Significant Reduction In Neonatal Mortality Research Articles

Factors contributing to neonatal mortality reduction in three regions in Ghana: a mixed-methods study using the Lives Saved (LiST) modelling tool

Background Ghana had significant reductions in neonatal mortality during the Millennium Development Goal (MDG) era. Few studies have attempted to identify the interventions, programs and policies that contributed to this progress. To understand the underlying factors which contributed to the reduction in neonatal mortality and to inform strategies to reach the Sustainable Development Goal (SDG) target to end preventable neonatal deaths, we conducted a mixed-methods study in the Northern, Upper West, and Volta Regions of Ghana. Methods The quantitative component consisted of an analysis of trends in coverage of key neonatal health interventions using subnational data from the Ghana Demographic and Health Surveys (DHS) and the Multiple Indicator Cluster Surveys (MICS). The Lives Saved Tool (LiST) was used to assess the contribution of various neonatal health interventions which resulted in reductions in neonatal mortality. Qualitative in-depth interviews (N=38) were conducted with government health officials, health workers, staff from non-government organizations, and community leaders, including traditional birth attendants and local chiefs from the Northern Region of Ghana. Findings Multiple interventions and contextual factors contributed to declines in the neonatal mortality rate (NMR) in all three regions. The Volta and Upper West Regions improved labor and delivery management practices which accounted for approximately one-third of the decline in NMR. The Northern Region had a substantial decline in NMR; the greatest proportion of the decline was attributed to control and management of infections in newborns (sepsis and pneumonia). Qualitative interviews suggest that improvements in neonatal survival were achieved through the prioritization of neonatal health at community-based health planning (CHPS) compounds and the development of a national-level strategic plan, coupled with neonatal health-related training for health workers. The establishment of neonatal intensive care units and strong partnership with local leaders and women’s groups to increase facility births and promote clean birth practices were also considered important. Conclusions The strategies that supported the reductions span from national-level policy intervention to facility-based quality improvement, to community level engagement. These strategies can be continued, strengthened, and scaled to improve neonatal survival in the SDG era.

Can an Enhanced Iron-Folic Acid Supplementation Program Reduce Neonatal Mortality? Analysis of Pooled Nepal Demographic and Health Surveys

Abstract Objectives Nepal has improved the national antenatal iron-folic acid (IFA) supplementation program through the ‘Iron Intensification Project’ (IIP) between 2003 and 2011. This study assesses the effect of this enhanced IFA supplementation on the risk of neonatal mortality over a 20-year period in Nepal. Methods For the impact evaluation, we used a non-randomized stepped wedge study design, using survival information from 16,159 most recent live births from the pooled data from four Nepal Demographic and Health Surveys (2001, 2006, 2011 and 2016). The primary outcomes were neonatal mortality indicators. The use of any antenatal care (ANC) services and antenatal IFA supplements were the secondary outcomes. The main exposure variable was the status of the IIP in the district of the mother's residence at the time of birth. Analyses used multivariate Cox proportional hazards regression, adjusted for up to 22 potential confounders, and the cluster sampling design. Results After the IIP, the risk of death on the first day of life was significantly reduced by 35% [adjusted hazard ratio (aHR) 0.65, 95% confidence interval (95% CI) 0.43 to 0.97], in the early neonatal period by 32% (aHR 0.68, 95% CI 0.48 to 0.96), and in the neonatal period by 29% (aHR 0.71, 95% CI 0.51 to 0.99). After the IIP, there was a significant reduction of the odds of non-use of ANC services and IFA supplements. Conclusions An enhanced IFA supplementation program was associated with a significant reduction in neonatal mortality in Nepal. Funding Sources Ph.D. scholarship from the University of Sydney.

Approaches to Noninvasive Respiratory Support in Preterm Infants: From CPAP to NAVA

Endotracheal intubation and invasive mechanical ventilation have been mainstays in respiratory care of neonates with respiratory distress syndrome. Together with antenatal steroids and surfactant, this approach has accounted for significant reductions in neonatal mortality. However, with the increased survival of very low birthweight infants, the incidence of bronchopulmonary dysplasia (BPD), the primary respiratory morbidity of prematurity, has also increased. Arrest of alveolar growth and development and the abnormal development of the pulmonary vasculature after birth are the primary causes of BPD. However, invasive ventilation-associated lung inflammation and airway injury have long been believed to be important contributors. In fact, discontinuing invasive ventilation in favor of noninvasive respiratory support has been considered the single best approach that neonatologists can implement to reduce BPD. In this review, we present and discuss the mechanisms, efficacy, and long-term outcomes of the four main approaches to noninvasive respiratory support of the preterm infant currently in use: nasal continuous positive airway pressure, high-flow nasal cannula, nasal intermittent mandatory ventilation, and neurally adjusted ventilatory assist. We show that noninvasive ventilation can decrease rates of intubation and the need for invasive ventilation in preterm infants with respiratory distress syndrome. However, none of these noninvasive approaches decrease rates of BPD. Accordingly, noninvasive respiratory support should be considered for clinical goals other than the reduction of BPD.

