1. 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

2. “ 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

3. 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
1983
2000
1983
2000
Source: RHR/WHO, 2003

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

6. 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%

7. 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.

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

9. Intra-partum Stillbirths an extension of Asphyxia deaths?

10. 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)

11. 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

12. 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

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

14. 30%
Empowerment
Support structures
39%
Fatalism
Past experience

15. What can be done?

16. 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)

17. 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)

18. 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

19. 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 %
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 %
Infancy
Neonatal period
Pre- pregnancy
Pregnancy
Birth

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

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

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

23. 30% reduction in neonatal mortality! Major impact on maternal mortality!

24. 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

25. 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

26. 8 clusters Hala Project Phase 2 Pilot (2003-2004) 317 villages
43000 households
284,000 population

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

28. Perinatal mortality trends (Hala, Pakistan)

29. Perinatal mortality trends (Hala, Pakistan)

30. 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

31. Participatory development Democratization of public health