Technical updates on Newborn Resuscitation and Home visits for Newborn Survival

6 May 2012, Dhaka Dr Ornella Lincetto

1 | Technical updates on newborn resuscitation and home visits for newborn survival

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 for newborn survival, Geneva, Feb 2012

2 | Technical updates on newborn resuscitation and home visits for newborn survival

Basic Newborn Resuscitation Guidelines 2012

3 | Technical updates on newborn resuscitation and home visits for newborn survival

Newborn resuscitation guidelines: principles

Systematically developed, based on all available evidence

Clear, unambiguous recommendations, stating the quality of evidence on which they are based - GRADE
Strength of recommendation based on the balance of benefits and risks, values and preferences, and costs Take into account the range of circumstances in which they will be used

4 | Technical updates on newborn resuscitation and home visits for newborn survival

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 reduced mortality

5 | Technical updates on newborn resuscitation and home visits for newborn survival

Before starting PPV

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

Additional stimulation after drying limited to rubbing the back 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 on his/her own Clear amniotic fluid and newborn not breathing on his/her own and mouth or nose full of secretions preventing effective PPV

6 | Technical updates on newborn resuscitation and home visits for newborn survival

How to provide PPV

Initiation of PPV within one minute after birth if newborn not 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 60 seconds of ventilation with visible chest movements Given priority over chest compressions

7 | Technical updates on newborn resuscitation and home visits for newborn survival

When to stop PPV

If no spontaneous breathing, resuscitation should stop: after 10 minutes of effective PPV if no detectable heart rate after 20 minutes of effective PPV if heart rate <60 per minute

8 | Technical updates on newborn resuscitation and home visits for newborn survival

2009

9 | Technical updates on newborn resuscitation and home visits for newborn survival

Evidence-base for the Joint Statement: 2009

Home Visits for Neonatal Care by Community Health Workers for Preventing Neonatal Mortality in Developing Countries: Systematic Review of Controlled Trials Gogia S and Sachdev HPS
Published in Bulletin of the World Health Organization 2010

10 | Technical updates on newborn resuscitation and home visits for newborn survival

38% reduction in neonatal mortality

Pooled effect on NMR in 5 studies: 0.62 (0.44, 0.87)

Risk

Study ID

Ratio (95% CI)

Weight

Gadhchiroli 2005

0.39 (0.27, 0.56)

18.49

Barabanki 2008

1.06 (0.81, 1.38)

20.46

Hala 2008

0.70 (0.54, 0.90)

20.67

Shivgarh 2008

0.47 (0.38, 0.58)

21.47

Sylhet 2008

0.66 (0.47, 0.93)

18.91

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

0.62 (0.44, 0.87)

100.00

NOTE: Weights are from random effects analysis .2 .5 1 2 5

11 | Technical updates on newborn resuscitation and home visits for newborn survival

Update of evidence-base
Three additional studies published since 2009:

The Mirzapur study (Darmstadt et al. PLoS ONE 2010)

The Hala study (Bhutta et al. Lancet 2011) The IMNCI study (Bhandari et al. BMJ 2012)

12 | Technical updates on newborn resuscitation and home visits for newborn survival

Characteristics of studies assessing impact of home visits

Gadchiroli Live births /year /gp Study design NMR (control) ~1000 Quasiexperiment (1vs1 area) Shivgarh ~1200 Cluster randomized trial Sylhet ~5000 Barabanki ~8000 Hala (pilot) ~2500 Mirzapur ~2500 Hala (main) Haryana ~6000 ~15000 Cluster randomized trial

Cluster Programme Quasiexperiment randomized evaluation trial (1vs1 district) (4vs4areas) 43 per 1000 46 per 1000

Cluster Cluster randomized randomized trial trial

60 per 1000 84 per 1000

52 per 1000 28 per 1000 49 per 1000 43 per 1000

Home births 95% Type of workers Coverage Specially recruited CHW 93%

93% Specially recruited CHW 68% Home visits Community promotion 49%

84% NGO CHW 65%

84% Government CHW 39%

79%

84%

56%

51%

Government Specially CHW recruited CHW 87% Home visits Community promotion 30%

Government Government CHW CHW 74% Home visits Community promotion Treatment of mild illness 15% Facility births: 0% Homebirths: 20% 24%

Intervention Home visits Community promotion Treatment of sepsis NMR impact 62%

Home visits Home visits Treatment of sepsis 34% None

80% among 24% home births Home visits Home visits 13%

Community promotion

1-11 month mortality 13 | Technical updates on newborn resuscitation and home visits for newborn survival impact

