Best buys

for women & babies:

Maximising returns on investments

Professor Joy Lawn MB BS, MRCP (Paeds), MPH,

PhD

MARCH, London School Hygiene and Tropical Medicine Director Evidence and Policy, Saving Newborn Lives/ Save the Children DFID Senior Research Fellow, Newborn Health

Our delivery goal

No newborn is born to die

~ 280,000 die 3 million die

No baby stillborn
2.6 million die

No child stunted or dying

2.9 million die

10 million deaths

3.5 million within a few days of birth

Evidence-based public health investment

1. Epidemiology
Burden (mortality, disability) Risk factors Equity gaps

Target

2. Evidence
Interventions, highest impact, cost effectiveness Implementation approaches, accelerators

Tools

3. Environment, including health system

Health system coverage and quality Context specific bottlenecks for implementation

Team,
supplies, and systems strength

Target

Target setting

The Big One!

The Big Five!

Target

Causes of confusion
Antepartum

Maternal deaths 0.28 m

Other Embolism direct 11% 1% Unsafe abortion 9% Indirect 18%

Stillbirths 2.6 m

Intrapartum

Neonatal deaths 3m

Infection Fetal growth Congenital 6% restriction 2% Other 3% 1% No condition identified 88%

Sepsis 8%

Diarrhoea Congenita Other Congenital 2% Infection l 6% 9% 5% 4% Pneumonia 11% No condition Intrapartum identified 29% related Sepsis Other 23% 13% 1% Fetal growth restriction 2% Acute intrapartu m event 59%

Hypertension 18%

Haemorrhag e 35%

Preterm 36%

Noahs Ark not the Big Five!

Sources: Stillbirths, Lawn JE et al Lancet SB series, Maternal, Countdown 2011 report, Neonatal Liu et al Lancet 2012

Target

The Big Five underlying conditions to target to save the lives of mothers and babies
Global number of maternal, neonatal deaths and stillbirths (approx)

1.

Childbirth complications
eg haemorrhage, obstructed labour

~ 2.12 million

2. 3.

Preterm birth complications Infections

Mother - HIV, syphilis, malaria, maternal sepsis, Baby - sepsis, pneumonia, diarhoea, tetanus

~1.1 million ~1.12 million

75%

4.

Maternal chronic conditions (NCDs)

eg hypertension, diabetes, (linked to preterm and to small for gest age)

5.

Nutrition (undernutrition and obesity)

Sources: Maternal, Countdown 2011 report, Stillbirths, Lawn JE et al Lancet SB series, Neonatal Liu et al Lancet 2012

Tools

RMNCH interventions evidence

Proliferating interventions and proliferating Lancet series..

Child 2003

PMNCH essential interventions (56) Overagreed 200 Sept 2011

single Primary focus on survival interventions MDG timeframe listed!!

Stillbirth series 2011

Non commun icable diseases

Newborn 2005 Reproductive Health Series 2006 Child develo pment series 2007

Malaria series 2010 Nutrition series 2008

AIDs multiple series

Maternal Series 2006

NEW LAST WEEK Pneumonia/ Diarrhoea GAPPD

Higher impact if achieve a systems approach

Integrated service delivery = efficiency Emphasis on impact for women and babies = value added

Tools

Evidence
Bedside

Action
Global reach
Still no WHO policy review
2010

A predictable timeline?
Bench
Initial trials First trial in Multiple in lambs humans RCTs
1970 1980

NIH consensus Cochrane review 19 RCTs statement

1990 2000

Standard of care in rich countries

Remains low coverage in middle and low income rich countries

rd First trial 3 RCT published published

Antenatal corticosteroid injections for women in preterm labour

2007

(all from Asia) 2012

WHO policy review in process

Chlorhexidine cord cleansing

Tools

Tools approach

Team,
supplies, and systems strength

The simple toolkit

The systems approach

Can use simple tools and then integrate in a systems approach

Tools

Newborn toolkit approach

Estimated annual newborn lives saved at universal coverage

Case management of neonatal sepsis * Chlorhexidine umbilical cord cleaning * Antenatal corticosteroids for preterm labour*

~ 500,000
(cannot yet estimate in LiST)

~ 430,000

Neonatal resuscitation*

~ 230,000

Kangaroo Mother care

~450,000

* Prioritised by the UN Commission on Life Saving Commodities for Women and Children
Sources: Born Too Soon Chap 5 2012, Lawn J et al, IJGO, 2009

Tools

Maximum return on investment The best buys to address deaths of mothers and babies
Women Stillbirths Newborn s SGA and stunting + preterm

eg

Family planning
Prevention/ management of infections in pregnancy especially syphilis and malaria Prevention/ management of hypertension in pregnancy + NCDs Quality care at birth
newborn care & resuscitation)

