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Arifeen S.E.,International Center for Diarrhoeal Disease Research | Mullany L.C.,Johns Hopkins University | Shah R.,Johns Hopkins University | Mannan I.,Johns Hopkins University | And 10 more authors.
The Lancet | Year: 2012

Background: Up to half of neonatal deaths in high mortality settings are due to infections, many of which can originate through the freshly cut umbilical cord stump. We aimed to assess the effectiveness of two cord-cleansing regimens with the promotion of dry cord care in the prevention of neonatal mortality. Design: We did a community-based, parallel cluster-randomised trial in Sylhet, Bangladesh. We divided the study area into 133 clusters, which were randomly assigned to one of the two chlorhexidine cleansing regimens (single cleansing as soon as possible after birth; daily cleansing for 7 days after birth) or promotion of dry cord care. Randomisation was done by use of a computer-generated sequence, stratified by cluster-specific participation in a previous trial. All livebirths were eligible; those visited within 7 days by a local female village health worker trained to deliver the cord care intervention were enrolled. We did not mask study workers and participants to the study interventions. Our primary outcome was neonatal mortality (within 28 days of birth) per 1000 livebirths, which we analysed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT00434408. Results: Between June, 2007, and September, 2009, we enrolled 29 760 newborn babies (10 329, 9423, and 10 008 in the multiple-cleansing, single-cleansing, and dry cord care groups, respectively). Neonatal mortality was lower in the single-cleansing group (22·5 per 1000 livebirths) than it was in the dry cord care group (28·3 per 1000 livebirths; relative risk [RR] 0·80 [95 CI] 0·65-0·98). Neonatal mortality in the multiple-cleansing group (26·6 per 1000 livebirths) was not statistically significantly lower than it was in the dry cord care group (RR 0·94 [0·78-1·14]). Compared with the dry cord care group, we recorded a statistically significant reduction in the occurrence of severe cord infection (redness with pus) in the multiple-cleansing group (risk per 1000 livebirths=4·2 vs risk per 1000 livebirths=1·2; RR 0·35 [0·15-0·81]) but not in the single-cleansing group (risk per 1000 livebirths=3·3; RR 0·77 [0·40-1·48]). Interpretation: Chlorhexidine cleansing of a neonate's umbilical cord can save lives, but further studies are needed to establish the best frequency with which to deliver the intervention. Funding: United States Agency for International Development and Save the Children's Saving Newborn Lives program, through a grant from the Bill & Melinda Gates Foundation. © 2012 Elsevier Ltd.


Lawn J.E.,London School of Hygiene and Tropical Medicine | Lawn J.E.,Save the Children United States | Lawn J.E.,Research and Evidence Division | Blencowe H.,London School of Hygiene and Tropical Medicine | And 12 more authors.
The Lancet | Year: 2014

