Improving Newborn Infant Health in Developing Countries Downloaded from www.worldscientific.com by 37.44.207.191 on 01/29/17. For personal use only.

Improving Newborn

Infant Health in

Developing Countries

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Improving Newborn Infant Health in Developing Countries

Editors

Anthony Costello University College, London

Dharma Manandhar Nepal Medical College, Kathmandu

Imperial College Press

Published by Imperial College Press 57 Shelton Street Covent Garden London WC2H 9HE Distributed by Improving Newborn Infant Health in Developing Countries Downloaded from www.worldscientific.com by 37.44.207.191 on 01/29/17. For personal use only.

World Scientific Publishing Co. Pte. Ltd. P O Box 128, Farrer Road, Singapore 912805 USA office: Suite IB, 1060 Main Street, River Edge, NJ 07661 UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE

Library of Congress CaUloging-ln-PublicatJon Data Improving newborn infant health in developing countries / editors, Anthony Costello, Dharma Manandhar. p. cm. Includes bibliographical references (p. ). ISBN 1-86094-097-8 1. Infants (Newborn) — Health and hygiene — Developing countries. 2. Infants (Newborn) - Diseases - Developing countries — Prevention 3. Medical care - Developing countries. I. Costello, Anthony. II. Manandhar, Dharma. RJ60.D44I47 1999 362.1'98920r091724-dc21 99-30272 CIP

British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library.

Copyright © 2000 by Imperial College Press All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system now known or to be invented, without written permission from the Publisher.

For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy is not required from the publisher.

Printed in Singapore by Uto-Print

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This book is dedicated to the memory of Dr Shameem Ahmed, an out­ standing paediatrician, scientist and mother, who died tragically in an airline accident in Kathmandu, September 1999.

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FOREWORD

As we approach the millenium it is useful to take stock of the progress and problems within the health sectors of developing countries. For many, significant progress has been achieved in promoting immunisation and other preventive programmes; in reducing childhood mortality; and in raising life expectancy for adults. But major problems remain. One of the highest health priorities for international agencies, especially those with a primary focus on poverty alleviation, is to help countries achieve further declines in infant mortality, and to improve reproductive health. The British Government Department for International Development which supported the Kathmandu workshop which stimulated the production of this book is committed to helping countries reduce their infant and child mortality rates by two-thirds by the year 2015. They are committed also to help reduce the huge risks to millions of women from a pregnancy-related illness or death. In some countries, women may face a one in 25 lifetime risk of a maternal death — up to 100 times greater than women in industrialised countries. Safer Motherhood Programmes (of which newborn care is an integral part) are therefore one of the highest investment priorities, but such programmes are often difficult to implement and monitor. It is challenging enough to ensure good emergency obstetric care services at district level linked to an active, effective and mother-friendly primary care referral system. But further problems are faced in reforming health sector manage­ ment, improving the socio-economic and educational status of women, changing cultural practices which may limit demand for services when they are needed, and in demonstrating the success of Safer Motherhood Programmes in terms of improved health outcomes. A crucial component is in ensuring that birth does not end in a neonatal death. Such an outcome is still common, represents a tragedy for the family, VII

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viii Foreword

and exposes the mother to the additional risk of another pregnancy in the near future. Essential newborn care is therefore an integral component of a Safer Motherhood programme, and neonatal outcome one important indicator of success. Anthony Costello and Dharma Manandhar have collated an extremely important set of papers, mostly from authors working in the south, which provide evidence, experience and ideas for improving newborn care within the framework of Safer Motherhood. The book should be essential reading for professionals working in this area, and I hope many newborn infants will benefit as a result.

Andrew Tomkins Director Centre for International Child Health Institute of Child Health University College, London

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INTRODUCTION

This book arose from a workshop held in Kathmandu in the summer of 1997. We are grateful to the British Government Department for International Development for financial support for the Kathmandu workshop, without which the book could not have been written. Participants were policymakers and professionals, mostly living and working in developing countries, with expertise in maternal and infant care, or in implementing Safer Motherhood (SMP) or essential newborn care programmes. The objectives of the book and the workshop were: • to review the current status of the newborn infant in the developing world, and especially South Asia where most perinatal deaths occur; • to consider the evidence-base for interventions included in essential and preventive neonatal care programmes in low income countries; • to discuss ways of improving perinatal service delivery; and • to identify priorities for future action and research. Although the book focuses on the newborn infant, a heavy emphasis, especially in the first two sections, has been placed on maternal health, a major determinant of neonatal survival. The book should be of interest to development workers, public health and tropical medicine specialists, as well as to district health staff, obstetricians and paediatricians. Although most contributors' experience was in Asia, the book should be of interest and relevance to all developing countries, especially in Africa. However the book does not address in detail the problems of malaria and human immunodeficiency virus (HIV) in pregnancy, and a number of important studies relevant to newborn care have been published since the Kathmandu workshop. Therefore this introduction summarises these issues below, and points the reader to valuable references. IX

