A collection of newborn health research from December to January 2013-2014.

Part 2! Research Round-Up: January 2014

The past two months were packed with excellent publications and research on newborn health. This is just Part 2 of what HNN has compiled. Did you miss Part 1? Read it here.

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Multiple Authors. Supplement – Beyond Newborn Survival. Pediatric Research (December, 2013).

Every year, 135 million newborns enter the world, each arriving naked and apparently equal. Yet, their chances of surviving and thriving vary dramatically depending on which world these babies are born into—ranging from high-income countries with universal neonatal intensive care to the world of home births without midwives, medical supplies, or health system support.
 
The Beyond Newborn Survival supplement in Pediatric Research, published by Nature, includes an editorial and six research articles presenting the first systematic estimates of impairment after neonatal morbidity. It brings together the work of almost 50 authors representing 35 institutions from 12 countries, from more than a thousand different data inputs. The authors summarize global estimates of the incidence of impairments in the year 2010 as a result of four major neonatal conditions: preterm birth (including separate estimates of visual impairment due to retinopathy of prematurity), intrapartum-associated neonatal encephalopathy (sometimes referred to as “birth asphyxia”), severe neonatal infections, and hyperbilirubinemia (seen clinically as jaundice).
 
Worldwide, of the 15.1 million preterm babies, 13 million survived beyond the first month of life. Of the survivors, 345,000 (2.7 percent) had moderate or severe impairment and 567,000 (4.4 percent) had mild impairment.
 
Background: Rhesus (Rh) disease and extreme hyperbilirubinemia (EHB) result in neonatal mortality and long-term neurodevelopmental impairment, yet there are no estimates of their burden.
 
Methods: Systematic reviews and meta-analyses were undertaken of national prevalence, mortality, and kernicterus due to Rh disease and EHB. We applied a compartmental model to estimate neonatal survivors and impairment cases for 2010.
 
Results: Twenty-four million (18% of 134 million live births ≥32 wk gestational age from 184 countries; uncertainty range: 23–26 million) were at risk for neonatal hyperbilirubinemia related adverse outcomes. Of these, 480,700 (0.36%) had either Rh disease (373,300; uncertainty range: 271,800–477,500) or developed EHB from other causes (107,400; uncertainty range: 57,000–131,000), with a 24% risk for death (114,100; uncertainty range: 59,700–172,000), 13% for kernicterus (75,400), and 11% for stillbirths. Three-quarters of mortality occurred in sub-Saharan Africa and South Asia. Kernicterus with Rh disease ranged from 38, 28, 28, and 25/100,000 live births for Eastern Europe/Central Asian, sub-Saharan African, South Asian, and Latin American regions, respectively. More than 83% of survivors with kernicterus had one or more impairments.
 
Conclusion: Failure to prevent Rh sensitization and manage neonatal hyperbilirubinemia results in 114,100 avoidable neonatal deaths and many children grow up with disabilities. Proven solutions remain underused, especially in low-income countries.
 
Background: Retinopathy of prematurity (ROP) is a leading cause of potentially avoidable childhood blindness worldwide. We estimated ROP burden at the global and regional levels to inform screening and treatment programs, research, and data priorities.
 
Methods: Systematic reviews and meta-analyses were undertaken to estimate the risk of ROP and subsequent visual impairment for surviving preterm babies by level of neonatal care, access to ROP screening, and treatment. A compartmental model was used to estimate ROP cases and numbers of visually impaired survivors.
 
 
Results: In 2010, an estimated 184,700 (uncertainty range: 169,600–214,500) preterm babies developed any stage of ROP, 20,000 (15,500–27,200) of whom became blind or severely visually impaired from ROP, and a further 12,300 (8,300–18,400) developed mild/moderate visual impairment. Sixty-five percent of those visually impaired from ROP were born in middle-income regions; 6.2% (4.3–8.9%) of all ROP visually impaired infants were born at >32-wk gestation. Visual impairment from other conditions associated with preterm birth will affect larger numbers of survivors.
 
Conclusion: Improved care, including oxygen delivery and monitoring, for preterm babies in all facility settings would reduce the number of babies affected with ROP. Improved data tracking and coverage of locally adapted screening/treatment programs are urgently required.
 
Background: Neonatal mortality and morbidity are increasingly recognized as important globally, but detailed estimates of neonatal morbidity from conditions and long-term consequences are yet to be published.
 
