1. Essential "nutrition-related" delivery care practices for short- and long-term infant and maternal health and nutrition AMTSL and the newborn – an immediate postpartum care package: new directions and collaborative efforts POPPHI PPH Working Group, March 20, 2008 Camila M Chaparro, PhD Pan American Health Organization

2. What are the practices? Delayed umbilical cord clamping Immediate mother to newborn skin-to- skin contact Early initiation of exclusive breastfeeding

3. Why are they important? Delayed cord clamping: –Evidence that a minimum delay of 2 minutes: Improves infant hematological and iron status through 6 months of age in full-term infants –Preterm infants: delay of 30-45 seconds shows immediate benefits: prevention of late- onset sepsis, intraventricular hemorrhage; decreased blood transfusions, increased hematocrit

4. Infant iron status Iron deficiency is the most common nutritional deficiency worldwide, the most common cause of anemia Up to 50% of infants in developing countries are estimated to become anemic by age 1 IDA in young children associated with impaired cognitive, motor and behavioral development Some effects may be irreversible even after treatment, and many years later negative effects still evident

5. Prevalence of anemia:6-9 mo

6. Iron deficiency during infancy: Preventive interventions? Particularly in developing countries there may be few feasible and affordable interventions to prevent iron deficiency in infants One intervention to improve infant iron status is delayed umbilical cord clamping (DC) (Chaparro CM et al, Lancet 2006)

7. DC significantly increased infant body storage iron at 6 months of age 1 EC DC 20 29 38 47 56 65 Body storage iron (mg) 30.7 57.6 p = 0.0003 1 Adjusting for maternal ferritin and employment 27 mg Fe = 1.25 mo Fe requirements

8. DC increases body iron more in infants born to ID mothers 1 Iron-replete mothers Iron deficient mothers EC DC 35 38 41 44 47 50 Infant Body Iron (mg/kg) 46.7 42.1 47.5 48.6 p = 0.008 for interaction term ID = ferritin < 12µg/L

9. DC increases body iron more in infants with birth weight ≤ 3000 g Birth weight > 3000 g Birth weight 2500 to 3000 g EC DC 35 38 41 44 47 50 Infant body iron (mg/kg) 45.2 41.2 47.7 48.3 p = 0.04 for interaction term

10. Why are they important? Skin-to-skin contact: –Improves time to effective breastfeeding, as well as more "successful" breastfeeding on the first latch breastcrawl.org –Positively associated with breastfeeding status at 1-4 months postpartum and a longer breastfeeding duration

11. Why are they important? Early initiation of exclusive breastfeeding –Reduces neonatal and infant morbidity and mortality Initiation of breastfeeding within the first hour could reduce 22% of all-cause mortality (Edmond et al Pediatrics, 2006) Single most effective intervention for preventing under-5 mortality (13%) (Lancet, 2005) –Nutritionally ideal food –Long-term health benefits for mother and infant

12. Are they being done? Delayed cord clamping –POPPHI data: % of deliveries where cord clamped ≤ 1 min Ethiopia: 93% Tanzania: 75% El Salvador: 71% Guatemala: 90% Honduras: 88% Nicaragua: 94% Indonesia: 96% Indonesia (domiciliary deliveries): 86%

13. Are they being done? Skin-to-skin contact –?–? Early initiation of exclusive breastfeeding –DHS data

14. Source: Macro International Inc, 2008. MEASURE DHS STATcompiler. http://www.measuredhs.com, March 3 2008.

15. Why not? Lack of research on benefits/risks Barriers to "evidence-based" clinical practice: habit, convenience, little access to medical literature, outdated guidelines/curricula/clinical norms Other barriers: cultural Lack of integrated nature of guidelines for maternal and newborn care (perceived incompatibility between maternal and newborn care practices)

16. Philip AGS, Saigal S. NeoReviews 2004;5:142-154.

18. Presents the evidence base for the three practices Recommendations for each practice Suggested steps to ensure integration within the context of other programs Addresses "common concerns/FAQs" with delayed cord clamping

19. Briefly presents the evidence supporting the three practices plus AMTSL Presents a suggested sequence of steps for integration of the practices

20. What can be done? Simple, safe, effective and no-cost practices to improve infant nutrition, with potential long-term implications for health and development Greater awareness of revised AMTSL guidelines (WHO/FIGO/ICM) recommending delayed cord clamping Coordination between obstetric and pediatric programs to bridge the divide between "maternal" and "newborn" care

21. What can be done? Re-emphasis on importance of delivery care practices/hospital routines for infant nutrition and health Renewed emphasis on BFHI certification, and importance of re-certification