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x Introduction

Until recently, the care of newborn infants in developing countries was low on the list of priorities for policymakers or health professionals. Most mothers in the developing world deliver at home, so newborn infants are 'out of sight, and out of mind.' Further, the images of neonatal care from the industrialised world are of extremely premature infants being rescued by expensive and heroic intensive care, a far cry from the economic realities of health services in the developing world. But times are changing and newborn care has moved up the policymaker's list of priorities. Firstly, the last two decades have seen significant reductions in infant mortality largely because post-neonatal causes of deadi — diarrhoea, pneumonia, vaccine-preventable infections, malaria — are gradually being tackled. More than 70% of infant deaths now occur in the neonatal period, so further reductions in infant mortality will depend on improvements in neonatal care. Secondly, SMP programmes are receiving welcomed attention and investment, and essential newborn care is an integral part of their success. After all, a pregnancy requires both a healthy mother and a healthy infant to be regarded as a success; and newborn infant health outcomes are a valuable proxy measure to monitor SMP progress. Thirdly, the message is slowly sinking in that essential newborn care is potentially a highly cost effective intervention. Simple resuscitation, warmth, early breastfeeding, hygiene, love and the recognition of neonatal illness do not require expensive ventilators, incubators or highly trained staff, but may be incorporated at low cost into existing primary and secondary care programmes. Some of the evidence and experience reviewed by the contributors is difficult to access, drawn as it is from national databases, or 'fugitive documents' from international agencies or non-government organisations. Therefore reference is often made to articles and reports which do not appear in international peer-reviewed journals. The reader must obviously be circumspect in judging the merits of this 'evidence', but we feel it is important to give it the light of day. Readers may also spot discrepancies in reported national statistics e.g. for mortality rates, in different chapters. Sources such as the World Bank, UNDP, UNICEF or national governments, often vary in their reporting of national statistics, as these figures are usually based on estimates derived from different census or national survey data.

Introduction xi

Since the Kathmandu workshop in 1997, several important papers on topics relevant to neonatal health in developing countries have been published.

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Preterm Birth Avoiding preterm birth would prevent many neonatal deaths. The role of infection in the aetiology of preterm birth has been of great interest, but remains unclear.12 Abnormal vaginal colonisation could predispose — via induction of cytokines such as TNFa, IL-lb, IL-6, IL-8 — to a prostaglandin driven premature onset of labour, and there is observational evidence for higher risk associated with bacterial vaginosis.3 This association has not been uniformly supported.4,5 Trials of screening and treatment have also had variable results6,7 and meta-analyses have failed to reach firm conclusions.8 Antibiotic treatment of asymptomatic bacteriuria, on the other hand, appears to be of value in preventing the onset of preterm labour.9,10 It also prolongs gestation in cases of premature rupture of membranes," although not if membranes are intact:12 there are issues around the arrest of a process that has already been intitiated, but these will hopefully be addressed in the large ORACLE trial. Wawer and colleagues have conducted a randomised, controlled, community-based trial of intensive sexually transmitted diseases (STD) control, via home-based mass antibiotic treatment, in Rakai district, Uganda. They showed, surprisingly, no effect of the STD intervention on the incidence of HIV-1 infection, contradicting earlier work in Tanzania, but significant effects on the prevalence of bacterial vaginosis and other STDs which might reduce preterm delivery, and a reduction in intrauterine growth retardation.13

HTV and Mother to Child Transmission (MTCT) Whether HIV contributes to neonatal mortality is still unclear. A recent meta-analysis by Brocklehurst14 concluded that "There appears to be an association, though not strong, between maternal HIV and abnormal perinatal outcome." However many of the studies reviewed had problems with observer bias, losses to follow-up, publication bias, and lack of matching for other