Treatment Patterns and Clinical Outcomes in Neonates Diagnosed With Respiratory Distress Syndrome in a Low-income Country: A Report From Bangladesh

(Anesth Analg. 2018;126:1684–1686) Advances in neonatal critical care, such as surfactant replacement therapy (SRT), have led to significant reductions in neonatal mortality in the United States. However, respiratory distress syndrome (RDS)-related mortality rates remain high, particularly in areas with low resource availability, for example low-income countries. The authors of the present study described practice patterns and treatment modalities in RDS neonates in resource-limited settings and identified potential predictors of mortality.

A Prospective Study of Causes of Illness and Death in Preterm Infants in Ethiopia: The SIP Study Protocol

BackgroundWith nearly 15 million annual preterm births globally, preterm birth is the most common cause of neonatal death. Forty to 60 % of neonatal deaths are directly or indirectly associated with preterm mortality. As countries aim to meet the Sustainable Development Goals to reduce neonatal mortality, significant reductions in preterm mortality are needed. This study aims to identify the common causes of preterm illness and their contribution to preterm mortality in low-resource settings. This article will describe the methods used to undertake the study.MethodsThis is a prospective, multi-centre, descriptive clinical study. Socio-demographic, obstetric, and maternal factors, and clinical and laboratory findings will be documented. The major causes of preterm mortality will be identified using clinical, laboratory, imaging, and autopsy methods and use the national Ethiopian guidelines on management of preterm infants including required investigations to reach final diagnoses. The study will document the clinical and management protocols followed in these settings. The approach consists of clinical examinations and monitoring, laboratory investigations, and determination of primary and contributory causes of mortality through both clinical means and by post-mortem examinations. An independent panel of experts will validate the primary and contributory causes of mortality.To obtain the estimated sample size of 5000 preterm births, the study will be undertaken in five hospitals in three regions of Ethiopia, which are geographically distributed across the country. All preterm infants who are either born or transferred to these hospitals will be eligible for the study. Three methods (last menstrual period, physical examination using the New Ballard Score, and ultrasound) will be used to determine gestational age.All clinical procedures will be conducted per hospital protocol and informed consent will be taken from parents or caretakers prior to their participation in the study as well as for autopsy if the infant dies.DiscussionThis study will determine the major causes of death and illness among hospitalized preterm infants in a low-resource setting. The result will inform policy makers and implementers of areas that can be prioritized in order to contribute to a significant reduction in neonatal mortality.

A care bundle including antenatal corticosteroids reduces preterm infant mortality in Tanzania a low resource country

BackgroundPreterm neonatal mortality (NM) has remained high and unchanged for many years in Tanzania, a resource-limited country. Major causes of mortality include birth asphyxia, respiratory insufficiency and infections. Antenatal corticosteroids (ACS) have been shown to significantly reduce mortality in developed countries. There is inconsistent use of ACS in Tanzania.ObjectiveTo determine whether implementation of a care bundle that includes ACS, maternal antibiotics (MA), neonatal antibiotics (NA) and avoidance of moderate hypothermia (temperature < 36°C) targeting infants of estimated gestational age (EGA) 28 to 34 6/7 weeks would reduce NM (< 7 days) by 35%.MethodsA Pre (September 2014 to May 2015) and Post (June 2015 to June 2017) Implementation strategy was used and introduced at three University-affiliated and one District Hospital. Dexamethasone, as the ACS, was added to the national formulary in May 2015, facilitating its free use down to the district level.FindingsNM was reduced 26% from 166 to 122/1000 livebirths (P = 0.005) and fresh stillbirths (FSB) 33% from 162/1000 to 111/1000 (p = 0.0002) Pre versus Post Implementation. Medications including combinations increased significantly at all sites (p<0.0001).By logistic regression, combinations of ACS, maternal and NA (odds ratio (OR) 0.33), ACS and NA (OR 0.30) versus no treatment were significantly associated with reduced NM. NM significantly decreased per 250g birthweight increase (OR 0.59), and per one week increase in EGA (OR 0.87). Moderate hypothermia declined pre versus post implementation (p<0.0001) and was two-fold more common in infants who died versus survivors.InterpretationA low-cost care bundle, ~$6 per patient, was associated with a significant reduction in NM and FSB rates. The former presumably by reducing respiratory morbidity with ACS and minimizing infections with antibiotics. If these findings can be replicated in other resource-limited settings, the potential for further reduction of <5 year mortality rates becomes enormous.