In this Series paper, we review trends since the 2005 Lancet Series on Neonatal Survival to inform acceleration of progress for newborn health post-2015. On the basis of multicountry analyses and multi-stakeholder consultations, we propose national targets for 2035 of no more than 10 stillbirths per 1000 total births, and no more than 10 neonatal deaths per 1000 livebirths, compatible with the under-5 mortality targets of no more than 20 per 1000 livebirths. We also give targets for 2030. Reduction of neonatal mortality has been slower than that for maternal and child (1-59 months) mortality, slowest in the highest burden countries, especially in Africa, and reduction is even slower for stillbirth rates. Birth is the time of highest risk, when more than 40% of maternal deaths (total about 290 000) and stillbirths or neonatal deaths (5·5 million) occur every year. These deaths happen rapidly, needing a rapid response by health-care workers. The 2·9 million annual neonatal deaths worldwide are attributable to three main causes: infections (0·6 million), intrapartum conditions (0·7 million), and preterm birth complications (1·0 million). Boys have a higher biological risk of neonatal death, but girls often have a higher social risk. Small size at birth - due to preterm birth or small-for-gestational-Age (SGA), or both - is the biggest risk factor for more than 80% of neonatal deaths and increases risk of post-neonatal mortality, growth failure, and adult-onset non-communicable diseases. South Asia has the highest SGA rates and sub-Saharan Africa has the highest preterm birth rates. Babies who are term SGA low birthweight (10·4 million in these regions) are at risk of stunting and adult-onset metabolic conditions. 15 million preterm births, especially of those younger than 32 weeks' gestation, are at the highest risk of neonatal death, with ongoing post-neonatal mortality risk, and important risk of long-term neurodevelopmental impairment, stunting, and non-communicable conditions. 4 million neonates annually have other life-threatening or disabling conditions including intrapartum-related brain injury, severe bacterial infections, or pathological jaundice. Half of the world's newborn babies do not get a birth certificate, and most neonatal deaths and almost all stillbirths have no death certificate. To count deaths is crucial to change them. Failure to improve birth outcomes by 2035 will result in an estimated 116 million deaths, 99 million survivors with disability or lost development potential, and millions of adults at increased risk of non-communicable diseases after low birthweight. In the post-2015 era, improvements in child survival, development, and human capital depend on ensuring a healthy start for every newborn baby - the citizens and workforce of the future.


Bhutta Z.A.,Aga Khan University | Soofi S.,Aga Khan University | Cousens S.,London School of Hygiene and Tropical Medicine | Mohammad S.,Aga Khan University | And 6 more authors.
The Lancet | Year: 2011

Newborn deaths account for 57 of deaths in children younger than 5 years in Pakistan. Although a large programme of trained lady health workers (LHWs) exists, the effectiveness of this training on newborn outcomes has not been studied. We aimed to evaluate the effectiveness of a community-based intervention package, principally delivered through LHWs working with traditional birth attendants and community health committees, for reduction of perinatal and neonatal mortality in a rural district of Pakistan. We undertook a cluster randomised trial between February, 2006, and March, 2008, in Hala and Matiari subdistricts, Pakistan. Catchment areas of primary care facilities and all affiliated LHWs were used to define clusters, which were allocated to intervention and control groups by restricted, stratified randomisation. The intervention package delivered by LHWs through group sessions consisted of promotion of antenatal care and maternal health education, use of clean delivery kits, facility births, immediate newborn care, identification of danger signs, and promotion of careseeking; control clusters received routine care. Independent data collectors undertook quarterly household surveillance to capture data for births, deaths, and household practices related to maternal and newborn care. Data collectors were masked to cluster allocation; those analysing data were not. The primary outcome was perinatal and all-cause neonatal mortality. Analysis was by intention to treat. This trial is registered, ISRCTN16247511. 16 clusters were assigned to intervention (23 353 households, 12 391 total births) and control groups (23 768 households, 11 443 total births). LHWs in the intervention clusters were able to undertake 4428 (63) of 7084 planned group sessions, but were only able to visit 2943 neonates (24) of a total 12 028 livebirths in their catchment villages. Stillbirths were reduced in intervention clusters (39.1 stillbirths per 1000 total births) compared with control (48.7 per 1000; risk ratio [RR] 0.79, 95 CI 0.68-0.92; p=0.006). The neonatal mortality rate was 43.0 deaths per 1000 livebirths in intervention clusters compared with 49.1 per 1000 in control groups (RR 0.85, 0.76-0.96; p=0.02). Our results support the scale-up of preventive and promotive maternal and newborn interventions through community health workers and emphasise the need for attention to issues of programme management and coverage for such initiatives to achieve maximum potential. WHO; Saving Newborn Lives Program of Save the Children USA, funded by the Bill & Melinda Gates Foundation. © 2011 Elsevier Ltd.