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xii Introduction

confounders. Coovadia and Rollins have recently reviewed the complexities of the HIV epidemic for maternal health and the risks of mother to child transmission (MTCT).15 Up to one-third of HIV positive mothers will transmit the virus to their infant in the perinatal period. The joint American-French study, ACTG 076, which employed zidovudine (AZT) given from 14 weeks of pregnancy to HIV infected women who subsequently avoided breastfeeding, clearly showed that MTCT was reduced by two-thirds, but the intervention is unaffordable for developing countries.16 In 1998, results were released of a trial in Thailand, which appeared to be more suited for developing countries. A short course of AZT given orally during the last four weeks of pregnancy, together with oral doses during labour, to nonbreastfeeding women, reduced MTCT by 51%, 95% confidence interval 1571%.17 The more recent and unfinished PETRA studies in southern Africa suggest a similar reduction can be achieved by treatment starting at delivery and continued during the first postnatal week. Experience with the cheaper and more practical option of vaginal antiseptic douches at delivery to reduce MTCT have not proved efficacious.18 Years of successful work to promote breastfeeding and reduce the promotion of breastmilk substitutes are threatened by the risk of transmission of HIV through breastmilk.19 Yet most babies are infected in utero or during childbirth and not through breastmilk. It seems also from a study in Durban, South Africa that exclusive breastfeeding has a reduced risk of MTCT compared with supplementary feeding with breastmilk substitutes.20 Nonetheless, policymakers in areas where HIV prevalence is high face difficult decisions in designing appropriate recommendations for infant feeding if mothers know their HIV status. Malaria Control in Pregnancy and the Perinatal Period Malaria prophylaxis in pregnancy, and early treatment of congenital infection, is an important and much neglected intervention in many countries with high prevalence.21 45 million women live in malarious areas, 23 million in sub-Saharan Africa. Prevalence rates of affected pregnant women may be higher than 75%, especially in primigravidae. The association between malaria

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Introduction xiii

infection and intrauterine growth retardation is strong, but effects in the neonatal period depend on the level of malaria transmission.22 If transmission is high, acquired immunity is also high, so there tends to be placental sequestration and mainly asymptomatic infection. When transmission is low, there is low immunity and hence more acutely ill mothers and congenital malaria cases are reported. The most important issues for district health staff relate to the promotion of bednet usage by mothers, the use of an effective drug regime for chemoprophylaxis, and how often drug treatment is necessary given the difficulties with compliance. Chemoprophylaxis has been undermined by chloroquine resistance. Drug efficacy studies indicate that pyrimethamine/ sulphadoxine (PSD) is now the best first choice, with quinine for complicated malaria, and mefloquine or artemisinin in areas with high resistance to PSD, although there is little data on the use of artemisinin compounds in pregnancy. Despite this evidence, only four countries in Africa (Kenya, Malawi, Botswana and South Africa) have made a change from chloroquine as national policy for chemoprophylaxis. A recent review by a group of the world's leading malaria experts suggests that widespread resistance to chloroquine, and increasing resistance to PSD, means a health calamity looms in the next few years. To avert disaster they recommend that single drug treatment be replaced by combination therapy in the same way as has happened for tuberculosis and AIDS. Artemisinin should be combined with chloroquine and PSD for treatment to reduce the development of resistance.23 The harsh reality remains that even if health workers recommend antimalarials in pregnancy, few women would take them. As such, one or two opportunistic doses at antenatal visits may be a more realistic practice, with useful effect, than to expect compliance with a weekly regime.22

Nutritional Interventions In the 1960's and 70's, the effect of food supplementation on neonatal outcomes was studied, but most groups reported relatively small effects on birth weight and perinatal mortality. The cost effectiveness of food supplementation was questioned because of the expense and leakage of