Workforce Interventions to Deliver Postnatal Care to Improve Neonatal Outcomes in Low- and Lower-Middle-Income Countries: A Narrative Synthesis.

Reducing neonatal mortality rates in low- and lower-middle-income countries (LMICs) requires postnatal interventions to be delivered through an appropriately prepared and supported workforce. This review examines health workforce interventions that deliver integrated packages of postnatal care to improve neonatal outcomes in LMICs. We conducted a structured search of peer-reviewed articles published during 2003-2014 that investigated the delivery of postnatal interventions by formal and lay health workers. We selected 13 studies and analyzed them using a narrative synthesis methodology. This review observed a wide divergence among studies regarding the outcomes as well as the approaches and duration of workforce training and staff supervision. Except 4, all studies observed a significant reduction in neonatal mortality. On the other hand, teams of lay health workers appear to be more effective in improving neonatal outcomes. Further improvement in the performance of health care providers may require emphasis on workforce interventions such as competency assessment, the acquisition of appropriate skills, and supervisory guidelines. Nevertheless, the heterogeneity and limited number of studies do not allow us to arrive at definitive conclusions, and we recommend the need for the harmonization of future studies, with uniformity of outcome measures and cost analyses.

The Antenatal Corticosteroids Trial (ACT): a secondary analysis to explore site differences in a multi-country trial.

BackgroundThe Antenatal Corticosteroid Trial (ACT) assessed the feasibility, effectiveness, and safety of a multifaceted intervention to increase the use of antenatal corticosteroids (ACS) in mothers at risk of preterm birth at all levels of care in low and middle-income countries. The intervention effectively increased the use of ACS but had no overall impact on neonatal mortality in the targeted <5th percentile birth weight infants. Being in the intervention clusters was also associated with an overall increase in neonatal deaths. We sought to explore plausible pathways through which this intervention increased neonatal mortality.MethodsWe conducted secondary analyses to assess site differences in outcome and potential explanations for the differences in outcomes if found. By site, and in the intervention and control clusters, we evaluated characteristics of the mothers and care systems, the proportion of the <5th percentile infants and the overall population that received ACS, the rates of possible severe bacterial infection (pSBI), determined from clinical signs, and neonatal mortality rates.ResultsThere were substantial differences between the sites in both participant and health system characteristics, with Guatemala and Argentina generally having the highest levels of care. In some sites there were substantial differences in the health system characteristics between the intervention and control clusters. The increase in ACS in the intervention clusters was similar among the sites. While overall, there was no difference in neonatal mortality among <5th percentile births between the intervention and control clusters, Guatemala and Pakistan both had significant reductions in neonatal mortality in the <5th percentile infants in the intervention clusters. The improvement in neonatal mortality in the Guatemalan site in the <5th percentile infants was associated with a higher level of care at the site and an improvement in care in the intervention clusters. There was a significant increase overall in neonatal mortality in the intervention clusters compared to the control. Across sites, this increase in neonatal mortality was statistically significant and most apparent in the African sites. This increase in neonatal mortality was accompanied by a significant increase in pSBI in the African sites.ConclusionsThe improvement in neonatal mortality in the Guatemalan site in the <5th percentile infants was associated with a higher level of care and an improvement in care in the intervention clusters. The increase in neonatal mortality in the intervention clusters across all sites was largely driven by the poorer outcomes in the African sites, which also had an increase in pSBI in the intervention clusters. We emphasize that these results come from secondary analyses. Additional prospective studies are needed to assess the effectiveness and safety of ACS on neonatal health in low resource settings.Trial registrationTrial registration: clinicaltrials.gov (NCT01084096)

Reducing neonatal mortality associated with preterm birth: gaps in knowledge of the impact of antenatal corticosteroids on preterm birth outcomes in low-middle income countries.

