Surviving the First Month of Life Lily Kak, USAID Indira Narayanan, BASICS Mini-University, George Washington University October 27, 2006

Four Million Newborn Deaths: Where? 99% of newborn deaths are in low/middle income countries 66% in Africa and Southeast Asia

Stagnating Trends in Neonatal Mortality Global Sub-Saharan Africa Asia and Middle East Latin America and Caribbean Source: DHS and RHS estimates for countries receiving USAID support Number of countries: Global-35; ANE -8; Africa – 17; LAC: 9

Millennium Development Goal 4 can only be achieved if neonatal deaths are addressed Global mortality per 1000 births Year Under-5 mortality rate Present trend MDG 1-60 mo. mortality < 1 mo. mortality (NMR) Neonatal Deaths and the Millennium Development Goals Source: Neonatal Lancet, 2005

Coverage of Newborn Care During the Most Critical Period 75% of neonatal deaths are in the 7 days Only 50% of deliveries are attended by skilled birth attendants Up to 50% of neonatal deaths are in the first 24 hours Only 21% receive postnatal care within 7 days

Newborn Care in Sub-Saharan Africa: the Weakest Link NIB: Non-Institutional Birth Source of data: DHS; State of the World’s Children, 2006

The Lancet Child and Neonatal Survival Series identified newborn survival as a priority, lacking information and action The World Health Report advocates the repositioning of MCH as MNCH (maternal, newborn and child health) Newborn Health: No longer Falling Through the Cracks

Infection 36% Sepsis/Pneumonia Tetanus Diarrhea Asphyxia 23% Other 7% Complications of Prematurity 27% Cong. Anom 7% Low birth weight is a significant contributor in 60–80% of neonatal deaths. Adapted from Lancet 2005 Major Causes of Neonatal Mortality Tetanus Toxoid Immunization of Mother Clean Delivery Cord Care Early & Exclusive Breastfeeding Antibiotics for mother and baby Warming Resuscitation Skilled Birth Attendants Syphilis Control Folate Supplementation Malaria Control Antenatal Corticosteriod Treatment of bacteriuria Kangaroo Mother Care Birth Spacing Maternal Nutrition Evidence Based Interventions for

Context-Specific Package Intermittent presumptive treatment for malaria Prevention of Mother-to-Child Transmission of HIV Syphilis detection and treatmentIodine Essential Maternal & Newborn Care USAID October, 2006 Other Essential Interventions Prophylactic Eye care Adequate nutrition Family planning Immunization Special care for LBW Emergency Obstetric and Newborn Care Iron and folate Minimum activities: Facility ANC Birth preparedness Tetanus toxoid Safe Birth with Skilled Attendance Partograph Infection prevention Active mgt of 3rd stage of labor Newborn resuscitation Postpartum Cord care Thermal care Immediate & excl breastfeeding Infection Treatment Minimum activities: Community ANC Birth preparedness Tetanus Toxoid Safe Birth Clean delivery Referral link for obstetric& newborn complications Postpartum Cord care Thermal Care Immediate & excl Breastfeeding Infection recognition & referral/treatment

Saksham LOGO A community based and community driven essential newborn care program Shivgarh, India Source: Global Research Activities, Johns Hopkins University

Neonatal Mortality Rate, Shivgarh, India Source: Global Research Activities, Johns Hopkins University

Projahnmo Projahnmo… Sylhet, Bangladesh A community based essential newborn care program Source: Global Research Activities, Johns Hopkins University

Significant reduction in neonatal mortality with home-based care Neonatal Mortality Rates Sylhet, Bangladesh Projahnmo… Source: A Community-based Effectiveness Trial to Improve Newborn Health in Sylhet District of Bangladesh, GRA/JHU, 2006

Pearl # 1 All newborns need essential newborn care

USAID’s Global Priorities Introduce and expand community-based essential newborn care globally Focus on major killers to reduce mortality: low birth weight, infections, asphyxia

Globally, 60-80% Neonatal Deaths occur in Babies below 2500 Gm (LBW) LBW Based on Vital Registration data for 45 countries (N = 96797). and modeled estimates for 146 countries (N = 13,685) - Lawn JE, Cousens SN. Zupan J, Lancet 2005 Management of Low Birth Weight

Low Birth Weight Infants c Global burden: 21 million, 96% in developing countries Global incidence: 16%

Distribution of 21 million LBW WHO, UNICEF. Country, regional and global estimates. 2004

The priority from a public health point of view is the group of larger / more mature LBW infants Currently, there is more evidence and experience on management than prevention of LBW infants Bang 2005 Priority Intervention

Outcome of LBW babies with extra care at first referral level facility CategorynDied/referredDischarged <1500g10128%72% g2647%93% g17441%99% All LBW21093%97% Paul VK- Ballafgarh Hospital ( )

With intervention, 95% LBW survived Bang 2005 Outcome with Extra Care at Community Level

Extra Care for LBW Babies Extra focus on essential newborn care especially –Temperature maintenance –Prevention of infection –More frequent breastfeeding and/or use of breast milk Kangaroo Mother Care - major components –Skin to skin contact –Position –Nutrition –Support to mother and baby –Discharge & follow-up policy

Baby wears only a diaper (cap and socks where needed) Placed vertically in between the mother’s breasts Wrapped firmly / securely on to the mother’s chest Can also be carried out by other family members Kangaroo Mother Care (KMC)

Thermal control—mother’s temperature adjusts for baby Vital signs better—breathing more regular—less ‘periodic breathing’; less apnea Less crying—less stress—even in term babies after delivery—salivary cortisol twice as high in control infants with standard care than with skin- to-skin contact 1 hr. post birth. Better breastfeeding Bonding KMC - Advantages

Simple, effective, low cost intervention At facility level and at home Has global applications—both for advanced and developing countries. May be the only alternative in resource-poor situations Other practical applications: –Just after birth for all babies (without problems needing immediate attention) –During transport of sick & LBW babies KMC - Conclusions

Pearl # 2 Kangaroo Mother Care is for humans too!