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xiv Introduction

supplements. Cultural taboos about having a big baby may also encourage mothers to "eat down" and deliberately reduce calorie intake.24 Low birth weight is also determined by many factors prior to conception.25 For these reasons food supplementation programmes in pregnancy have been largely discredited, and not introduced on a large scale. A recent study from the Gambia has reopened the debate. Ceesay et al. gave a large supplement (900kcals per day) made up of locally prepared high energy biscuits.26 Using a randomised controlled study design they showed a 136 g increase in birth weight, a small increase (3 mm) in head circumference, a 35% reduction in the low birth weight (LBW) rate, and big effects on stillbirths (55% reduction), perinatal (49% reduction) and neonatal mortality (40%). Recent studies of different interventions to treat anaemia on pregnancy outcomes have demonstrated the beneficial effects of antihelminthic treatment with mebendazole in Sri Lanka,27 100 mg per day of supplemental iron on the iron status of both mothers and newborns in Niger,28 and intermittent sulphadoxine-pyrimethamine to prevent severe anaemia (protective efficacy 39 per cent) in Kenya.29 Presumably these interventions will have variable but beneficial effects on perinatal and neonatal mortality. Many studies have evaluated micronutrient supplementation on perinatal and neonatal outcomes. An important recent trial is the study by Fawzi and colleagues in Tanzania who screened 14,000 women for HIV, identifying 1806 as HIV positive.30 All women received iron and folate and weekly chloroquine, and HIV positive women were randomised to receive either multivitamins or vitamin A in a four arm factorial design. They showed no effect with vitamin A supplements on birthweight or neonatal mortality, a finding confirmed by the recent vitamin A supplementation trial in Nepal,31 but with multivitamin supplements there was nearly a 40% reduction in stillbirths and foetal deaths and also a big reduction in LBW prevalence and IUGR. Nonetheless, the problem with all pregnancy food and micronutrient supplementation research remains: almost no interventions have been translated into national policy or large scale programmes. The effects of various micronutrients are also inter-related. Supplementing iron and folic acid without zinc may not be useful, and zinc administration without copper may lead to hypercholesterolaemia or immunodeficiency. So future

Introduction xv

interventions should be balanced packages of micronutrients, rather than single nutrients.

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Interventions During Delivery There are many proven, low cost interventions during delivery that are hardly used in developing countries: magnesium sulphate for eclampsia, tocolytic drugs to prevent preterm labour, and antenatal steroids to reduce neonatal hyaline membrane disease. Partography has long been demonstrated to be an efficacious method for the detection of delay in labour, with positive benefits for both mother and baby.32 An important area for operational research is why the partogram is so rarely used in maternity hospitals, and how organisational change might encourage obstetricians and midwives to make partography a routine practice. It is not enough for researchers to prove the value of interventions; they need active promotion through continuing medical education programmes. A recent study in Zimbabwe has also shown the potential value of amnioinfusion for meconium stained amniotic fluid (MSAF) with a 66% reduction in perinatal deaths.33 Metaanalysis of available studies on the utility of amnioinfusion in the management of MSAF is less convincing so the procedure is not yet uniformly recommended. Thermal Protection Two important issues have arisen in the most recent literature. Firstly, the Kangaroo Care Method (KCM), introduced by Rey and Gomez in Colombia in the 1970s as a means of managing LBW and premature infants, has been shown to improve survival, reduce infection and improve neonatal growth patterns.34-38 In Asia, KCM lacks widespread cultural acceptance, but many centres are implementing partial KCM, and its widespread adoption is a challenge for the next few years. Secondly, in industrialised countries, there is current interest in the role of thermal protection (brain cooling methods) for the treatment of infants with neonatal encephalopathy.39 The results of trials will have implications for

xvi Introduction

developing countries because the methods involved are relatively simple and affordable.

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Breastfeeding Promotion Talukder and Ahmed in their chapters discuss ways to promote exclusive breastfeeding — support and counselling for mothers in hospital and through home visits can be highly effective. Morrow and colleagues have recently reported a randomised controlled trial of home-based support for mothers in Mexico, where exclusivity of breastfeeding is the exception, and report dramatic improvements from 12% exclusive breastfeeding at three months in control mothers to 67% in those visited repeatedly at home.40 A recent systematic review estimated that in a low income country with a post-neonatal mortality rate of 90 per 1,000 children, the excess number of post-neonatal deaths per million births due to artificial feeding(AF) would range from 11,290 (13%) to 112,900 (59%) depending on a prevalence of AF at six months of age ranging from 10% to 100%.41 Sadly promotion of breastmilk substitutes by formula milk companies in contravention of the International Code of Marketing of Breastmilk Substitutes in 1981, (which was reaffirmed by all member states at the 1996 World Health Assembly, and endorsed by manufacturers' representatives) continues. Now an Interagency Group on Breastfeeding Monitoring has conducted a large, systematic and random survey of mothers and health professionals to quantify the level of Code violations in four countries: Bangladesh, Poland, Thailand and South Africa.42,43 The paper provides compelling evidence that Code violations remain widespread.

