make them count using the best data for maximum impact
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Newborn Indicators Marketplace
Kate KerberJune 30, 2010
Make them count: using the best data for maximum impact
Outline
• Numbers, Rates and Causes • UN vs IHME?
• Countdown• Coverage of service use and behaviours• Equity, Policy, Finance
• Making an impact: presenting results• Using and improving your own programme data
(Tanya)
Definitions for reference• Neonatal: death within 0-28 days of life. (Early: day 0-7, Late: day 8-
28)– Neonatal Mortality Rate: deaths / annual births * 1000
• Infant – birth to one year• Child – deaths after 1 year and before 5 years• Under 5 – deaths from birth to age 5• Maternal mortality: death due to pregnancy-related causes
– Maternal Mortality Ratio: deaths / annual births * 100,000• Stillbirth: babies born dead after 28 weeks gestation
– Stillbirth rate: deaths / total births * 1000• Perinatal: Stillborn babies of 22+ wks plus deaths in the first 7 days
of life but definition varies. – Perinatal mortality rates: confusing!
Numbers – neonatal deaths
• NMR = number of deaths / number of annual births * 1000
• Number of deaths = NMR * annual births / 1,000
• Annual births?– Number of deaths will change if annual births change– Birth registration range: 4% Uganda to 87% Vietnam– UN Population Division estimates for consistency (e.g.
SOWC)
Progress to MDG 4 – child survival (global)
MDG 4 target (32)
Ref: Lawn, Kerber et al BJOG 2009 updated with data for 2008 from UN Child Mortality Group, WHO//CHERG and IHME (Rajaratnam J eta l 2010)
3.6 million neonatal deaths41% of under 5 deaths: Links closely with MDG 5
We are at a tipping point regardless of the estimates used
USA NMR is 4
Progress towards MDG 4 in 2008
On track: under-five mortality rate (U5MR) is less than 40, or U5MR is 40 or more and the average annual rate of reduction (AARR) in the U5MR observed for 1990-2008 is 4.0 percent or more
No Progress: U5MR is 40 or more and AARR is less than 1.0 per cent
Insufficient Progress: U5MR is 40 or more and AARR is less than 4.0 percent but equal to or greater than 1.0 percent
Data not available
Source: UNICEF, The State of Africa’s Children. Celebrating 20 Years of the Convention on the Rights of the Child. New York, 2010 (Table 10. The rate of progress)
Global progress to MDG 5 – maternal survival (Africa)
Ref: Kinney et al, PLoS 2010. Data from Hill et al 2007, Hogan et al 2010.
Overlapping estimatesStill not enough progress
IHME projects for 2010 on modeled data whereas the UN estimates for 2008 on existing data
Consistency and comparing like with like where possible
Not enough opportunity to review IHME methods
Other UN partners and bodies, including Countdown, are continuing to use UN numbers which have been through “country validation”
Reality: many countries aren’t using either of the UN or IHME numbers
We should continue to the use UN numbers because (25 June):
Everyone’s a critic but they are not very critical
Know the mortality rates in your country: UN, IHME, DHS, MICS - and when to use them
MMR in particular subject to very high uncertainty so do not use to show trends over time
Know how many deaths your estimate is based on (beware of small numbers) and where they come from
Encourage vital registration and strong HMIS in your countries
Source: CHERG/WHO 2010. Estimates for 193 countries for 2008. Black R et al Lancet 2010
New estimates of causes of newborn deaths
New from 2003 “Real” data used
for China and India Multi-cause model
used for all U5 Uncertainty
bounds
Neonatal messages 3 causes = 81% Tetanus declining National profiles
differ greatly
Countdown to 2015 for MNCH
68 countries accounting for 95% of deaths Multi-agency effort to analyze, summarize,
synthesize and disseminate data Contraceptive use Antenatal care Skilled attendance at delivery Postnatal care Child health Financial investment Equity of access Health systems and policy
Released at Women Deliver: Decade report with data profiles for 68 countries
SC representation through Joy Lawn as technical co-chair
Countdown to 2015: Coverage
20 coverage indicators tracked over time – increase is possible!
