Gary L. Darmstadt

Evidence-based, cost-effective interventions: how many newborn babies can we save?

In this second article of the neonatal survival series, we identify 16 interventions with proven efficacy (implementation under ideal conditions) for neonatal survival and combine them into packages for scaling up in health systems, according to three service delivery modes (outreach, family-community, and facility-based clinical care). All the packages of care are cost effective compared with single interventions. Universal (99%) coverage of these interventions could avert an estimated 41-72% of neonatal deaths worldwide. At 90% coverage, intrapartum and postnatal packages have similar effects on neonatal mortality--two-fold to three-fold greater than that of antenatal care. However, running costs are two-fold higher for intrapartum than for postnatal care. A combination of universal--ie, for all settings--outreach and family-community care at 90% coverage averts 18-37% of neonatal deaths. Most of this benefit is derived from family-community care, and greater effect is seen in settings with very high neonatal mortality. Reductions in neonatal mortality that exceed 50% can be achieved with an integrated, high-coverage programme of universal outreach and family-community care, consisting of 12% and 26%, respectively, of total running costs, plus universal facility-based clinical services, which make up 62% of the total cost. Early success in averting neonatal deaths is possible in settings with high mortality and weak health systems through outreach and family-community care, including health education to improve home-care practices, to create demand for skilled care, and to improve care seeking. Simultaneous expansion of clinical care for babies and mothers is essential to achieve the reduction in neonatal deaths needed to meet the Millennium Development Goal for child survival.

Two million intrapartum-related stillbirths and neonatal deaths: Where, why, and what can be done?

Intrapartum‐related neonatal deaths (“birth asphyxia”) are a leading cause of child mortality globally, outnumbering deaths from malaria. Reduction is crucial to meeting the fourth Millennium Development Goal (MDG), and is intimately linked to intrapartum stillbirths as well as maternal health and MDG 5, yet there is a lack of consensus on what works, especially in weak health systems.

Systematic scaling up of neonatal care in countries

Every year about 70% of neonatal deaths (almost 3 million) happen because effective yet simple interventions do not reach those most in need. Coverage of interventions is low, progress in scaling up is slow, and inequity is high, especially for skilled clinical interventions. Situations vary between and within countries, and there is no single solution to saving lives of newborn babies. To scale up neonatal care, two interlinked processes are required: a systematic, data-driven decision-making process, and a participatory, rights-based policy process. The first step is to assess the situation and create a policy environment conducive to neonatal health. The next step is to achieve optimum care of newborn infants within health system constraints; in the absence of strong clinical services, programmes can start with family and community care and outreach services. Addressing missed opportunities within the limitations of health systems, and integrating care of newborn children into existing programmes--eg, safe motherhood and integrated management of child survival initiatives--reduces deaths at a low marginal cost. Scaling up of clinical care is a challenge but necessary if maximum effect and equity are to be achieved in neonatal health, and maternal deaths are to be reduced. This step involves systematically strengthening supply of, and demand for, services. Such a phased programmatic implementation builds momentum by reaching achievable targets early on, while building stronger health systems over the longer term. Purposeful orientation towards the poor is vital. Monitoring progress and effect is essential to refining strategies. National aims to reduce neonatal deaths should be set, and interventions incorporated into national plans and existing programmes.

Why are 4 million newborn babies dying each year

In the summer of 2003 The Lancet published five articles on child survival written by the Bellagio Child Survival Group. These publications have had tangible effects. A Global Partnership for Child Survival secretariat is being established to assist the development and implementation of plans to reduce child deaths in 42 countries that account for 90% of deaths in those younger than 5 years of age. Two national meetings in Ethiopia and Cambodia have been held to discuss strategies for implementing the interventions outlined in the Bellagio child-survival series. Other countries are revising their child health and survival programmes. Although the Bellagio series has had an important effect in the child-survival arena a major gap in information and action remains about deaths in the first 4 weeks of life—the neonatal period. The second half of the 20th century witnessed a remarkable reduction in child mortality with a halving of the risk of death before the age of 5 years. Most of this reduction however has been because of lives saved after the first 4 weeks of life with little reduction in the risk of death in the neonatal period for most babies worldwide. Neonatal deaths estimated at nearly 4 million annually now account for 36% of deaths worldwide in children aged under 5 years. Millenium Development Goal 4 (MDG-4) regarding child survival stipulates a reduction of two-thirds in deaths in children aged under 5 years from 95 per 1000 in 1990 to 31 per 1000 in 2015. Given that the current global neonatal mortality rate is estimated to be 31 per 1000 live-births8 a substantial reduction in neonatal deaths will be required to meet MDG-4. Reduction of neonatal deaths should become a major public-health priority. (excerpt)

