1. Every NewborN Overview of the Series
“A healthy start is central to the human life course, with birth holding the highest risk of death, disability and loss of development potential, leading to major societal effects.”
His Honourable Minister, distinguished ladies and gentlemen and standing on all existing protocol
This presentation is given on behalf of the rest of the Lancet Every Newborn study team. If you are on twitter, please use #EveryNewborn
Mary Kinney, MSc
on behalf of the Lancet Study Team
Nigeria Newborn Health Conference
October 23, 2014

2. Building a movement Strategic use of key momentsx
WHO World Health Assembly
A movement has been building since 2005 when the first Lancet Neonatal Series was launched and we are climbing from success to success. Even in the past 3 years, major milestones have included the Lancet stillbirths in 2011 and the Born Too Soon report in 2012.
In 2013, we had the first ever global newborn conference where the idea of a global newborn action plan was launched and consultations began.
-> The launch of The Lancet Every Newborn series in May 2014 was followed by the Every Newborn Action Plan endorsed at the World Health Assembly and the plan was then launched officially in June.
Today, The Lancet Every Newborn series provides the underlining evidence for this conference as it present the clearest picture to date of a newborn’s chance of survival and highlight the steps that must be taken to end preventable newborn deaths.
The end of MDGs brings new clarity about what is left behind on the agenda – newborns, adolescents

3. 5 articles, 6 comments, 55 authors from 18+ countries,
Every Newborn Series
Who has been caring for the baby?
Every Newborn: Progress, priorities, and potential beyond survival
Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?
Every Newborn: Health-systems bottlenecks and strategies to accelerate scale-up in countries
From evidence to action to deliver a healthy start for the next generation
The Series contains 5 articles, 6 comments from 55 authors from 18+ countries, and over 60 partner organizations who supported the launch on 19th May 2014
The first paper “Who has been caring for the baby?” was led by Gary Darmstadt at the Bill and Melinda Gates Foundation and reflects what has changed in newborn health in the past decade.
The second paper “Every Newborn: Progress, priorities, and potential beyond survival” led by Joy Lawn at the London School for Hygiene and Tropical Medicine provides various analyses on newborn mortality and morbidity, birth and death certificates across countries, and details on the analyses and consultation process in developing the Every Newborn targets for ending preventable newborn deaths and stillbirths.
The third paper led by Zulfiqar Bhutta from the Aga Khan University and SickKids Toronto presents a review of the evidence-based solutions and how many lives could be saved if these interventions reached universal coverage and how much this would cost.
The fourth paper led by Kim Dickson from UNICEF undertook a systematic assessment of health systems bottlenecks constraining the scale-up of care at birth and care of small and sick newborns which included results from an analysis conducted in Nigeria.
The final paper led by Liz Mason from WHO was the call for action - “From evidence to action to deliver a healthy start for the next generation” presenting the Every Newborn action plan goals, targets and milestones within the post-2015 framework.
Rather than going through details on each of these papers, this presentation will rather highlight key messages across the series. And all of the papers are freely accessable at this website
5 articles, 6 comments, 55 authors from 18+ countries,
60+ partner organizations

4. Within reach: ENDING PREVENTABLE CHILD AND MATERNAL DEATHS
Every Newborn Series key actions
Within reach: ENDING PREVENTABLE CHILD AND MATERNAL DEATHS
First message, ending preventable child and maternal deaths is within our reach

5. Average annual rate reduction
We’ve made significant progress toward MDGs 4 & 5, but newborn survival is lagging behind
Average annual rate reduction
Maternal mortality ratio*
2.6%
Children aged months
3.4%
Neonatal mortality
(newborn, first 4 weeks after birth)
2.1%
Stillbirths
(last 3 months of pregnancy)
1.0%
( )
At least 40% slower for newborn survival and slower still for stillbirths
Since 1990, under-5 and maternal deaths have been halved worldwide owing to the Millennium Development Goals (MDGs). However, the average annual progress for reductions in neonatal mortality rate was much lower than child and maternal mortality. Progress is even slower for stillbirths. Regional variations are also enormous. At present rates of progress, it will be more than a century before a baby born in Africa has the same chance of survival as one born in a high-income country; this is three-times longer than it took in high-income countries before the advent of intensive care.
-> Every Newborn sets bold, but achievable, targets for newborn mortality and stillbirths in the next two decades. Lily will go through these targets and the consultative process
The Every Newborn Action Plan sets new and achievable targets for ending preventable deaths: Newborn deaths, stillbirths and maternal deaths
Source: Adapted from Lawn J,E. et al Newborn survival: a multi-country analysis of a decade of change. Health Policy and Planning. 27(Suppl. 3): iii6-ii28. Data sources: UNICEF WHO MMR estimates 2014
* Maternal mortality ratio annual rate reduction

