Lawn: Best Buys for Women & Babies - Maximising Returns on Investments

7/28/2019 Lawn: Best Buys for Women & Babies - Maximising Returns on Investments

1/21

Best buysfor women & babies:Maximising returns on investments

Professor Joy Lawn MB BS, MRCP (Paeds), MPH, PhD

MARCH, London School Hygiene and Tropical Medicine

Director Evidence and Policy, Saving Newborn Lives/ Save the ChildrenDFID Senior Research Fellow, Newborn Health


2/21

Nobabystillborn

Our delivery goal

Nonewborn isborn to die

2.9 million die~ 280,000 die 2.6 million die

Nochildstuntedor dying3 million die

3.5 million within a few days of birth

10 million deaths


3/21

1. Epidemiology

Burden (mortality, disability)

Risk factors

Equity gaps

2. Evidence

Interventions, highest impact, cost effectiveness

Implementation approaches, accelerators

3. Environment, including health system

Health system coverage and quality

Context specific bottlenecks for implementation

Evidence-based public health investment

Target

Tools

Team,supplies,

and systems

strength


4/21

Target setting

The Big Five!

Target

The Big One!


5/21

Congenital9%

Intrapartumrelated23%

Preterm36%

Sepsis13%

Pneumonia11%

Diarrhoea2% Other

6%Indirect18%

Haemorrhage

35%

Hypertension18%

Sepsis8%

Unsafeabortion

9%

Embolism1%

Other

direct11%

Congenital2%

Infection6%

Fetalgrowth

restriction3%Other

1%

Noconditionidentified

88%

Congenital

4%Infection

5%

Acute

intrapartum event59%

Fetal

growthrestriction

2%

Other1%

No conditionidentified

29%

Maternal deaths0.28 m

Neonatal deaths3 m

Stillbirths2.6 m Intrapartumntepartum

Noahs Ark

not the Big Five!

Causes of confusionTarget

Sources: Stillbirths, Lawn JE et al Lancet SB series, Maternal, Countdown 2011 report, Neonatal Liu et al Lancet 2012


6/21

Global number of maternal, neonatal

deaths and stillbirths (approx)

1. Childbirth complicationseg haemorrhage, obstructed labour

~ 2.12 million

2. Preterm birth complications ~1.1 million

3. InfectionsMother - HIV, syphilis, malaria, maternal sepsis,

Baby - sepsis, pneumonia, diarhoea, tetanus

~1.12 million

4. Maternal chronic conditions (NCDs)eg hypertension, diabetes,

(linked to preterm and to small for gest age)

5. Nutrition (undernutrition and obesity)

The Big Five underlying conditions to target to

save the lives of mothers and babies

75%

Target

Sources: Maternal, Countdown 2011 report, Stillbirths, Lawn JE et al Lancet SB series, Neonatal Liu et al Lancet 2012


7/21

Maternal

Series2006

Repro-

ductive

Health

Series

2006

Child

develo

pment

series2007

Newborn

2005

Child2003

Over 200

single

interventions

listed!!

Nutrition

series

2008

Stillbirth

series

2011

Higher impact if achieve a systems approachIntegrated service delivery = efficiency

Emphasis on impact for women and babies = value added

Malaria

series

2010

Noncommun

icable

diseases

AIDs

multiple

series

PMNCH essential interventions (56)agreed Sept 2011

Primary focus on survival

MDG timeframe

RMNCH interventions evidenceProliferating interventions and proliferating Lancet series..

NEW LAST WEEKPneumonia/ Diarrhoea GAPPD

Tools


8/21

1970

Initial trials

in lambs

First trial in

humans

NIH consensus

statement

Cochrane review

19 RCTs

Standard of carein rich countries

Remains low coverage

in middle and low

income rich countries

1980 201020001990

Bench Bedside Global reach

Still no WHO

policy review

2007

First trial

published

2012

3rd RCT

published(all from Asia)

WHO policy

review in

process

Evidence Action

A predictable timeline?

Multiple

RCTs

Antenatal corticosteroid injections

for women in preterm labour

Chlorhexidine

cord cleansing

Tools


9/21

Tools approach

The systems approachThe simple toolkit

Tools

Team,supplies,

and systems

strength

Can use simple tools and then integrate in a

systems approach


10/21

Newborn toolkit approachTools

Sources: Born Too Soon Chap 5 2012, Lawn J et al, IJGO, 2009

Estimated annual newborn lives

saved at universal coverage

Case management of neonatal sepsis * ~ 500,000

Chlorhexidine umbilical cord cleaning * (cannot yet estimate in LiST)

Antenatal corticosteroids for preterm labour* ~ 430,000

Neonatal resuscitation*

Kangaroo Mother care

~ 230,000

~450,000

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


11/21

Maximum return on investment

The best buys to address deaths of mothers and babies

Women Still-

births

Newborn

s

SGA and

stunting +

pretermFamily planning + + + +

Prevention/ management of

infections in pregnancy especially

syphilis and malaria

+ + + +

Prevention/ management ofhypertension in pregnancy + NCDs

+ + + +

Quality care at birth(including Em Obstetric care, essential

newborn care & resuscitation)

