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Surviving the First Month of Life. Lily Kak, USAID Indira Narayanan, BASICS Mini-University, George Washington University October 27, 2006. Four Million Newborn Deaths: Where?. 99% of newborn deaths are in low/middle income countries 66% in Africa and Southeast Asia.

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surviving the first month of life

Surviving the First Month of Life

Lily Kak, USAID

Indira Narayanan, BASICS

Mini-University, George Washington University

October 27, 2006

four million newborn deaths where
Four Million Newborn Deaths: Where?

99% of newborn deaths are in low/middle income countries

66% in Africa and Southeast Asia

stagnating trends in neonatal mortality
Stagnating Trends in Neonatal Mortality

Sub-Saharan Africa


Asia and Middle East

Latin America and Caribbean

Source: DHS and RHS estimates for countries receiving USAID support

Number of countries: Global-35; ANE -8; Africa – 17; LAC: 9

millennium development goal 4 can only be achieved if neonatal deaths are addressed

Neonatal Deaths and the Millennium Development Goals


Under-5 mortality rate


Global mortality per 1000 births








Millennium Development Goal 4 can only be achieved if neonatal deaths are addressed

1-60 mo. mortality

< 1 mo. mortality (NMR)

Present trend


Source: Neonatal Lancet, 2005

coverage of newborn care during the most critical period

Only 50% of


are attended


skilled birth


Coverage of Newborn Care During the Most Critical Period

Up to 50%

of neonatal

deaths are in

the first 24 hours

Only 21%




within 7 days

75% of neonatal

deaths are in

the 7 days

newborn care in sub saharan africa the weakest link
Newborn Care in Sub-Saharan Africa: the Weakest Link

NIB: Non-Institutional Birth

Source of data: 1999-2005 DHS; State of the World’s Children, 2006

newborn health no longer falling through the cracks

The Lancet Child and Neonatal Survival Series identified newborn survival as a priority, lacking information and action

  • The World Health Report advocates the repositioning of MCH as MNCH (maternal, newborn and child health)
Newborn Health: No longer Falling Through the Cracks

Evidence Based Interventions for

  • Syphilis Control
  • Folate Supplementation
  • Tetanus Toxoid Immunization of Mother
  • Clean Delivery
  • Cord Care
  • Early & Exclusive
  • Breastfeeding
  • Antibiotics for mother and baby

Malaria Control

Antenatal Corticosteriod

Treatment of bacteriuria

  • Kangaroo Mother Care
  • Birth Spacing
  • Maternal Nutrition
  • Warming
  • Resuscitation
  • Skilled Birth Attendants

Major Causes of Neonatal Mortality









Complications of Prematurity






Low birth weight is a significant

contributor in 60–80% of neonatal deaths.

Adapted from Lancet 2005

essential maternal newborn care


Eye care

Special care for LBW

Iron and folate

Other Essential Interventions






Obstetric and

Newborn Care



Syphilis detection and treatment

Prevention of



of HIV

Intermittent presumptive treatment for malaria

Context-Specific Package

  • Minimum activities: Community
  • ANC
    • Birth preparedness
    • Tetanus Toxoid
  • Safe Birth
    • Clean delivery
    • Referral link for obstetric& newborn complications
  • Postpartum
    • Cord care
    • Thermal Care
    • Immediate & excl Breastfeeding
    • Infection recognition & referral/treatment
  • Minimum activities: Facility
  • ANC
    • Birth preparedness
    • Tetanus toxoid
  • Safe Birth with Skilled Attendance
    • Partograph
    • Infection prevention
    • Active mgt of 3rd stage of labor
    • Newborn resuscitation
  • Postpartum
    • Cord care
    • Thermal care
    • Immediate & excl breastfeeding
    • Infection Treatment
Essential Maternal & Newborn Care