6. How many? Where? The countries with highest neonatal mortality rates 2
Cen African Rep (40.9)
Mali (41.5)
DR Congo (43.5)
Lesotho (45.3)
Angola (45.4)
Guinea Bissau (45.7)
Somalia (45.7)
Sierra Leone (49.5)
The countries with highest neonatal mortality rates 2 1
Countries with highest numbers of neonatal deaths
1. India (779,000)
2. Nigeria (267,000)
3. Pakistan (202,400)
4. China (157,400)
5. DR Congo (118,100)
6. Ethiopia (87,800)
7. Bangladesh (75,900)
8. Indonesia (72,400)
9. Angola (41,200)
10. Kenya (40,000)
It is within our reach because we know how many die and where they die. More than 75% of newborn deaths occur in south Asia and sub-Saharan Africa.
-> Nigeria ranks number two for highest number of deaths. In many cases, the countries with the highest neonatal mortality rates also have the highest number of deaths and the slowest progress for reducing neonatal mortality.
Every year:
2·9 million newborns die
2·6 million babies are stillborn
287,000 women die from complications in pregnancy and childbirth
Source: Lancet Every Newborn series, paper 2

7. BUT in every region there are countries with rapid progress
Which countries are progressing?
Countries in dark red are making slowest progress for newborn survival, 29 countries need to at least double progress to meet post 2015 targets 2 1
It is within our reach because we know which countries are progressing fastest and which ones need more attention. Countries in dark red shown here have to double progress to meet the new targets by 2035.
->But in every region there are countries with rapid progress and want to learn from these examples.
Source: Lancet Every Newborn series, paper 2
BUT in every region there are countries with rapid progress

8. Causes of under five deaths 44% are from neonatal causes
3 main killers to address:
Preterm birth
Birth complications
Neonatal infections
80% of newborns deaths are in small babies of which
2/3rds are preterm
It is within our reach because we know the causes of newborn deaths
Four out of five newborn deaths result from three preventable and treatable conditions: Complications from preterm birth, infections, complications during childbirth. In fact new estimates published this month show that preterm birth is now the leading cause of under-5 deaths globally. More than 80% of neonatal deaths in sub-Saharan Africa and south Asia occur in small babies, and many could be prevented with simple newborn care.
Small babies are also at a raised risk of longer term complications, including stunting, loss of human capital, and noncommunicable diseases.
Data source: Cause of death - WHO. Global Health Observatory Child deaths - UN Inter-agency Group for Child Mortality Estimates. Levels and Trends in Child Mortality. Report 2013; Stillbirths - Lawn et al The Lancet stillbirth series (9775) p1448 – 1463 8

9. 71% of newborn deaths preventable
The three main causes of newborn deaths all have effective and feasible interventions = 3 by 2
Preterm birth
Antenatal corticosteroids*, preterm labor management
Care including essential newborn care + Kangaroo mother care
Birth complications (and intrapartum stillbirths)
Prevention by skilled attendance and obstetrics*
Care including essential newborn care + resuscitation*
Neonatal infections
Prevention, essential newborn care especially breastfeeding, Chlorhexidine where appropriate*
Case management of neonatal sepsis with antibiotics * 1 2 3
It is within our reach because we know how to reduce the main causes of neonatal death
For each of the main causes of death there are prevention and management evidence based solutions. This slides shows examples of some of these solutions.
-> 71% of newborn deaths are preventable now without intensive care
71% of newborn deaths preventable
actionable now without intensive care
* Prioritised by the UN Commission on Life Saving Commodities for Women and Children