Methods: We describe the general methods for systematic reviews, meta-analyses, and modeling used in this supplement, highlighting differences from the Global Burden of Disease (GBD2010) inputs and methods. For five conditions (preterm birth, retinopathy of prematurity, intrapartum-related conditions, neonatal infections, and neonatal jaundice), a standard three-step compartmental model was applied to estimate— by region, for 2010—the numbers of (i) affected births by sex, (ii) postneonatal survivors, and (iii) impaired postneonatal survivors. For conditions included in GBD2010 analyses (preterm birth and intrapartum-related conditions), impairment at all ages was estimated, and disability weights were applied to estimate years lived with disability (YLD) and summed with years of life lost (YLL) to calculate disability-adjusted life years (DALYs).
 
Results: GBD2010 estimated neonatal conditions (preterm birth, intrapartum-related, neonatal sepsis, and “other neonatal”) to be responsible for 202 million DALYs or 8.1% (7.3–9.0%) of the worldwide total. Mortality contributed 95% of the DALYs, and the estimated 26% reduction in neonatal condition DALYs since 1990 is primarily due to a 44% reduction in neonatal mortality rate due to these conditions, counterbalanced by increased numbers of babies born (17%). Impairment following neonatal conditions remained stable globally and is therefore relatively more important, especially in high- and middle-income countries. Crucial data gaps were identified.
 
Conclusion: These results confirm neonatal conditions as a significant burden, reemphasizing the need to reduce deaths further, to count the linked 2.6 million stillbirths, and to better measure and address their long-term effects.
 
Background: Intrapartum hypoxic events (“birth asphyxia”) may result in stillbirth, neonatal or postneonatal mortality, and impairment. Systematic morbidity estimates for the burden of impairment outcomes are currently limited. Neonatal encephalopathy (NE) following an intrapartum hypoxic event is a strong predictor of long-term impairment.
 
Methods: Linear regression modeling was conducted on data identified through systematic reviews to estimate NE incidence and time trends for 184 countries. Meta-analyses were undertaken to estimate the risk of NE by sex of the newborn, neonatal case fatality rate, and impairment risk. A compartmental model estimated postneonatal survivors of NE, depending on access to care, and then the proportion of survivors with impairment. Separate modeling for the Global Burden of Disease 2010 (GBD2010) study estimated disability adjusted life years (DALYs), years of life with disability (YLDs), and years of life lost (YLLs) attributed to intrapartum-related events.
 
Results: In 2010, 1.15 million babies (uncertainty range: 0.89–1.60 million; 8.5 cases per 1,000 live births) were estimated to have developed NE associated with intrapartum events, with 96% born in low- and middle-income countries, as compared with 1.60 million in 1990 (11.7 cases per 1,000 live births). An estimated 287,000 (181,000–440,000) neonates with NE died in 2010; 233,000 (163,000–342,000) survived with moderate or severe neurodevelopmental impairment; and 181,000 (82,000–319,000) had mild impairment. In GBD2010, intrapartum-related conditions comprised 50.2 million DALYs (2.4% of total) and 6.1 million YLDs.
 
Conclusion: Intrapartum-related conditions are a large global burden, mostly due to high mortality in low-income countries. Universal coverage of obstetric care and neonatal resuscitation would prevent most of these deaths and disabilities. Rates of impairment are highest in middle-income countries where neonatal intensive care was more recently introduced, but quality may be poor. In settings without neonatal intensive care, the impairment rate is low due to high mortality, which is relevant for the scale-up of basic neonatal resuscitation.
 
Background: Survivors of neonatal infections are at risk of neurodevelopmental impairment (NDI), a burden not previously systematically quantified and yet important for program priority setting. Systematic reviews and meta-analyses were undertaken and applied in a three-step compartmental model to estimate NDI cases after severe neonatal bacterial infection in South Asia, sub-Saharan Africa, and Latin America in neonates of >32 wk gestation (or >1,500 g).
 
Methods: We estimated cases of sepsis, meningitis, pneumonia, or no severe bacterial infection from among estimated cases of possible severe bacterial infection ((pSBI) step 1). We applied respective case fatality risks ((CFRs) step 2) and the NDI risk among survivors (step 3). For neonatal tetanus, incidence estimates were based on the estimated deaths, CFRs, and risk of subsequent NDI.
 
Results: For 2010, we estimated 1.7 million (uncertainty range: 1.1–2.4 million) cases of neonatal sepsis, 200,000 (21,000–350,000) cases of meningitis, 510,000 cases (150,000–930,000) of pneumonia, and 79,000 cases (70,000–930,000) of tetanus in neonates >32 wk gestation (or >1,500 g). Among the survivors, we estimated moderate to severe NDI after neonatal meningitis in 23% (95% confidence interval: 19–26%) of survivors, 18,000 (2,700–35,000) cases, and after neonatal tetanus in 16% (6–27%), 4,700 cases (1,700–8,900).
 