PNC database – advancing the indicator
SC representation through Allisyn Moran
Download the Countdown to 2015 meeting presentations:www.countdown2015mnch.org/conferences/2010conference/2010-session-reports
Countdown to 2015: Finance
Download the Countdown to 2015 meeting presentations:www.countdown2015mnch.org/conferences/2010conference/2010-session-reports
Download the Countdown to 2015 meeting presentations:www.countdown2015mnch.org/conferences/2010conference/2010-session-reports
Critical determinants of coverage across the continuum of care
SC representation through UK – Simon Wright/Nouria Brikci
Countdown to 2015: Policy
CCMTask shiftin
g
IMNCI
Costed
plans
Download the Countdown to 2015 meeting presentations:www.countdown2015mnch.org/conferences/2010conference/2010-session-reports
Poorest compared to richest across 8 interventions
Validity? Usability? SC representation – Kate Kerber
If all families in Nigeria got the same care as the richest families:NMR would be halved and 127,000 newborn deaths would be prevented
Countdown to 2015: Equity
Gap between poorest and richest households along the continuum of care in Uganda
0%
20%
40%
60%
80%
100%
Antenatal care(1+ visit)
Skilledattendant atchildbirth
Postnatal carewithin 2 days
DPT1
P oorest fifth householdsRichest fifth households
Uganda DHS 2006
Locally owned and Locally owned and led data for actionled data for action Country data Country data
profilesprofiles
Translating data into policy and programmatic action
Newborn Indicators Marketplace
Indicators for Newborn Health Programs
Tanya GuentherJune 30, 2010
Outline
• Newborn Indicator TWG Updates• Indicators for Kangaroo Mother Care• Resources • Discussion
Newborn Indicator TWG
Rationale:• Growing interest in newborn health
– Millennium Development Goals (MDGs 4 and 5)– WHO/UNICEF Joint Statement on Home Visits – Global Health Initiative
• Data gaps in monitoring and tracking newborn health– Countdown 2015 profiles and tracking process– LiST review of evidence
• Opportunities exist– DHS, MICS, SPA revision– SNL and partners’ sub-national surveys
Newborn Indicator TWG
Progress to date:• April 2008 Consultative Meeting convened by SNL• Inter-agency Working group formed • Research conducted to address gaps
– PNC/PPC data analysis for home/facility births (Bangladesh and Egypt using DHS data)
– Qualitative study on recall and practices (Bangladesh, Malawi by Macro and Ghana by ICH)
– MICS4 pre-test in Kenya
• Follow-up TWG meetings: January & June 2010
Newborn Indicator TWG
Areas of Focus:• PNC indicator
– Timing and place of visit, care provider– Content of visit – how much can we expect in large surveys?– Denominator – all births
• Newborn behaviors/practices – What to measure, how to ask questions, timing
• Newborn services at facilities– Ensure key drugs/equipment and staff competency measured: eg ANC
and PNC visits, EmOC, resuscitation, KMC, sepsis• Other areas
– Pregnancy vs birth histories, recognition of danger signs, care seeking, referral, KMC, HMIS, verbal autopsy, perinatal audit, policy and finance benchmarks
Newborn Indicator TWG
Progress and Recommendations:
PNC contact – Consensus on:
• timing of visit (within 2 days)• denominator should include all births • data must be comparable for the mother and baby• place of visit/provider may vary• there are issues with the numerator as it is currently measured
Newborn Indicator TWG
PNC (con’t):– MICS4 being finalized
– DHS will include all births– Outstanding issues:
• Content of PNC check • Cut-off for PNC to distinguish between intra-partum check and
postnatal check (i.e. 1 hr? 2 hrs?)
Facility Birth Home birth w/ attendant Home birth w/o attendant Duration of stay NA NA Check in facility Check with provider post
birth NA
Check post facility Check with provider Check with provider Who was the provider, where was the check, when was the check
Newborn Indicator TWG
Newborn care practices/behaviors:– Consensus on questions considered robust for use in population-based
surveys• Baby’s weight and size• Time of first breastfeed
– Consensus on areas that require more testing and validation– Measurement a work in progress– Effect of immediate newborn care practices is also under study and
will hopefully make the next LiST iteration
Newborn Indicator TWG
Newborn care practices/behaviors:Indicator Description Comments
1. Thermal care: Drying
Percent of newborns dried as soon as baby is born
No easy way to ask about timing; delivery of placenta not a good reference point due to variation
2. Thermal care: Wrapping
Percent of newborns wrapped as soon as baby is born
Analysis of SNL datasets to explore correlation between drying and wrapping; if high, will remove wrapping
3. Thermal care: Delayed bath
Percent of newborns with first bath delayed at least 6 hours after birth
Question should be open so different cut-offs can be used
4. Cord care: Clean instrument
Percent of newborns with cord cut with a clean instrument
Only home births where new instrument not used should be asked about boiling
5. Cord care: Dry cord care
Percent of newborns with nothing ever applied to the cord
Earlier questions ask about what was applied after cutting cord and did not cover entire period
Newborn Indicator TWG
Newborn care practices/behaviors (con’t):– Other areas identified for study:
• Clean delivery kits• Skin-to-skin• Care of small newborns (extra visits; facility-based KMC)• Care-seeking
– Draft questionnaire for newborn care practices developed – More work needed to refine questions– Need to analyze existing data sets (13 SNL baseline studies, with lots
of variation)
Newborn Indicator TWG
• Newborn services at facilities– Much less work in this area– Lack standard indicators for newborn services– Consensus on expanding SPA to include observations of delivery and
newborn care– Consensus that many tools exist that can be reviewed and built upon
(DHS SPA, MCHIP pilot SPA in Kenya; Rapid Health Services Assessment)
– Group meeting in July to begin drafting indicators and questions
Newborn Indicator TWG
Next Steps:• Continue work in small groups (PNC, NB practices; NB
services)• Analyze baseline datasets from SNL• Learn from MICS 4 roll-out and Kenya SPA• Next meeting in November 2010
Indicators for KMC
• Focus on facility-based KMC • High impact-low resource intervention• No standard indicators exist• SNL has developed some indicators to test• Tools are being developed to support these
indicators
Indicators for KMC
Core indicators:1. % of LBW babies on admission who received KMC2. % of facilities where KMC is operational3. # of health providers trained in KMC4. % of LBW babies on admission who received KMC
and survived to discharge5. % of LBW babies on admission who received KMC
lost to follow-up
Indicators for KMC
Supplemental indicators:6. % of health providers trained in KMC7. # of health facility staff oriented to KMC8. Average length of stay in KMC services (in days)9. Average number of follow-up visits among KMC babies
discharged from facility10. % of LBW babies on admission who graduated KMC
Resources
• List of helpful websites (handout)
• Sharepoint (coming soon: M&E page)– https://savenet2.savechildren.org/op/snl/Pages/snl_welcome.aspx – https://savenet2.savechildren.org/op/snl/Pages/Technical.aspx
• Technical assistance
Discussion
• Questions for us?• Discussion points:
– What are you measuring in your programs? – What information would you like to have? – What statistics do you see used incorrectly? – Are you planning to collect data on newborn health?– Have you been involved in DHS/MICS?
Be in touch for more information:
tguenther@savechildren.orgkkerber@savechildren.org
Thank you!
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