Newborn survival and perinatal health in resource-constrained settings in Asia and the Pacific: Applying Global Evidence to Priorities Beyond 2015 12 April 2013

1. Models of neonatal care in the
Pacific and Asia
Trevor Duke
Centre for International Child Health
University of Melbourne
Royal Children’s Hospital
School of Medicine & Health Sciences
University of PNG

2. • Neonatal health as a research priority
• Linking models of care with NMR
• Components of models of care
• Evidence of effectiveness
• Resources for improving neonatal care
• Sepsis: new data on antimicrobial efficacy
• The “regional action plan for neonatal
health”

3. Controlled trials in child health in developing
countries n=1342
Pneumonia Parasitic Neonatal Mental
Year
Malaria
Nutrition
Vaccines
HIV
Diarrhoea
ARI
Development
infections
health
TB
health
2003
4
15
2
1
6
3
1
4
0
1
0
2004
18
22
7
7
8
5
5
10
3
3
0
2005
22
17
6
7
2
5
3
4
2
1
0
2006
31
31
8
12
11
4
3
3
2
3
0
2007
33
40
10
13
10
7
6
8
2
1
0
2008
40
30
15
13
11
9
3
4
9
1
2
2009
29
29
18
11
10
11
10
11
5
0
2
2010
51
32
23
13
14
8
7
8
7
2
6
2011
42
39
24
21
20
12
8
11
8
4
6
2012
44
46
32
26
21
16
9
8
11
7
1
Total
314
301
145
124
113
80
55
71
49
23
17
3.7% of all RCTs in child health in developing countries were
on neonatal care, or included neonatal outcomes

4. • Community care:
– Skilled birth attendant delivery and essential
newborn care leads to 30-50% reduction in
neonatal mortality in communities with very
high neonatal mortality rates (e.g. >45/1000
live births)…
– Where the proportion of health facility
deliveries is low…
– Where health systems are weak…

5. Community based neonatal health intervention trials
Reference Country Baseline or control Post Intervention NMR
NMR*
Bang AT et al. Journal of Perinatology 2005; 25 India 62/1000 25/1000
Suppl 1, S92-107
Kumar V. Lancet 2008; 372:1151-1162 India 58.9-64.1/1000 41/1000 (Essential
newborn care-ENC),
43.2/1000 (Essential
newborn care +
hypothermia indicator)
Bhutta ZA. Lancet 2011; 377:403-412 Pakistan 48/1000 live 43.0/1000
Midhet F et al. Reproductive Health 2010, 7:30. Pakistan 48/1000* 30.5-32.4/1000
Bacqui, AH. Lancet 2008; 371:1936-44 Bangladesh 46-48/1000 29.2/1000 (home care),
45.2/1000 (community-
care)
Jokhio AH et al. NEJM. 2005; 252(20): 2091-9. Pakistan 46-67/1000* 33-42/1000
Gill CJ. BMJ. 2011; 342:d346 Zambia 40.4/1000* (actual 22.8/1000 (actual
numbers 59/1466) numbers 43/1889)
Manandhar DS et al. Lancet. 2004; 364(9438): Nepal 36.9/1000* 26.2/1000
970-9
Azad K. Lancet.2010; 375: 1193–20 Bangladesh 36.5/1000* (cluster level No significant decrease in
mean NMR) NMR observed.
Darmstadt GL. PLoS One 2010; 5(3); e9696 Bangladesh 25.2/1000 No significant decrease in
NMR observed.
Carlo WA et al. NEJM. 2010; 362(7): 614-23 6 countries (Argentina, Early (<7day) NMR No significant decrease in
Democratic Republic of 23/1000 (ENC group) NMR observed.
Congo, Guatemala, India,
Pakistan,and Zambia)

6. Neonatal mortality rates for countries in the WHO South East Asian and Western
Pacific Regions
Country Neonatal mortality rate per 1000 live births (NMR)
1990 2008 2010 * 2011
(WHO) (WHO)
NMR 30-40
Bangladesh 64.5 (52.1-76.4) 33 31.3 (25.4-36.9)
Bhutan 63.7 (40.9-91.1) 35 30.1 (19.1-41.5)
India 53.9 (43.4-64.5) 37 34.3 (27.7-40.8)
Nauru 33 21.7
Niue 30 10.3
PNG 46.6 (28.6-68.0) 26 39.3 (23.4-61.1) 22.6
* Li L, et al. Lancet 2012; 379: 2151-2161

