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Maternal and Child Health_ a global perspective

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Maternal and Child Health_ a global perspective Powered By Docstoc
					Newborn Survival and Maternal Health: a key to child survival

Zulfiqar A. Bhutta
Husein Lalji Dewraj Professor & Chairman Department of Paediatrics & Child Health Aga Khan University Karachi, Pakistan

“ 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

TheInequity in maternal and newborn health health of the mother and newborn is inseparable

Deaths among infants under 7 days are decreasing more slowly than among older infants

100

Developing Regions
80

Post-neonatal mortality
Late neonatal mortality

60

Early neonatal mortality

40

20

Developed Regions

0

1983
Source: RHR/WHO, 2003

2000

1983

2000

Where do 4 million newborns die?
1.5 million (38% of all newborn deaths) occur in 4 countries of South Asia

Tertiary
University Hospital

Referral Hospital

Secondary
District General Hospital Sub-district Hospitals

35-40%
Primary
Rural Health Center

5-10%

Village Health Units

50-60%

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

Spectrum of Asphyxia outcomes
• Neonatal encephalopathy (mild/ mod / severe) Neonatal death as a consequence of NE

•

•

Neurological disability as a complication of neonatal encephalopathy

Intra-partum Stillbirths
an extension of Asphyxia deaths?
160 140 120 100 80 60 40 20 0 Hala Matiari Kot Diji All

Macerated (LCM) Macerated (Normal) Fresh (LCM) Fresh (Intra-partum) Unclassified

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)

4 million newborn deaths – Why?
almost all are due to preventable conditions

Two thirds of all neonatal deaths are in LBW infants

Maternal & Newborn illness Malnutrition
Care for women Breastfeeding/Feeding; Psychosocial Care; Hygiene Practices; Home Health Practices
Inadequate Education
Resources & Control Human, Economic & Organisational

Manifestations

Disease

Immediate causes

Insufficient Household Food Security

Insufficient Health Services & Unhealthy Environment

Underlying causes

Political and Ideological Superstructure Economic Structure

Basic Determinants

Political, social and economic structures

Three dimensions of poverty

• Poverty of means and access • Poverty of Hope! • Poverty of Imagination

REASONS FOR NOT SEEKING CARE (n=31)

6%

13% 3% 6%

30%
Empowerment Support structures
33%

16%

39%
Fatalism Past experience

23%

BABY NOT CONSIDERED ILL ENOUGH TO SEEK CARE MONEY UNAVAILABLE TRANSPORTATION UNAVAILABLE POOR OPINION/PREVIOUS NEGATIVE EXPERIENCE OF HEALTH SYSTEM FATALISM (BELIEF THAT CHILD WILL DIE ANYWAY) NO PERMISSION FROM HUSBAND/IN LAWS/NOBODY AT HOME TO TAKE CARE OF OTHER CHILDREN DIED TOO SOON AFTER BIRTH

What can be done?

Effective interventions for Newborn Care Lancet Series on Newborn Survival Paper 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)

Effective interventions for Newborn Care Lancet Series on Newborn Survival Paper 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)

Tertiary
University Hospital

Referral Hospital

Secondary
District General Hospital Taluka Hospital

Clinical or Facility-based care

Primary
Rural Health Center Outreach

Basic Health Units

Family and Community Packages

Intervention Packages
Skilled obstetric and immediate newborn care including resuscitation

Clinical care

Emergency obstetric care to manage complications such as obstructed labour and hemorrhage Antibiotics for preterm rupture of membranes# Corticosteroids for preterm labour# 4-visit antenatal package including

Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies

23 - 50% NMR effect

Postnatal care to support healthy practices Early detection and referral of complications

Outreach services

Administering basic community-based 6 - 9% Malaria intermittent intervention packages at full coverage presumptive therapy* Detection and can bacteriuria treatment of all newborn deaths! of save ~ 37%
#

tetanus immunisation, detection & management of syphilis, other infections, preeclampsia, etc

Familycommunity

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

15 - 32%
Extra care of low birth weight babies
Case management for pneumonia

Pre- pregnancy

Pregnancy

Neonatal period Birth

Infancy

Coverage rates are low!

How can these be scaled-up much faster?

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

Analysis of systematic reviews for maternal and newborn health interventions
Developing Countries Community/Primary Care settings 98 Effectiveness trials

72

39 19
13

7
Antenatal

3

1

2
Post-natal

Intrapartum

Bhutta et al (Pediatrics & GFHR 2005)

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

Shivgarh (India) Trial Community Mobilization and Behavior Change Communication
1. 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

2.

3.

4. 5.

6.

Shivgarh (India) Trial Community Mobilization and Behavior Change Communication
1. Birth preparedness for essential newborn care
120
Perinatal Mortality Rate Neonatal Mortality Rate

2.

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

100 80 60

3.

4. 5.

40 20 0
Control Intervention 1 Intervention 2

6.

Hala Project Phase 2 Pilot (2003-2004)

8 clusters
317 villages 43000 households 284,000 population

Community organization & mobilization

Improved Primary Maternal, Perinatal & Newborn Care (through Lady Health Workers)

Improved Referral Pathways & Clinical Care
(Common in all areas)

Perinatal mortality trends (Hala, Pakistan)
Stillbirth rate
70 60 50 40 30 20 10 0 Control area (2002-3) Intervention area (2002-3)

Early neonatal mortality

Late neonatal mortality

Perinatal mortality trends (Hala, Pakistan)
Stillbirth rate
70 60 50 40 30 20 10 0 Control area (2003-4) Intervention area (2003-4)

Early neonatal mortality

Late neonatal mortality

Conclusions
• Improving newborn health and care is critical to attaining the MDG targets for child survival • To do so would require concerted efforts to improve maternal care, outreach and provide innovative models of community support and education • Emerging data from demonstration projects in health system settings indicate that this is doable and can be scaled up using affordable models of care • Community engagement and ownership is a critical element in successful intervention models for maternal and newborn care

Participatory development Democratization of public health


				
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