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Global Newborn Health Conference Johannesburg, South Africa April 16, 2013
EVERY PERSON, INCLUDING NEWBORNS DESERVES THE CHANCE TO LIVE A HEALTHY, PRODUCTIVE LIFE.
Outline Preterm burden Implementation & research horizons Purpose-driven, catalytic partnerships
China
Nigeria Pakistan Indonesia USA Bangladesh Philippines Dem Rep Congo Brazil 774 1,172
3,519
748
676 517 424 349 341 279 0 1,000 2,000 3,000 4,000
Extrapolating to rest of developed world based on per-capita HC spend and PT birth rate suggests cost of ~$40B annually
Creates unique opportunity to leverage investments & learning from low- and middle- and high-income countries to improve preterm birth and newborn health
1. Includes costs of medical care services, early intervention services, special education services, and lost household and labor market productivity. Methods: total economic cost associated with 1 preterm baby estimated to be $51,600 in the US in 2005 (Behman et al). Estimate for other countries obtained by scaling each country's per capita health expenditure in 2005 to that of the US. Total economic cost saved for a given country is cost per PTB infant x projected number of preterm births averted . Total sum here for all 42 UN high human development index countries (in green). Source: World Bank statistics, Behrman et al. (2007) Institute of Medicine: Preterm Birth: Causes, Consequences, and Prevention, Born Too Soon; BCG analysis
Neonatal mortality is declining slower than child mortality and prematurity is the 2nd leading cause of under-5 deaths 2010 Childhood Mortality
Neonatal mortality is not dropping as fast as under-five mortality 40% Neonatal Period Preterm birth is the #2 cause of U5 death
Under 5 Mortality Neonatal Mortality
35%
Preterm
23%
Intrapartum
27%
Infection
15%
Other
Source: Lawn J E et al. Health Policy Plan. 2012;27:iii6-iii28; Liu L et al. Lancet. 2012; 79(9832):2151-61.
Mild: disorders of executive functioning Moderate to severe: global developmental delay Psychiatric/behavioral sequalae Impact on family Impact on health service Intergenerational
Two groups formed to channel momentum from Born Too Soon into actionable steps
Research Group Care Group Purpose: Accelerate implementation of priority interventions Core Members: UNICEF, WHO, SNL, USAID, BMGF, CIFF, AAP/IPA, PMNCH Next steps: Efforts feeding into Global Newborn Actionwith a Plan to be launched later this year
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www.facebook.com/worldprematurityday
What: A global movement to accelerate access to simple, cost-effective solutions, and support families who have experienced preterm birth. Who: > 55 global partners and > 60 countries, all continents, media reach of 1.4 billion High income countries, e.g. Illumination Initiative for famous buildings
Malawi: high level event, commitment made Uganda: high level event with Minister of Health, commitment made for KMC and ACS scale up
#Borntoosoon #WorldPrematurityDay
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Infection case management Cervical pessary CPAP / novel surfactant Neonatal resuscitation
ANCS
KMC
Reduced hypothermia (RR 0.23, 95% CI 0.1-0.55) Mothers more likely to breastfeed @ 3/12 (RR 1.2, Earlier discharge (2.4 days on average) Increased maternal infant attachment (24 vs. 18)
95% CI 1.01-1.43)
Could save an estimated 450,000 babies by 2015 if 95% of preterm babies are reached
Lawn et al Kangaroo mother care to prevent neonatal deaths due to preterm birth complications. Int J Epid: 2010, Conde-Agudelo A, Belizan JM, Diaz-Rossello, Cochrane Review: 2011
Action
Conduct faction analysis, partner landscaping and apply a systems approach Catalyze coordinated thinking, communication and action among partners, and align around common goals Elaborate the fact base for KMC and identify points of alignment vs. points of contention
Integrate recordkeeping and reporting on KMC into routine monitoring and evaluation systems Countries self-selected to become champions Promote a KMC continuum of care culture and framework Promote early care-seeking through community engagement Understand social support needs of moms and families to practice KMC
Sources: MCHIP, Save the Children (2012). Tracking Implementation Progress for Kangaroo Mother Care.
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Action
Application to add to WHO Essential Medicines List Policy brief for use at country level Frequently asked questions to dispel myths Online portal for quick reference to key information In-country education and training
Identification of multiple, low cost (<$1/dose) generic suppliers Technical support to UN Commission country plans to specifically address supply constraints Community mobilization to identify danger signs in pregnancy and ensure transport to health facility Caregiver training on basic measurement of gestational age
Sources: Althabe F et al, Reproductive Health 2012 ; Born Too Soon Care Group; Lawn JE, Segre J et al. Antenatal Corticosteroids for the reduction of deaths in preterm babies. UN Commission Report. March 2012
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We are working with research and funding partners to map out a preterm solution pathway to coordinate our efforts
Research group Care group
Discovery
Development
PTB biomarkers Fetal Fibronectin
Requires validation of high potential options and dev. of field ready Dx
Delivery
Understand etiopathogenesis of PTB & develop interventions to predict and prevent PTBs
Requires clearly defined research agenda and more traction from research and funding communities
Mainly used to rule out PTB, has low positive predictive value
Social factors
e.g. stress
Progesterone
Requires tools to enable deployment & user friendly formulation
Cervical pessary
Very promising but requires validation and tools to enable deployment
Community KMC
Being implemented in select locations but still requires more operational research before widespread uptake
Institutional KMC
Requires effort to drive uptake
Novel surfactant
Requires more user friendly & inexpensive formulation
CPAP
Requires adaptation for use in low resource settings
Antenatal Corticosteroids
Requires effort to drive uptake
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First published RCT assessing use of cervical pessary in PTB showed efficacy on all end points
Women with cervical length 25mm randomized to pessary or control
726 women with cervix 25mm
341 opted out
BW < 1500 g
192 assigned to cervical pessary
2 lost to follow up
While impressive, consensus is that more trials are needed to confirm RCT findings
Source: Goya et al. Lancet (2012): Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial, Data from Goya et al study converted into relative risk and 95% CI using online calculator from Centre for Evidence Based Medicine, Toronto which is accessible at http://ktclearinghouse.ca/cebm/practise/ca/calculators/statscalc BCG analysis
Cochrane meta-analysis by Dodd et al. showed benefit of progesterone1 in women with different PTB risk profiles
[95% CI]
PTB history
PTB < 34 wks PTB < 37 wks BW < 2500 g RR 0.15 [0.04-0.64] RR 0.80 [0.70-0.92]
RR 0.64 [0.49-0.83]
RR 0.75 [0.57-0.97]
Multiple pregnancy
Risk of tocolysis
Threatened PT labor
PTB < 37 wks
RR 0.29 [0.12-0.69]
1. Cochrane review did not differentiate between subtypes of progesterone (natural progesterone vs. synthetic 17-alpha-hydroxyprogesterone caproate (17P)). 2. Short cervix definition varies, and Cochrane review included only cervical length < 15 mm Source Dodd et al. Cochrane Library (2012), Romero. Women's Health (2011), BCG analysis
The late preterm @ 32-36 weeks (85% of PTB) more prone to adverse effects than @ 40 weeks
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We cannot view newborn health in isolation. We must take a holistic, panoramic view involving catalytic partnerships
Partnerships can lead to better, faster, greater health outcomes within the context of healthy and productive families
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-Ghanaian proverb
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Thank You
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