Why Essential Newborn Care? What is Essential Newborn Care?

1. Why Essential Newborn Care?What is Essential Newborn Care? Subodh S Gupta MGIMS, Sewagram

2. “Fate has allowed humanity such a pitifully meagre coverlet that in pulling it over one part of the world, another has to be left bare … ”Rabindranath Tagore

3. 4 million newborns die each year 1.5 million (38%of all newborn deaths) occur in 4 countries of South Asia

4. Inequity in maternal and newborn health The health of the mother and newborn is inseparable

5. Deaths among infants under 7 days are decreasing more slowly than among older infants 100 Developing Regions Post-neonatal mortality 80 Late neonatal mortality Early neonatal mortality 60 40 Developed Regions 20 0 1983 2000 1983 2000 Source: RHR/WHO, 2003

6. Infant and Neonatal Mortality

7. SEARCH Study • Trained VHW/1000 population • Intervention • Birth asphyxia • LBW • Temp. maintenance. • promotion of breast feeding • prevention of superficial infection • Management of sepsis • Health education

8. 4 million newborn deaths – Why?almost all are due to preventable conditions Two thirds of all neonatal deaths are in LBW infants

9. Causes of Neonatal Mortality

10. When do they die? Up to 50% of neonatal deaths are in the first 24 hours 75% of neonatal deaths are in the first week – 3 million deaths

11. Newborn Deaths from Asphyxia:the tip of an iceberg 0.9 million asphyxia deaths 1-2 million suffer medium to long–term impairment Stillbirths from intrapartum hypoxia (~ 1 million deaths)

12. Three dimensions of poverty • Poverty of means and access • Poverty of Hope! • Poverty of Imagination

13. 30% Empowerment Support structures 39% Fatalism Past experience

14. What can be done?

15. Evidence-based Interventions to Reduce Newborn Deaths Syphilis Control Folate Supplementation Tetanus Toxoid Immunization of Mother Clean Delivery Cord Care Early & Exclusive Breastfeeding Antibiotics for mother and baby Cong. Anom 7% Infection 36% Sepsis/Pneumonia Tetanus Diarrhea Malaria Control Antenatal Corticosteriod Treatment of Bacteriuria Complications of Prematurity 27% Other 7% Asphyxia 23% Kangaroo Mother Care Birth Spacing Maternal Nutrition Warming Resuscitation Skilled Birth Attendants Low birth weight is a significant contributor in 40–70% of neonatal deaths. Adapted from Lancet 2005

16. Evidence of effectiveness of Home Based Neonatal Care

17. SEARCH Study • Trained VHW/1000 population • Intervention • Birth asphyxia • LBW • Temp. maintenance. • promotion of breast feeding • prevention of superficial infection • Management of sepsis • Health education

18. Effective interventions for Newborn CareLancet Series on Newborn SurvivalPaper 2 (2005) • 16 interventions identified with adequate evidence of effect on neonatal deaths (e.g., tetanus toxoid immunization, clean delivery, obstetric care, breastfeeding, antibiotics for infections) • All are highly cost-effective especially if packaged and delivered within other programmes (e.g., maternal and child health)

19. Tertiary University Hospital Referral Hospital Secondary District General Hospital Taluka Hospital Clinical or Facility-based care Primary Rural Health Center Outreach Family and Community Packages Basic Health Units

20. Intervention Packages Skilled obstetric and immediate newborn care including resuscitation Emergency obstetric care to manage complications such as obstructed labour and hemorrhage Antibiotics for preterm rupture of membranes# Corticosteroids for preterm labour# Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies Clinical care 4-visit antenatal package including tetanus immunisation, detection & management of syphilis, other infections, pre-eclampsia, etc Malaria intermittent presumptive therapy* Detection and treatment of bacteriuria# Postnatal care to support healthy practices Early detection and referral of complications Administering basic community-based intervention packages at full coverage can save ~ 37% of all newborn deaths! Outreach services Folic acid # Counseling and preparation for newborn care and breastfeeding, emergency preparedness Clean home delivery Simple early newborn care Healthy home care including breastfeeding promotion,hygienic cord/skin care, thermal care, promoting demand for quality care Extra care of low birth weight babies Case management for pneumonia Family-community Infancy Neonatal period Pregnancy Pre- pregnancy Birth 23 - 50% NMR effect 6 - 9% 15 - 32%

21. Coverage rates are low! How can these be scaled-up much faster?

22. Know ….Do gap Don’t know….Don’t do gap

23. 30% reduction in neonatal mortality!Major impact on maternal mortality!