The Global Network’s Antenatal Corticosteroids Trial (ACT), was a multi-country, cluster-randomized trial to improve appropriate use of antenatal corticosteroids (ACS) in low-resource settings in low-middle income countries (LMIC). ACT substantially increased ACS use in the intervention clusters, but the intervention failed to show benefit in the targeted < 5th percentile birth weight infants and was associated with increased neonatal mortality and stillbirth in the overall population. In this issue are six papers which are secondary analyses related to ACT that explore potential reasons for the increase in adverse outcomes overall, as well as site differences in outcomes. The African sites appeared to have increased neonatal mortality in the intervention clusters while the Guatemalan site had a significant reduction in neonatal mortality, perhaps related to a combination of ACS and improving obstetric care in the intervention clusters. Maternal and neonatal infections were increased in the intervention clusters across all sites and increased infections are a possible partial explanation for the increase in neonatal mortality and stillbirth in the intervention clusters, especially in the African sites. The analyses presented here provide guidance for future ACS trials in LMIC. These include having accurate gestational age dating of study subjects and having care givers who can diagnose conditions leading to preterm birth and predict which women likely will deliver in the next 7 days. All study subjects should be followed through delivery and the neonatal period, regardless of when they deliver. Clearly defined measures of maternal and neonatal infection should be utilized. Trials in low income country facilities including clinics and those without newborn intensive care seem to be of the highest priority.

The effect of coverings, including plastic bags and wraps, on mortality and morbidity in preterm and full-term neonates.

Neonatal hypothermia is an important risk factor for mortality and morbidity, and is common even in temperate climates. We conducted a systematic review to determine whether plastic coverings, used immediately following delivery, were effective in reducing the incidence of mortality, hypothermia and morbidity. A total of 26 studies (2271 preterm and 1003 term neonates) were included. Meta-analyses were conducted as appropriate. Plastic wraps were associated with a reduction in hypothermia in preterm (⩽29 weeks; risk ratio (RR)=0.57; 95% confidence interval (CI) 0.46 to 0.71) and term neonates (RR=0.76; 95% CI 0.60 to 0.96). No significant reduction in neonatal mortality or morbidity was found; however, the studies were underpowered for these outcomes. For neonates, especially preterm, plastic wraps combined with other environmental heat sources are effective in reducing hypothermia during stabilization and transfer within hospital. Further research is needed to quantify the effects on mortality or morbidity, and investigate the use of plastic coverings outside hospital settings or without additional heat sources.

A Study of Cardiotocography in Hypertensive Disorders of Pregnancy and Its Correlation with the Neonatal Outcome

ABSTRACT Aim To study the effect of antepartum and intrapartum surveillance with cardiotocography (CTG) on the neonatal morbidity and survival in cases of hypertensive disorders of pregnancy in a rural medical college hospital in Jabalpur. Materials and methods A total of 200 cases of hypertensive disorders &gt; 32 weeks of gestation were subjected to antepartum and intrapartum surveillance with CTG. The neonatal outcome was recorded. This was compared with the records of 200 matched controls who had delivered in the department when CTG was not available. Statistical analysis was done in Statistical Package for the Social Sciences (SPSS) software with x2 test in 2 × 2 tables, and p-value &lt; 0.05 was set as the value of a significant result. Results Cardiotocography led to a significantly higher number of induced labors (p &lt; 0.05) and cesarean sections (p &lt; 0.001). There was a significant reduction in neonatal mortality in the study group (p &lt; 0.001). Conclusion Surveillance with CTG leads to improved neonatal survival, at the same time increasing the cesarean rates in cases of hypertensive disorders in pregnancy. Further methods such as fetal scalp blood sampling may have to be applied to reduce the high cesarean rate with CTG. How to cite this article Tiwari P, Sahu B, Raghuvanshi P, Tiwari R. A Study of Cardiotocography in Hypertensive Disorders of Pregnancy and Its Correlation with the Neonatal Outcome. J South Asian Feder Obst Gynae 2016;8(2):149-153.

Neuroprotection for Perinatal Hypoxic Ischemic Encephalopathy in Low- and Middle-Income Countries

From the Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada; 2 3 the standard of care for treating newborns with moderate to severe HIE. Therapeutic hypothermia has been found to reduce the risk of death or major neurodevelopmental disability at age 18 months (risk ratio [RR], 0.76; 95% CI, 0.69-0.84) and to increase survival with normal neurologic function (RR, 1.63; 95% CI, 1.36-1.95). Recent studies have confirmed improved neurocognitive outcomes at school age. Those studies involved predominantly developed countries. In contrast, a systematic review of 7 trials including 567 newborns from LMI countries, using mainly low-cost cooling techniques, did not show a significant reduction in neonatal mortality (RR, 0.74; 95% CI, 0.441.25). Although the point estimate is consistent with estimates from the developed world, the wide CI of that result means that a clinically important benefit or harm could not be excluded. Furthermore, there was insufficient long-term follow-up to allow assessment of whether hypothermia had improved neurodevelopmental outcomes. The heterogeneity of outcomes in studies from LMI countries may be an artifact of poorly designed studies, many of which were very small. The largest study in that review, which carried almost one-half of the weight in the primary outcome (neonatal mortality), may have introduced selection bias by including more boys (85%) and violated its protocol by including 20% cases with mild encephalopathy. Overall, 15% of the patients in these studies hadmild encephalopathy, and, consistent with this, only 12% required ventilation. Newborns with mild HIE have a low risk of mortality, reducing the study’s power and potentially leading to a false conclusion that the intervention is not conclusive when the intervention was not applied to the correct target population. It is unclear whether the low frequency of mechanical ventilation reflects only selection for milder cases, or whether resource limitations constrained care. Alternatively, the heterogeneity of outcomes potentially could be “real,” that is, related to medical factors that impair

