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GlobalNeonatalSurvival

Susan Niermeyer MD, MPH, FAAP

Global neonatal survivalobjectives

• Understand the importance of newborn survival to global child survival

• Know when, where, and why newborns die• Describe the ENAP goals for stillbirth, newborn and maternal death

• Identify potential actions and challenges to improving newborn survival 

Transition from MDGs to SDGs

2000 – 20158 goals49 indicators

2015 – 203017 goals169 indicators

Under‐5 child mortality45% of deaths occur in the neonatal period

2.7 million neonatal deaths and 2.6 million stillbirths per year worldwide

WHO, Levels and Trends in Child Mortality, 2015

Vision for Every Newborn Action PlanA world in which there are no preventable deaths of newborns or stillbirths, where every pregnancy is wanted, every birth celebrated, and women, babies and children thrive and reach their full potential

Lawn JE Lancet 2014  www.thelancet.com/series/everynewborn

When newborns are dyingtime of highest risk the same for newborns, stillbirths, women

Birth is the time of greatest risk of death and disability Triple return on investment – quadruple if count development outcomes

1.2 million intrapartum stillbirths

>1 million neonatal deaths

~113,000 maternal deaths

75% neonatal deaths

Birth day

Where newborns are dying 

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Countries with highest neonatal mortality rates

Central African Republic (40.9)Mali (41.5)Pakistan (42.2)DR Congo (43.5)Lesotho (45.3)Angola (45.4)Guinea Bissau (45.7)Somalia (45.7)Sierra Leone (49.5)

Countries with highest numbersof  neonatal deaths

1.  India (779,000)2.  Nigeria (267,000)3.  Pakistan (202,400)4.  China (157,400)5.  DR Congo (118,100)6.  Ethiopia (87,800)7.  Bangladesh (75,900)8.  Indonesia (72,400)9.  Angola (41,200)10. Kenya (40,000)

Lawn JE Lancet 2014  www.thelancet.com/series/everynewborn

Why newborns are dying 3 major causes of neonatal mortality

SevereInfections

Intrapartum‐related complications

Complications from low weight and preterm birth

Evidence‐based interventions3 major causes of neonatal mortality

HygieneMaternal tetanus immunizationDx/rx bacteruriaClean birth kitsChlorhexidineAntibiotic rx of neonatal infections in community

Improved fetal monitoringAccess to C‐sectionNeonatal resuscitation

Dx/rx pre‐eclampsiaAntenatal steroids and tocolyticsAntibiotics for PROMCPAP/SurfactantKangaroo mother careFeeding support

Essential Interventions, commodities and guidelines          

for  reproductive, maternal, newborn, child health Referral        1st level        Community

Ending preventable newborn and child deaths

Source: Lancet Every Newborn series, paper 2

From 2.9 to 0.8 million neonatal deaths About 29 countries will have to more than double their rates of progress

Sub national equity goals should also be set

A Promise Renewed target: National U5MR of 20 or less

Every Newborn target: National NMR of 10 or less

Source: Lancet Every Newborn series, paper 2

From 2.6 to 1.1 million stillbirthsAligned with NMR target

Sub national equity goals should also be set

Every Newborn targetNational stillbirth rate of 10 or less

Ending preventable stillbirths

Lancet GH Sept 2013 : The Lancet Global Health 2013; 1:e176‐e177 (DOI:10.1016/S2214‐109X(13)70059‐7)

Global average MMR of 70 per 100,000With different targets for different countries

Ending preventable maternal deaths 

Lawn et al http://www.nature.com/pr/journal/

In low income countries the major challenge is still survivalBUT in middle income countries higher disability

Must track and minimize disability when scaling up more complex neonatal care

Beyond newborn survivalwhere you are born predicts your survival and risk of disability

Preterm birth• Antenatal corticosteroids*, preterm labor management• Care including essential newborn care + Kangaroo mother

care

Birth complications

(and intrapartum stillbirths)

