4 million neonatal deaths: an analysis of available cause-of-death data and systematic country estimates with a focus on “birth asphyxia”

BACKGROUND: Of the world’s four million neonatal deaths, 99% occur in low/middleincome countries, but most information relates to the 1% dying in high-income countries. Reliable cause-of-death data are lacking. The aim of this thesis is to develop programmatically-relevant, national estimates for neonatal cause-of-death, focusing on “birth asphyxia” to illustrate specific challenges in the available data and for systematic national estimates. OBJECTIVES: 1. Review estimation methods, giving implications for neonatal cause-of-death estimation. 2. Propose programmatic categories for neonatal cause-of-death, reviewing measurement options for intrapartum-related outcomes (“birth asphyxia”). 3. Identify and analyse existing neonatal cause-of-death data. 4. Estimate intrapartum-related neonatal deaths for all countries, comparing single-cause and multi-cause models. 5. Summarise priorities for improving neonatal cause-of-death estimates and input data. DATA INPUTS: Case definitions were reviewed for neonatal cause-of-death and intrapartumrelated outcomes. Six programmatically relevant cause-of-death categories were defined, plus a residual “other neonatal” category. Two sources of neonatal cause-of-death data were examined: Vital Registration (VR) datasets for countries with high coverage (>90%) based on a new analysis from 83 countries; and published/unpublished studies identified through systematic searches. Inclusion criteria for representativeness and comparability were applied. Data from 44 countries with VR (96,797 neonatal deaths) and from 56 studies (29 countries, 13,685 neonatal deaths) met inclusion criteria, despite screening almost 7,000 abstracts. These data represent <3% of the world’s neonatal deaths. Thus estimation is necessary for global level information. No useable data were identified from Central and North-West Africa, or Central Asia. MODELLING: Methods were developed to estimate intrapartum-related neonatal deaths (single-cause), and then simultaneously estimate seven causes of neonatal death (multi-cause). Applying these proportions to the numbers of neonatal deaths in 192 countries gives a global estimate of intrapartum-related neonatal deaths of 0.90 (0.65-1.17) million using single-cause and 0.91 (0.60-1.08) million using multi-cause methods. DISCUSSION: The multi-cause model has become WHO’s standard method for neonatal cause-of-death estimates. However, complex statistical models are not a panacea. More representative data are required. Simplified case definitions and consistent hierarchical cause-of- death attribution would improve comparability, especially for intrapartum-related deaths

Uterotonics for prevention of postpartum haemorrhage: EN-BIRTH multi-country validation study

Background Postpartum haemorrhage (PPH) is a leading cause of preventable maternal mortality worldwide. The World Health Organization (WHO) recommends uterotonic administration for every woman after birth to prevent PPH. There are no standardised data collected in large-scale measurement platforms. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) is an observational study to assess the validity of measurement of maternal and newborn indicators, and this paper reports findings regarding measurement of coverage and quality for uterotonics. Methods The EN-BIRTH study took place in five hospitals in Bangladesh, Nepal and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data. We compared observation data for uterotonics to routine hospital register-records and women’s report at exit-interview survey. We analysed the coverage and quality gap for timing and dose of administration. The register design was evaluated against gap analyses and qualitative interview data assessing the barriers and enablers to data recording and use. Results Observed uterotonic coverage was high in all five hospitals (> 99%, 95% CI 98.7–99.8%). Survey-report underestimated coverage (79.5 to 91.7%). “Don’t know” replies varied (2.1 to 14.4%) and were higher after caesarean (3.7 to 59.3%). Overall, there was low accuracy in survey data for details of uterotonic administration (type and timing). Register-recorded coverage varied in four hospitals capturing uterotonics in a specific column (21.6, 64.5, 97.6, 99.4%). The average coverage measurement gap was 18.1% for register-recorded and 6.0% for survey-reported coverage. Uterotonics were given to 15.9% of women within the “right time” (1 min) and 69.8% within 3 min. Women’s report of knowing the purpose of uterotonics after birth ranged from 0.4 to 64.9% between hospitals. Enabling register design and adequate staffing were reported to improve routine recording. Conclusions Routine registers have potential to track uterotonic coverage – register data were highly accurate in two EN-BIRTH hospitals, compared to consistently underestimated coverage by survey-report. Although uterotonic coverage was high, there were gaps in observed quality for timing and dose. Standardisation of register design and implementation could improve data quality and data flow from registers into health management information reporting systems, and requires further assessment