Conclusion: Data are lacking for impairment after neonatal sepsis and pneumonia, especially among those of >32 wk gestation. Improved recognition and treatment of pSBI will reduce neonatal mortality. Lack of follow-up data for survivors of severe bacterial infections, particularly sepsis, was striking. Given the high incidence of sepsis, even minor NDI would be of major public health importance. Prevention of neonatal infection, improved case management, and support for children with NDI are all important strategies, currently receiving limited policy attention.
 
R. Nesbitt, T. Lohela, A. Manu, et al. Quality along the Continuum: A Health Facility Assessment of Intrapartum and Postnatal Care in Ghana. PLoS One (November, 2013).
 
Objective: To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate “effective coverage” of skilled attendance in Brong Ahafo, Ghana.
 
Methods: We conducted an assessment of all 86 health facilities in seven districts in Brong Ahafo. Using performance of key signal functions and the availability of relevant drugs, equipment and trained health professionals, we created composite quality categories in four dimensions: routine delivery care, emergency obstetric care (EmOC), emergency newborn care (EmNC) and non-medical quality. Linking the health facility assessment to surveillance data we estimated “effective coverage” of skilled attendance as the proportion of births in facilities of high quality.
 
Findings: Delivery care was offered in 64/86 facilities; only 3-13% fulfilled our requirements for the highest quality category in any dimension. Quality was lowest in the emergency care dimensions, with 63% and 58% of facilities categorized as “low” or “substandard” for EmOC and EmNC, respectively. This implies performing less than four EmOC or three EmNC signal functions, and/or employing less than two skilled health professionals, and/or that no health professionals were present during our visit. Routine delivery care was “low” or “substandard” in 39% of facilities, meaning 25/64 facilities performed less than six routine signal functions and/or had less than two skilled health professionals and/or less than one midwife. While 68% of births were in health facilities, only 18% were in facilities with “high” or “highest” quality in all dimensions.
 
Conclusion: Our comprehensive facility assessment showed that quality of routine and emergency intrapartum and postnatal care was generally low in the study region. While coverage with facility delivery was 68%, we estimated “effective coverage” of skilled attendance at 18%, thus revealing a large “quality gap.” Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.
 
L. Nkonki, E. Daviaud, D. Jackson, et al. Costs of Promoting Exclusive Breastfeeding at Community Level in Three Sites in South Africa. PLoS One (January, 2014).
 
Background: Community-based peer support has been shown to be effective in improving exclusive breastfeeding rates in a variety of settings.
 
Methods: We conducted a cost analysis of a community cluster randomised-controlled trial (Promise-EBF), aimed at promoting exclusive infant feeding in three sites in South Africa. The costs were considered from the perspective of health service providers. Peer supporters in this trial visited women to support exclusive infant feeding, once antenatally and four times postpartum.
The total economic cost of the Promise-EBF intervention was US$393 656, with average costs per woman and per visit of US$228 and US$52, respectively. The average costs per woman and visit in an operational ‘non research’ scenario were US$137 and US$32 per woman and visit, respectively. Investing in the promotion of exclusive infant feeding requires substantial financial commitment from policy makers. Extending the tasks of multi-skilled community health workers (CHWs) to include promoting exclusive infant feeding is a potential option for reducing these costs. In order to avoid efficiency losses, we recommend that the time requirements for delivering the promotion of exclusive infant feeding are considered when integrating it within the existing activities of CHWs.
 
Discussion: This paper focuses on interventions for exclusive infant feeding, but its findings more generally illustrate the importance of documenting and quantifying factors that affect the feasibility and sustainability of community-based interventions, which are receiving increased focus in low income settings.
 
R. Salam, J. Das, G. Darmstadt, et al. Emollient therapy for preterm newborn infants – evidence from the developing world. BioMed Central (December, 2013).
 
Introduction: Application of emollients is a widespread traditional newborn care practice in many low and middle-income countries (LMICs) and may have the potential to decrease infection and consequent mortality in preterm neonates.
 
Methods: We systematically reviewed literature published up to December 2012 to identify studies describing the effectiveness of emollient therapy. We used a standardized abstraction and grading format to estimate the effect of emollient therapy by applying the standard Child Health Epidemiology Reference Group (CHERG) rules.
 
