Neonatal Mortality Measurement – what’s new?

Joy Lawn Saving Newborn Lives / Save the Children

Outline1. Neonatal mortality rates

2. Neonatal cause of death

3. Improving neonatal mortality data in surveys

With thanks to Colin Mathers et al at WHO and to Simon Cousens in CHERG

Child mortality Neonatal mortality

Sources Vital registration, censuses, DHS, MICS, other surveys

Vital registration, censuses, DHS, (MICS), other surveys

Frequency of estimation

Every year Every 10 years?

(1996 for 1995, 2006 for 2000)

Frequency of publication (SOWC)

Every year In SOWC since 2007 but using 2000 estimates

Methods transparency

Expert review group, Increasingly transparent inputs and methods

Previously no expert review

Limited detail on methods

MICS surveys can estimate NMR but not powered to do so unless sample size is increased eg Malawi 2006

Availability of mortality estimates

• Led by WHO Dept of Information Evidence and Research, in with Child Health Epidemiology Reference Group (CHERG)

• Expected annual cycle linked to UN child mortality estimates

• Methods have had expert review and adapt from: – Previous WHO Making Pregnancy Safer methods (WHO 2006)– IHME methods (Murray et al) 2007

• Inputs include:– Vital Registration data– Survey data– Regression model based on U5MR UN country estimates for 2008

New NMR estimates for 2008

Oestergen, Mathers et al WHO – work in progress

Results to be released in World Statistics Report - May 2010Separate methods paper and detailed results in preparation

Target for MDG-4(32)

Progress to MDG 4 for child survival

Source: Graph Lawn JE et al 4 million neonatal deaths- where? When? Why? Lancet 2005. Data updated 2009 for progress until 2008 using UN data

3.59 million neonatal deaths each year around 42% of under-5 deaths

2004 2008

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2. NEONATAL CAUSE OF DEATH

country data in puts and

Invisible deaths….Global estimates of causes of death for children under the age of 5 years

Diarrhoea

20%

12%

Other 29%

HIV/AIDS

4%

Malaria

8%

Measles

5%

ARI

Malnutrition

54%

Perinatalcauses

22%

Asphyxia

Preterm

Injuries

Other

Source: WHO and UNICEF under-5 causes of death estimates 2004

Neonatal sepsis/ pneumonia

Neonatal tetanus

Congenital

Estimates of causes of neonatal death (year 2000)

Lawn et al, Lancet 2005

WHO WHR 2005Detailed methods: Lawn et al, IJE 2006

Bryce et al, Lancet 2005

Estimates of causes of neonatal death (year 2004)

Countdown report 2008 – National level estimates

New Countdown report to be released at Women Deliver and Countdown meeting June 2010

Sub-national estimates for cause of deatheg Nigeria

Neonatal tetanus nationally estimated at 8% and Northern zones at 17%

Source: Saving Newborn Lives in Nigeria. FMOH Jan 2009Estimates for 2005 by CHERG neonatal group

1. MORE data inputs Vital registration up to mid 2009 Previously 46 countries – now 72 countries Total of ~130,000 neonatal deaths (4% of all neonatal deaths)

Study datasets Revised systematic searches (>6,000 abstracts) and unpublished datasetsNow 71 datasets, 23,638 deaths China and India – huge national datasets used instead of estimates

2. MORE detail for cause of death categories

3. MORE detail by time for first week of life

Neonatal cause of death for year 2008Advancing the estimates

Source: Lawn JE, Cousens SN, Adler A, Ozi S for the CHERG neonatal group. DO NOT CITE

Results to be released in World Statistics Report May 2010Expected annual cycle – also in SOWC and Countdown

Separate methods paper and detailed results in preparation

Causes of death in the neonatal period for 193 countries (2000-2008)

Cause of death 2000 2004 2008

“Asphyxia” 0.91 (23%) 0.91 (24%) 0.84 (24%)

Congenital 0.30 ( 7%) 0.31 ( 8%) 0.33 ( 9%)

Infection Sepsis

Pneumonia

1.04 (26%) 0.94 (25%) 0.89 (25%)0.550.33

Preterm 1.12 (28%) 1.23 (33%) 1.19 (33%)

Diarrhoea 0.11 ( 3%) 0.07 ( 2%) 0.06 ( 2%)

Tetanus 0.26 ( 6%) 0.10 ( 2.7%) 0.09 ( 2.5%)

Other 0.26 ( 6%) 0.19 ( 4.9%) 0.19 ( 5.3%)

Total 4.00 million 3.75 million 3.59 million

Note not final : India and China own data yet to be added

Source: Lawn JE, Cousens SN, Adler A, Ozi S for the CHERG neonatal group. DO NOT CITE

3.2 million stillbirths.

(Stanton, Lawn et al)

Beyond survival….

?? babies with major neonatal morbidity

(birth asphyxia, preterm birth, infections, congenital, jaundice)

3.6 million

neonatal deaths

?? Children/adults with poor development or disability due to fetal/neonatal ill-health

20 million LBW

babies

Up coming work from CHERG/Global Burden of Disease- Estimates for morbidity and disability

- Also preterm birth and/or IUGR as a risk factor

3. IMPROVING NEONATAL DATA IN SURVEYS

Neonatal mortality data• Module options

• Indirect question and Brass methodology (MICS)• Birth history• Pregnancy history• Modifications (eg truncated pregnancy history)

Neonatal cause of death data• Follow up after survey with Verbal Autopsy

Survey data for neonatal mortality measurement

Mortality data for 75% of neonatal deaths is dependent on household surveysRemarkably little evaluation…

Stillbirths

Neonatal death data in DHSHeaping on certain days

Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths)

Heaping index for deaths on days 7, 14, 21 and 30/31Age heaping on day 7 may reduce the early NMR

Age heaping on day 30/31 may reduce the overall NMR

Age heaping index in 106 DHS surveys(Hill et al 2006)

Source: Hill K et al 2006, Neonatal mortality in the developing world

There seems to be regional variation – is this cultural or due to training of the interviewers?

(Maharashtra, India, Bang et al., 2002)

Prospective surveillance

NFHS II (recall)

SRS

NMR 51 32 (-38%) 29 (-43%)

Postneonatal IMR 18 12 (-33%) 20 (+14%)

Child (1-4) MR 14 15 (+ 6%) 14 (- 4%)

NHFS II – 5 year recall

SRS – ongoing data collection by local part-time enumerator with 6- monthly supervision visits

Are deaths misclassified to another day or missing especially in retrospective

surveys?

1. Neonatal mortality measurement • Annual NMR estimates likely altho process still not fully

institutionalised...• Data reliability is under-researched and concerns remain re

underestimation in DHS/MICS • Pregnancy history module would be expected to improve the

neonatal death capture and also count stillbirths

2. Neonatal cause of death• Advances in country based neonatal estimates using

programmatic cause categories• Increasing data especially for large countries (India, China)• Increasing comparability - 3 time points with consistent

methods (2000, 2004 and 2008) and now should be annual• Trends - definite reduction in neonatal tetanus and apparent

reductions in infections in some regions/countries

Conclusions

Thank you!