Reducing stillbirths: screening and monitoring during pregnancy and labour

BackgroundScreening and monitoring in pregnancy are strategies used by healthcare providers to identify high-risk pregnancies so that they can provide more targeted and appropriate treatment and follow-up care, and to monitor fetal well-being in both low- and high-risk pregnancies. The use of many of these techniques is controversial and their ability to detect fetal compromise often unknown. Theoretically, appropriate management of maternal and fetal risk factors and complications that are detected in pregnancy and labour could prevent a large proportion of the worlds 3.2 million estimated annual stillbirths, as well as minimise maternal and neonatal morbidity and mortality.MethodsThe fourth in a series of papers assessing the evidence base for prevention of stillbirths, this paper reviews available published evidence for the impact of 14 screening and monitoring interventions in pregnancy on stillbirth, including identification and management of high-risk pregnancies, advanced monitoring techniques, and monitoring of labour. Using broad and specific strategies to search PubMed and the Cochrane Library, we identified 221 relevant reviews and studies testing screening and monitoring interventions during the antenatal and intrapartum periods and reporting stillbirth or perinatal mortality as an outcome.ResultsWe found a dearth of rigorous evidence of direct impact of any of these screening procedures and interventions on stillbirth incidence. Observational studies testing some interventions, including fetal movement monitoring and Doppler monitoring, showed some evidence of impact on stillbirths in selected high-risk populations, but require larger rigourous trials to confirm impact. Other interventions, such as amniotic fluid assessment for oligohydramnios, appear predictive of stillbirth risk, but studies are lacking which assess the impact on perinatal mortality of subsequent intervention based on test findings. Few rigorous studies of cardiotocography have reported stillbirth outcomes, but steep declines in stillbirth rates have been observed in high-income settings such as the U.S., where cardiotocography is used in conjunction with Caesarean section for fetal distress.ConclusionThere are numerous research gaps and large, adequately controlled trials are still needed for most of the interventions we considered. The impact of monitoring interventions on stillbirth relies on use of effective and timely intervention should problems be detected. Numerous studies indicated that positive tests were associated with increased perinatal mortality, but while some tests had good sensitivity in detecting distress, false-positive rates were high for most tests, and questions remain about optimal timing, frequency, and implications of testing. Few studies included assessments of impact of subsequent intervention needed before recommending particular monitoring strategies as a means to decrease stillbirth incidence. In high-income countries such as the US, observational evidence suggests that widespread use of cardiotocography with Caesarean section for fetal distress has led to significant declines in stillbirth rates. Efforts to increase availability of Caesarean section in low-/middle-income countries should be coupled with intrapartum monitoring technologies where resources and provider skills permit.

3.2 million stillbirths: epidemiology and overview of the evidence review.

More than 3.2 million stillbirths occur globally each year, yet stillbirths are largely invisible in global data tracking, policy dialogue and programme implementation. This mismatch of burden to action is due to a number of factors that keep stillbirths hidden, notably a lack of data and a lack of consensus on priority interventions, but also to social taboos that reduce the visibility of stillbirths and the associated family mourning. Whilst there are estimates of the numbers of stillbirths, to date there has been no systematic global analysis of the causes of stillbirths. The multiple classifications systems in use are often complex and are primarily focused on high-income countries. We review available data and propose a programmatic classification that is feasible and comparable across settings. We undertook a comprehensive global review of available information on stillbirths in order to 1) identify studies that evaluated risk factors and interventions to reduce stillbirths, 2) evaluate the level of evidence for interventions, 3) place the available evidence for interventions in a health systems context to guide programme implementation, and 4) elucidate key implementation, monitoring, and research gaps. This first paper in the series outlines issues in stillbirth data availability and quality, the global epidemiology of stillbirths, and describes the methodology and framework used for the review of interventions and strategies.

