Massee BatemanMassee BatemanDirector, Saving Newborn Lives, Save the ChildrenFunded by the Bill & Melinda Gates Foundation

Global Maternal Health ConferenceGlobal Maternal Health ConferenceSeptember 2010

Evolution of NBH and convergence with maternal health

Outline

1.

The Situation

2.

Decade Evolution of Newborn Health

3.

Convergence with Maternal Health

The Situation

Ideal

CHALLENGEMajority of births occur at home,

without access to skilled care

Antenatal Care

(Tetanus toxoid, STI mgmt, counseling,

birth preparedness)

Emergency Obstetric Care

(Treatment of

obstructed labor, hemorrhage)

Emergency Newborn Care

(Treatment for very

low birthweight, sepsis, asphyxia)

Postnatal Care

(Early detection and

treatment of complications, breastfeeding,

hygiene, warmth)

Reality

Each year…..

•

340,000 mothers die•

3.6 million newborns die

•

3.2 million babies are stillborn

Global progress to MDG 4

MDG 4 target (32)

Ref: Lawn, Kerber et al BJOG 2009 updated with data for 2008 from UN Child Mortality Group, WHO//CHERG and IHME (Rajaratnam J eta l 2010)

Newborn deaths comprise 41% of under 5 deathsLinks closely with maternal health and MDG 5

2010 is a tipping point for progress

USA NMR is 4

Decade Evolution of Newborn Health

Evolution of NBH2000 –

2005 2006-

2011

ISSUE •Newborn absent from global and national policy agendas. •N

Falls between M and C of MCH.•Limited and mostly linked actors

•Newborn in national and global policy, increasing partner inputs•MNCH reflected in global partnerships and some countries•Global, national, regional champions

INTER-

VENTIONS

•

Intensive community approaches

•Integrated MNCH programs at community and facility, with links•Addressing PNC gap

RESEARCH •

Efficacy trials •

Larger effectiveness trials, local research teams, multi-

site costing

DATA •

Few global indicators, limited project data

•

Better global estimates of NMR, COD & coverage

Lancet Neonatal

Series

UN Joint Statement on Home Visits

14 Situation Analyses

What have we learned?

Defined the issue

Tested approaches

Advocated for adoption

at scale

WHERE? Neonatal & maternal deaths

Ranking for numbers of neonatal

deathsRanking for numbers of

maternal deaths

India 1 1Nigeria 2 2Pakistan 3 8China 4 13DR Congo 5 3

Ethiopia 6 5Bangladesh 7 6Indonesia 8 7Afghanistan 9 4Tanzania 10 9

2.4 million neonatal deaths

Approx 67% of global total

340,000 maternal deaths

Approx 65% of global total

Ref: Lawn JE et al BJOG sept

2009. Data sources: Estimates of maternal (2005) and neonatal (2008) deaths from WHO. Updated June 2010

Countries with the highest numbers

of neonatal deaths are similar to those with high maternal deaths

WHEN? The first days are criticalUp to 50%of neonatal

deaths occur in the first 24 hours

Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths)

75% of neonatal deaths occur in

the first week

WHY? Causes of newborn deaths (2008)

These 3 killers

account for 81% of all neonatal deaths3.6 million

Source: CHERG/WHO 2010. Estimates for 193 countries for 2008. Black R et al Lancet 2010

Almost all deaths are due to preventable conditions

Tested Approaches

Study site Intervention NMR NMR Reduction

SEARCH (India)

Preventive home care, resuscitation, mgmt of infection and LBW

65 62%

Ankur(India)

Preventive home care, resuscitation, mgmt of infection and LBW

35 -

55 51%

Projahnmo(Bangladesh)

Preventive home care, mgmt of infection

48 34%

Hala(Pakistan)

Preventive home care, community mobilization

52 30%

Makwanpur(Nepal)

Community mobilization (women’s groups)

39 30%

Shivgar(India)

Preventive care 84 54%

To improve newborn health and survival, we must…

•

Deliver

interventions at scale

-- effectively, efficiently, equitably

–

Show how to expand delivery of newborn interventions in existing systems and programs.

–

Promote an enabling environment for delivery at scale –

policies, resources

Convergence with Maternal Health

Intrapartum Stillbirths Intrapartum-related neonatal deaths

Maternal deaths

© Copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan). Used with permission

Women’s health is closely linked to neonatal mortality and stillbirth

Care at birth is critical

Intrapartum‐

related 42%

Intrapartum 32%

Intrapartum‐

related  23%

Intrapartum‐relatedOther

Data sources: Maternal deaths: WHO/UNICEF/UNFPA estimates, Hill K et al, 2007. Timing of maternal deaths based on Li XF et al, 1996.Stillbirths: Stanton et al, 2006 Intrapartum stillbirth rate Lawn JE et al 2005. Neonatal deaths: WHO (UNICEF 2009 [2]. Intrapartum-related neonatal deaths based on CHERG/WHO estimates updated for 2009 using neonatal mortality and revised neonatal cause specific estimates for Countdown 2008[91] based on methods from Lawn et al., 2006

