Newborn Survival and Maternal Health: a key to child survival

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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

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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
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Inequity in maternal and newborn health
The health of the mother and newborn is
inseparable
4
Deaths among infants under 7 days are decreasing
more slowly than among older infants
100
Developing Regions
Post-neonatal mortality
80
Late neonatal mortality
Early neonatal mortality
60
40
Developed Regions
20
0
1983
2000
1983
2000
Source RHR/WHO, 2003
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Where do 4 million newborns die?
1.5 million (38 of all newborn deaths) occur in
4 countries of South Asia
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Tertiary University Hospital
Referral Hospital
Secondary District General Hospital Sub-district
Hospitals
35-40
Primary Rural Health Center
5-10
Village Health Units
50-60
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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
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Spectrum of Asphyxia outcomes

• Neonatal encephalopathy (mild/ mod / severe)
• Neonatal death as a consequence of NE
• Neurological disability as a complication of
  neonatal encephalopathy

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Intra-partum Stillbirthsan extension of Asphyxia
deaths?
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Newborn Deaths from Asphyxiathe tip of an
iceberg
0.9 million asphyxia deaths
1-2 million suffer medium to longterm impairment
Stillbirths from intrapartum hypoxia ( 1
million deaths)
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4 million newborn deaths Why?almost all are
due to preventable conditions
Two thirds of all neonatal deaths are in LBW
infants
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Maternal Newborn illness
Manifestations
Immediate causes
Malnutrition
Disease
Care for women Breastfeeding/Feeding
Psychosocial Care Hygiene Practices Home
Health Practices
Underlying causes
Insufficient Health Services Unhealthy Environme
nt
Insufficient Household Food Security
Inadequate Education
Resources Control Human, Economic
Organisational
Basic Determinants
Political and Ideological Superstructure
Economic Structure
Political, social and economic structures
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• Three dimensions of poverty
• Poverty of means and access
• Poverty of Hope!
• Poverty of Imagination

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30 Empowerment Support structures
39
Fatalism Past experience
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What can be done?
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Effective interventions for Newborn CareLancet
Series on Newborn SurvivalPaper 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)

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Effective interventions for Newborn CareLancet
Series on Newborn SurvivalPaper 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)

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Tertiary University Hospital
Referral Hospital
Secondary District General Hospital Taluka
Hospital
Clinical or Facility-based care
Primary Rural Health Center
Outreach
Family and Community Packages
Basic Health Units
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Intervention Packages
23 - 50 NMR effect
6 - 9
15 - 32
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Coverage rates are low!
How can these be scaled-up much faster?
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Know .Do gap
Dont know.Dont do gap
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Analysis of systematic reviews for maternal and
newborn health interventions
Bhutta et al (Pediatrics GFHR 2005)
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30 reduction in neonatal mortality!Major impact
on maternal mortality!
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Shivgarh (India) Trial Community Mobilization
and Behavior Change Communication

• Birth preparedness for essential newborn care
• Clean delivery, cord and skin care
• Immediate wiping, drying and keeping the baby
  warm
• Skin-to-Skin Care
• Promotion of immediate and exclusive
  breastfeeding
• Recognition and management of hypothermia

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Shivgarh (India) Trial Community Mobilization
and Behavior Change Communication

• Birth preparedness for essential newborn care
• Clean delivery, cord and skin care
• Immediate wiping, drying and keeping the baby
  warm
• Skin-to-Skin Care
• Promotion of immediate and exclusive
  breastfeeding
• Recognition and management of hypothermia

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Hala Project Phase 2 Pilot (2003-2004) 8
clusters 317 villages 43000 households 284,000
population
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Community organization mobilization
Improved Referral Pathways Clinical Care
Improved Primary Maternal, Perinatal Newborn
Care
(Common in all areas)
(through Lady Health Workers)
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Perinatal mortality trends (Hala, Pakistan)
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Perinatal mortality trends (Hala, Pakistan)
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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

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Participatory development Democratization of
public health