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Addressing the Challenge of Neonatal Mortality

Addressing the Challenge of Neonatal Mortality. Simon Cousens. Millennium Development Goal 4. Reduce by two-thirds, between 1990 and 2015, the under 5 mortality rate. Millennium Development Goal 4.

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Addressing the Challenge of Neonatal Mortality

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  1. Addressing the Challenge of Neonatal Mortality Simon Cousens

  2. Millennium Development Goal 4 • Reduce by two-thirds, between 1990 and 2015, the under 5 mortality rate

  3. Millennium Development Goal 4 • Source: Levels and trends in Child Mortality. Report 2011. Estimates developed by the Inter-agency Group for Mortality Estimation.

  4. Millennium Development Goal 4 • Sources: Levels and trends in Child Mortality. Report 2011. Estimates developed by the Inter-agency Group for Mortality Estimation. Oestergaard et al.PLoS Med. 2011 8:e1001080

  5. Geographical distribution of neonatal mortality in 2009 • Source: Oestergaard et al.PLoS Med. 2011 8:e1001080

  6. Neonatal mortality rates in England and Wales • Source: ONS mortality statistics (www.statistics.gov.uk)

  7. Community-based care: a seminal paper from India • Bang et al. Lancet 1999. 354: 1955-1961 • Implemented a home care package in a rural setting with high NMR • Trained village health workers to perform home visits, to promote breastfeeding and thermal management, in simple techniques to manage birth asphyxia, and to treat infections

  8. Community-based care: a seminal paper from India Treatment of sepsis  • Source: Bang et al. Lancet 1999. 354: 1955-1961 c. 60% reduction in NMR

  9. The Lancet Neonatal Survival Series (2005) • Editors: JE Lawn and S Cousens

  10. Source: Lancet 2005. 365:977-988 • Developed a model to estimate how many neonatal deaths could be prevented by increasing coverage of a package of relatively simple, cost-effective interventions • Estimated that 36-67% of neonatal deaths in 75 high mortality countries could be averted by high coverage (90%) with 16 interventions • Only about half of this reduction was through community-based care

  11. Lives Saved Tool (LiST) • Freely available software tool for programme planners • http://www.futuresinstitute.org/pages/Spectrum.aspx

  12. Two recent studies:The Hala Trial, Pakistan • Lancet 2011. 377: 403-412

  13. The Hala Trial, Pakistan • Intervention: • Lady Health Workers (LHWs) trained in preventive newborn care • Dais (TBAs) trained in basic newborn care • Communities encouraged to establish Community Health Committees • 16 clusters randomised: • Approximately 23,000 live births identified over a 30 month period • Primary outcome: all-cause neonatal mortality • Lancet 2011. 377: 403-412

  14. The Hala Trial, Pakistan • Trial differed from other community-based trials in region in that intervention principally delivered through government health system rather than workers employed by research team. •  lower intervention coverage than has been reported in other trials •  smaller mortality impact • Despite limitations, encouraging that public sector programme promoting preventive care can produce health benefits

  15. Cord care • WHO recommends dry cord care BUT in a Cochrane review from 2004 • all 21 trials were conducted in hospitals • all but one in high income settings • no systemic infections or deaths in any of the trials • Source: Zupan et al. Cohrane Database Syst Rev 2004. 3: CD001057

  16. Cord care • A subsequent community-based trial of topical chlorhexidine in Nepal reported: • a 75% reduction in severe omphalitis • a 24% reduction in neonatal mortality compared with dry cord care • Source:Mullany et al. Lancet 2006. 367:910-918

  17. Chlorhexidine trial, Pakistan • Lancet 2012. 379:1029-1036

  18. Chlorhexidine trial, Pakistan • 187 clusters randomly allocated in 2x2 factorial design • 2 interventions • Chlorhexidine (daily for 2 weeks) vs dry cord care • Handwashing promotion vs no handwashing promotion • Interventions delivered through Dais • Facility births excluded • 9741 livebirths enrolled over 18 months

  19. Chlorhexidine trial, Pakistan

  20. Chlorhexidine • “We could argue that more research is needed—questions certainly exist about the duration and timing of application and about external validity. Evidence from high-mortality populations in Africa would be useful. Nevertheless, to demand more evidence of effectiveness might be to repeat an old public health debate: if the need is clear, the possibilities attractive, and the risk low, how much evidence is necessary before we act on plausible findings?” • Osrin and Hill. Commentary. Lancet 2012. 379:984-986.

  21. The challenge of neonatal mortality: what needs to be done? • Effective interventions are available: how do we make sure they reach mother’s and newborns? • Improve the quality and quantity of data available to: • assist rational policy making • Monitor progress

  22. Acknowledgements • Joy Lawn, ZulfiqarBhutta, Gary Darmstadt, Hannah Blencowe, Susana Scott, Neff Walker, MikkelOestergaard, Colin Mathers and many others

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