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

Source: Levels and trends in Child Mortality. Report 2011. Estimates developed by the Inter-agency Group for Mortality Estimation.

29

025

5075

100

Und

er 5

mor

talit

y ra

te

1990 1995 2000 2005 2010 2015Year

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

29

025

5075

100

Mor

talit

y ra

te

1990 1995 2000 2005 2010 2015Year

U5MR NMR

Geographical distribution of neonatal mortality in 2009

Source: Oestergaard et al. PLoS Med. 2011 8:e1001080

Region NMR % of neonatal deaths

High income 3.6 1.4%

sub-Saharan Africa 35.9 34%

South East Asia 30.7 36%

Neonatal mortality rates in England and Wales

Source: ONS mortality statistics (www.statistics.gov.uk)

010

2030

40M

orta

lity

per

1000

live

birt

hs

1920 1940 1960 1980 2000Year

Early neonatal mortality Late neonatal mortality

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

Source: Bang et al. Lancet 1999. 354: 1955-1961

Treatment of sepsis

c. 60% reduction in NMR

Community-based care: a seminal paper from India

The Lancet Neonatal Survival Series (2005)

Editors: JE Lawn and S Cousens

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

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

Two recent studies:

The Hala Trial, Pakistan

Lancet 2011. 377: 403-412

Intervention:Lady Health Workers (LHWs) trained in preventive newborn careDais (TBAs) trained in basic newborn careCommunities encouraged to establish Community Health Committees

Lancet 2011. 377: 403-412

The Hala Trial, Pakistan

16 clusters randomised:Approximately 23,000 live births identified over a 30 month period

Primary outcome: all-cause neonatal mortality

The Hala Trial, Pakistan

Intervention clusters

Control clusters

Risk ratio(95% c.i.)

NMR 43.0 49.1 0.85 (0.76, 0.96) P=0.02

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

Cord care

WHO recommends dry cord care BUT in a Cochrane review from 2004

all 21 trials were conducted in hospitalsall but one in high income settingsno systemic infections or deaths in any of the trials

Source: Zupan et al. Cohrane Database Syst Rev 2004. 3: CD001057

Cord care

A subsequent community-based trial of topical chlorhexidine in Nepal reported:

a 75% reduction in severe omphalitisa 24% reduction in neonatal mortality

compared with dry cord care

Source: Mullany et al. Lancet 2006. 367:910-918

Chlorhexidine trial, Pakistan

Lancet 2012. 379:1029-1036

Chlorhexidine trial, Pakistan

187 clusters randomly allocated in 2x2 factorial design2 interventions

Chlorhexidine (daily for 2 weeks) vs dry cord careHandwashing promotion vs no handwashing promotion

Interventions delivered through Dais Facility births excluded9741 livebirths enrolled over 18 months

Chlorhexidine trial, Pakistan

Neonatal mortality Neonatal deaths (NMR)

Risk ratio (95% c.i.)

P

No handwashing promotion

147 (29.1) 1.0

Handwashing promotion 140 (29.9) 1.08 (0.79, 1.48)

0.62

Dry cord care 176 (36.1) 1.0

Chlorhexidine 111 (22.8) 0.62(0.45, 0.85)

0.003

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.

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 makingMonitor progress

Acknowledgements

Joy Lawn, Zulfiqar Bhutta, Gary Darmstadt, Hannah Blencowe, Susana Scott, Neff Walker, Mikkel Oestergaard, Colin Mathers and many others