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Newborn Survival and Maternal

Health: a key to child survival


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

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