Every Newborn Action Plan (ENAP)

Worldwide each year, there are an estimated 2.5 million newborn deaths, 2.6 million stillbirths, and over 300,000 maternal deaths, with the majority in sub-Saharan Africa and Asia. The Every Newborn Action Plan (ENAP), including an ambitious Measurement Improvement Roadmap was launched in 2014 with a World Health Assembly Resolution endorsed by all United Nations member states and >80 development partners. ENAP aims to support countries to achieve a target of less than 12 newborn deaths per 1000 livebirths and less than 12 stillbirths per 1000 total births by 2030. However, a critical lack of data in many high-burden countries makes it very difficult to track progress. Many newborn deaths and stillbirths are not registered, not counted, and lack details on birthweight, cause of death, and avoidable factors that could have prevented their deaths. As a result, it is challenging to hold governments to account for their commitments, to target investment, or to prioritise resource use.

The Newborn and Early Child Development Team are part of the Every Woman, Every Child global movement to mobilise and intensify action by governments, multi-lateral organisations, the private sector, and civil society around the world to address the major health challenges facing women, newborns, children and adolescents. The movement puts into action the Global Strategy for Women’s, Children’s and Adolescents’ Health, which includes ENAP targets for newborn mortality, and stillbirths. The work presented below has a specific focus on the ENAP Measurement Improvement Roadmap, which aims to promote global use of accurate timely data by 2020, in order to support countries in reaching their 2030 Sustainable Development Goal targets.

This work is funded by the Children’s Investment Fund Foundation (CIFF) and builds on previous investments by Bill & Melinda Gates Foundation, USAID, WHO and CIFF.

Every Newborn Action Plan metrics streams:

  1. Every Newborn-Birth Indicators Research Tracking in Hospitals (EN-BIRTH)

Team contacts: Joy Lawn, LouiseTina Day, Harriet Ruysen

As facility births increase globally, currently >80% of all births, routine Health Management Information Systems (HMIS) data have more potential to track coverage of evidence-based high-impact interventions. This study aims to test validity of selected newborn and maternal health care intervention indicators (coverage/quality aspects and/or safety) in facilities, and aims to increase the evidence base to inform selection and use of these indicators in national HMIS (particularly DHIS2) and global tracking. This study also seeks to address current evidence gaps for routine facility data use for both HMIS and population surveys. Both the Every Newborn and Ending Preventable Maternal Mortality strategies prioritise quality of care at birth, and metrics need to advance from health service contact alone to content of care, including coverage of evidence-based high impact interventions.

EN-BIRTH is the largest known study to observe >20 000 facility births in five sites in Tanzania, Bangladesh and Nepal. Additional observation for small and sick newborns include >900 newborns treated for infection and >800 babies in Kangaroo mother care. Validity is tested by comparison against gold standard observation for both facility routine register extracted data and a survey of maternal report at exit. The intervention indicators of focus include uterotonic for third stage of labour, immediate breastfeeding, neonatal bag and mask ventilation and Kangaroo mother care. Neonatal infection management will be validated against verification from inpatient records. This study also explores barriers and enablers to routine recording in high-burden low- and middle-income settings.

Publications/resources:

  1. Every Newborn-INDEPTH (EN-INDEPTH)

Team contacts: Joy Lawn, Hannah Blencowe

Population-based household surveys, notably Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys, are major sources of population-level data on child mortality in countries with weaker civil registration and vital statistics systems, where over two-thirds of global child deaths occur. To estimate neonatal/child mortality and pregnancy outcomes (stillbirths, miscarriages, birthweight, gestational age) the most common direct methods are: (1) the standard DHS-7 with Full Birth History with additional questions on pregnancy losses in the past 5 years (FBH+) or (2) a Full Pregnancy History (FPH). No direct comparison of these two methods has been undertaken, although descriptive analyses suggest that the FBH+ may underestimate mortality rates particularly for stillbirths.

The EN-INDEPTH project aims to undertake a randomised comparison of FBH+ and FPH to measure pregnancy outcomes in a household survey in five selected INDEPTH Network sites in: Bandim in Guinea-Bissau, Dabat in Ethiopia, Iganga-Mayuge in Uganda, Kintampo in Ghana, and Matlab in Bangladesh. The survey will reach >68,000 pregnancies, and will capture birthweight, gestational age, birth and death certification, termination of pregnancy, stillbirth, and fertility intendedness for women who have experienced a livebirth, stillbirth and/or neonatal death since 1st January 2012. A mixed methods assessment of barriers and enablers to reporting of pregnancy and adverse pregnancy outcomes will be undertaken, and data collected on timing of survey completion will be analysed.

Publications/resources:

  1. Every Newborn-Simplified Measurement Integrating Longitudinal Neurodevelopment & Growth (EN-SMILING)

Team contacts: Joy Lawn, Jaya Chandna, Gornmigar Winijkul

The link between newborn health and early child development (ECD) is crucial. Birth is a time of great risk and opportunity for death, disability and child development. Nearly 10% of Disability Adjusted Life Years (DALYs) globally are due to newborn death and impairment after newborn complications. Less is known about developmental consequences for newborns who had basic interventions such as basic resuscitation, KMC, and inpatient treatment for presumed neonatal infection. Prevention of impairment, early detection and intervention for developmental delays can transform individual and population potential; simplification and integration of routine measurement within newborn and child health care could lead to earlier intervention and school readiness.

The EN-SMILING project is an extension to the EN-BIRTH project outlined above. The project is a cohort study following up infants recruited from the EN-BIRTH study in Tanzania, Nepal and Bangladesh from birth to the age of 5 years. Using a simplified ECD measurement approach, the children will be assessed at 6, 9, 12, 18, 24, 36 and 60 months. Through comparison with ‘gold standard’ comprehensive child development assessments, performance of the simplified ECD measurement approach will be evaluated. A mixed methods assessment of feasibility and acceptability will inform the possibility of use of this method at scale.

Publications/resources: The study protocol will be published in 2020.

  1. Small & Sick Newborn service readiness

Team contacts: Joy Lawn, Hannah Blencowe, Sarah Moxon

Millions of babies are born small and sick and require inpatient hospital care with skilled health workers and appropriate equipment. The highest risk is for the 15 million born preterm (<37 weeks gestation) and especially for those born before 32 weeks who may stay in hospital for several weeks. For years, obstetric care has had clear definitions for Basic and Comprehensive Obstetric care, enabling assessments of a single facility, or a whole region or country to be compared. This helps improve programmes, advocate for staff, equipment, and link to accountability. Similarly, care for newborns (especially small and sick) must be provided at different health system levels and with varying complexity both for staff (especially midwives and neonatal nurses) and for equipment. This stream of the ENAP metrics work is focused on defining the service readiness inputs and levels of care required to measure delivery of quality inpatient care for newborns including small and sick, and working towards institutionalising these measures in global metrics systems.

Publications/resources: There are multiple publications from this work. Key publications listed below:

 

 

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