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Technical updates on newborn resuscitation and home visits for newborn survival1|

Technical updates onNewborn Resuscitation

and Home visits forNewborn Survival

6 May 2012, DhakaDr Ornella Lincetto


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Outline of the presentation

New WHO guidelines on Newborn Resuscitation

Update of evidence for Home Visits for Newborn

Survival

Meeting on policies and practice of home visits fornewborn survival, Geneva, Feb 2012


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Basic Newborn Resuscitation Guidelines

2012


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Newborn resuscitation guidelines: principles

Systematically developed, based on all available evidence

Clear, unambiguous recommendations, stating the qualityof evidence on which they are based - GRADE

Strength of recommendation based on the balance ofbenefits and risks, values and preferences, and costs

Take into account the range of circumstances in which they

will be used


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Recommendation

In a newly born term or preterm (>32 weeks gestation)baby requiring positive-pressure ventilation,ventilation should be initiated with air.

Strong recommendation

Based on moderate quality evidence of reducedmortality


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Before starting PPV

Late cord clamping (at least after 1 minute of birth)

Additional stimulation after drying limited to rubbing theback 2-3 times, before cutting the cord and starting PPV

No routine suctioning. Use of suction limited to:

Meconium stained amniotic fluid and newborn not breathing onhis/her own

Clear amniotic fluid and newborn not breathing on his/her own

and mouth or nose full of secretions preventing effective PPV


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How to provide PPV

Initiation of PPV within one minute after birth if newbornnot breathing on his/her own

PPV should be:

Initiated with air

Given using a self-inflating bag and face mask

Assessed by measurement of heart rate after 60seconds of ventilation with visible chest movements

Given priority over chest compressions


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When to stop PPV

If no spontaneous breathing, resuscitation should stop:

after 10 minutes of effective PPV if no detectableheart rate

after 20 minutes of effective PPV if heart rate


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2009


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Evidence-base for the Joint Statement:2009

Home Visits for Neonatal Care by Community HealthWorkers for Preventing Neonatal Mortality inDeveloping Countries: Systematic Review of

Controlled Trials

Gogia S and Sachdev HPS

Published in Bulletin of the World Health Organization 2010


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38% reduction in neonatal mortalityPooled effect on NMR in 5 studies: 0.62 (0.44, 0.87)

NOTE: Weights are from random effects analysis

Overall (I-squared = 86.4%, p = 0.000)

Shivgarh 2008

Gadhchiroli 2005

Sylhet 2008

Study ID

Barabanki 2008

Hala 2008

0.62 (0.44, 0.87)

0.47 (0.38, 0.58)

0.39 (0.27, 0.56)

Risk

0.66 (0.47, 0.93)

Ratio (95% CI)

1.06 (0.81, 1.38)

0.70 (0.54, 0.90)

100.00

21.47

18.49

%

18.91

Weight

20.46

20.67

0.62 (0.44, 0.87)

0.47 (0.38, 0.58)

0.39 (0.27, 0.56)

Risk

0.66 (0.47, 0.93)

Ratio (95% CI)

1.06 (0.81, 1.38)

0.70 (0.54, 0.90)

100.00

21.47

18.49

%

18.91

Weight

20.46

20.67

1.2 .5 1 2 5


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Update of evidence-base

Three additional studies published since 2009:

The Mirzapurstudy (Darmstadt et al. PLoS ONE 2010)

The Halastudy (Bhutta et al. Lancet 2011)

The IMNCIstudy (Bhandari et al. BMJ 2012)


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Characteristics of studies assessing impact of home visits

Gadchiroli Shivgarh Sylhet Barabanki Hala (pilot) Mirzapur Hala (main) HaryanaLive births/year /gp ~1000 ~1200 ~5000 ~8000 ~2500 ~2500 ~6000 ~15000

Studydesign Quasi-experiment

(1vs1 area)Clusterrandomizedtrial

Clusterrandomizedtrial

Programmeevaluation(1vs1 district)

Quasi-experiment(4vs4areas)



Clusterrandomized trial

NMR(control) 60 per 1000 84 per 1000 43 per 1000 46 per 1000 52 per 1000 28 per 1000 49 per 1000 43 per 1000

Home births 95% 93% 84% 84% 79% 84% 56% 51%Type ofworkers

SpeciallyrecruitedCHW


NGOCHW

GovernmentCHW

GovernmentCHW


GovernmentCHW

GovernmentCHW

Coverage 93% 68% 65% 39% 87% 80% amonghome births 24% 74%

Intervention Home visitsCommunitypromotionTreatmentof sepsis

Home visits

Communitypromotion-

Home visits

-Treatmentof sepsis

Home visits

--

Home visitsCommunitypromotion

-

Home visits

--

Home visits

Communitypromotion

Home visits

CommunitypromotionTreatment of mildillness

NMR impact 62% 49% 34% None 30% 13% 15% Facility births: 0%Homebirths: 20%

1-11 monthmortalityimpact

- - - - - - - 24%


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21% reduction in neonatal mortality

NOTE: Weights are from random effects analysis


Hala main - Bhutta 2011

Gadchiroli - Bang 1999

Haryana - Bhandari 2012

Shivgarh - Kumar 2008

Sylhet - Baqui 2008

Barabanki - Baqui 2008

Study

ID

Mirzapur - Darmstadt 2010

Hala pilot - Bhutta 2008

0.72 (0.59, 0.88)