Board 384 - Research Abstract Low-Dose High-Frequency Simulation Training Reduces Early Neonatal Mortality (Submission #993)

Introduction/Background Globally, almost 4 million newborn infants die each year. The simulation-based Helping Babies Breathe (HBB) course, developed by the American Academy of Pediatrics to train providers in basic neonatal resuscitation, is under implementation in more than 55 low-resource countries, aiming to reduce early neonatal mortality worldwide. Tanzania was the first country to pilot test National implementation of HBB.1 In April 2010 Tanzanian master instructors conducted a one day HBB course at Haydom Lutheran Hospital in Northern Tanzania. Seven months later, in November 2010 staff from labor ward was tested simulating routine care of neonates and basic neonatal resuscitation. The pass-rate increased from 41% to 74% (p=0.016) and from 18% to 74% (p≤0.0001) respectively, however, no improvement of clinical management was observed in the delivery room during these seven months.2 Therefore, systematic low-dose high-frequency (LDHF) HBB simulation training in the labor ward was initiated by local HBB trainers supported by local leaders. The objective of this study was to determine whether implementation of LDHF HBB training would enhance performance of basic neonatal resuscitation in clinical practice, reduce the incidence of early neonatal mortality within 24 hours, and the number of fresh stillbirths. Methods An ongoing observational study in the delivery room started in July 2009. Trained research assistants (n=14), working shifts (3/24 hours), have observed every delivery and recorded data (e.g. perinatal characteristics, time to stimulation and bag mask ventilation and perinatal outcomes) on a data collection form. Implementation of LDHF HBB training started in February 2011. A newborn simulator was placed in the labor ward easily accessible for frequent practicing. Local HBB trainers have assisted and conducted frequent re-trainings supported by local leaders. Results Observational baseline data (01.02.10-31.01.11) includes 4876 deliveries/newborns. Observational after implementation data (01.02.11-31.01.12) includes 4743 deliveries/newborns. Birth attendants trained in HBB was 67.5% versus 90.8% (p≤ 0.0005) in the two periods. Number of neonates being stimulated was 704 (14.4%) versus 758 (16.0%) (p=0.032). Number of neonates in need of bag mask ventilation was 352 (7.2%) versus 259 (5.7%) (p=0.003). Early neonatal mortality was 11.1/1000 (n=54) versus 7.2/1000 (n=34) (p=0.047). Fresh stillbirth rate was 16.0/1000 (n=78) versus 14.4/1000 (n=68) (p=0.517). Conclusion LDHF in-situ HBB training facilitated by local HBB trainers improved clinical management and outcome of neonates at Haydom Lutheran Hospital. This was not the case after a one day HBB training. The significant reduction in neonatal mortality likely reflects the increase in babies being stimulated with induction of spontaneous breathing among newborns in primary apnea, reversing the asphyxial process and reducing the need for bag mask ventilation. Thus, transfer of new knowledge and skills into clinical practice with improved patient outcome was achievable through systematic LDHF in-situ simulation training supported by local trainers and leaders.

Therapeutic Hypothermia for Neonatal Encephalopathy in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Although selective or whole body cooling combined with optimal intensive care improves outcomes following neonatal encephalopathy in high-income countries, the safety and efficacy of cooling in low-and middle-income countries is not known.ObjectiveWe performed a systematic review and meta-analysis of all published randomised or quasi-randomised controlled trials of cooling therapy for neonatal encephalopathy in low-and middle-income countries.ResultsSeven trials, comprising a total of 567 infants were included in the meta-analysis. Most study infants had mild (15%) or moderate encephalopathy (48%) and did not receive invasive ventilation (88%). Cooling devices included water-circulating cooling caps, frozen gel packs, ice, water bottles, and phase-changing material. No statistically significant reduction in neonatal mortality was seen with cooling (risk ratio: 0.74, 95% confidence intervals: 0.44 to 1.25). Data on other neonatal morbidities and long-term neurological outcomes were insufficient.ConclusionCooling therapy was not associated with a statistically significant reduction in neonatal mortality in low-and middle-income countries although the confidence intervals were wide and not incompatible with results seen in high-income countries. The apparent lack of treatment effect may be due to the heterogeneity and poor quality of the included studies, inefficiency of the low technology cooling devices, lack of optimal neonatal intensive care, sedation and ventilatory support, overuse of oxygen, or may be due to the intrinsic difference in the population, for example higher rates of perinatal infection, obstructed labor, intrauterine growth retardation and maternal malnutrition. Evaluation of the safety and efficacy of cooling in adequately powered randomised controlled trials is required before cooling is offered in routine clinical practice in low-and middle-income countries.