USAID October, 2006


Shivgarh, India

Saksham LOGO

A community based and community driven

essential newborn care program

Source: Global Research Activities, Johns Hopkins University

neonatal mortality rate shivgarh india
Neonatal Mortality Rate, Shivgarh, India

Source: Global Research Activities, Johns Hopkins University


Sylhet, Bangladesh



A community based essential

newborn care program

Source: Global Research Activities, Johns Hopkins University


Neonatal Mortality RatesSylhet, Bangladesh


Significant reduction in neonatal mortality with home-based care

Source: A Community-based Effectiveness Trial to Improve Newborn Health in Sylhet District of Bangladesh, GRA/JHU, 2006

pearl 1

Pearl # 1

All newborns need essential newborn care

usaid s global priorities
USAID’s Global Priorities
  • Introduce and expand community-based essential newborn care globally
  • Focus on major killers to reduce mortality: low birth weight, infections, asphyxia
globally 60 80 neonatal deaths occur in babies below 2500 gm lbw

Management of Low Birth Weight

Globally, 60-80% Neonatal Deaths occur in Babies below 2500 Gm (LBW)


Based on Vital Registration data for 45 countries (N = 96797). and modeled estimates for 146 countries (N = 13,685) - Lawn JE, Cousens SN. Zupan J, Lancet 2005

low birth weight infants
Low Birth Weight Infants
  • Global burden: 21 million,

96% in developing countries

  • Global incidence: 16%


distribution of 21 million lbw
Distribution of 21 million LBW

WHO, UNICEF. Country, regional and global estimates. 2004


Priority Intervention

The priority from a public health point of view is the group of larger / more mature LBW infantsCurrently, there is more evidence and experience on management than prevention of LBW infants

Bang 2005

outcome of lbw babies with extra care at first referral level facility
Outcome of LBW babies with extra care at first referral level facility

Category n Died/referred Discharged

<1500g 101 28% 72%

1501-1999g 264 7% 93%

2000-2499g 1744 1% 99%

All LBW 2109 3% 97%

Paul VK- Ballafgarh Hospital (1994-1999)

extra care for lbw babies
Extra Care for LBW Babies
  • Extra focus on essential newborn care especially
    • Temperature maintenance
    • Prevention of infection
    • More frequent breastfeeding and/or use of breast milk
  • Kangaroo Mother Care - major components
    • Skin to skin contact
    • Position
    • Nutrition
    • Support to mother and baby
    • Discharge & follow-up policy
kangaroo mother care kmc
Kangaroo Mother Care (KMC)
  • Baby wears only a diaper (cap and socks where needed)
  • Placed vertically in between the mother’s breasts
  • Wrapped firmly / securely on to the mother’s chest
  • Can also be carried out by other family members
kmc advantages
KMC - Advantages
  • Thermal control—mother’s temperature adjusts for baby
  • Vital signs better—breathing more regular—less ‘periodic breathing’; less apnea
  • Less crying—less stress—even in term babies after delivery—salivary cortisol twice as high in control infants with standard care than with skin-to-skin contact 1 hr. post birth.
  • Better breastfeeding
  • Bonding
kmc conclusions
KMC - Conclusions
  • Simple, effective, low cost intervention
  • At facility level and at home
  • Has global applications—both for advanced and developing countries. May be the only alternative in resource-poor situations
  • Other practical applications:
    • Just after birth for all babies (without problems needing immediate attention)
    • During transport of sick & LBW babies
pearl 2

Pearl # 2

Kangaroo Mother Care is for humans too!

causes of neonatal mortality
Causes of Neonatal Mortality

7 %


Complications of



Neonatal tetanus 7%



Sepsis /


26 %

Infections 36 %



7 %

Diarrhea 3%

Birth asphyxia & trauma

23 %

neonatal sepsis timing of deaths and interventions
Neonatal Sepsis Timing of Deaths and Interventions