21% reduction in neonatal mortality

Study Study ID

% ESES (95% CI) (95% CI)

ID

Weight Weight

Gadchiroli - Bang Gadchiroli - Bang 1999 1999 Shivgarh - Kumar Shivgarh - Kumar 2008 2008 Hala pilot - Bhutta Hala pilot - Bhutta 2008 2008
Sylhet Sylhet -2008 2008 - Baqui Baqui Barabanki - Baqui 2008

0.39 (0.27, 0.56) 10.17 0.39 (0.27, 0.56) 3.42 0.47 (0.38, 0.58) 13.15 0.47 (0.38, 0.58) 10.17 0.70 (0.54, 0.90) 12.31 0.70 (0.54, 0.90) 6.97 0.66 (0.47, 0.93) 10.63 0.66 (0.47, 0.93) 3.91 1.06 (0.81, 1.38) 12.10 1.06 (0.81, 1.38) 6.41 0.87 (0.68, 1.12) 12.43
0.87 (0.68, 1.12) 0.85 (0.76, 0.96) 0.91 (0.80, 1.03) 0.79 (0.74, 0.84) 7.31 33.33 28.49 100.00

Barabanki - Baqui 2008 Mirzapur - Darmstadt 2010 Hala main - Bhutta 2011 Haryana - Bhandari 2012 Overall (I-squared = 86.3%, p = 0.000)

Mirzapur - Darmstadt 2010 Hala main - Bhutta 2011

0.85 (0.76, 0.96) 14.66 0.91 (0.80, 1.03) 14.54

Haryana - Bhandari 2012

Overall (I-squared = 86.3%, p = 0.000)

0.72 (0.59, 0.88) 100.00

NOTE: Weights are from random effects analysis .27 1 .27 1 14 | Technical updates on newborn resuscitation and home visits for newborn survival 3.7

3.7

Variability in impact of home visits

Study size: Smaller efficacy studies show larger mortality impact (40%) than larger effectiveness studies (12%). NMR: Studies with higher NMR in control areas show larger mortality impact.

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

15 | Technical updates on newborn resuscitation and home visits for newborn survival

Effect on key newborn care practices: Early initiation of breastfeeding

Study Shivgarh Hala (pilot) Mirzapur Sylhet Hala (within 30 minutes) Barabanki Haryana Control clusters 16% 21% 55% 57% 27% 6% 11% Intervention clusters 71% 66% 80% 81% 43% 38% 41% Difference + 55% + 45% + 25% + 24% + 16% + 32% + 30%

16 | Technical updates on newborn resuscitation and home visits for newborn survival

Evidence summary:
Home visits for newborn survival
Home visits, in combination with community promotion of practices, reduce NMR by about 21% Larger impact is likely in settings with high NMR and where most births occur at home All studies show impressive improvements in newborn care practices Data from India indicates that the impact extends to post neonatal period (24% reduction)
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Informal WHO meeting: February 2012 Home visits for newborn survival: Policies and Practices in Priority Countries

18 | Technical updates on newborn resuscitation and home visits for newborn survival

Home visit policies: SEAR and AFR

28/47 (60%) countries surveyed have a policy on postnatal 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%)

19 | Technical updates on newborn resuscitation and home visits for newborn survival

Reach of home visits

2 6 <1/3of national population covered >1/3 of national population covered Nationally Not implemented

PNC home visits implemented in:

African Asian countries countries N=36 N=11

5 15

<1/3of national population covered >1/3 of national population covered Nationally Not implemented

6 4 6 1

0 1 7 1

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Timing of Postnatal Care Home Visits

25 21 20 18

15 12 10

0 Three home visits: <24 h/ASAP, day 3 and day 7 1st home visit within 24 hours At least two visits within 7 days

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Content of Home Visits

30 25 20 15 10 5 0 0 Promotion of appropriate care Identification of danger signs Feeding support All of the above Treatment

27

27

27

25

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Human Resources for Home Visits

25 20 15 10 5 0 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 3 14 8 6 14 9 22

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Difficulties with Programme Components

5
Score: least (1) to most difficult (5)

Median 25% 75%

IQR

0 Policy adoption Reruitment and training Maintaining competencies and motivation Health systems supports Community participation

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Global Recommendations: PNC home visits

Advocate for increased adoption of PNC policies and increased resources for implementation WHO to define optimal package of interventions for mother and baby, and provide estimates of implementation costs WHO/UNICEF/USAID/SC to develop implementation guide and 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

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