Immediate newborn care and breastfeeding: EN-BIRTH multi-country validation study

Background Immediate newborn care (INC) practices, notably early initiation of breastfeeding (EIBF), are fundamental for newborn health. However, coverage tracking currently relies on household survey data in many settings. “Every Newborn Birth Indicators Research Tracking in Hospitals” (EN-BIRTH) was an observational study validating selected maternal and newborn health indicators. This paper reports results for EIBF. Methods The EN-BIRTH study was conducted in five public hospitals in Bangladesh, Nepal, and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data on EIBF and INC practices (skin-to-skin within 1 h of birth, drying, and delayed cord clamping). To assess validity of EIBF measurement, we compared observation as gold standard to register records and women’s exit-interview survey reports. Percent agreement was used to assess agreement between EIBF and INC practices. Kaplan Meier survival curves showed timing. Qualitative interviews were conducted to explore barriers/enablers to register recording. Results Coverage of EIBF among 7802 newborns observed for ≥1 h was low (10.9, 95% CI 3.8–21.0). Survey-reported (53.2, 95% CI 39.4–66.8) and register-recorded results (85.9, 95% CI 58.1–99.6) overestimated coverage compared to observed levels across all hospitals. Registers did not capture other INC practices apart from breastfeeding. Agreement of EIBF with other INC practices was high for skin-to-skin (69.5–93.9%) at four sites, but fair/poor for delayed cord-clamping (47.3–73.5%) and drying (7.3–29.0%). EIBF and skin-to-skin were the most delayed and EIBF rarely happened after caesarean section (0.5–3.6%). Qualitative findings suggested that focusing on accuracy, as well as completeness, contributes to higher quality with register reporting. Conclusions Our study highlights the importance of tracking EIBF despite measurement challenges and found low coverage levels, particularly after caesarean births. Both survey-reported and register-recorded data over-estimated coverage. EIBF had a strong agreement with skin-to-skin but is not a simple tracer for other INC indicators. Other INC practices are challenging to measure in surveys, not included in registers, and are likely to require special studies or audits. Continued focus on EIBF is crucial to inform efforts to improve provider practices and increase coverage. Investment and innovation are required to improve measurement

Antibiotic use for inpatient newborn care with suspected infection: EN-BIRTH multi-country validation study

Background An estimated 30 million neonates require inpatient care annually, many with life-threatening infections. Appropriate antibiotic management is crucial, yet there is no routine measurement of coverage. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aimed to validate maternal and newborn indicators to inform measurement of coverage and quality of care. This paper reports validation of reported antibiotic coverage by exit survey of mothers for hospitalized newborns with clinically-defined infections, including sepsis, meningitis, and pneumonia. Methods EN-BIRTH study was conducted in five hospitals in Bangladesh, Nepal, and Tanzania (July 2017–July 2018). Neonates were included based on case definitions to focus on term/near-term, clinically-defined infection syndromes (sepsis, meningitis, and pneumonia), excluding major congenital abnormalities. Clinical management was abstracted from hospital inpatient case notes (verification) which was considered as the gold standard against which to validate accuracy of women’s report. Exit surveys were conducted using questions similar to The Demographic and Health Surveys (DHS) approach for coverage of childhood pneumonia treatment. We compared survey-report to case note verified, pooled across the five sites using random effects meta-analysis. Results A total of 1015 inpatient neonates admitted in the five hospitals met inclusion criteria with clinically-defined infection syndromes. According to case note verification, 96.7% received an injectable antibiotic, although only 14.5% of them received the recommended course of at least 7 days. Among women surveyed (n = 910), 98.8% (95% CI: 97.8–99.5%) correctly reported their baby was admitted to a neonatal ward. Only 47.1% (30.1–64.5%) reported their baby’s diagnosis in terms of sepsis, meningitis, or pneumonia. Around three-quarters of women reported their baby received an injection whilst in hospital, but 12.3% reported the correct antibiotic name. Only 10.6% of the babies had a blood culture and less than 1% had a lumbar puncture. Conclusions Women’s report during exit survey consistently underestimated the denominator (reporting the baby had an infection), and even more so the numerator (reporting known injectable antibiotics). Admission to the neonatal ward was accurately reported and may have potential as a contact point indicator for use in household surveys, similar to institutional births. Strengthening capacity and use of laboratory diagnostics including blood culture are essential to promote appropriate use of antibiotics. To track quality of neonatal infection management, we recommend using inpatient records to measure specifics, requiring more research on standardised inpatient records