24. Shivgarh (India) Trial Community Mobilization and Behavior Change Communication • Birth preparedness for essential newborn care • Clean delivery, cord and skin care • Immediate wiping, drying and keeping the baby warm • Skin-to-Skin Care • Promotion of immediate and exclusive breastfeeding • Recognition and management of hypothermia

25. Shivgarh (India) Trial Community Mobilization and Behavior Change Communication • Birth preparedness for essential newborn care • Clean delivery, cord and skin care • Immediate wiping, drying and keeping the baby warm • Skin-to-Skin Care • Promotion of immediate and exclusive breastfeeding • Recognition and management of hypothermia

26. Essential Newborn Care Interventions • Clean childbirth and cord care • Prevent newborn infection • Thermal protection • Prevent and manage newborn hypo/hyperthermia • Early and exclusive breastfeeding • Started within 1 hour after childbirth • Initiation of breathing and resuscitation • Early asphyxia identification and management Normal Newborn Care

27. Essential Newborn Care Interventions (continued) • Eye care • Prevent and manage ophthalmia neonatorum • Immunization • At birth: bacille Calmette-Guerin (BCG) vaccine, oral poliovirus vaccine (OPV) and hepatitis B virus (HBV) vaccine (WHO) • Identification and management of sick newborn • Care of preterm and/or low birth weight newborn Normal Newborn Care

28. Cleanliness to Prevent Infection • Principles of cleanliness essential in both home and health facilities childbirths • Principles of cleanliness at childbirth • Clean hands • Clean delivery surface • Clean cord cut • Clean cord clamp • Clean cord care • Clean perineum • Nothing unclean introduced vaginally • Infection prevention/control measures at healthcare facilities

29. Thermal Protection • Newborn physiology • Normal temperature: 36.5–37.5°C • Hypothermia: < 36.5°C • Stabilization period: 1st 6–12 hours after birth • Large surface area • Poor thermal insulation • Small body mass to produce and conserve heat • Inability to change posture or adjust clothing to respond to thermal stress • Increase hypothermia • Newborn left wet while waiting for delivery of placenta • Early bathing of newborn (within 24 hours)

30. Hypothermia Prevention • Deliver in a warm room • Dry newborn thoroughly and wrap in dry, warm cloth • Keep out of draft and place on a warm surface • Give to mother as soon as possible • Skin-to-skin contact first few hours after childbirth • Promotes bonding • Enables early breastfeeding • Check warmth by feeling newborn’s feet every 15 minutes • Bathe when temperature is stable (after 24 hours) Normal Newborn Care

31. Early and Exclusive Breastfeeding • Early contact between mother and newborn • Enables breastfeeding • Rooming-in policies in health facilities prevents nosocomial infection • Best practices • No prelacteal feeds or other supplement • Giving first breastfeed within one hour of birth • Correct positioning to enable good attachment of the newborn • Breastfeeding on demand • Psycho-social support to breastfeeding mother

32. Breathing Initiation and Resuscitation • Spontaneous breathing (> 30 breaths/min.) in most newborns • Gentle stimulation, if at all • Effectiveness of routine oro-nasal suctioning is unknown • Biologically plausible advantages – clear airway • Potentially real disadvantages – cardiac arrhythmia • Bulb suctioning preferred • Newborn resuscitation may be needed • Fetal distress • Thick meconium staining • Vaginal breech deliveries • Preterm Normal Newborn Care Hamilton 1999.

33. Eye Care To Prevent or Manage Ophthalmia Neonatorum • Ophthalmia neonatorum • Conjunctivitis with discharge during first 2 weeks of life • Appears usually 2–5 days after birth • Corneal damage if untreated • Systemic progression if not managed • Etiology • N. gonorrhea • More severe and rapid development of complications • 30–50% mother-newborn transmission rate • C. trachomatis Normal Newborn Care

34. Eye Care To Prevent or Manage Ophthalmia Neonatorum (continued) • Prophylaxis • Clean eyes immediately • 1% Silver nitrate solution • Not effective for chlamydia • 2.5% Povidone-iodine solution • 1% Tetracycline ointment • Not effective vs. some N. gonorrhea strains • Common causes of prophylaxis failure • Giving prophylaxis after first hour • Flushing of eyes after silver nitrate application • Using old prophylactic solutions Normal Newborn Care

35. Immunization • BCG vaccinations in all population at high risk of tuberculosis infection • Single dose of OPV at birth or in the two weeks after birth • HBV vaccination, wherever possible

36. Summary The essential components of normal newborn care include: • Clean delivery and cord care • Thermal protection • Early and exclusive breastfeeding • Monitoring • Eye care • Immunization Normal Newborn Care

37. Thank you