Blencowe H.,London School of Hygiene and Tropical Medicine | Vos T.,Institute for Health Metrics and Evaluation | Vos T.,University of Queensland | Lee A.C.C.,Brigham and Women's Hospital | And 6 more authors.
Pediatric Research | Year: 2013

Background: Neonatal mortality and morbidity are increasingly recognized as important globally, but detailed estimates of neonatal morbidity from conditions and long-term consequences are yet to be published. Methods: We describe the general methods for systematic reviews, meta-analyses, and modeling used in this supplement, highlighting differences from the Global Burden of Disease (GBD2010) inputs and methods. For five conditions (preterm birth, retinopathy of prematurity, intrapartum-related conditions, neonatal infections, and neonatal jaundice), a standard three-step compartmental model was applied to estimate - by region, for 2010 - the numbers of (i) affected births by sex, (ii) postneonatal survivors, and (iii) impaired postneonatal survivors. For conditions included in GBD2010 analyses (preterm birth and intrapartum-related conditions), impairment at all ages was estimated, and disability weights were applied to estimate years lived with disability (YLD) and summed with years of life lost (YLL) to calculate disability-adjusted life years (DALYs). Results: GBD2010 estimated neonatal conditions (preterm birth, intrapartum-related, neonatal sepsis, and "other neonatal") to be responsible for 202 million DALYs or 8.1% (7.3-9.0%) of the worldwide total. Mortality contributed 95% of the DALYs, and the estimated 26% reduction in neonatal condition DALYs since 1990 is primarily due to a 44% reduction in neonatal mortality rate due to these conditions, counterbalanced by increased numbers of babies born (17%). Impairment following neonatal conditions remained stable globally and is therefore relatively more important, especially in high- and middle-income countries. Crucial data gaps were identified. Conclusion: These results confirm neonatal conditions as a significant burden, reemphasizing the need to reduce deaths further, to count the linked 2.6 million stillbirths, and to better measure and address their long-term effects. Copyright © 2013 International Pediatric Research Foundation, Inc.


Puett C.,Tufts University | Coates J.,Tufts University | Alderman H.,International Food Policy Research Institute | Sadruddin S.,Save the Children United States | Sadler K.,Tufts University
Food and Nutrition Bulletin | Year: 2012

Background. Community health workers (CHWs) perform a range of important tasks; however, limited evidence is available regarding the association between their workload and the quality of care they provide. Objective. To analyze the quality of preventive and curative care provided by two groups of CHWs with different workloads in southern Bangladesh. Methods. One group of CHWs provided preventive care in addition to implementing community case management (CCM) of acute respiratory infection and diarrhea, and another group additionally treated severe acute malnutrition (SAM). Preventive care was measured by case management observation at a routine household visit. Curative care was measured by case scenarios. Qualitative methods were used to contextualize CHWs' performance by examining their perceptions of challenges related to their workload. A total of 338 CHWs were assessed. Results. CHWs managing cases of SAM worked significantly more hours than the other group (16.7 ± 6.9 hours compared with 13.3 ± 4.6 hours weekly, p < .001) but maintained quality of care on curative and preventive work tasks. Effectively treating cases of SAM appeared to motivate CHWs. Conclusions. This was one of the first trials adding the treatment of SAM to a CHW workload and suggests that adding SAM to a well-trained and supervised CHW's workload, including preventive and curative tasks, does not necessarily yield lower quality of care. However, increased workloads had consequences for CHWs' domestic life, and further increases in workload may not be possible without additional incentives. © 2012, The United Nations University.


Chowdhury S.,Central Hospital Ltd | Banu L.A.,Laboratory AID Specialized Hospital | Chowdhury T.A.,Bangladesh Institute of Research and Rehabilitation in Diabetes | Rubayet S.,Save the Children United States | Khatoon S.,Bangladesh Medical College
BJOG: An International Journal of Obstetrics and Gynaecology | Year: 2011

Bangladesh has made commendable progress in achieving Millennium Development Goals (MDGs) 4 and 5. Since 1990, there has been a remarkable reduction in maternal and child mortality, with an estimated 57% reduction in child mortality and 66% in maternal mortality. This review highlights that, whereas Bangladesh is on track for achieving MDG 4 and 5A, progress in universal access to reproductive health (5B) is not yet at the required pace to achieve the targets set for 2015. In addition, Bangladesh needs to further enhance activities to improve newborn health and promote skilled attendance at birth. © 2011 RCOG.


