Zulfiqar A. Bhutta Husein Lalji Dewraj Professor & Chairman Department of Paediatrics & Child Health Aga Khan University Karachi, Pakistan
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 Inequity in maternal and newborn health The health of the mother and newborn is inseparable 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 Where do 4 million newborns die? 1.5 million (38% of all newborn deaths) occur in 4 countries of South Asia Referral Hospital Tertiary University Hospital Secondary District General Hospital Sub-district Hospitals Primary Rural Health Center Village Health Units 50-60% 35-40% 5-10% When do they die? Up to 50% of neonatal deaths are in the first 24 hours 75% of neonatal deaths are in the first week 3 million deaths Spectrum of Asphyxia outcomes
Neonatal encephalopathy (mild/ mod / severe)
Neonatal death as a consequence of NE
Neurological disability as a complication of neonatal encephalopathy
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 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) 4 million newborn deaths Why? almost all are due to preventable conditions Two thirds of all neonatal deaths are in LBW infants Insufficient Health Services & Unhealthy Environment
Maternal & Newborn illness
Insufficient Household Food Security Resources & Control Human, Economic & Organisational Political, social and economic structures Malnutrition Disease Basic Determinants
Immediate causes Underlying causes Inadequate Education Political and Ideological Superstructure Economic Structure Manifestations Care for women Breastfeeding/Feeding; Psychosocial Care; Hygiene Practices; Home Health Practices
Three dimensions of poverty
Poverty of means and access Poverty of Hope! Poverty of Imagination
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 What can be done? Effective interventions for Newborn Care Lancet Series on Newborn Survival Paper 2 (2005) 16 interventions identified with adequate evidence of effect on neonatal deaths (e.g., tetanus toxoid immunization, clean delivery, obstetric care, breastfeeding, antibiotics for infections)
All are highly cost-effective especially if packaged and delivered within other programmes (e.g., maternal and child health)
Effective interventions for Newborn Care Lancet Series on Newborn Survival Paper 2 (2005) 16 interventions identified with adequate evidence of effect on neonatal deaths (e.g., tetanus toxoid immunization, clean delivery, obstetric care, breastfeeding, antibiotics for infections)
All are highly cost-effective especially if packaged and delivered within other programmes (e.g., maternal and child health)
Referral Hospital Tertiary University Hospital Secondary District General Hospital Taluka Hospital Primary Rural Health Center Basic Health Units Clinical or Facility-based care Outreach
Family and Community Packages
Intervention Packages Skilled 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 l i n i c a l
c a r e
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 F a m i l y - c o m m u n i t y
Clean home delivery
Simple early newborn care 15 - 32% 4-visit antenatal package including tetanus immunisation, detection & management of syphilis, other infections, pre- eclampsia, etc Malaria intermittent presumptive therapy*
Detection and treatment of bacteriuria #
O u t r e a c h
s e r v i c e s
Postnatal care to support healthy practices
Early detection and referral of complications
6 - 9% 23 - 50% NMR effect Infancy Neonatal period Pre- pregnancy Pregnancy Birth Administering basic community-based intervention packages at full coverage can save ~ 37% of all newborn deaths!
Coverage rates are low! How can these be scaled-up much faster? Know .Do gap Dont know.Dont do gap Analysis of systematic reviews for maternal and newborn health interventions 72 19 7 13 3 1 98 39 2 Antenatal Intrapartum Post-natal Developing Countries Community/Primary Care settings Effectiveness trials Bhutta et al (Pediatrics & GFHR 2005) 30% reduction in neonatal mortality! Major impact on maternal mortality! Shivgarh (India) Trial Community Mobilization and Behavior Change Communication 1. Birth preparedness for essential newborn care
2. Clean delivery, cord and skin care
3. Immediate wiping, drying and keeping the baby warm
4. Skin-to-Skin Care
5. Promotion of immediate and exclusive breastfeeding
6. Recognition and management of hypothermia
Shivgarh (India) Trial Community Mobilization and Behavior Change Communication 1. Birth preparedness for essential newborn care
2. Clean delivery, cord and skin care
3. Immediate wiping, drying and keeping the baby warm
4. Skin-to-Skin Care
5. Promotion of immediate and exclusive breastfeeding
6. Recognition and management of hypothermia
0 20 40 60 80 100 120 Control Intervention 1 Intervention 2 Perinatal Mortality Rate Neonatal Mortality Rate Hala Project Phase 2 Pilot (2003-2004)
8 clusters
317 villages 43000 households 284,000 population Community organization & mobilization Improved Primary Maternal, Perinatal & Newborn Care Improved Referral Pathways & Clinical Care (Common in all areas) (through Lady Health Workers) 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 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 Conclusions Improving newborn health and care is critical to attaining the MDG targets for child survival To do so would require concerted efforts to improve maternal 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 can be scaled up using affordable models of care Community engagement and ownership is a critical element in successful intervention models for maternal and newborn care Participatory development Democratization of public health