+ + +

Care of preterm labour & of preterm

babies

- - +

Prevention/management of

infections in newborns

- - +

Optimal nutrition through the

lifecycle especially breastfeeding

+ +/- +

Tools

eg

eg

eg

eg


12/21

Family planning

222 million women and girls lack access to family

planning which would change their lives, and their

families

16 million adolescent girls (age 15-19) give birth each

year (~11% of all births), and are at risk of adverse

outcomes for themselves and their babies

Risk is also higher for elderly pregnant women (>30

yrs) and their babies

Family planning reduces numbers of births, and hence ofdeaths. The risk reduction evidence is less clear cut

Tools

Need more analyses regarding the linkages of family

size and newborn survival


13/21

Lack of family planning also affects

coverage of the health system

Coverage vs women reached

In Nigeria, continued

population explosion means

modest gains in coverage

hide large gains in numbers

reached with skilled

attendance

Coverage Number of

attended births

1990

2008

31% 38%

1.3m

2.7m

Skilled attendant at birth, Nigeria

Data from Countdown to 2015 for Maternal, Newborn and Child Health, 2012.


14/21

Care during pregnancy - infections

Malaria in pregnancy

Severe malaria, low birth weight

Malaria in pregnancy interventions include Insecticide

treated bed nets (ITNs) and intermittent presumptive

treatment (IPTp) High coverage might prevent 75000200000 neonatal

deaths

Tools

Newman L, Kamb M, Hawkes S, Global Estimates of Syphilis in Pregnancy and Associated Adverse Outcomes: Analysis of Multinational Antenatal

Surveillance Data. PLoS Med 10(2): e1001396. doi:10.1371/journal.pmed.1001396

Steketee RW, Nahlen BL, Parise ME, Menendez C. The burden of malaria in pregnancy.Am J Trop Med Hyg2001; 64 (suppl 12): 2835.

Sexually transmitted infections, especially syphilis

~ 91,800 neonatal deaths,

~212,000 stillbirths (>28 wk) or early fetal deaths (22 to 28 wk),

Improved simplified testing available, low cost treatment

Yet ~ 66% of adverse outcomes occurred in ANC attendees who not tested

or were not treated for syphilis

WHO. The global elimination of congenital syphilis. Geneva: RHR, World Health Organization; 2007

Missed opportunity to save lives, especially stillbirths

Missed opportunities to measure gestational age and small for gestational age


15/21

Source: Pattinson R, Kerber K, Buchmann E, et al, for The Lancets Stillbirths Series steering committee. Stillbirths: how can health systems

deliver for mothers and babies? Lancet2011; published online April 14. DOI:10.1016/S0140-6736(10)62306-9.TRIPLE RETURN ON INVESTMENT

Basic

antenatal

Advanced

antenatal

Childbirth careCare at birthTools

T


16/21

Our delivery reality

SavetheChildren

Under use Over use

Both are a quality gap

But the over use scenario is a major impact opportunity

Team,supplies,

and systems

strength

T


17/21

0

20

40

60

80

100

Skilledattendance at

birth

C-section Basic Em ObsCare

Comp Em ObsCare

Activemanagement

of the 3rdstage of labour

Antenatalcorticosteroids

Neonatalresusitation

KangarooMother Care

Covera

ge

(%)

QUALITY GAPS = Opportunities to seize

Eg Uganda

Quality gap

Ref: Science in ActionSaving the lives of Africas mothers, newborns and children.ASADI 2009. Eds Kinney MV, Lawn JE, Kerber KJ

Data sources: Example of Uganda using current coverage data and LiST

Coverage Gap

to reach all births

Team,supplies,

and systems

strength


18/21Born Too Soon: The Global Action Report on Preterm Birth

15 million babies are born too soon every year...

Survival gap10 90

Over 90% of extremely preterm babies (


19/21

- In 39 high income countries the potential for preterm birth prevention is

VERY SMALL at about 5%

- Interventions examined included smoking reduction, C section practices,

progesterone, cerclage.

- URGENT need to examine preterm birth syndrome and understand and

develop solutions especially for spontaneous preterm birth

- EVEN more urgent for low income settings as likely much greater scope

possible in addressing high infection load in pregnancy, adolescent

pregnancy, birth spacing etc Limited evidence partly because of failure to

measure gestational age eg only one high quality malaria in pregnancy

trial had gestational age outcome

KNOWLEDGE GAP


20/21

3.5 million deaths within days of birthHappier Birth Days are key to reducing deaths and also disability

We are the first generation with tools to

transform global maternal and newborn and

child survival - will we reach our goal?

Best buys

Who? Addressing more than one target group (women, babies)

When? Focus around the time of birth

Which?

Family planning, Antenatal care especially infections in pregnancy

Care at birth including essential newborn care and resuscitation

Care of the preterm and sick newborn

How? Context specific programme action and leadership#globalnewbornaction


21/21

Be part of the actionfor newborns

#Newborn2013 #GlobalNewbornAction

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Lawn: Best Buys for Women & Babies - Maximising Returns on Investments