Role of calcium supplementation during pregnancy in reducing risk of developing gestational hypertensive disorders: a meta-analysis of studies from developing countries

BackgroundHypertension in pregnancy stand alone or with proteinuria is one of the leading causes of maternal mortality and morbidity in the world. Epidemiological and clinical studies have shown that an inverse relationship exists between calcium intake and development of hypertension in pregnancy though the effect varies based on baseline calcium intake and pre-existing risk factors. The purpose of this review was to evaluate preventive effect of calcium supplementation during pregnancy on gestational hypertensive disorders and related maternal and neonatal mortality in developing countries.MethodsA literature search was carried out on PubMed, Cochrane Library and WHO regional databases. Data were extracted into a standardized excel sheet. Identified studies were graded based on strengths and limitations of studies. All the included studies were from developing countries. Meta-analyses were generated where data were available from more than one study for an outcome. Primary outcomes were maternal mortality, eclampsia, pre-eclampsia, and severe preeclampsia. Neonatal outcomes like neonatal mortality, preterm birth, small for gestational age and low birth weight were also evaluated. We followed standardized guidelines of Child Health Epidemiology Reference Group (CHERG) to generate estimates of effectiveness of calcium supplementation during pregnancy in reducing maternal and neonatal mortality in developing countries, for inclusion in the Lives Saved Tool (LiST).ResultsData from 10 randomized controlled trials were included in this review. Pooled analysis showed that calcium supplementation during pregnancy was associated with a significant reduction of 45% in risk of gestational hypertension [Relative risk (RR) 0.55; 95 % confidence interval (CI) 0.36-0.85] and 59% in the risk of pre-eclampsia [RR 0.41; 95 % CI 0.24-0.69] in developing countries. Calcium supplementation during pregnancy was also associated with a significant reduction in neonatal mortality [RR 0.70; 95 % CI 0.56-0.88] and risk of pre-term birth [RR 0.88, 95 % CI 0.78-0.99]. Recommendations for LiST for reduction in maternal mortality were based on risk reduction in gestational hypertensive related severe morbidity/mortality [RR 0.80; 95% CI 0.70-0.91] and that for neonatal mortality were based on risk reduction in all-cause neonatal mortality [RR 0.70; 95% CI 0.56-0.88].ConclusionCalcium supplementation during pregnancy is associated with a reduction in risk of gestational hypertension, pre-eclampsia neonatal mortality and pre-term birth in developing countries.

Effect of community based behavioural change communication intervention to improve neonatal mortality in developing countries: A Systematic Review

Executive Summary Background A great burden of infant and under-five childhood mortality occurs during the neonatal period, usually within a few days of birth. Community based behavioural change communication (such as interpersonal, group and mass media channels, including participatory methods at community level) intervention trials have been shown to be effective in reducing this mortality. However, to guide policy makers and programme planners, there is a need to systematically appraise and synthesise this evidence. Objective To systematically search, appraise and synthesise the best available evidence on the effect of community based behavioural change communication intervention to improve neonatal mortality in developing countries. Inclusion Criteria This review considered randomised controlled community trials on the effectiveness of community based behavioural change communication interventions aimed at decreasing neonatal mortality that were conducted in developing countries. Search Strategy This review considered English language articles on studies published between December, 2006 to January, 2011 and indexed in PubMed, CINAHL, EMBASE, Mednar, popline, Proquest, or Hinari. Methodological quality Studies that met the inclusion criteria were assessed for methodological quality using the Joanna Briggs Institute Meta Analysis of Statistical Assessment and Review Instrument by two independent reviewers. Data were analysed using a fixed effects model with RevMan5 software. Results: Community based behavioural change communication interventions were found to be associated with a significant reduction in neonatal mortality of 19% (average OR 0.81; 95%CI 0.75 to 0.88), early neonatal mortality by 20% (average 0.80; 95%CI 0.70 to 0.91), late neonatal mortality by 21% (average 0.79; 95%CI 0.63 to 0.99). In addition, the intervention also resulted in significant improvement of newborn care practice; breast feeding initiation, clean cord cutting and delay in bathing were improved by 185%, 110% and 196% respectively. Conclusions Community-based behavioural change communication interventions such as health education, information education and communication, behavioural change communication, social mobilisation, community mobilisation, community conversation, and home based counselling were found to be associated with a significant reduction in neonatal mortality, early neonatal mortality and post neonatal mortality. The findings of this systematic review call for integration of such interventions into conventional strategies in developing countries. Implications for practice This systematic review has shown that community based behavioural change communication interventions that are implemented through community health volunteers and other community based health workers, targeted at pregnant women and also involving influential people such as mothers-in-law, fathers-in-law and husbands/partners, consistently demonstrated that community based intervention packages significantly reduced early neonatal, late neonatal and neonatal mortality rates and also have a pivotal role in improving household newborn care practice. Thus, this review provides encouraging evidence of the value of integrating newborn care and neonatal mortality reduction strategies into community based approaches. Implications for research The review findings were largely derived from a limited number of community trials from developing regions, particularly the African setting. Thus, there is a clear need for additional research on a larger scale and in more varied settings. There is also a need for more evidence based on higher quality research. The cost effectiveness of these community based interventions may impact on their adoption; however it was outside the scope of this review. Cost-effectiveness of these interventions should become a priority area for future research.

