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Global Network for Women’s and Children’s Health Research Resuscitation: How to Save One Million Lives Per Year. Albert Manasyan, MD; Wally Carlo, MD and the FIRST BREATH Study Group For the Global Network for Women’s and Children’s Health Research. Stillbirth and Neonatal Deaths Per Year.

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Albert Manasyan, MD; Wally Carlo, MD and the FIRST BREATH Study Group

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Albert manasyan md wally carlo md and the first breath study group

Global Network for Women’s and Children’s Health ResearchResuscitation: How to Save One Million Lives Per Year

Albert Manasyan, MD; Wally Carlo, MD and the FIRST BREATH Study Group

For the Global Network for Women’s and

Children’s Health Research


Stillbirth and neonatal deaths per year

Stillbirth and Neonatal Deaths Per Year

  • 98% of all stillbirths and neonatal deaths occur

    in developing countries

    • ~ 2.6 million stillbirths

    • ~ 3.5 million neonatal deaths

      • Preterm 1.0 mil

      • Birth asphyxia 0.8 mil

      • Sepsis0.5 mil

      • Other1.2 mil


Background essential newborn care

Background: Essential Newborn Care

  • The WHO developed Essential Newborn Care (ENC) course sets minimum standards for training birth attendants in neonatal care including:

    • Basic resuscitation

    • Universal precautions

    • Routine neonatal care

    • Thermoregulation

    • Breastfeeding

    • Kangaroo mother (skin-to-skin) care

    • Care of the small baby

    • Danger signs


First breath protocols

First Breath Protocols

  • The First Breath protocols were designed to address the impact of Essential Newborn Care (ENC) on perinatal mortality:

    • First Breath: Clinic Study

    • First Breath: Common Protocol


Comparison of first breath protocols

Comparison of First Breath Protocols


First breath clinic study

First Breath: Clinic Study

Design:Pre-Post controlled study with active baseline data collection

Setting:Level 1 health delivery centers in Zambia

Interventions:WHO ENC (including resuscitation training) and NRP

Patients:71,689 low risk newborns

Carlo W et al. Pediatrics 126:e1064-71, 2010.


First breath clinic study1

First Breath: Clinic Study

ResultsPre-ENCPost-ENCp value

All cause 7-day mortality/100011.56.8p<0.001

Perinatal mortality/100018.312.9p=0.002

Mortality due to asphyxia/10003.41.9p=0.02

Mortality due to infection/10002.20.8p=0.02

Mortality < 1500/1000gr576407p=0.049

SB rate/10004.94.9NS

Carlo W et al. Pediatrics 126:e1064-71, 2010.


Delivery by birth attendant

Delivery by Birth Attendant

Birth

Attendant Home

10%

Family members

19%

Physician

16%

Clinic 9%

TBA

37%

Nurse/Midwife

28%

Hospital 25%

Home 56%

Carlo et al. N Engl J Med. 362:614-23, 2010.


First breath common protocol

First Breath: Common Protocol

1. Population-based prospective study

2. 96 communities in 6 countries (7 clinical sites) in South America, Africa, and Asia

3. 3,676 birth attendants trained in data collection and clinical measures (fetal heart rate monitoring, Apgar scoring etc.)

4. Active baseline data collection

5. Training in ENC

6. Post-ENC data collection


First breath common protocol1

Results

Pre-ENC

Rate/1000

Post-ENC

Rate/1000

RR (CI)

Stillbirth

23.0

15.9

0.69 (0.54 ,0.88)

All cause 7-day mortality

23.4

23.2

0.99 (0.81, 1.22)

Perinatal mortality

45.9

38.9

0.85 (0.70, 1.02)

First Breath: Common Protocol

Carlo et al. N Engl J Med. 362:614-23, 2010.


Pre post enc perinatal mortality rates by birth attendant

Family/ Unattended

Traditional Birth Attendant

Nurse/Midwife

Physician

All Birth Attendants

Pre-Post ENC Perinatal Mortality Rates by Birth Attendant

Perinatal Mortality

*

*

Carlo et al. N Engl J Med. 362:614-23, 2010.


Methods cost analysis

Methods: Cost Analysis

  • Cost-effectiveness was calculated as follows:

    Cost per life saved = Cost

    Reduction in death

  • Cost per disability-adjusted life years (DALY) was calculated as follows:

    Cost per DALY = Cost per life saved

    Life expectancy


Results daly

Results: DALY

Cost per DALY = Cost per life saved

Life expectancy

Cost per DALY = $208

39.7 years

Cost per DALY = $5.24


Final conclusions

Final Conclusions

1. WHO ENC training of midwives in first level centers reduced neonatal mortality by ~10/1000

2. This intervention was very cost-effective in first level facilities ($5 per DALY)

3. In communities, ENC reduced fresh stillbirths and perinatal mortality without increasing neonatal mortality

4. Survivors of birth asphyxia have low rates of impairment


Acknowledgement

Acknowledgement

Support for this project from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), part of the National Institutes of Health within the U.S. Department of Health and Human Services, and the Bill and Melinda Gates Foundation


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