Investing in the foundation of sustainable development: pathways to scale up for early childhood development

Building on long-term benefits of early intervention (Paper 2 of this Series) and increasing commitment to early childhood development (Paper 1 of this Series), scaled up support for the youngest children is essential to improving health, human capital, and wellbeing across the life course. In this third paper, new analyses show that the burden of poor development is higher than estimated, taking into account additional risk factors. National programmes are needed. Greater political prioritisation is core to scale-up, as are policies that afford families time and financial resources to provide nurturing care for young children. Effective and feasible programmes to support early child development are now available. All sectors, particularly education, and social and child protection, must play a role to meet the holistic needs of young children. However, health provides a critical starting point for scaling up, given its reach to pregnant women, families, and young children. Starting at conception, interventions to promote nurturing care can feasibly build on existing health and nutrition services at limited additional cost. Failure to scale up has severe personal and social consequences. Children at elevated risk for compromised development due to stunting and poverty are likely to forgo about a quarter of average adult income per year, and the cost of inaction to gross domestic product can be double what some countries currently spend on health. Services and interventions to support early childhood development are essential to realising the vision of the Sustainable Development Goals.

Reducing stillbirths: interventions during labour

BackgroundApproximately one million stillbirths occur annually during labour; most of these stillbirths occur in low and middle-income countries and are associated with absent, inadequate, or delayed obstetric care. The low proportion of intrapartum stillbirths in high-income countries suggests that intrapartum stillbirths are largely preventable with quality intrapartum care, including prompt recognition and management of intrapartum complications. The evidence for impact of intrapartum interventions on stillbirth and perinatal mortality outcomes has not yet been systematically examined.MethodsWe undertook a systematic review of the published literature, searching PubMed and the Cochrane Library, of trials and reviews (N = 230) that reported stillbirth or perinatal mortality outcomes for eight interventions delivered during labour. Where eligible randomised controlled trials had been published after the most recent Cochrane review on any given intervention, we incorporated these new trial findings into a new meta-analysis with the Cochrane included studies.ResultsWe found a paucity of studies reporting statistically significant evidence of impact on perinatal mortality, especially on stillbirths. Available evidence suggests that operative delivery, especially Caesarean section, contributes to decreased stillbirth rates. Induction of labour rather than expectant management in post-term pregnancies showed strong evidence of impact, though there was not enough evidence to suggest superior safety for the fetus of any given drug or drugs for induction of labour. Planned Caesarean section for term breech presentation has been shown in a large randomised trial to reduce stillbirths, but the feasibility and consequences of implementing this intervention routinely in low-/middle-income countries add caveats to recommending its use. Magnesium sulphate for pre-eclampsia and eclampsia is effective in preventing eclamptic seizures, but studies have not demonstrated impact on perinatal mortality. There was limited evidence of impact for maternal hyperoxygenation, and concerns remain about maternal safety. Transcervical amnioinfusion for meconium staining appears promising for low/middle income-country application according to the findings of many small studies, but a large randomised trial of the intervention had no significant impact on perinatal mortality, suggesting that further studies are needed.ConclusionAlthough the global appeal to prioritise access to emergency obstetric care, especially vacuum extraction and Caesarean section, rests largely on observational and population-based data, these interventions are clearly life-saving in many cases of fetal compromise. Safe, comprehensive essential and emergency obstetric care is particularly needed, and can make the greatest impact on stillbirth rates, in low-resource settings. Other advanced interventions such as amnioinfusion and hyperoxygenation may reduce perinatal mortality, but concerns about safety and effectiveness require further study before they can be routinely included in programs.