Neonatal Sepsis and the Study by Bang and Colleagues in Maharashtra An important study Dr Abhay Bang and colleagues in India will soon be published and readers are strongly advised to study this exciting data in more detail. They have conducted a field trial of home based newborn care management and control of sepsis in an extremely poor district of Maharashtra

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Introduction xvii

state where 95% of births occur at home. Bang's data was presented in outline at a conference on global perinatal mortality at Johns Hopkins School of Public Health in May 1999. He found at baseline that 48% of all newborn infants had "high risk morbidities", of which over half was ascribed to sepsis. Village health workers were trained to visit homes, to identify warning signs in newborn infants and to manage cases using gentamicin and penicillin given intramuscularly (using insulin syringes) and cotrimoxazole syrup. Before training there was 17% case fatality, which fell to 2.8% after training. By the third year of the intervention neonatal mortality rate was 26 in intervention and 60 in control areas, a 62% fall. Bang estimated the cost to be $182 per village, or $1.6 per life year saved, better value than almost any other primary care intervention! Interventions to reduce neonatal mortality are at the cutting edge of child survival programmes. There are many efficacious interventions available but a major problem exists with "getting research into policy and practice". There is always a trade off between impact and sustainability: it is better to have a small effect on a large population than a large effect on a small population. It is therefore essential to evaluate sustainable packages of care, or health promotion interventions, discussed in Bolam's chapter, which might be scaled up quickly even in severely resource deficient countries.44 We have many effective interventions for sustainable neonatal care, and low cost approaches can achieve dramatic results. Political commitment and organisational changes are needed if research is to be translated into policy and practice. Acknowledgements The authors are grateful to Dr David Osrin and Professor Meharban Singh for their help when preparing this introduction and research update. References 1. Wawer MJ, Sewankambo NK, Serwadda D, Quinn TC, Paxton LA, Kiwanuka N, Wabwire Mangen F, Li C, Lutalo T; Nalugoda F, Gaydos CA, Moulton LH,

xviii Introduction

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2.

3. 4.

5.

6.

7. 8.

9.

10.

11. 12.

Meehan MO, Ahmed S and Gray RH, "Control of sexually transmitted diseases for AIDS prevention in Uganda: a randomised community trial," Rakai Project Study Group, Lancet 353(9152) (1999): 525-535. Brocklehurst P and French R, "The association between maternal HIV infection and perinatal outcome: a systematic review of the literature and meta-analysis," British Journal of Obstetrics and Gynaecology 105 (1998): 836-848. Coovadia HM and Rollins N, "Current controversies in the perinatal transmission of HIV in developing countries," Seminars in Neonatology (1999, in press). Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O'Sullivan MJ, Van Dyke R, Bey M, Shearer W and Jacobson RL, "Reduction of maternalinfant transmission of human immunodeficiency virus type I with zidovudine treatment," Paediatric AIDS Clinical Trials Group Protocol 076 Study Group, New England Journal of Medicine 331 (1994): 1173-1180. Vuthipongse P, Bhadrakom C and Chaisilwattana P, "Administration of zidovudine during late pregnancy and delivery to prevent perinatal HIV transmission — Thailand," Morbidity and Mortality Weekly Report 47 (1998): 151-154. Biggar RJ, Miotti PG, Taha TE, Mtimavalye L, Broadhead R, Jutesen A, Yellu F, Liomba G, Miley W, Waters D, Chiphangwi JD and Goedert JJ, "Perinatal intervention trial in Africa: effect of a birth canal cleaning intervention to prevent HIV transmission," Lancet 347 (1996): 1647-1650. Latham MC and Greiner T, "Breastfeeding versus formula feeding in HIV infection," Lancet 352 (1988): 737. Coutsoudis A, Pillay P, Spooner E, Kuch L and Coovadia HM, "Influence of infant feeding pattermns on early mother to child transmission of HIV-1 in Durban, South Africa," Lancet (in press). Foster SO, "Malaria in the pregnant African woman: epidemiology, practice, research and policy," American Journal of Tropical Medicine and Hygiene 55(1) (1996): 1. Steketee RW, Wirima JJ, Slutsker L, Heymann DL and Breman JG, "The problem of malaria and malaria control in pregnancy in sub-Saharan Africa," American Journal of Tropical Medicine and Hygiene 55(1) (1996): 2-7. White NJ, Nosten F, Looareesuwan S, Watkins WM, Marsh K and Snow RW, "Averting a malaria disaster," Lancet 353 (1999): 1965-1967. Osrin D and Costello A, "What can be done about intrauterine growth retardation?" Seminars in Neonatology (1999, in press).

