1. Generating the evidence to save newborn lives Uzma Syed, MBBS, MPH, MSc Advisor, Asia Region Saving Newborn Lives/Save the Children Reconvening Bangkok: 2007-2010 March 6-11, 2010, Bangkok Improving Newborn Survival: A Priority Towards MDG-4

2. Outline Newborn Health in the region Evidences –Addressing the 3 killers –Newborn health ‘packages’ Evidence to action

3. Source: Lawn JE et al Lancet 2005 66% of global neonatal deaths Most of the Countries with very high NMR Newborn Deaths: where & when? 4 million dies within 28 days 3 million dies within 1st week 2 million intrapartum related stillbirths & neonatal deaths 1 million dies within 1st day

4. Achieving MDG4 depends on the newborn

5. GA P 1 GAP 2 Coverage along the continuum of care Source: Lancet Countdown Coverage writing group, Lancet Countdown special issue, 2008

6. Disparity in coverage: Indonesia data DHS 2007. Courtesy: Dr Kirana Pritasari, MQIH

7. Asia regional key issues Stagnation of NMR trend across the countries Causes of neonatal death broadly similar regardless of NMR Gaps in continuum of care Need for institutional integration to scale up Difficult to manage long term HR problems Data and indicators –No national data –need for NBH MIS indicators –Inadequate quality of data Opportunities and innovations –integration into national programs –engaging the private sector –Addressing equity and disparity across the board

8. Evidence for Newborn Health

9. Danger signReferenceIntervention↓NMR birth asphyxia Wall et al. Int J Obstetr Gynaecol 2009 Resuscitation by Facility providers Community workers 30% intrapartum 20% intrapartum pretermLawn et al. Int J Epi (in press) Shivgarh/India skin-to-skin care Facility community 51% in <2kg 54% (as a package) Prevention of infection Rhee et al Bhutta et al Projahnmo/ Sylhet Handwashing Clean delivery Chlorhexidine 41% As a package Data forthcoming Management of Infection Sazawal and Black. Lancet Inf Dis 2003;3:547056 SEARCH/India Projahnmo MINI/Nepal Community case management by CHWs 27% CFR declined from 16.6% to 6.9% CFR 4.4% Evidence for newborn complications

10. Evidence for Packages including early home visits StudyProvider Home visits for newborn care onContent of home visits ↓NMR SEARCH (India) Source: Bang et al. Lancet 1999 Community health worker (paid. Plus performance incentives) Prenatal, Delivery, Days 1, 2, 3, 5, 7, 14, 21 and 28 Prenatal counselling Care at birth (resuscitation) Postnatal visit (care & counselling) Infection management LBW care (extra visits) 61% ANKUR (India) Source: Bang et al. Unpublished Community health worker (paid, plus performance incentives) Prenatal, Delivery, Days 1, 2, 3, 5, 7, 14, 21 and 28 Prenatal counselling Care at birth (resuscitation) Postnatal visits (care & counselling) Infection management LBW care (extra visits) 51% Projahnmo (Bangladesh) Source: Baqui et al. Lancet 2008 Community health worker (paid)Prenatal, Days 1, 3, and 7Prenatal counselling Postnatal visits (newborn assessment, counselling) Treatment of newborn infection (if refused referral) 34% Shivgarh (India) Source: Kumar et al. Lancet 2008 Community health worker (paid), changed to community volunteers Prenatal, Days 1 and 3Prenatal counselling Postnatal visits (counselling) 54% Hala (Pakistan) Source: Bhutta. Bull World Health Organ 2008 Lady Health Worker (government paid)Prenatal, Days 1, 3, 7, 14 and 28Prenatal counselling Postnatal visits (newborn assessment, counselling, referral if needed) 30%

11. Evidence Summary Interventions exist to save lives from 3 major newborn killers. Community based management of newborn complications improves newborn survival significantly. Evidence-based packages implemented by community workers are highly effective in reducing neonatal death. Based on compelling evidence, there is global consensus for early postnatal home visits linked to strengthened health systems as a key strategy to improve newborn survival.

12. Evidence to policy and action

13. Evidence to Action: few examples National Neonatal Health Strategies developed: Nepal, Bangladesh Newborn Health in action plans: Vietnam, Afghanistan, Bangladesh Large-scale Newborn Programs Launched: Pakistan, India, Bangladesh, Nepal, National surveys included newborn indicators and set targets: DHS Global policy adapted to national policy: e.g.; UN Joint Statement – Postnatal home visits modified, tested, scaled up

14. Integrated approach for Delivering at Scale Nepal: Piloting community based newborn care package in 10 districts Bangladesh: P ostnatal care package in GO and NGO settings Afghanistan: Strengthening Postnatal Care in national BPHS program Pakistan: CB management of newborn complications in existing large scale programs Vietnam : Piloting NBC model in Thanh Hoa province Indonesia : postnatal visits integrated in Garut district

15. Integration to address the gap: Nepal example Source: DHS, 2006 CBNCP package Counseling during pregnancy Promotion of skilled delivery Care of the mother & newborn within 24hr, 3d, 7d, Comm Case mgt. – infection/Asphyxia care of the low birth weight

16. Evidence to action: Steps Generated evidence National policy formulated MOH-led development of integrated packages for pilot testing/OR embedded in existing service delivery structures Systematic evaluation and planning for scale up at national level

17. Implementation challenges Pregnancy surveillance; notification of labor/births Health worker retention Linkages between home and facility Weak referral Policy barriers Absence of data/experience with program implementation at scale

18. Cultural Challenges Common cultural barriers for care-seeking –40-day postnatal seclusion –Vulnerability to “evil eye” –Cultural explanations for newborn illness –Preferences for religious or traditional remedies

19. Evidence to Action: Lessons There is never a smooth linear progression Policy and implementation are only rarely based solely on evidence. Research is most effective when undertaken to understand gaps identified by governments. Priority must be given to delivering these in existing health systems at scale. International learning can be effective. Success requires governments to be in the driving seat and to be able to call on quality TA from genuine partners if necessary