• Prevention by skilled attendance and obstetrics*• Care including essential newborn care + resuscitation*

Neonatal infections

• Prevention, essential newborn care especially breastfeeding, Chlorhexidine where appropriate*

• Case management of neonatal sepsis with antibiotics *

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* Prioritised by the UN Commission on Life Saving Commodities for Women and Children

71% of newborn deaths preventable actionable now without intensive care

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The three main causes of newborn deaths all have effective and feasible interventions = 3 by 2

Every Newborn’s guiding principles  

Country leadershipGood governance,

community participation, partner alignment

IntegrationIntegrated service

delivery, continuum of care, programme

coordination

EquityUniversal coverage,

closing the equity gap

Human rightsPrinciples, standards

AccountabilityTransparency,

oversight

InnovationInterventions, delivery

approaches, technologies

Helping Babies Breathe

• Action Plan • Facilitator Flip Chart• Learner Workbook• Neonatal Simulator• Bag and Mask• Suction Device

Learner pair + neonatal simulator6:1 learner‐to‐facilitator ratio

Facilitation of case scenarios in pairs

Peer learning/teaching

Clinical outcomesTanzania and India

• 60% of deaths <24 hours due to asphyxia ‐ TanzaniaN=4720 observational cohort

• ↓death at 24 hours among babies not breathing at birth (RR 0.53) and ↓ fresh s llbirth (RR 0.76) ‐Tanzania 

N=8124/78,500 pre/post training

• ↓ all s llbirths (OR 0.76) and fresh s llbirths (OR 0.54) with no change in neonatal deaths – India

N=4187/5411 pre/post training

Ersdal HL et al. Pediatrics 2012; 129:e1238 Msemo G et al. Pediatrics 2013; 131:e353   Goudar S et al. Pediatrics 2013; 131:e344

HBB as a framework for improved survivalNepal

KC Ashish et al. Pediatrics 2016

Continued practice and improvementin the facility

• Low-dose, high-frequency practice

• Self-reflection, debriefing, case review

• Perinatal quality improvement

Bookman L et al. PAS 2009 2505.7

Singhal N, McMillan DD, Cristobal FL, et al. Health Care for Women Intl 2001; 22:569

Essential Care for Every Baby

Essential Care for Small Babies

Helping Babies Survive addressing 3 major causes of neonatal mortality

SevereInfections

Intrapartum‐related complications

Complications from preterm birth

HBB: Basic resuscitation

ECSB: Continuous skin‐to‐skin careAlternative feeding methodsHygieneRecognition of problems

ECEB:Hygiene, cord careSkin‐to‐skin contactExclusive breastfeedingRecognition of danger signs, antibiotic treatment

Challenges for essential newborn care

Kangaroo mother (and father) care

Challenges to sick newborn care

Oxygen delivery

Thermal support

Helping Babies Breatheimplementation in 77 countries

The Formula for Survivalpatient survival is the product of three important factors

Søreide E et al. Resuscitation 2013;84:1487-93

Medical Science

EducationalEfficiency

LocalImplementation

Survival

WHO Quality Framework for Maternal and Newborn Health

Every Newborn Action Planchanging the landscape for newborn health

Newborn Indicators 2014 2016 Essential Medicines List 2014 2016

• Neonatal Mortality Rate• Stillbirth rate • Antenatal corticosteroid in HMIS• Resuscitation in HMIS• Kangaroo Mother Care in HMIS• Neonatal Sepsis in HMIS

000000

851527

• Antenatal corticosteroid• Chlorhexidine• Injectable antibiotics• Resuscitation devices

2211

71097

Every Newborn Action PlanWorld Health Assembly2014

Every Newborn Progress Reports

2015 & 2016

*11 USAID priority countries

National Newborn Action Plans2014: 2 countries2016: 17 countries*

www.everynewborn.orgwww.helpingbabiesbreathe.orgwww.usaid.gov/actingonthecall