0.85 (0.76, 0.96)

0.39 (0.27, 0.56)

0.91 (0.80, 1.03)

0.47 (0.38, 0.58)

0.66 (0.47, 0.93)

1.06 (0.81, 1.38)

ES (95% CI)

0.87 (0.68, 1.12)

0.70 (0.54, 0.90)

100.00

14.66

10.17

14.54

13.15

10.63

12.10

%

Weight

12.43

12.31

0.72 (0.59, 0.88)

0.85 (0.76, 0.96)

0.39 (0.27, 0.56)

0.91 (0.80, 1.03)

0.47 (0.38, 0.58)

0.66 (0.47, 0.93)

1.06 (0.81, 1.38)

ES (95% CI)

0.87 (0.68, 1.12)

0.70 (0.54, 0.90)

100.00

14.66

10.17

14.54

13.15

10.63

12.10

%

Weight

12.43

12.31

1.27 1 3.7


Sylhet - Baqui 2008

ID

Barabanki - Baqui 2008

Hala main - Bhutta 2011

Shivgarh - Kumar 2008

Mirzapur - Darmstadt 2010

Hala pilot - Bhutta 2008

Haryana - Bhandari 2012

Gadchiroli - Bang 1999

Study

0.79 (0.74, 0.84)

0.66 (0.47, 0.93)

ES (95% CI)

1.06 (0.81, 1.38)

0.85 (0.76, 0.96)

0.47 (0.38, 0.58)

0.87 (0.68, 1.12)

0.70 (0.54, 0.90)

0.91 (0.80, 1.03)

0.39 (0.27, 0.56)

100.00

3.91

Weight

6.41

33.33

10.17

7.31

6.97

28.49

3.42

%

0.79 (0.74, 0.84)

0.66 (0.47, 0.93)

ES (95% CI)

1.06 (0.81, 1.38)

0.85 (0.76, 0.96)

0.47 (0.38, 0.58)

0.87 (0.68, 1.12)

0.70 (0.54, 0.90)

0.91 (0.80, 1.03)

0.39 (0.27, 0.56)

100.00

3.91

Weight

6.41

33.33

10.17

7.31

6.97

28.49

3.42

%

1.27 1 3.7


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Variability in impact of home visits

Study size: Smaller efficacy studies show largermortality impact (40%) than larger effectiveness studies(12%).

NMR: Studies with higher NMR in control areas showlarger mortality impact.

Home births: Studies in settings with predominantlyhome births show larger mortality impact.


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Effect on key newborn care practices:Early initiation of breastfeeding

Study Control clusters Intervention clusters Difference

Shivgarh 16% 71% + 55%

Hala (pilot) 21% 66% + 45%

Mirzapur 55% 80% + 25%

Sylhet 57% 81% + 24%

Hala(within 30 minutes)

27% 43% + 16%

Barabanki 6% 38% + 32%

Haryana 11% 41% + 30%


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Evidence summary:Home visits for newborn survival

Home visits, in combination with communitypromotion of practices, reduce NMR by about 21%

Larger impact is likely in settings with high NMR andwhere most births occur at home

All studies show impressive improvements innewborn care practices

Data from India indicates that the impact extends topost neonatal period (24% reduction)


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Informal WHO meeting: February 2012

Home visits for newborn survival:

Policies and Practices in Priority Countries


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Home visit policies: SEAR and AFR

28/47 (60%) countries surveyed have a policy onpostnatal care home visits

Africa 18/36 (50%)

Asia 10/11 (91%)

All of these refer to the mother and the child

25/28 include a home visit during pregnancy

Africa 16/18 (89%)

Asia 9/10 (90%)


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Reach of home visits

6

5

15

2 1/3 of national population covered

Nationally

Not implemented

N=36 N=11

1/3 of national population

covered4 1

Nationally 6 7

Not implemented 1 1

Africancountries

AsiancountriesPNC home visits

implemented in:


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Timing of Postnatal Care Home Visits

12

18

21

0

5

10

15

20

25

Three home visits:


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Content of Home Visits

27 27 2725

00

5

10

15

20

25

30

Promotion of

appropriate care

Identification of

danger signs

Feeding support All of the above Treatment


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Human Resources for Home Visits

14

3

8

14

6

9

22

0

5

10

15

20

25

Volunteers

without

incentives

Volunteers

with incentives

CHW on

government

payroll

Health

professionals

(e.g. nurses or

midwives)

Other Health

professionals

and any

CHV/CHW

Any

combination


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Difficulties with Programme Components

0

1

2

3

4

5

Policy adoption Reruitment and

training

Maintaining

competencies and

motivation

Health systems

supports

Community

participation

Score:least(1)to

mostdifficult(5)

0

1

2

3

4

5

Median

25%

75%

IQR


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Global Recommendations: PNC home visits

Advocate for increased adoption of PNC policies andincreased resources for implementation

WHO to define optimal package of interventions for motherand baby, and provide estimates of implementation costs

WHO/UNICEF/USAID/SC to develop implementation guideand define standard indicators for tracking progress

Address research priorities:

Linking CHWs to facilities Models for implementing PNC in different settings

Use of technology to support implementation


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Thank you

Documents

Bahl_Voices Changing Lives for Mothers and Newborns in Asia