Kangaroo mother care: a multi-country analysis of health system bottlenecks and potential solutions

BackgroundPreterm birth is now the leading cause of under-five child deaths worldwide with one million direct deaths plus approximately another million where preterm is a risk factor for neonatal deaths due to other causes. There is strong evidence that kangaroo mother care (KMC) reduces mortality among babies with birth weight <2000 g (mostly preterm). KMC involves continuous skin-to-skin contact, breastfeeding support, and promotion of early hospital discharge with follow-up. The World Health Organization has endorsed KMC for stabilised newborns in health facilities in both high-income and low-resource settings. The objectives of this paper are to: (1) use a 12-country analysis to explore health system bottlenecks affecting the scale-up of KMC; (2) propose solutions to the most significant bottlenecks; and (3) outline priority actions for scale-up.MethodsThe bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system bottlenecks, factors that hinder the scale-up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for KMC.ResultsMarked differences were found in the perceived severity of health system bottlenecks between Asian and African countries, with the former reporting more significant or very major bottlenecks for KMC with respect to all the health system building blocks. Community ownership and health financing bottlenecks were significant or very major bottlenecks for KMC in both low and high mortality contexts, particularly in South Asia. Significant bottlenecks were also reported for leadership and governance and health workforce building blocks.ConclusionsThere are at least a dozen countries worldwide with national KMC programmes, and we identify three pathways to scale: (1) champion-led; (2) project-initiated; and (3) health systems designed. The combination of all three pathways may lead to more rapid scale-up. KMC has the potential to save lives, and change the face of facility-based newborn care, whilst empowering women to care for their preterm newborns.

Early childhood development: the foundation of sustainable development

www.thelancet.com Vol 389 January 7, 2017 9 Momentum for improving early childhood development has grown since The Lancet published the landmark Series, Child Development in Developing Countries in 2007, followed by Child Development in Developing Countries 2 in 2011. As shown in this new Series, Advancing Early Childhood Development: from Science to Scale, between 2000 and 2015 the number of scientifi c publications on topics central to early childhood development increased substantially, about a third of countries had adopted multisectoral policies on early childhood development, and there has been an increase in funding for early childhood development. Yet, few countries have institutionalised mechanisms to implement these policies, services remain fragmented and of variable quality, and programmes at scale are rare and poorly evaluated. Compelling new evidence in two areas strengthens our resolve to act to reach pregnant women and young children with holistic early childhood development services (panel). First, new research in early human development shows that epigenetic, immunological, physiological, and psychological adaptations to the environment occur from conception, and that these adaptations aff ect development throughout the life course. This knowledge calls for an approach targeting caregivers and children with eff ective interventions during sensitive times across the life course, with the period from conception to age 2–3 years being of particular importance. Second, evidence on long-term outcomes from lowincome and middle-income countries shows that a programme to increase cognitive development of stunted children in Jamaica 25 years ago resulted in a signifi cant, 25% increase in average adult earnings. Conversely, long-term follow-up of children from birth shows that growth failure in the fi rst 2 years of life has harmful eff ects on adult health and human capital, including chronic disease, and lower educational attainment and adult earning. Moreover, defi cits and disadvantages persist into the subsequent generation, producing a vicious inter-generational cycle of lost human capital and perpetuation of poverty. These fi ndings shine light on the transformative potential of early childhood development programmes in low-income and middle-income countries. Only by breaking this cycle will the Sustainable Development Goals (SDGs) be achieved. The past two to three decades have seen great improvements in child survival. As a result of global eff orts to achieve the Millennium Development Goals, under-5 child mortality dropped by 53% between 1990 and 2015. Yet, this Series shows that the burden of risk for poor developmental outcomes remains extremely high, aff ecting an estimated 250 million children (43%) younger than 5 years in low-income and middle-income countries, and rising to over two-thirds of children in sub-Saharan Africa. These estimates are based on just two known risks for which we have global data: extreme poverty and stunting. Adding other risks to young children’s development, such as low levels of maternal schooling and physical maltreatment, substantially raises exposure to risks for poor development outcomes in many parts of the world. Nurturing interactions are crucial to mitigating these risks. A young child’s developing brain is activated Early childhood development: the foundation of sustainable development Selina Lo, Pamela Das, Richard Horton The Lancet, London EC2Y 5AS, UK