Effect of community based behavioural change communication intervention to improve neonatal mortality in developing countries: A Systematic Review.

Background A great burden of infant and under-five childhood mortality occurs during the neonatal period, usually within a few days of birth. Community based behavioural change communication (such as interpersonal, group and mass media channels, including participatory methods at community level) intervention trials have been shown to be effective in reducing this mortality. However, to guide policy makers and programme planners, there is a need to systematically appraise and synthesise this evidence.Objective To systematically search, appraise and synthesise the best available evidence on the effect of community based behavioural change communication intervention to improve neonatal mortality in developing countries.Inclusion Criteria This review considered randomised controlled community trials on the effectiveness of community based behavioural change communication interventions aimed at decreasing neonatal mortality that were conducted in developing countries.Search Strategy This review considered English language articles on studies published between December, 2006 to January, 2011 and indexed in PubMed, CINAHL, EMBASE, Mednar, popline, Proquest, or Hinari.Methodological quality Studies that met the inclusion criteria were assessed for methodological quality using the Joanna Briggs Institute Meta Analysis of Statistical Assessment and Review Instrument by two independent reviewers. Data were analysed using a fixed effects model with RevMan5 software. Community based behavioural change communication interventions were found to be associated with a significant reduction in neonatal mortality of 19% (average OR 0.81; 95%CI 0. to 0.88), early neonatal mortality by 20% (average 0.80; 95%CI 0. to 0.91), late neonatal mortality by 21% (average 0.79; 95%CI 0. to 0.99). In addition, the intervention also resulted in significant improvement of newborn care practice; breast feeding initiation, clean cord cutting and delay in bathing were improved by 185%, 110% and 196% respectively.Conclusions Community-based behavioural change communication interventions such as health education, information education and communication, behavioural change communication, social mobilisation, community mobilisation, community conversation, and home based counselling were found to be associated with a significant reduction in neonatal mortality, early neonatal mortality and post neonatal mortality. The findings of this systematic review call for integration of such interventions into conventional strategies in developing countries.Implications for practice This systematic review has shown that community based behavioural change communication interventions that are implemented through community health volunteers and other community based health workers, targeted at pregnant women and also involving influential people such as mothers-in-law, fathers-in-law and husbands/partners, consistently demonstrated that community based intervention packages significantly reduced early neonatal, late neonatal and neonatal mortality rates and also have a pivotal role in improving household newborn care practice. Thus, this review provides encouraging evidence of the value of integrating newborn care and neonatal mortality reduction strategies into community based approaches.Implications for research The review findings were largely derived from a limited number of community trials from developing regions, particularly the African setting. Thus, there is a clear need for additional research on a larger scale and in more varied settings. There is also a need for more evidence based on higher quality research. The cost effectiveness of these community based interventions may impact on their adoption; however it was outside the scope of this review. Cost-effectiveness of these interventions should become a priority area for future research.