Clean delivery

Cord care

Colostrum and exclusive breastfeeding

Identify signs of illness- algorithms / Antibiotics

Source: South Asia Newborn Health Investigators Group (Unpublished courtesy Steve Wall )

types of infections
Types of Infections
  • Minor Infections:
    • Thrush
    • Conjunctivitis
    • Skin infections
    • Umbilical infection ( localized)
  • Major Infections
    • Specific entities such as pneumonia, diarrhea, septicemia and meningitis difficult to diagnose in the newborn . Hence catch-all term “sepsis” is used in public health
    • Easy spread and rapid progression of disease
    • High case fatality
  • Specific infections such as syphilis, HIV/AIDS, Hepatitis B, tetanus, and malaria
timing of infections
Timing of Infections
  • Early onset of infection (0-3d) is usually acquired from maternal risk factors and during delivery such as:
    • Maternal fever
    • Premature rupture of the membranes (>12-18-24 hr)
    • Unhygienic delivery practices
    • Poor cord care
  • Late onset of infection (4-30d) are usually acquired from the environment (most likely acquired in the home or facility - nosocomial) due to factors such as:
    • Unhygienic newborn care practices (i.e., lack of hand washing)
    • Excessive invasive procedures

Trotman Ann. Tropical Paediatrics 2006 and Robillard West Indian Medical Journal 2001

neonatal sepsis key components of prevention
Neonatal Sepsis Key Components Of Prevention
  • Antenatal period:
    • Addressing tetanus, STD, HIV/AIDS and malaria
  • Delivery:
    • Clean delivery practices, preventive Essential Newborn Care (ENC) –hygiene-clean cord and skin care, breastfeeding
  • Postnatal period:
    • Preventive maternal and newborn care – clean cord and skin care, breastfeeding

Newborn Care: Impact of Options on Mortality - Community Level

Fall in




Fall in



Preventive ENC+HBC of

sick babies


Bang et al

Pratinidhi et al

neonatal sepsis clinical characteristics
Neonatal Sepsis: Clinical Characteristics
  • Newborns, notably LBW infants are at high risk for infection
  • Easy spread to other organs and rapid progression of disease
  • Specific diagnosis difficult in major infections – hence catch-all term “sepsis” is used
  • High case fatality
  • Susceptible to special germs that do not affect normal older infants
  • Most require injectable antibiotics
  • Organisms vary by region, over time and with long term use of antibiotics

All these have public health implications

neonatal sepsis danger signs
Neonatal Sepsis :Danger Signs
  • Numbers vary (1st 4 or 5 most important)
    • refusal to feed/suck/poor feeding
    • inactivity/lethargy/ ‘limp limbs’
    • body hot/cold
    • Rapid breathing /difficulty in breathing
      • chest in-drawing, grunting/nasal flaring
    • weak/no cry
    • vomiting/abdominal distention
    • periumbilical redness/pus discharge

Based on Bang et al, BASICS country programs

  • IMCI – 11-15 signs
neonatal sepsis needed government policies
Neonatal Sepsis:Needed Government Policies
  • Availability of drugs, supplies, and equipment

Need for appropriate

      • Antibiotics, including required strengths
      • Supplies and equipment including suitable sizes
  • Quality of services at the facility
  • Policies of administration of antibiotics by less qualified health workers in special situations
neonatal sepsis link with imci
Neonatal Sepsis: Link with IMCI
  • Conventional IMCI addresses babies older than 1 week
  • Now newborns included by WHO and by some countries
  • One prominent example is IMNCI-India
    • Includes 0-6 days of age
    • 50% of training time on infants 0-2 months of age
    • Home-based care of young infants by workers added
    • In severe illness administration of first dose of oral antibiotics before referral
  • Requires training, supervision, and suitable drugs and supplies
  • Needs to be applied at facility and community level
neonatal sepsis major infections
Neonatal Sepsis: Major Infections
  • Major infections:
    • Early stage: Baby can accept feeds and maintain temperature with simple aids
    • Late stage: Baby cannot feed and/or maintain temperature with simple aids
  • Influences level of treatment
pearls for today

Pearls for Today

All newborns need …

Kangaroo mother care is for…


Care of the sick newborn is challengingbut will improve mortality outcomes to better achieve MDG #4Babies are worth itWe need to act NOW!