Maternal deaths535,900 per year

Stillbirths (> 1000 g)3.2 million per year

Neonatal deaths3.8 million per year

Intrapartum-related maternal deaths

= Death during labour, birth & first 24 hrs

Intrapartum-related neonatal deaths

previously termed "birth asphyxia"

Intrapartum

stillbirthsDefined as fetal death during labour

(fresh stillbirths)

Source: Lawn JE et al, IJGO 2009

225,000 1.02 million 904,000+ +

More than 2 million deaths at the time of birth

Missed Opportunities

Slow progress especially for South Asia and sub Saharan Africa

-

access to care and human

resources are major gap

Two track process1.

Seize missed opportunities to improve care for births already in facilities

2.

Bridge the gap for 60 million non facility births

Coverage of care for facility and home births according to attendant

• 60 million births occur outside health facilities• 50 million births lack skilled care

Original data source: New analysis based on data from SOWC 2009 and Demographic Health Surveys (2000–2007). Source: Darmstadt GL et al IJGO, 2009

Barriers to obstetric care

Key barriers:FinancialTransport/distanceSocio-cultural

Original Source: New analysis based on DHS data I2000-2007)Source: Lee CC et al IJGO 2009

Lawn JE, Lee AC, et al IJGO 2009

CEmOCFacility

BEmOCFacility

Maternity Waiting Homes

Reducing delays to emergency obstetric and newborn care

Delay 1:Recognition and decision to seek

care

Delay 2: Transport to

care

Delay 3: Receiving

quality care

Moving the

family to the

facility

Moving care

closer to the

family

Lawn JE, Lee AC, et al IJGO 2009

Moving the family towards facilities

CEmOCFacility

Community MobilizationBirth preparedness

BEmOCFacility

Maternity Waiting Homes

Financial incentivesCommunications technologyCommunity transport/ referral systems

Antenatal risk screeningMaternity Waiting Homes

Financial incentivesCommunications technology Transport /referral systems

Delay 1:Recognition and decision to seek

care

Delay 2: Transport to

care

Delay 3: Receiving

quality care

•

(some sort of conclusion?)

THANK YOU

It all started when….

•

SEARCH study in India demonstrated that NBC can be delivered at home

•

10 years ago, SNL built on this theory seeking to:–

Mobilize commitment for NBH

–

And understand: •

Why newborns were dying

•

What intervention could save lives•

And how these interventions could be delivered at scale

Research, data and consensus for policy and program action

Countdown to 2015Countdown to 2015 Child Health Epidemiology Child Health Epidemiology Reference GroupReference Group

Joint Statement on Postnatal Joint Statement on Postnatal Home VisitsHome Visits

??

Administering these intervention packages at 90% coverage can save up to two thirds of all newborn deaths!

Newborn health -

changing parameters 2000-2005 2006-2011 What next?

Issue Newborn survival More emphasis on early neonatal deaths

Early neonatal deaths, neonatal morbidity, stillbirths

Issue(advocacy)

Getting newborn survival on global / national agendas

National advocacy and policy, increasing partner inputs and increasing scale

National and district implementation at scale

Ideas (Interventio

ns focus)

Intensive community approaches

Integrated MNCH packages at community and facility, with linkagesAddressing postnatal care gap

Health system strengtheningDistrict hospital packages

Ideas(Research )

Efficacy trials Larger effectiveness trialsLocal research teams, multi-site costing

Implementation researchInnovative technology

Ideas (Tracking progress)

Few global indicators, limited project data

Better global estimates of NMR and COD, some progress on coverage

Coverage and quality of high impact interventions, Better tracking of finance and policy

“Land scape”

MCH -

Newborns fall between M and C

MNCH reflected in global partnerships, and some countries, newborn still not institutionalized

Integrated MNCH(family health), newborn more institutionalized

Actors Limited and mostly linked

More complex, informally linked, SNL playing convening role

More diverse championsHNN recreates wider alliance

Deliver interventions through existing systems

SNL has 16 projects (in 15 countries) testing delivery of newborn interventions in existing systems.

•

Bangladesh: Family Welfare Assistants•

Pakistan: Lady Health Workers

•

Nepal: Female Community Health Volunteers•

Ethiopia: Health Extension Workers

•

Malawi: Heath Surveillance Assistants•

Indonesia: Community Midwives

•

Antenatal Care (Tetanus Toxoid, STI Mgmt, Counseling, Birth Preparedness)

•

Emergency Obstetric Care (obstructed labor; hemorrhage)

•

Emergency Newborn Care (very low birthweight; sepsis; asphyxia)

•

Postnatal Care (Early detection and treatment of complications, Breastfeeding, Hygiene, Warmth)