Young M.,Health Section | Wolfheim C.,World Health Organization | Marsh D.R.,Save the Children United States | Hammamy D.,URS Corporation
American Journal of Tropical Medicine and Hygiene | Year: 2012

This statement presents the latest evidence for integrated community case management of childhood illness, describes the necessary program elements and support tools for effective implementation, and lays out actions that countries and partners can take to support the implementation of integrated community case management at scale. Copyright © 2012 by The American Society of Tropical Medicine and Hygiene.


Tenkir A.,Jimma University | Teshome S.,Save the Children United States
BMC Ophthalmology | Year: 2010

Background. Goltz syndrome or focal dermal hypoplasia (FDH) is an uncommon multisystem disorder. Herein, we report a typical case of FDH with unilateral ocular, cutaneous and skeletal features. Case Presentation. a 4-year-old girl presented with microphthalmos and iris coloboma of the left eye, facial asymmetry, and a low-set protruding ear. Cutaneous changes included hypopigmented atrophic macules on the left side of the face, chest, abdomen and limbs. Characteristic lobster claw deformity of left hand and oligodactyly and syndactyly of left foot were present. Conclusions. FDH usually affects both sides of the body. This case represents the unusual unilateral manifestation of the syndrome. © 2010 Tenkir and Teshome; licensee BioMed Central Ltd.


Thapa S.,Save the Children United States | Thapa S.,World Health Organization
Global Public Health | Year: 2010

Nepal's national vitamin A programme, that started in a few districts in 1993, was incrementally and systematically expanded to cover the targeted population - children ages 6-59 months - in all the 75 districts of the country over a decade. By 2001, four-fifths of the eligible children had received vitamin A supplementation. Based on data from the 2006 Nepal Demographic and Health Survey, this paper analyses the extent to which the levels and patterns of the programme's coverage have continued to sustain over time, and identifies the children who are still missed by the programme. The overall coverage in 2006 increased to 87.5% nationally, ranging between 80 and 93% (except for two population subgroups), indicating that the programme has been effective in eliminating large inequities in access and utilisation of programme services. The children still missed by the programme (12.5%) have been found to disproportionately represent the poorest of the poor families, mothers with no education, and residents of rural areas and certain ecological and development subregions. The programme is most likely to sustain its achievements thus far, assuming that programme support ingredients and inputs are not interrupted or affected adversely in any way. Emerging policy and programmatic issues are discussed. © 2010 Taylor & Francis.


Sarriot E.G.,ICF International | Swedberg E.A.,Save the Children United States | Ricca J.G.,ICF International
Health Policy and Planning | Year: 2011

The pursuit of the Millennium Development Goals and advancing the 'global health agenda' demand the achievement of health impact at scale through efficient investments. We have previously offered that sustainability-a necessary condition for successful expansion of programmes-can be addressed in practical terms. Based on benchmarks from actual child survival projects, we assess the expected impact of translating pro-sustainability choices into investment strategies.We review the experience of Save the Children US in Guinea in terms of investment, approach to sustainability and impact. It offers three benchmarks for impact: Entry project (21 lives saved of children under age five per US$100000), Expansion project (37 LS/US$100k), and Continuation project (100 LS/US$100k).Extrapolating this experience, we model the impact of a traditional investment scenario against a pro-sustainability scenario and compare the deaths averted per dollar spent over five project cycles.The impact per dollar spent on a pro-sustainability strategy is 3.4 times that of a traditional one over the long run (range from 2.2 to 5.7 times in a sensitivity analysis).This large efficiency differential between two investment approaches offers a testable hypothesis for large-scale/long-term studies. The 'bang for the buck' of health programmes could be greatly increased by following a pro-sustainability investment strategy. © 2010 The Author.

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