Kangaroo mother care: EN-BIRTH multi-country validation study

Background Kangaroo mother care (KMC) reduces mortality among stable neonates ≤2000 g. Lack of data tracking coverage and quality of KMC in both surveys and routine information systems impedes scale-up. This paper evaluates KMC measurement as part of the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study. Methods The EN-BIRTH observational mixed-methods study was conducted in five hospitals in Bangladesh, Nepal and Tanzania from 2017 to 2018. Clinical observers collected time-stamped data as gold standard for mother-baby pairs in KMC wards/corners. To assess accuracy, we compared routine register-recorded and women’s exit survey-reported coverage to observed data, using different recommended denominator options (≤2000 g and ≤ 2499 g). We analysed gaps in quality of provision and experience of KMC. In the Tanzanian hospitals, we assessed daily skin-to-skin duration/dose and feeding frequency. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine register design, filling and use. Results Among 840 mother-baby pairs, compared to observed 100% coverage, both exit-survey reported (99.9%) and register-recorded coverage (92.9%) were highly valid measures with high sensitivity. KMC specific registers outperformed general registers. Enablers to register recording included perceptions of data usefulness, while barriers included duplication of data elements and overburdened health workers. Gaps in KMC quality were identified for position components including wearing a hat. In Temeke Tanzania, 10.6% of babies received daily KMC skin-to-skin duration/dose of ≥20 h and a further 75.3% received 12–19 h. Regular feeding ≥8 times/day was observed for 36.5% babies in Temeke Tanzania and 14.6% in Muhimbili Tanzania. Cup-feeding was the predominant assisted feeding method. Family support during admission was variable, grandmothers co-provided KMC more often in Bangladesh. No facility arrangements for other family members were reported by 45% of women at exit survey. Conclusions Routine hospital KMC register data have potential to track coverage from hospital KMC wards/corners. Women accurately reported KMC at exit survey and evaluation for population-based surveys could be considered. Measurement of content, quality and experience of KMC need consensus on definitions. Prioritising further KMC measurement research is important so that high quality data can be used to accelerate scale-up of high impact care for the most vulnerable

Fetal heart rate monitoring: the challenge in under-resourced settings

Background: Intrapartum-related deaths are the second most common cause of neonatal death, resulting in 1.2 million stillbirths each year, many of which could be prevented with improved intrapartum monitoring. The partograph was developed as a tool to help health professionals to provide better and more efficient care during labour. This study set out to address whether this low-cost tool was reaching under-resourced settings and whether it was being used correctly. Aim: To assess barriers and enablers for the use of a partograph in under-resourced settings, especially to monitor fetal heart rate. Method: Evaluation of 538 partographs as well as in-depth interviews and knowledge assessments with 24 midwives. Findings: The general score for partograph use and completion was 59.3%. The score for fetal heart rate assessment was 56%. The midwives interviewed felt that partograph use and fetal heart rate monitoring were important but also felt insecure and undertrained in this aspect of midwifery practice. Conclusions: This review showed that very few partographs were completed according to standard, despite the fact that the midwives knew the importance of fetal heart rate monitoring and were motivated to monitor well. Time constraints and a lack of training were identified as the biggest barriers to correct monitoring