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Introduction xix 13. Kramer MS, "Determinants of low birth weight: methodological assessment and meta-analysis," Bulletin of the World Health Organization 65(5) (1987): 663-737. 14. Ceesay SM, Prentice AM, Cole TJ, Foord F, Weaver LT, Poskitt EM and Whitehead RG, "Effects on birth weight and perinatal mortality of maternal dietary supplements in rural Gambia: 5 year randomised controlled trial," published erratum appears in British Medical Journal 315(7116) (1997): 1141. 15. Atukorala TM, de Silva LD, Dechering WH, Dassenaeike TS and Perera RS, "Evaluation of effectiveness of iron-folate supplementation and anthelminthic therapy against anemia in pregnancy, a study in the plantation sector of Sri Lanka," American Journal of Clinical Nutrition 60(2) (1994): 286-292. 16. Preziosi P, Prual A, Galan P, Daouda H, Boureima H and Hercberg S, "Effect of iron supplementation on the iron status of pregnant women: consequences for newborns," American Journal of Clinical Nutrition 68(2) (1998): 404-405; American Journal of Clinical Nutrition 66(5) (1997): 1178-1182. 17. Shulman CE, Dorman EK, Cutts F, Kawuondo K, Bulmer JN, Peshu N and Marsh K, "Intermittent sulphadoxine-pyrimethamine to prevent severe anaemia secondary to malaria in pregnancy: a randomised placebo-controlled trial," Lancet 353(9153) (1999): 632-636. 18. Fawzi W, Msamanga G, Spiegelman D, Urassa E, McGrath N and Mwakagile D, "Randomised trial of effects of vitamin supplements on pregnancy outcomes and T cell counts in HIV-1-infected women in Tanzania," Lancet 351 (1998): 1477-1482. 19. West KP, Jr, Katz J, Khatry SK, LeClerq SC, Pradhan EK, Shrestha SR, Connor PB, Dali SM, Christian P, Pokhrel RP and Sommer A, "Double blind, cluster randomised trial of low dose supplementation with vitamin A or carotene on mortality related to pregnancy in Nepal," British Medical Journal 318 (1999): 570-575. 20. World Health Organization partograph in management of labour. World Health Organization Maternal Health and Safe Motherhood Programme, Lancet 343(8910) (1994): 1399-1404. 21. Mahomed K, Mulambo T, Woelk G, Hofmeyr GJ and Gulmezoglu AM, "The Collaborative Randomised Amnioinfusion for Meconium Project (CRAMP): 2. Zimbabwe," British Journal of Obstetrics Gynaecology 105(3) (1998): 309-313. 22. Christensson K, Bhat GJ, Eriksson B, Shilalukey Ngoma MP and Sterky G, "The effect of routine hospital care on the health of hypothermic newborn infants in Zambia," Journal of Tropical Pediatrics 41(4) (1995): 210-214.

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xx Introduction 23. Christensson K, Bhat GJ, Amadi BC, Eriksson B and Hojer B, "Randomised study of skin-to-skin versus incubator care for rewarming low-risk hypothermic neonates," Lancet 352(9134) (1998): 1115. 24. Cattaneo A, Davanzo R, Uxa F and Tamburlini G, "Recommendations for the implementation of Kangaroo Mother Care for low birth weight infants," International Network on Kangaroo Mother Care, Acta Paediatrica 87(4) (1998): 440-445. 25. Kambarami RA, Chidede O and Kowo DT, "Kangaroo care versus incubator care in the management of well preterm infants: a pilot study," Annals of Tropical Paediatrics 18(2) (1998): 81-86. 26. Tessier R, Cristo M, Velez S, Giron M, de Calume ZF, Ruiz Palaez JG, Charpak Y and Charpak N, "Kangaroo mother care and the bonding hypothesis," Pediatrics 102(2) (1998): 17. 27. Edwards AD, Wyatt JS and Thoresen M, 'Treatment of hypoxic-ischaemic brain damage by moderate hypothermia," Archives of Disease in Childhood 78 (1998): F85-F91. 28. Morrow AL, Lourdes Guerrero M, Shults J, Calva JJ, Lutter C, Bravo J, Ruiz-Palacios G, Morrow RC and Butterfoss FD, "Efficacy of home-based peer counselling to promote exclusive breastfeeding," Lancet 353 (1999): 1226-1231. 29. Golding J, Emmett P and Rogers IS, "Breastfeeding and infant mortality," Early Human Development 49 Suppl (1997): S143-S155. 30. Taylor A, "Violations of the international code of marketing of breast milk substitutes: prevalence in four countries," British Medical Journal 316 (1998): 1117-1122. 31. Costello AM de L and Sachdev HPS, "Protecting breastfeeding from breastmilk substitutes," British Medical Journal 316 (1998): 1103-1104. 32. Bolam D, Manandhar S, Shrestha P, Malla K, Ellis M and Costello AM de L, "The effects of postnatal health education for mothers on infant care and family planning practices in Nepal: a randomised, controlled trial," British Medical Journal 7134 (1988): 805-810.

