Evaluation of micronutrient supplementation for the reduction of LBW, and improved neonatal health.

● Evaluation of the safety and efficacy of maternal caloric supplementation for reducing low birth weight, and methods to reduce maternal anemia through the use of iron supplements, antihelminths and antimalarials, and

● Evaluation of micronutrient supplementation for the reduction of LBW, and improved neonatal health.

● An ongoing dialogue must be established between governments and researchers to combat perinatal and neonatal mortality

● Governments must be able to call upon researchers to help them solve health problems, and research results must be used to formulate national programs and policies.

● An ongoing dialogue must be established between governments and researchers to combat perinatal and neonatal mortality

● Governments must be able to call upon researchers to help them solve health problems, and research results must be used to formulate national programs and policies.

We must create sustainable interventions

in countries where the needs are greatest

We must create sustainable interventions

in countries where the needs are greatest

More than nine million children will continue to die

before or just after birth each year, unless the international

health community finds solutions for and implements

programs to reduce their numbers.

More than nine million children will continue to die

before or just after birth each year, unless the international

health community finds solutions for and implements

programs to reduce their numbers.Duff Gillespie, Ph.D.,

Deputy Assistant AdministratorUSAID Population Health and Nutrition/Global Programs

Duff Gillespie, Ph.D., Deputy Assistant Administrator

USAID Population Health and Nutrition/Global Programs

THANK YOUFOR THINKING OF US

06 reducing perinatal & neonatal mortality

neonatal mortality decline

neonatal periods98

year mortality rates

perinatal deaths

child mortalityneonatal

deliveryrelated complications

global impact of infection

developing worldmost

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