Results: We included seven studies and one unpublished trial in this review. Topical emollient therapy significantly reduced neonatal mortality by 27% (RR: 0.73, 95% CI: 0.56, 0.94) and hospital acquired infection by 50% (RR: 0.50, 95% CI: 0.36, 0.71). There were significant increases in weight (g) (MD: 98.04, 95% CI: 42.64, 153.45) and weight gain (g/kg/day) (MD: 1.57, 95% CI: 0.79, 2.36), whereas the impacts were non-significant for length and head circumference.
 
Conclusion: Emollient therapy is associated with improved weight gain, reduced risk of infection and associated newborn mortality in preterm neonates and is a potentially promising intervention for use in low resource settings. Large scale effectiveness trials are required to further assess the impact of this intervention.
 
Save the Children, USAID’s Maternal and Child Integrated Health Program (MCHIP). Postnatal Care Home Visit: A Review of the Current Status of Implementation in Five Countries. (January, 2014).
 
This report gives an account of the early development of community-based newborn programs in 5 countries (2 in Asia, 3 in Africa), in which post-natal home visits have featured prominently. Efforts are made to draw lessons applicable to similar efforts elsewhere. This documentation was done as background for a multi-partner consultative meeting held at WHO early in 2012. It is based on a combination of document review and field work (as described in more detail in the methods section below). For each of the countries, there is a description of the policy adoption process and early implementation experience. Actual program performance is explored primarily through use of baseline and endline household surveys in a small number of “early implementation districts”; for most of the countries, such data were available only from a single district. It can be expected that such early implementation experiences would be more robustly supported than would be possible for nation-wide roll-out and that observed performance in such settings would therefore over-estimate what could be achieved sustainably at scale. Nevertheless, even in these early implementation districts certain important performance issues came to light. Notably, the proportion of newborns receiving early post-natal home visits was consistently lower than expected.
 
At the end of the day, the rationale for any new program initiative is to bring about improved population health outcomes. This, in turn, requires achievement of high effective coverage. In early program experiences, when effective coverage is lower than expected this is an important cue that we need to look closely at our assumptions, our design choices, and the quality of our execution. The current report draws out certain lessons but is only a first step in a process that will need further elaboration. Furthermore, the current report is based on information that was available in late 2011 and early 2012. Since that time, community-based newborn programs have further expanded in these countries and have been introduced elsewhere, and more data is now available on how these programs are performing. Building on the learning captured in this report, supplemented by more recent experience, documentation and data, we are now in an even better position to characterize the contribution that such approaches can make but also what are the requirements for such programs actually to deliver. With such guidance, we are better able to make sound, contextually-appropriate design choices.
 
A. Tatem, J. Campbell, M. Guerra-Arias, et al. Mapping for maternal and newborn health: the distributions of women of childbearing age, pregnancies and births. International Journal of Health Geographics (January, 2014).
 
Background: The health and survival of women and their new-born babies in low income countries has been a key priority in public health since the 1990s. However, basic planning data, such as numbers of pregnancies and births, remain difficult to obtain and information is also lacking on geographic access to key services, such as facilities with skilled health workers. For maternal and newborn health and survival, planning for safer births and healthier newborns could be improved by more accurate estimations of the distributions of women of childbearing age. Moreover, subnational estimates of projected future numbers of pregnancies are needed for more effective strategies on human resources and infrastructure, while there is a need to link information on pregnancies to better information on health facilities in districts and regions so that coverage of services can be assessed.
 
Methods: This paper outlines demographic mapping methods based on freely available data for the production of high resolution datasets depicting estimates of numbers of people, women of childbearing age, live births and pregnancies, and distribution of comprehensive EmONC facilities in four large high burden countries: Afghanistan, Bangladesh, Ethiopia and Tanzania. Satellite derived maps of settlements and land cover were constructed and used to redistribute areal census counts to produce detailed maps of the distributions of women of childbearing age. Household survey data, UN statistics and other sources on growth rates, age specific fertility rates, live births, stillbirths and abortions were then integrated to convert the population distribution datasets to gridded estimates of births and pregnancies.
 
Results and conclusion: These estimates, which can be produced for current, past or future years based on standard demographic projections, can provide the basis for strategic intelligence, planning services, and provide denominators for subnational indicators to track progress. The datasets produced are part of national midwifery workforce assessments conducted in collaboration with the respective Ministries of Health and the United Nations Population Fund (UNFPA) to identify disparities between population needs, health infrastructure and workforce supply. The datasets are available to the respective Ministries as part of the UNFPA programme to inform midwifery workforce planning and also publicly available through the WorldPop population mapping project.
 