Congenitalmalformations 7 % Birth asphyxia & trauma 23 % Neonatal tetanus 7% Diarrhea 3% Sepsis / Pneumonias 26 % 7 % Others Complications of Prematurity27% Low Birthweight Infections 36 % Causes of Neonatal Mortality

Neonatal Sepsis Timing of Deaths and Interventions Source: South Asia Newborn Health Investigators Group (Unpublished courtesy Steve Wall ) Clean delivery Cord care Colostrum and exclusive breastfeeding Identify signs of illness- algorithms / Antibiotics

Types of Infections  Minor Infections:  Thrush  Conjunctivitis  Skin infections  Umbilical infection ( localized)  Major Infections  Specific entities such as pneumonia, diarrhea, septicemia and meningitis difficult to diagnose in the newborn. Hence catch- all term “sepsis” is used in public health  Easy spread and rapid progression of disease  High case fatality  Specific infections such as syphilis, HIV/AIDS, Hepatitis B, tetanus, and malaria

Trotman Ann. Tropical Paediatrics 2006 and Robillard West Indian Medical Journal 2001 Timing of Infections  Early onset of infection (0-3d) is usually acquired from maternal risk factors and during delivery such as:  Maternal fever  Premature rupture of the membranes (> hr)  Unhygienic delivery practices  Poor cord care  Late onset of infection (4-30d) are usually acquired from the environment (most likely acquired in the home or facility - nosocomial) due to factors such as:  Unhygienic newborn care practices (i.e., lack of hand washing)  Excessive invasive procedures

Neonatal Sepsis Key Components Of Prevention Antenatal period: –Addressing tetanus, STD, HIV/AIDS and malaria Delivery: –Clean delivery practices, preventive Essential Newborn Care (ENC) –hygiene-clean cord and skin care, breastfeeding Postnatal period: –Preventive maternal and newborn care – clean cord and skin care, breastfeeding

Preventive ENC Preventive ENC+HBC of sick babies Pratinidhi et al Bang et al Fall in NMR 23.1% Fall in NMR 62.2% Percentage Newborn Care: Impact of Options on Mortality - Community Level

Neonatal Sepsis: Clinical Characteristics Newborns, notably LBW infants are at high risk for infection Easy spread to other organs and rapid progression of disease Specific diagnosis difficult in major infections – hence catch-all term “sepsis” is used High case fatality Susceptible to special germs that do not affect normal older infants Most require injectable antibiotics Organisms vary by region, over time and with long term use of antibiotics All these have public health implications

Neonatal Sepsis : Danger Signs Numbers vary (1 st 4 or 5 most important) –refusal to feed/suck/poor feeding –inactivity/lethargy/ ‘limp limbs’ –body hot/cold –Rapid breathing /difficulty in breathing chest in-drawing, grunting/nasal flaring –weak/no cry –vomiting/abdominal distention –periumbilical redness/pus discharge Based on Bang et al, BASICS country programs IMCI – signs

Neonatal Sepsis: Needed Government Policies –Availability of drugs, supplies, and equipment Need for appropriate –Antibiotics, including required strengths –Supplies and equipment including suitable sizes –Quality of services at the facility –Policies of administration of antibiotics by less qualified health workers in special situations

Neonatal Sepsis: Link with IMCI Conventional IMCI addresses babies older than 1 week Now newborns included by WHO and by some countries One prominent example is IMNCI-India –Includes 0-6 days of age –50% of training time on infants 0-2 months of age –Home-based care of young infants by workers added –In severe illness administration of first dose of oral antibiotics before referral Requires training, supervision, and suitable drugs and supplies Needs to be applied at facility and community level

Neonatal Sepsis: Major Infections Major infections: –Early stage: Baby can accept feeds and maintain temperature with simple aids –Late stage: Baby cannot feed and/or maintain temperature with simple aids Influences level of treatment

Strategies/OptionsLevels for Implementation Strategy No. 1: Preventive essential newborn care + detection of danger signs + care seeking/referral Home, community and facility; prevention key Strategy No. 2: Strategy #1 plus treatment of minor infections and first dose of antibiotics at community / facility level before referral Health posts/centers, ? home/community Strategy No. 3: Strategy # 2 plus treatment with injectable antibiotics for moderate sepsis at community /facility level Health centers and higher Strategy No. 4: Strategy # 3 plus full treatment including intravenous fluids Referral hospitals Management of Neonatal Infections

Pearls for Today 1.All newborns need … 2.Kangaroo mother care is for…

Care of the sick newborn is challenging but will improve mortality outcomes to better achieve MDG #4 Babies are worth it We need to act NOW!