7. NMR 15-29
Country 1990 2008 2010 * 2011
(WHO) (WHO)
Cambodia 41.5 (32.5-51.7) 31 26.2 (18.7-35.9) 19.4
Democratic People's 32.7 (21.4-41.8) 29 21.1 (13.4-27.5)
Republic of Korea
Timor-Leste 36.2 (21.4-57.2) 43 26.8 (15.6-42.3)
Indonesia 27.5 (21.5-33.8) 19 17.8 (14.0-22.2)
Kiribati 36.6 (21.8-51.9) 17 23.8 (13.5-35.0) 19.1
Lao PDR 44.8 (26.8-71.2) 20 28.3 (15.8-46.5) 17.5
Marshall Islands 25.6 (15.1-37.2) 15 23.8 (13.5-35.0) 11.7
Mongolia 33.0 (19.5-53.6) 14 16.7 (9.5-24.8) 11.7
Myanmar 40.5 (23.3-62.9) 48 24.4 (14.4-38.5)
Nepal 59.1 (47.2-71.5) 31 25.4 (20.5-30.9)
Solomon Islands 20.0 (11.8-28.8) 14 15.8 (8.9-23.0) 10.5
* Li L, et al. Lancet 2012; 379: 2151-2161

8. When mortality less than 25-30 per
1000 live births
• Community care still important
– inequity
• Models of care needed at all levels of health service
• Questions
• What services are needed at
– health clinic
– district hospital
– referral hospital…
– to establish minimal standard of neonatal care
• What current capacity exists?
• What human resources are needed?
• What technical resources are needed (physical facility
space, medications, equipment, guidelines, training)?
• What are the appropriate referral criteria and
mechanisms?

9. Historical evidence
Community based public health, sanitation,
education, maternal nutrition
Facility-based obstetric and neonatal care, improved
access to antibiotics, attention to thermal care, infant
nutrition and care of LBW and prematurity
Neonatal intensive care

10. Models of care
• WHO/UNICEF Regional Action Plan for
Neonatal Care
• Modelled on “The First Embrace”
• Philippines hospital survey Sobel HL et al. Acta Paed. 2011
– 51 hospitals, obstetric and immediate newborn care
– Widespread gaps in implementation of essential
newborn care (e.g. skin-skin contact, drying, thermal
care)
– Unhelpful interventions common (early separation,
suctioning)

11. Regional Action Plan 2013-2020
Goals
1. To reduce national NMR 10 per 1000 or less in all member states
2. To reduce sub-national NMR 10 per 1000 or less

12. Models of care
• Quality improvement approach
• What services are needed at
– health clinic
– district hospital
– referral hospital…
– to establish a minimal standard of neonatal care
• What current capacity exists?
• What human resources are needed?
• What technical resources are needed (physical facility
space, medications, equipment, guidelines, training)?
• What are the appropriate referral criteria and
mechanisms?

13. Models of care: Health clinics
• Newborn resuscitation
• Support for breastfeeding
• Thermal protection, skin-to-skin contact
• Infection prevention: general hygiene, hand washing, cord care
• Eye infection prophylaxis
• Immunization and Vitamin K prophylaxis
• Identification, treatment or referral of signs of severe illness, injury or
malformation (IMCI, referral guidelines)
• Birth registration
• Counseling regarding newborn care, care-seeking, health promotion
including immunizations and avoidance of indoor air pollution
• Developmental care including newborn stimulation and play
• Follow up visits for vaccines, growth monitoring
• Family planning

14. Models of care: District and
provincial hospitals
• All interventions at the clinic level, plus…
• A special care / high dependency nursery
• Management of a newborn with serious illness:
– Oxygen and oximetry
– Apnoea: monitoring and prevention
– Warming (includes KMC)
– Breast feeding and prevention of hypoglycaemia
– Safe administration of intravenous fluids
– Standard antibiotics
• Guidelines for management and referral of common conditions:
– Preterm and VLBW babies
– Severe respiratory distress
– Severe infection
– Severe birth asphyxia
– Severe jaundice - phototherapy
– Malformations and common surgical conditions
• Audit
• Prevention of nosocomial infection

15. Models of care: Referral hospitals
• All interventions at the clinic and
district hospital level, plus…
• Respiratory distress:
– CPAP / high flow nasal prong oxygen
therapy
• Surgical services for neonates
• Care for the VLBW baby (weight for
referral depending on access and
capacity at district / provincial
hospital)
• Exchange transfusion for severe
jaundice