'Kangaroo mother care' to prevent neonatal deaths due to preterm birth complications

Background ‘Kangaroo mother care’ (KMC) includes thermal care through continuous skin-to-skin contact, support for exclusive breastfeeding or other appropriate feeding, and early recognition/response to illness. Whilst increasingly accepted in both high- and low-income countries, a Cochrane review (2003) did not find evidence of KMC’s mortality benefit, and did not report neonatal-specific data.Objectives The objectives of this study were to review the evidence, and estimate the effect of KMC on neonatal mortality due to complications of preterm birth.Methods We conducted systematic reviews. Standardized abstraction tables were used and study quality assessed by adapted GRADE methodology. Meta-analyses were undertaken.Results We identified 15 studies reporting mortality and/or morbidity outcomes including nine randomized controlled trials (RCTs) and six observational studies all from low- or middle-income settings. Except one, all were hospital-based and included only babies of birth-weight <2000 g (assumed preterm). The one community-based trial had missing birthweight data, as well as other limitations and was excluded. Neonatal-specific data were supplied by two authors. Meta-analysis of three RCTs commencing KMC in the first week of life showed a significant reduction in neonatal mortality [relative risk (RR) 0.49, 95% confidence interval (CI) 0.29–0.82] compared with standard care. A meta-analysis of three observational studies also suggested significant mortality benefit (RR 0.68, 95% CI 0.58–0.79). Five RCTs suggested significant reductions in serious morbidity for babies <2000 g (RR 0.34, 95% CI 0.17–0.65).Conclusion This is the first published meta-analysis showing that KMC substantially reduces neonatal mortality amongst preterm babies (birth weight <2000 g) in hospital, and is highly effective in reducing severe morbidity, particularly from infection. However, KMC remains unavailable at-scale in most low-income countries.

Infant outcomes following diabetic pregnancies

Diabetes remains a major contributor to both perinatal mortality and morbidity. The complex problems associated with both gestational and pre-gestational (types 1 and 2) diabetes in pregnancy are diverse and are not always managed optimally. Improvement of obstetric and newborn care in these patients has undoubtedly resulted in a significant reduction in neonatal mortality and morbidity over the last few decades. However, there is still significant room for improvement, and progress has been slow in some areas of clinical management. Evidence has now emerged that type 2 diabetes during pregnancy has a similar outcome for infants as type 1 diabetes. This has obvious implications for the future as the incidence of type 2 diabetes is rising worldwide. The key to success remains pre-pregnancy planning and tight glycaemic control throughout pregnancy/labour, as well as the early recognition and intensive care treatment of newborn complications. A thorough knowledge of potential problems in diabetic pregnancies and the infants of diabetic mothers is mandatory for professionals involved in their care.

Surfactant use for neonatal lung injury: beyond respiratory distress syndrome.

Surfactant has led to a significant reduction in neonatal mortality for premature infants with lung immaturity and respiratory distress. However, surfactant therapy has been shown to be effective in the treatment of a number of other neonatal respiratory disorders and the evidence for surfactant use in such circumstances is presented. Meconium aspiration is characterised by severe atelectasis, the influx of neutrophils, edema, and hyaline membranes, with decreased levels of SP-A and SP-B and the large aggregate fraction of lung surfactant, and altered surfactant surface morphology. Meconium contains cholesterol, free fatty acids and bilirubin all of which can interfere with surfactant function in a dose-dependent fashion. Providing larger amounts of surfactant can overcome some of this inhibition. Animal models of meconium aspiration treated with surfactant have improved histology, lung mechanics and gas exchange. Studies in human infants with meconium aspiration have found elevated concentrations of total protein, albumin, and membrane-derived phospholipid in lung lavage fluid, and haemorrhagic pulmonary edema. Clinical studies in such neonates have reported improved gas exchange and clinical outcomes following surfactant treatment. More recently surfactant lavage has been shown to be a potentially efficacious therapy for such infants. The inflammatory exudate containing plasma proteins and cytokines which accompanies neonatal pneumonia may inactivate surfactant. Surfactant treatment given to animals following the tracheal instillation of group B Streptococcal resulted in significantly less bacterial growth and improved lung function. Small clinical experiences have demonstrated the benefit of surfactant to infants with pneumonia/sepsis. Pulmonary haemorrhage, which some consider a complication of surfactant therapy, has also been effectively managed using surfactant instillation. The hemoglobin and red blood cell lipids may act to inhibit natural surfactant and treatment with surfactant has been shown to improve outcome for infants with pulmonary haemorrhage. Animal models of congenital diaphragmatic hernia (CDH) have hypoplastic lungs with evidence of decreased lamellar bodies in their type II pneumocytes and resultant surfactant deficiency, and respond to surfactant replacement with improved gas exchange and lung mechanics. The lungs of human infants with CDH contain less phospholipids and phosphatidylcholine per milligram of DNA than control infants. Case reports have reported a benefit of surfactant for infants with CDH. In the near-term infants with severe respiratory distress, surfactant is one of the therapies along with inhaled nitric oxide and high frequency ventilations, that have resulted in improved outcomes. Surfactant treatment may be of significant benefit in newborn infants with respiratory compromise secondary to a number of insults, and further prospective evidence of its efficacy in such disorders is needed.