10. Prioritize day of birth
Every Newborn Series key actions
Prioritize day of birth
Second, prioritize day of birth

11. When? For women, stillbirths, newborns, the time of highest risk is the same
1.2 million intrapartum stillbirths
>1 million neonatal deaths
~113,000 maternal deaths
75% neonatal deaths
Birth day
The time of labour and the day of birth is when 46% of all maternal deaths and 40% of all stillbirths and neonatal deaths occur. About three-quarters of all neonatal deaths occur during the first week of life, with 1 million babies dying on the day they are born
Birth is the time of greatest risk of death and disability.
Birth is the time of greatest risk of death and disability
Triple return on investment – quadruple if count development outcomes
Source: Lancet Every Newborn series Lawn et al

12. Beyond newborn survival
The world you are born into determines your survival and your risk of disability
Every year, an estimated 19 million newborn babies face life-threatening conditions, including preterm birth, intrapartum-related brain insults, severe bacterial infection, and pathological jaundice. At least 1·5 million newborn babies survive with long-term disabilities every year.
-> As countries improve mortality outcomes, we must track and minimize disability by scaling up more complex neonatal care.
In low income countries the major challenge is still survival
BUT in middle income countries higher disability
Must track and minimise disability as we scale up more complex neonatal care
Lawn et al

13. Invest In care at birth and reap a triple return
Our third message, Invest in care at birth and reap a triple return

14. Lives that could be saved per year with universal coverage
Based on an analysis conducted for the third paper inThe Lancet Every Newborn Series, care around the time of birth (labour, childbirth and the first day after birth) provides a unique period along the continuum of care to prevent maternal and newborn deaths as well as intrapartum stillbirths.
-> 370,000 lives could be saved in Nigeria each year with high cover of these packages of care: 29,000 women, 250,000 newborns and 97,000 stillborns
370,000 lives could be saved in Nigeria each year
29,000 women, 250,000 newborns and 97,000 stillborns
Source: The Lancet Every Newborn series, paper 3

15. Packages for integrated care for women and children
Effective interventions for improving survival and health of newborns form only part of integrated health services for reproductive, maternal, newborn and child and adolescent health. These interventions have been well documented and discussed already. By strengthening and investing in this critical window, it is a triple return on investment saving women and newborns and preventing stillbirths – it is a quadruple return when you count development outcomes
-> With High coverage of care globally, 3 million lives per year would be saved at an additional running cost of US$1·15 per person
CARE AT BIRTH, TRIPLE RETURN
Highest impact, Highly cost effective
Benefits women, stillbirths, newborns
3 MILLION LIVES SAVED PER YEAR
Running cost $1.15 per person
Source: Lancet Every Newborn series, paper 5

16. TARGET SPECIFIC HEALTH SYSTEM BOTTLENECKS
Fourth message, target specific health system bottlenecks

17. Major bottlenecks in care of small and sick newborns
Health System bottleneck assessment for care around birth and care of small and sick newborns
We undertook systematic assessments of health system bottlenecks constraining the scale-up of care at birth and for small and sick newborns. The assessments involved more than 600 experts, identifying 2465 bottlenecks and solutions in eight countries (>50% of the burden) including Nigeria.
What we found is that
- High-burden countries have similar health system challenges, particularly for financing (notably higher out-of-pocket expenditure) and health workforce (low health workforce density of doctors and midwives).
- Context-specific health data are important since an intervention might be perceived feasible in some countries but challenging in others. For example, kangaroo mother care was judged highly feasible in African countries but challenging in Asia.
There are intervention specific findings with some having several bottlenecks. For example, there are major bottlenecks for care of small and sick newborns. Others, for example essential newborn care, have few major bottlenecks but might rely on behavioural changes by families and health workers.
Since health system constraints vary for different interventions and different contexts, it is crucial to assess these in detail nationally and sub nationally to target these bottlenecks.
Major bottlenecks in care of small and sick newborns
Green 1-3 countries, orange 4-5 countries, red 6-8 countries
Source: Lancet Every Newborn series, paper 4

18. What works in fast progressing countries?
Lessons from countries that have reduced neonatal deaths
Malawi
Workforce planning increases numbers and specific skills
Peru
Financial protection measures including expansion of health insurance
Nepal
Dynamic leadership, innovation and community empowerment
Strategies to systematically scale-up care
High mortality countries → Improve supply, demand, equity and quality
Low mortality countries → Focus on quality and equity, and beyond survival
Rapidly progressing countries
We also took lessons from countries that have reduced neonatal deaths by overcoming bottlenecks and improving access to and quality of care, including workforce planning in Malawi to increase numbers and upgrade specific skills, task sharing, and incentives for rural health workers; dynamic leadership including innovation and community empowerment in Nepal; and financial protection in Peru.
If all countries achieved the same rate of progress as these regional neighbour, then the Every Newborn target for 2035 would be met.
Source: Lancet Every Newborn series, paper 4