17. Effect of minimal standards of neonatal care
Admit Deaths Mortality Relative risk p value
(%) (95% CI)
Total admissions
A 1167 205 17.5
B 1247 122 9.8 0.56 (0.45-0.69) <0.0001
RR adjusted for higher number of neonates <2kg in ‘95-97 0.59 (0.48-0.74) <0.0001
Birth weight <1000g
A 17 15 88.2
B 10 7 70.0 0.79 (0.51-1.23) 0.32
Birth weight 1000-1499g
A 90 60 66.7
B 71 21 29.6 0.44 (0.30-0.65) <0.0001
Birth weight 1500-2000g
A 134 31 23.1
B 120 14 11.7 0.50 (0.28-0.90) 0.02
Septicaemia or pneumonia
A 341 47 13.8
B 224 11 4.9 0.36 (0.19-0.67) 0.0006
Birth asphyxia or meconium aspiration
A 135 30 22.2
B 137 18 13.1 0.59 (0.35-1.01) 0.057

18. Models of care: referral criteria
Indications for referring newborns to hospital
• Birth-weight between 1-1.5 kg
• Birth-weight between 1.5–2.0 kg if:
¨ Respiratory distress or apnoea
¨ Signs of sepsis
• Birth asphyxia
• Severe respiratory distress
• Severe infection
¨ Sepsis
¨ Meningitis
¨ Osteomyelitis / septic arthritis
• Any infection that does not improve after 48 hours of appropriate treatment
• Severe abdominal distension
• Signs of shock (>3 seconds for capillary refill, weak pulse, cold hands)
• Congenital abnormalities:
¨ Suspected congenital heart
¨ Open abdominal lesions
¨ Ambiguous genitalia
¨ Imperforate anus
¨ Bile (green) stained vomiting
¨ Frequent vomiting and lots of saliva in the first few hours of life
¨ Pain and swelling of the testes or the inguinal area
• Recurrent apnoeas (>3 periods of no breathing for longer than 20 seconds per day)
• Coma and / or convulsions
• Uncontrolled bleeding despite Vitamin K injection
• Pallor
• Severe jaundice or jaundice that lasts longer than 2 weeks
• Unexplained poor weight gain for more than 2 weeks after birth
Call or radio National Referral Hospital or provincial hospital

19. Models of care: referral
mechanisms
• Communication
• Transport
• Funding
• The model in Fiji

20. Other resources
• Training on the WHO Pocket Book of Hospital
Care
– Training in care of the neonate with LBW,
sepsis, birth asphyxia
• Assessment tools for neonatal care standards at
hospitals
• Appropriate technology
• Posters
• Simple standardized data reporting system

21. Training strategies
• Training CD-ROM

24. NEONATAL RESUSCITATION
Neonatal resuscitation can be highly effective even without oxygen using a self-inflating resuscitation bag & mask
All newborn babies should be given their first dose of BCG and Hepatitis B vaccines and a dose of vitamin K
Babies should be breast-fed within the first hour of birth
Produced by the Paediatric Society of PNG and the World Health Organization 2008

25. Systematic approach to the use of oxygen
• Concentrators
• Oximetry
• Bubble-CPAP

26. Simple systems of data for surveillance

27. Simple standardised outcome
reporting

28. Simple standardised outcome
reporting
2010 2011
Diagnoses Admit Deaths CFR Admit Deaths CFR
All neonatal 2752 335 12.3 4180 480 11.5
Neonatal sepsis 592 37 6.3 2124 152 7.1
Asphyxia 467 54 11.6 1219 165 13.5
VLBW 106 32 30.2 518 169 32.6

30. Sepsis
• Half a million neonatal deaths each year
• WHO recommends treatment with
penicillin / ampicillin and gentamicin
• Many countries use third-generation
cephalosporins to treat neonatal sepsis

31. • 19 studies, 13 countries, >4000 cases of bacteraemia
• Staph aureus, Klebsiella spp. and E. coli accounted for
55% (39–70%)
• Penicillin/gentamicin had comparable in vitro coverage to
third-generation cephalosporins (57% vs 56%)
• Resistance to the combination of penicillin and
gentamicin and to third-generation cephalosporins
occurs in more than 40% of cases

32. Implications
• How to determine criteria for second-line therapy that are
implementable in resource-limited settings
• How to ensure recommendations are effective but
minimise the development of further resistance
• How to make available more expensive or higher-
generation antibiotics in resource-limited developing
countries but ensure their use is based on evidence
• How to address the poor state of bacteriology services in
most developing countries and improve local surveillance
data

33. Summary
• Models of care at primary, district, referral level
• It can be done…and saves lives
• Tools available
• Implementation science
• Monitor neonatal outcomes – it can be done
• Antibiotic stewardship needed

34. How to start
• What services are needed at
– health clinic
– district hospital
– referral hospital…
– to establish a minimal standard of neonatal care
• What current capacity exists?
• What human resources are needed?
• What technical resources are needed (physical facility
space, medications, equipment, guidelines, training)?
• What are the appropriate referral criteria and
mechanisms?