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

“ 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

Inequity in maternal and newborn health The health of the mother and newborn is inseparable

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 1983 2000 1983 2000 Source: RHR/WHO, 2003

Where do 4 million newborns die? 1.5 million (38% of all newborn deaths) occur in 4 countries of South Asia

35-40% 5-10% 50-60% Tertiary Secondary Primary University Hospital Referral Hospital Secondary District General Hospital Sub-district Hospitals 35-40% Primary Rural Health Center 5-10% Village Health Units 50-60%

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 Data from DHS surveys in 47 countries, 10,048 neonatal deaths. A very high proportion of deaths occur in the first hours and days after birth. Prevention of these early neonatal deaths will require improvements in care at the time of birth and improvements in care in the early neonatal period.

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

Intra-partum Stillbirths an extension of Asphyxia deaths?

Newborn Deaths from Asphyxia: the tip of an iceberg 0.9 million asphyxia deaths 1-2 million suffer medium to long–term impairment Stillbirths from intrapartum hypoxia (~ 1 million deaths)

Two thirds of all neonatal deaths are in LBW infants 4 million newborn deaths – Why? almost all are due to preventable conditions Two thirds of all neonatal deaths are in LBW infants

Immediate causes Underlying causes Basic Determinants Maternal & Newborn illness Manifestations Immediate causes Malnutrition Disease Care for women Breastfeeding/Feeding; Psychosocial Care; Hygiene Practices; Home Health Practices Underlying causes Insufficient Household Food Security Insufficient Health Services & Unhealthy Environment Inadequate Education Resources & Control Human, Economic & Organisational Basic Determinants Political and Ideological Superstructure Economic Structure Political, social and economic structures

Three dimensions of poverty Poverty of means and access Poverty of Hope! Poverty of Imagination

30% Empowerment Support structures 39% Fatalism Past experience

What can be done?

Effective interventions for Newborn Care Lancet Series on Newborn Survival Paper 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)

Effective interventions for Newborn Care Lancet Series on Newborn Survival Paper 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)

Clinical or Facility-based care 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

Intervention Packages Skilled obstetric and immediate newborn care including resuscitation Emergency obstetric care to manage complications such as obstructed labour and hemorrhage Antibiotics for preterm rupture of membranes# Corticosteroids for preterm labour# Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies Clinical care 23 - 50% NMR effect 4-visit antenatal package including tetanus immunisation, detection & management of syphilis, other infections, pre-eclampsia, etc Malaria intermittent presumptive therapy* Detection and treatment of bacteriuria# Outreach services Postnatal care to support healthy practices Early detection and referral of complications Administering basic community-based intervention packages at full coverage can save ~ 37% of all newborn deaths! 6 - 9% Folic acid # Counseling and preparation for newborn care and breastfeeding, emergency preparedness Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care Extra care of low birth weight babies Case management for pneumonia Family-community Clean home delivery Simple early newborn care 15 - 32% Infancy Neonatal period Pre- pregnancy Pregnancy Birth

How can these be scaled-up much faster? Coverage rates are low! How can these be scaled-up much faster?

Know ….Do gap Don’t know….Don’t do gap

Analysis of systematic reviews for maternal and newborn health interventions Bhutta et al (Pediatrics & GFHR 2005)

30% reduction in neonatal mortality! Major impact on maternal mortality!

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

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

8 clusters Hala Project Phase 2 Pilot (2003-2004) 317 villages 43000 households 284,000 population

Community organization & mobilization Improved Referral Pathways & Clinical Care Improved Primary Maternal, Perinatal & Newborn Care (Common in all areas) (through Lady Health Workers)

Perinatal mortality trends (Hala, Pakistan)

Perinatal mortality trends (Hala, Pakistan)

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

Participatory development Democratization of public health