19. We know What should change?
Fifth message, we know what should change

20. Adoption curves for global health innovations
One major challenge has been slow scale up of newborn health interventions – this graph shows
-> low use of ACS and KMC despite evidence from the 1970s and
-> little progress for skilled birth attendance and exclusive breastfeeding – but we now know what needs to be done and it is time to scale up known life saving interventions in appropriate settings
22%

21. Official development assistance for MNCH as tracked by Countdown to 2015
“Stillbirth” or “fetal” missing in donor funding databases
More funding is essential for change to take place in countries. Less than 10% of official development assistance for maternal, newborn, and child health, mentions the word “newborn”, with only two mentions of “stillbirth”. However, it is a myth to assume that funding “maternal, newborn and child health” will automatically finance the specific additional investments in skills, commodities, and practices required to reduce newborn deaths. This is also true in national health budgets.
22%
Source: Lancet Every Newborn series, paper 1

22. Count every mother every newborn
Every Newborn Series key actions
Count every mother every newborn
Sixth message, count every mother every newborn

23. Count every newborn
One third of babies have no birth certificate in their first year
The majority of neonatal deaths and almost all stillbirths have no death certificate
Counting programme coverage and quality
Most high impact neonatal care interventions lack coverage data
One third of babies have no birth certificate in their first year and the majority of neonatal deaths and almost all stillbirths have no death certificate. Yet almost 75% of births worldwide occur in facilities. It is a missed opportunity to certify and undertake mortality audits.
If we don’t count them, they are not counted by society leading to inevitably of their death.
-> each year, 5.5 million babies enter and leave the world without certificates. This must change
5.5 million babies enter and leave the world without certificates
Urgent need to improve birth and death registration
Opportunities with facility-based minimum perinatal dataset and perinatal audit

24. Unprecedented opportunity for progress is now
Will we act on the call?
The time is now!
Final message, there is unprecedented opportunity for progress now. Lily will take over now and present the Every Newborn action plan. Will we act on the call?
Every Newborn Action Plan
Get involved!

25. Could save 2 million lives a year by closing this quality gap
Care at birth, and care of small and sick newborns First opportunity is the QUALITY gap for facility births
Please put this back in your presentation since I couldn’t find a place in mine.
Could save 2 million lives a year by closing this quality gap
Particular focus on health workers especially midwives
“Every Mother Every Newborn” quality initiative
Source: Lancet Every Newborn series, paper 3

26. Launch of the Lancet series -May 19th
+90 individual media hits with articles across the world
+100 million twitter impressions in first week and 12 million people reached through social media
Launch events in NYC and Geneva to coincide with WHA
Country launches: India, Nigeria, China, Pakistan, Malawi, and others

27. Series key findings
Within reach: ending of preventable child and maternal deaths
Prioritize day of birth
Invest in care at birth and reap a triple return
Target specific health system bottlenecks
Count every mother and every newborn baby
Unprecedented opportunity for progress is now

28. When will every newborn have the same survival chance as newborns in the richest countries?
Sub-Saharan Africa
Year: 2124
Southern Asia
Year: 2103
South-East Asia
Year: 2070
Latin America/Caribbean
Year: 2043
Eastern Asia
Year: 2028
North Africa/West Asia
Year: 2051
Caucasus/Central Asia
Year: 2062
Years for each region to reach NMR of 3 = industrialized countries current average
By projecting regional average rate of reduction
At present rates of progress, it will be more than a century before a baby born in Africa has the same chance of survival as one born in a high-income country; this is three-times longer than it took in high-income countries before the advent of intensive care, despite the possibility of more rapid progress now given new evidence and many feasible innovations.
NMR 3
NMR 1
110 YEARS FOR AFRICAN NEWBORNS…
Nearly 3 times longer than this change took rich countries, despite new interventions
Source: Lancet Every Newborn series, paper 2