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CONTENTS Foreword

vii

Introduction

ix

List of Contributors

xxvii

Section 1: Current Status of Newborn Infants and Perinatal Health in South Asia Chapter 1

Chapter 2

Current State of the Health of Newborn Infants in Developing Countries Anthony Costello and Dharma Manandhar Recent Trends in Perinatal Health in South Asia 2.1 Bangladesh NazmunNahar 2.2 India Santosh K. Bhargava 2.3 Nepal Dharma Manandhar 2.4 Pakistan Shakila Zaman 2.5 Sri Lanka Ananda Wijekoon

Section 2: Social, Economic and Cultural Aspects of Motherhood in South Asia Chapter 3

Social and Developmental Issues Affecting the Perinatal Health of Mothers and Their Infants Hilary Standing and Anthony Costello xxi

1

3 15 17 29 49 57 69 77

79

xxii

Contents

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Chapter 4

Epidemiological Trends in Nutritional Status of Children and Women in India Harshpal Sachdev

Commentary Maternal Nutrition and Health of the Newborn Ramesh K. Adhikari Chapter 5

99 129

Women's Work and Maternal-Child Health: Anthropological Views on Intervention Catherine Panter-Brick

135

Perinatal Mortality in Nepal: Implications for Behaviour Modification Shyam Thapa

157

Traditional and Cultural Aspects of Neonatal Care in Developing Countries ShashiN.Vani

169

Commentary Traditional Beliefs and Practices in Newborn Care in Nepal Munu Thapa

181

Section 3: Cost-Effective Essential Newborn Care in Poor Communities: The Evidence-Base

189

Chapter 6

Chapter 7

Chapter 8

Chapter 9 Chapter 10

Chapter 11

Effective Interventions in Pregnancy to Improve Foetal Growth Amali Lokugamage and Charles H. Rodeck

191

Hypothermia: Epidemiology and Prevention Ragnar Tunell

207

New Methods for Monitoring Neonatal Hypothermia and Cold Stress Anthony Costello

221

Birth Asphyxia in Developing Countries: Epidemiology, Sequelae and Prevention Matthew Ellis

233

Contents xxiii

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Chapter 12

Effective Resuscitation Siddarth Ramji

Commentary Effective Resuscitation: Research from Bombay on the Use of a Mouth-To-Mask Method Simin Irani Chapter 13

Chapter 14

Chapter 16

Chapter 17

Chapter 18

Chapter 19

289

The Importance of Breastfeeding and Strategies to Sustain High Breastfeeding Rates M. Q-K. Talukder

309 343

Neonatal Hypoglycaemia Anthony Costello and Deb Pal

347

Neonatal Hyperbilirubinaemia in Developing Countries Therese Hesketh

359

Low Birth Weight Newborns — The Risks in Infancy and Beyond Dipak K. Guha

367

Does Health Education Improve Newborn Care? Alison Bolam, Dominique Tillen and Anthony Costello

393

Community Based Strategies to Improve Newborn and Infant Care Practices Fehmida Jalil

409

Section 4: Improving Health Service Delivery Chapter 20

283

Effective Interventions to Reduce Neonatal Mortality and Morbidity from Perinatal Infection Zulfiqar Ahmed Bhutta

Commentary Improving Breastfeeding Support in the Community Shameem Ahmed Chapter 15

273

Special Care of Newboms at the District Hospital Dharma Manandhar

425 427

xxiv Contents

Commentary Lessons from a Neonatal Death Sajid Maqbool

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Chapter 21

Chapter 22

Chapter 23

Chapter 24 Chapter 25

Chapter 26

Current Controversies and Recommendations for the Care of High Risk Newborn Infants Meharban Singh

441

Audit — A Tool to Improve the Quality of Perinatal Care Sophie Mancey-Jones

459

Trained Traditional Birth Attendants and Essential Newborn Care in South Asia Marta J. Levitt-Dayal

479

TBA Training: Cost-Effective? Carole Present

493

What to do About Referral and Transfers of High Risk Mothers and Newborns? Daljit Singh

503

Making Perinatal Services More User-Friendly Susan F. Murray

517

Commentary Improving the User-Friendliness of District Perinatal Services Shameem Ahmed Chapter 27

