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NEWBORN HEALTH AND SURVIVAL
OVERVIEW & CASE STUDY
KIWOKO, UGANDAGH/HSERV 544MCH IN DEVELOPING COUNTRIES
Maneesh Batra MD, MPHFeb 15, 2011
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Goals Provide an overview of the current
status of Newborn Survival in the world
Place Newborn Survival within the context of Childhood Survival in the world
Provide an in-country example Highlight potential areas for
intervention to improve Newborn Survival
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The Newborn Period is Risky - Pop Quiz
Each year _ million children (<5 yrs old) die~8.8 million
Each year _ million infants (<1 yr old) die~5.9 million
Each year _ million newborns (<1 mo old) die~3.6 million = 10,000 per day!
How many die within the first 24 hrs of life ?~1.8 million
Black, 2010
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Millennium Development Goals
2000 UN Millennium Declaration:1. Eradicate extreme poverty and hunger2. Achieve universal primary education3. Promote gender equality and empower women4. Reduce child mortality5. Improve maternal health6. Combat HIV/AIDS, malaria and other diseases7. Ensure environmental sustainability8. Develop a global partnership for development
MDG-4 “Reduce Child Mortality by 2/3 between 1990 and 2015”
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Lawn Sem Peri 2010
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Is It Possible to Change This Trend?
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Childhood Deaths…Where?
Black, Lancet 2010
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Childhood Deaths…Why?
Black, Lancet 2010
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Lawn, IJGO 2010
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Half of neonatal deaths occur on day 1
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Neonatal Deaths – Why?
• Physiologic adjustments and adaptation to extrauterine life:• Establish breathing• Change fetal circulation to newborn• Body temperature regulation• Feeding and digestion• Immune system development
• Recognizing illness is a challenge
• Majority of births occur at home
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Neonatal Deaths – Where?
66% in 10 countries 99% in low/middle income countries Majority of deaths occur in-home, not in a
health facility
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Causes of Neonatal Deaths
Lawn, Sem Peri 2010
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Lawn, Sem Peri 2011
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Neonatal Deaths – Why?
60-80% of neonatal deaths occur in babies with birth weight <2500g
Risk of early death: 1500-2499g, 6 times greater <1500g, 100 times greater
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~3 million newborn deaths can be prevented with low-cost, low-tech interventions ~$1 per inhabitant per year! Marginal cost of adding neonatal resuscitation training and
equipment for midwives: <$0.02 per capita per year Most deaths could be prevented with simple interventions such
as: Thermoregulation Breast feeding, Kangaroo care Early treatment of infections A very small minority of patients require costly intensive care
How…
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Lawn, IJGO 2010
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Risk of Mortality Peaks Around Childbirth
ChildhoodNewborn/postnatalPre-pregnancy Pregnancy Birth
Maternal deaths
StillbirthsNewborn deaths
Child Deaths
Courtesy of ZA Bhutta
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Kiwoko, Uganda
Case Study
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Setting - Uganda
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Population: 27 million 84% rural
Languages: English, Luganda, Swahili
Literacy Rate: 69% (male), 59% (female)
Per capita GNP: $270 Fertility rate: 7.1 (5th in world) Malnourished Children: 26% Life expectancy: 42 years
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Setting - Uganda
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Per Capita Govt healthcare spending: $5
NMR: 29/1000 live births Annual Neonatal Deaths 40,900
IMR: 88.3/1000 live births
U5MR: 137/1000 live births
MMR: 435/100,000 live births Annual Maternal Deaths: 6,100
Stillbirths: 31/1000 deliveries
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Setting - Uganda
25Opportunities for Africa’s Newborns, 2006
21% of childhood deaths are newborns
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Setting – Luwero District
Area: 5773.53 sq. km Population: 492,184 (proj. 2000)
91.1% rural Population within 5 km of a health
services unit: 53%. Doctors to Population Ratio
1:23,438 16 doctors in the district
IMR: 112/1000 live births U5MR: 150/1000 live births
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Setting – Luwero District
Immunization Coverage: 46% Stunting Rate: 36% Acute Malnutrition: 7% Antenatal Care
ANC attendance rate: 75 % Delivery by trained staff: 36 %
Access to Safe Water: 42% Latrine Coverage: 54%
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Kiwoko Hospital
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Kiwoko Hospital Early 1990s - Abandoned
school into a health clinic by Dr. Ian Clarke
One of 3 hospitals in the district
4 full time doctors Serves population of 500,000 Treats 25,000 people per year 1000 deliveries per year 1500 operations per year Most patients arrive by foot or
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Kiwoko Hospital 150-250 beds 8 wards (Peds, Malnutrition, Male, Female, Surgical, TB,
Maternity, NICU) Outreach/Education
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Kiwoko Hospital - Resources
Majority of care by family members
Sporadic electricity Rain + well water Limited vaccine supply
BCG, DTP, Td, Measles, OPV Limited laboratory Limited medication supply Limited blood supply
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Kiwoko Hospital - NICU35
Built by ISIS, opened in 1999
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Kiwoko Hospital - NICU36
Primary Diagnoses: LBW, Sepsis, Tetanus, Malaria, Meningitis, Asphyxia, Meconium
Aspiration, Respiratory Distress
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Kiwoko Hospital - NICU
20 beds, 3 functioning incubators ½ of admissions inborn Overall Mortality 20-30% Tetanus Mortality 80-90%
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Why do babies die in Luwero?
At Home
Largely unknown magnitude and scope of problem
Barriers to seeking care Knowledge $$$$$$$$$ Impact on family unit What if the baby dies?
Critical point of intervention!39
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Why do babies die in Luwero?
In the Hospital In-born
LBW Sepsis Asphyxia
Out-born Delayed presentation LBW Sepsis, Meningitis, Skin infections Tetanus ? Etiology
Majority present with non-specific signs
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World Bank 2003
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Improving Newborn Outcomes
Framework Antenatal
Antenatal care Immunization Malaria treatment Maternal nutrition
Birth spacing Breast feeding
counselling
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Improving Newborn OutcomesFramework
Peripartum Skilled birth attendant Immediate newborn care Obstetric emergencies
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Improving Newborn Outcomes
Framework Postpartum
Recognition of illness Appropriate initial stabilization
Prevent hypoglycemia Maintain temperature Eye care Prevent/treat infections
Nutritional management of LBW
Availability of referral care Birth spacing
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Thanks!45