+
+

+
+

+
+

+
+

eg

eg (including Em Obstetric care, essential

eg

Care of preterm labour & of preterm babies Prevention/management of infections in newborns Optimal nutrition through the lifecycle especially breastfeeding

+/-

+ + +

Tools

Family planning

222 million women and girls lack access to family planning which would change their lives, and their families 16 million adolescent girls (age 15-19) give birth each year (~11% of all births), and are at risk of adverse outcomes for themselves and their babies Risk is also higher for elderly pregnant women (>30 yrs) and their babies Family planning reduces numbers of births, and hence of deaths. The risk reduction evidence is less clear cut

Need more analyses regarding the linkages of family size and newborn survival

Lack of family planning also affects coverage of the health system

Skilled attendant at birth, Nigeria

2.7m
1990 2008

Coverage vs women reached In Nigeria, continued population explosion means modest gains in coverage hide large gains in numbers reached with skilled attendance

1.3m

31% 38%

Coverage

Number of attended births

Data from Countdown to 2015 for Maternal, Newborn and Child Health, 2012.

Tools

Care during pregnancy - infections

~ 91,800 neonatal deaths, ~212,000 stillbirths (>28 wk) or early fetal deaths (22 to 28 wk),

Sexually transmitted infections, especially syphilis

Improved simplified testing available, low cost treatment Yet ~ 66% of adverse outcomes occurred in ANC attendees who not tested or were not treated for syphilis Missed opportunity to save lives, especially stillbirths Malaria in pregnancy
Severe malaria, low birth weight Malaria in pregnancy interventions include Insecticide treated bed nets (ITNs) and intermittent presumptive treatment (IPTp) High coverage might prevent 75000200000 neonatal deaths

Newman L, Kamb M, Hawkes S, Global Estimates of Syphilis in Pregnancy and Associated Adverse Outcomes: Analysis of Multinational Antenatal Surveillance Data. PLoS Med 10(2): e1001396. doi:10.1371/journal.pmed.1001396

Missed opportunities to measure gestational age and small for gestational age

WHO. The global elimination of congenital syphilis. Geneva: RHR, World Health Organization; 2007
Steketee RW, Nahlen BL, Parise ME, Menendez C. The burden of malaria in pregnancy. Am J Trop Med Hyg 2001; 64 (suppl 12): 2835.

Tools

Care at birth

Childbirth care

Basic antenatal

Advanced antenatal

Source: Pattinson R, Kerber K, Buchmann E, et al, for The Lancets Stillbirths Series steering committee. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62306-9.

TRIPLE RETURN ON INVESTMENT

Team,
supplies, and systems strength

Our delivery reality

Under use

Over use

Both are a quality gap But the over use scenario is a major impact opportunity

Save the Children

Team,
supplies, and systems strength

QUALITY GAPS = Opportunities to seize Eg Uganda

100

80

Coverage (%)

60

Coverage Gap to reach all births

40

20

Quality gap
Skilled attendance at birth C-section Basic Em Obs Comp Em Obs Active Antenatal Neonatal Care Care management corticosteroids resusitation of the 3rd stage of labour Kangaroo Mother Care

Ref: Science in Action Saving the lives of Africas mothers, newborns and children. ASADI 2009. Eds Kinney MV, Lawn JE, Kerber KJ Data sources: Example of Uganda using current coverage data and LiST

15 million babies are born too soon every year...

Survival gap 10 90
Over 90% of extremely preterm babies (<28 weeks) born in high-income countries survive; yet less than 10% of these babies survive in low-income settings.

YET most of the 1.1 million deaths due to preterm complications could be saved with current interventions not including intensive care
Born Too Soon: The Global Action Report on Preterm Birth

KNOWLEDGE GAP

- In 39 high income countries the potential for preterm birth prevention is VERY SMALL at about 5% - Interventions examined included smoking reduction, C section practices, progesterone, cerclage.

- URGENT need to examine preterm birth syndrome and understand and develop solutions especially for spontaneous preterm birth
- EVEN more urgent for low income settings as likely much greater scope possible in addressing high infection load in pregnancy, adolescent pregnancy, birth spacing etc Limited evidence partly because of failure to measure gestational age eg only one high quality malaria in pregnancy trial had gestational age outcome

3.5 million deaths within days of birth

Happier Birth Days are key to reducing deaths and also disability

Best buys Who? Addressing more than one target group (women, babies)
When? Focus around the time of birth

Which?
Family planning, Antenatal care especially infections in pregnancy Care at birth including essential newborn care and resuscitation Care of the preterm and sick newborn

How? Context specific programme action and leadership

#globalnewbornaction

We are the first generation with tools to transform global maternal and newborn and child survival - will we reach our goal?

Be part of the action for newborns

#Newborn2013 #GlobalNewbornAction