BornToDieintheFirstMonthofLife:Causation,Inequities&SocialDisparities

Socorro De Leon-Mendoza, M.D.NeonatalPediatrics

KangarooMotherCare Foundation,Philippines

GlobalScenario:Under-5Deaths

5.9Milliondeaths<5yrs old16,000deaths/day1in12children inAfrica1in19children inSoutheast Asia

WHOStatistics2016

GlobalPovertyMap

40%willdiewithintheirfirstmonthoflife

• 3.1Millionnewborndeaths/year• 14%ofU5deathsduetocomplicationsofprematurity

• 1.1Millionpretermdeaths/year

MDG2015ReportRecommendation

Majorityofthecountriesmadelittleprogressinachievingtheirtargets2015

Every 2 minutes, 1 newborn dies

209,000 neonatal deaths in the Western Pacific Regionevery year

1 dot represents 100 neonatal deaths

•WHOGlobalHealthObservatory,2011

Prematurity:Adirect&IndirectCauseofnewborndeath

TOP10COUNTRIESforpretermbirths

Blencowe etal.BornTooSoon:TheGlobalEpidemiologyofPretermBirths2013

Philippines’ScenarioU5Deaths:28/1,000livebirths 45%NewbornDeaths:13/1,000livebirths

• TotalLiveBirths:2.3Million(2015)• Under5Deaths:66,000• Neonataldeaths:29,700

• 81newborndeaths/day• 17pretermdeaths/day

LowBirthWeight

• Definedasbirthweight<2500g• Singlemostimportantdeterminantofchancesofsurvivalandfuturedevelopment

• Easiertomeasureandgloballyfeasiblecomparedtogestationalageassessment

• Includes:• Pretermbabies• Termbabieswhoaregrowth-restricted

LowBirthWeightBabies(<2500g):Heterogenous Population

Leeetal.GlobalStatisticalEstimatesonPreterm&LBW.Lancet2013

PublicHealthImplicationsofBeingBornLBW<2500g

Leeetal.GlobalStatisticalEstimatesonPreterm&LBW.Lancet2013

GlobalMapofSmallforGestationalAgeBabies

TOP10COUNTRIESWITHHIGHESTLBW’S

Philippines:No.1inRegionalLBWEstimates

CausativeFactorsofLowBirthWeight:(BornTooSoonorBornTooSmall)Prematurity

• SpontaneousPrematurity• Maternalage&pregnancyspacing• Multiplepregnancy• Infections• Maternalchronicmedicalconditions

• Nutritionalfactors• Lifestyle/work-relatedfactors• Maternalpsychologicalhealth• PreviousPretermDelivery• Genetic&others

• Provider-InitiatedPretermBirth• Obstetricindication• Fetalindication

In-UteroGrowthRestriction• Maternal

• Samefactorsthatcauseprematurity• ShortStature• Environmentalexposures

• Tobaccosmoke• Illicitdrugs• Alcohol• Lead• AirPollution

• SocialConditions• Poverty• DomesticViolence• Stress• Singleparenthood

• Fetal• Chromosomalanomalies

RecommendedInterventions:DualTrackModelWHOrecommendationsforimprovingoutcomesofpretermbirth2015

Preventionofpretermbirth1. Preconceptioncarepackageespecially familyplanning

2. Antenatalcarepackage3. Effectivechildbirthcare4. Policysupportincludingsmokingcessationandemploymentsafeguardsofpregnantwomen

Pretermnewborncare1. Essential andextranewborncare,especiallyfeedingsupport

2. KangarooMotherCare3. ManagementofprematurebabieswithcomplicationsespeciallyRDS,infectionsandjaundice

4. Neonatalresuscitation5. Comprehensiveneonatalintensivecare

Management of Preterm Labor

•Tocolyticsto slow down labor•Antenatal corticosteroids•Antibiotics for pROM•MgSO4 for neuroprotection

Reduction of Preterm Birth

Mortality Reduction Among babies born

preterm

PackagedInterventionsModellingScenarios

Intervention Scenario1 Scenario2 Scenario3

Antenatalsteroidsforpretermlabor Yes Yes YesKangaroomother care Yes Yes Yes

Earlybreastfeeding(within 1hourofbirth)

Yes Yes Yes

Injectableantibiotics forneonatalinfection

Yes Yes

Antibiotics forp/PROM Yes Yes

Resuscitation ofasphycticnewborn atbirth

Yes Yes

Staffhandwashingwithsoap&water Yes Yes

SurfactantforRDS Yes

Calibo A.DOHPhilippines: Scaling upEarlyEssential Newborn Care Interventions 2014

ModellingresultsS1 – 3 interventions S2 – 7 interventions S3 – 8 interventions

5-yearFacility-BasedKMCprojects- Philippines

• Trained:72hospitalfacilities• Totalnumberoflicensedhealthcarefacilities:1,233

• Coveragerate:5.8%• RegionalCentersofTraining:15• Evenwithsecondleveloftrainingavailable,coverageratestilllow

Socio-economicDisparities:ImpactonSurvival• TheChildintheruralareais1.7xmoreatriskofdyingthanthoseinthecity

• Thepoorestisalmost2xmorelikelytodiebefore5yrs old

• Childrenborntouneducatedmotherswillbe1.5xmoreatriskofdeath

• Childrenborntoeducatedmothershave2.8xhigherchancesofsurvival

Summary• Closetohalf(40%)ofchildrenunder-5willdiewithinthefirstmonthoflife(newbornperiod)

• Halfofnewborndeathsisattributabletoprematurityanditscomplications

• TheglobalprematurityandLBWmapcloselyapproximatesthepovertymapoftheworld

• CausativefactorsofprematurityandLBWaremostlyrelatedtosocio-culturalfactorsandenvironmentalexposureswhichcallsformoreresearch

• Accesstoandapplicationofrecommendedpackageofinterventionsbyconcernedcountriesremainlow