Data to inform accelerated progress

JOY LAWN: Now we move forward to say, what data do we have to inform accelerated progress? The principal going forward in the Sustainable Development Goals is that every child, every newborn, should have the same chance of survival. And if we look at this chart, what we see is taking the current rate of change over the last decade– so when we’ve been going more quickly– and projecting forward for each region of the world, when will each of these regions have the same chance for their newborns to survive as those born in the richest countries? So, for example, I’m standing here in London, and the UK has a neonatal mortality rate of three per thousand.

This is pretty much the average for industrialised countries. And if we look at Asia, Latin America, the progress is really picking up fast. Eastern Asia, driven by remarkable progress in China. And these and the rates of reduction mean that it’s not long before the newborns will have the same chance of survival. If we look out into southern Asia, the time is much longer, not until after the year 2100.

But if we look at Africa– so I’m an African, I was born in Uganda, I just collected the wrong colour of skin at birth– but if we look at this, it is going to be 150 years before a baby born in Africa has the same chance of survival as a baby born in the UK. Now I think this is unacceptable. And it’s doubly unacceptable because the rate of change that is happening in Africa is slower than the rate of change was historically in industrialised countries, even 50 years ago when we had less in our hands.

We’ve now been able to simplify and advance newborn care and maternal care in such a way that we should be able to go faster, not slower. So what will it take to get that speed up? So let’s learn from history. Neonatal deaths can be reduced before neo intensive care is available. And yet, for most of the science that’s published in papers, most of the discussions around the world, you would think there was nothing we could do if we couldn’t ventilate. So if we look back, for example, at the UK and the US with neonatal mortality rates around 40 at the turn of the last century– so around 1900– and this is similar, for example, to Afghanistan today.

And this first phase to reduce neonatal mortality rate by about 10 to 30 per 1,000, which happened before the First World War– was really through public health approaches. Improved hygiene, water and sanitation practises, and so on, that were being improved. Then we have this huge drop from 30 down to 15. So a halving, which is really through obstetric care and individualised neonatal care, the advent of antibiotics, caesarean sections, and improved midwifery care as well. And these hold really the highest proportionate reduction that was achieved and is remarkable. But if we go forward, then into the era of neonatal intensive care, starting with neonatal mortality rate, around 15.

Once you get below about 15 per 1,000, the biggest proportion of your neonatal deaths are preterm. And you’re going to have to look at ways of providing respiratory support and more moving towards more complex neonatal care. And again a huge proportionate reduction. But the reality is that the largest drop has come before we got to intensive care. And as we go forward into intensive care, quality becomes critical. And we move also from just thinking about survival to really thinking about disability. So particularly in this phase where we’re pushing forward into more intensive neonatal intensive care, pushing the thresholds of survival down way below even the 28 weeks, we now have 22, 23 weekers that are surviving.

We’re really having to focus very much on following up disability. But if we look at where we can achieve this, so first of all, in facilities. So the world has seen a huge shift into facility births. And the potential for mortality reduction in these settings is massive. So in The Lancet “Every Newborn” series– in the paper led by Zulfiqar Bhutta, et al.– we undertook lives saved estimates. And of the newborn deaths that can be prevented– so around 3/4 are preventable without intensive care– most of these are coming through facility birth, particularly through care at birth. So obstetric care and through care of small and sick newborns, Kangaroo Mother Care, and the supportive care with antibiotics and basic prevention as well.

And yet, despite this huge shift into facility births, we have a massive quality gap. So this picture is from a hospital that I worked at in Ghana. And fantastic approaches to bringing the cost barriers down for accessing facility birth, but major overcrowding. And this is seen throughout Asia and Africa. And in the next five years, the single thing that we could do most for reducing preventable deaths for stillbirths, for neonatal, and for maternal, would be to address this quality gap. And a particular issue here is having more health workers and especially midwives and looking at skilling them and enabling them to be part of a team that can make a huge difference.

And one of the biggest gaps I would like to highlight here is the huge and increasing evidence base that we have for some of the simple things that we can do for newborns. Delayed cord clamping. Now 16 randomised controlled trials showing benefit. Cord care, for example, innovations such as chlorhexidine, for cord cleansing, particularly for home births in high mortality settings. Hand washing. Breastfeeding. A massive literature with a high degree of evidence, particularly for exclusive breastfeeding, thermal more protection for newborns. Something we can’t even do randomised controlled trials on, and so the evidence is not high quality. But all these apparently simple things are things that we’re still failing to deliver on.

So in looking at the evidence base that we have, and looking at what we should be able to do, some of these things have a massive knowledge to action gap that we need to act on. And yet, despite this push into facility births, despite this tipping point– so in Africa we’ve now reached that half our births are in facilities– we still have major numbers, probably around 40 to 45 million births that are happening at home. And even in those settings where births are happening in facility, discharge of the mother and the newborn is rapid– often just a median stay of just a few hours. So what works in these settings?

Well, the newer estimates in The Lancet “Every Newborn” series, 2014, suggests that community care could avert that 25% to 30% of preventable newborn deaths. But what does that involve? What do we do? Well, the evidence for community-based strategies for maternal and newborn care is increasing all the time. It’s one of the most downloaded Cochrane reviews with Zulfiqar Bhutta’s team looking at what can be done. But it’s not all the same approaches. So women’s groups, that is particularly being led by Anthony Costello’s group from UCL, and the meta-analysis in Lancet shows a huge range in what can be achieved in these settings. Preventive home visits also show a range up to about 50% reduction in neonatal deaths.

And then if we add curative care at home, particularly antibiotic therapy, could go up to perhaps 2/3 reduction. What I would like to highlight here is, these become increasingly complicated to do. Adding curative care at home with antibiotics and high complex supervision needed is important if it’s the only thing we can do to reach the poor. But it’s not simple to scale up. So for each of these, the context, the cadre of worker, the content of care, and the cost are all crucial before we move forward to scale them up. So newborn deaths, stillbirths are preventable. The highest impact is at facility.

What we do at home is critical, but we really need to think through how that is best scalable and best links to make an integrated system for community and facility care for mother and for newborn.