*N. Thakur, A. Saili, A. Kumar, et al. Predictors of mortality of extremely low birthweight babies in a tertiary care centre of a developing country. Postgraduate Medical Journal (December, 2013).
 
Introduction: Perinatal care has changed dramatically over last decade contributing to improved survival of extremely low birthweight (ELBW) babies.
 
Objective: We conducted the present study with the objective to identify immediate obstetric causes of preterm delivery; analyse the maternal risk factors and to evaluate the morbidity and mortality of ELBW babies delivered in our hospital. The results were compared with those of 10 years ago from the same hospital to determine whether there has been any significant change in the predictors of mortality
 
Methods: A retrospective analysis of case records of 283 ELBW babies delivered in our hospital over a period of 24 months from 1 April 2010 to 31 March 2012 was conducted.
 
Results: The total neonatal mortality rate was 38.7%. 85 babies (30%) were small for gestational age. Mean gestational age and mean birth weight was 28.5 weeks and 883.4 g, respectively. Using multivariate logistic regression analysis, significant risk factors for neonatal mortality in mothers were anaemia (p=0.00001, OR 3.13, CI 1.756 to 5.56), inadequate antenatal care (p=0.00001, OR 4.74, CI 2.59 to 8.69) premature rupture of membrane with antenatal antibiotic usage (p=0.003, OR 3.375, CI 1.512 to 7.53. Risk factors for mortality in babies were male sex (p=0.08, OR 3.48 CI 1.4 to 8.8), lower birth weight (p=0.000005), lower gestational age (p=0.00001) use of respiratory support in the form of continuous positive airway pressure (p=0.03), or mechanical ventilation (p=0.00001) and pulmonary or intraventricular haemorrhage (p=0.0001).
 
Conclusions: Babies with lower gestational age lower birth weight and those babies whose mothers had not received adequate antenatal care or antenatal steroids had worse prognosis.
 
USAID, Centers for Disease Control and Prevention (CDC), Columbia University. Saving Mothers Giving Life: Making Pregnancy & Childbirth Safer in Uganda & Zambia Annual Report 2013 (January, 2014).
 
The death of a woman from complications during pregnancy or childbirth continues to be a serious global health challenge and a sentinel indicator of how well a health system is functioning. Saving Mothers, Giving Life is an ambitious five-year public-private partnership to rapidly reduce maternal mortality in sub-Saharan Africa, where many of these deaths occur. As this report indicates, an intensive effort to strengthen health services in countries facing high levels of maternal mortality and HIV can produce impressive — and rapid — results in saving women’s lives.
 
Beginning in four districts each in Uganda and Zambia, Saving Mothers successfully built upon existing maternal and child health programs, as well as HIV programs supported by PEPFAR, and integrated these services during its 12-month proof-of-concept phase. In close alignment with both governments’ national health plans, Saving Mothers has put in place life-saving interventions that are making high quality, safe childbirth services available and accessible to women and their newborns.
This report highlights the findings of evaluations conducted by the Centers for Disease Control and Prevention (CDC), USAID and Columbia University after Saving Mothers’ first year.
 
 
Background: The Yashoda program, named after a legendary foster-mother in Indian mythology, under the Norway-India Partnership Initiative was launched as a pilot program in 2008 to improve the quality of maternal and neonatal care at facilities in select districts of India. Yashodas were placed mainly at district hospitals, which are high delivery load facilities, to provide support and care to mothers and newborns during their stay at these facilities. This study presents the results from the evaluation of this intervention in two states in India.
 
Methods: Data collection methods included in-depth interviews with healthcare providers and mothers and a survey of mothers who had recently delivered within a quasi-experimental design. Fifty IDIs were done and 1,652 mothers who had delivered in the past three months were surveyed during 2010 and 2011.
 
Results: A significantly higher proportion of mothers at facilities with Yashodas (55 percent to 97 percent) received counseling on immunization, breastfeeding, family planning, danger signs, and nutrition compared to those in control districts (34 percent to 66 percent). Mothers in intervention facilities were four to five times more likely to receive postnatal checks than mothers in control facilities. Among mothers who underwent cesarean sections, initiation of breastfeeding within five hours was 50 percent higher in intervention facilities. Mothers and families also reported increased support, care and respect at intervention facilities.
 
Conclusion: Yashoda as mothers’ aide thus seems to be an effective intervention to improve quality of maternal and newborn care in India. Scaling up of this intervention is recommended in district hospitals and other facilities with high volume of deliveries.
 
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