435

How to Improve Information, Education and Communication for Better Newborn Care 27.1 Planning a CME Programme on Neonatal Care at the District Level O. N. Bhakoo 27.2 Effective Dissemination of Health Learning Materials Hemang Dixit 27.3 Dissemination of Health Information Matthew Ellis

531 537

537

541 545

Contents xxv

Section 5: Challenges for Future Policy Implementation and Research

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Chapter 28

Index

Challenges for Future Policy Implementation and Research Anthony Costello and Sophie Mancey-Jones

553

555 565

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LIST OF CONTRIBUTORS

Ramesh K. Adhikari Professor of Paediatrics and Child Health Institute of Medicine, Tribhuvan University Kathmandu Shameem Ahmed Health Scientist, Operations Research Project International Centre for Diarrhoeal Disease Research Bangladesh (ICDDR,B) Dhaka, Bangladesh Santosh K. Bhargava Former Professor of Paediatrics University College of Medical Sciences and Safdarjung Hospital New Delhi, India O. N. Bhakoo Professor of Paediatrics Postgraduate Institute for Medical Education and Research (PGIMER) Chandigarh, India Zulfiqar Ahmed Bhutta Professor of Child Health and Director of Neonatal Services The Aga Khan University Medical Center Karachi, Pakistan Alison Bolam Research Fellow, Institute of Child Health London, UK xxvii

xxviii

List of Contributors

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Anthony Costello Reader in International Child Health Institute of Child Health University of London, UK Hemang Dixit Professor of Paediatrics and Director of the Health Learning Materials Centre Institute of Medicine, Tribhuvan University Kathmandu, Nepal Matthew Ellis Lecturer in Paediatrics University of Bristol Dipak K. Guha Senior Consultant Neonatologist Sunderlal Jain Hospital Delhi, India Therese Hesketh Research Fellow Institute of Child Health, London Simin Irani Professor of Paediatrics Bombay, India Fehmida Jalil Professor of Social Paediatrics King Edward Medical School Lahore, Pakistan Marta J. Levitt-Dayal Country Director Centre for Development and Populations Activities (CEDPA), India

List of Contributors xxix

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Amali Lokugamage Honorary Lecturer and Specialist Registrar in Obstetrics and Gynaecology University College London Medical School London, UK Dharma Manandhar Executive Director, Mother and Infant Research Activities (MIRA) and Professor of Paediatrics, Nepal Medical College, Kathmandu Sophie Mancey-Jones Research Fellow Institute of Child Health, London UK Sajid Maqbool Professor of Pediatrics Shaikh Zayed Medical Complex Lahore Susan F. Murray Lecturer in Maternal Health Institute of Child Health London Nazmun Nahar Professor of Paediatrics Dhaka Medical College Bangladesh Deb Pal Research Fellow Institute of Child Health University College London, UK

xxx

List of Contributors

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Catherine Panter-Brick Reader in Anthropology Durham University UK Carole Presern Health Adviser Department for International Development UK Siddhartha Ramji Professor of Neonatal Medicine Maulana Azad Medical School Delhi, India Charles Rodeck Professor of Obstetrics and Gynaecology University College London Medical School London, UK Harshpal Sachdev Professor and In-charge, Division of Clinical Epidemiology Department of Paediatrics Maulana Azad Medical College New Delhi, India Daljit Singh Professor of Paediatrics Dayanand Medical College Ludhiana, India Meharban Singh Professor and Head, Department of Paediatrics WHO Collaborating Centre for Training and Research in Newborn Care All India Institute of Medical Sciences New Delhi, India

List of Contributors xxxi

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Hilary Standing Senior Lecturer in Social Anthropology University of Sussex UK M. Q-K. Talukder Professor of Paediatrics Institute of Child and Mother Health Matuail, Dhaka, Bangladesh Munu Thapa Reproductive Health and Gender Coordination Reproductive Health Project, GTZ Shyam Thapa Senior Scientist Family Health International, North Carolina At present: Technical Advisor, Family Health Division, Ministry of Health and Population Division, Ministry of Population and Environment Kathmandu, Nepal Dominique Tillen Research Fellow Institute of Child Health London, UK Ragnar Tunell Emeritus Professor of Paediatrics Stockholm, Sweden Shashi N. Vani Professor of Paediatrics Ahmedabad, Gujarat, India

xxxii

List of Contributors

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Ananda Wijekoon Consultant Neonatologist University of Peradeniya Sri Lanka Shakila Zaman Consultant in Paediatric Epidemiology King Edward Medical School Lahore, Pakistan