Figures & Tables
Figures
- FIGURE
MANDATE Model Estimates of the Number of Preterm Deaths Associated With Subconditions Impacting Preterm Mortality, Sub-Saharan Africa, 2015
Abbreviation: MANDATE, Maternal and Neonatal Directed Assessment of Technology.
Tables
- TABLE 1.
WHO Interventions and Recommendations to Improve Preterm Birth Mortality, With MANDATE Model Assumptions of Intervention Penetration, Utilization, and Efficacy in Sub-Saharan Africa, 2015
Intervention Recommendation Summary WHO Strength of Recommendation for Implementation Quality of Evidence Baseline Penetration in MANDATE Home/Clinic/Hospital, % Baseline Utilization in MANDATE Home/Clinic/Hospital, % Efficacy in MANDATE Model, % Key References Prenatal interventions for preterm Antenatal corticosteroids For women at risk of preterm birth (24–34 weeks gestation) under specific conditions Strong Moderate 0/10/50 0/5/25 RDS: 50
IVH: 42
NEC: 5416–18,28 Antibiotics for preterm labor For women with preterm prelabor rupture of membranes Strong Moderate Not included in model Postnatal care Cord care Daily CHX application to the umbilicus for newborns born at home in settings with high neonatal mortality. Clean, dry cord care for newborns born in health facilities and at home in low neonatal mortality settings. Strong Moderate 0/0/0 0/0/0 55 29–32 Care of the preterm/LBW neonate Thermal care for preterm newborns KMC for the routine care of newborns weighing ≤2,000 g at birth, and should be initiated in health care facilities as soon as the newborns are clinically stable. Strong Moderate 95/95/95 0/0/2 51 15,33 Unstable newborns weighing ≤2,000 g or stable newborns weighing ≤2,000 g who cannot be given KMC should be cared for in a thermo-neutral environment either under radiant warmers or in incubators. Strong Very low 0/0/50 0/0/30 60 34–36 Feeding LBW infants, including those with very low birth weight, should be fed mother's own milk. Strong Moderate 99/99/99 20/40/55 Sepsis: 55
LBW: 1837–39 Management: newborn resuscitation Immediate drying and additional stimulation Newly born babies who do not breathe spontaneously after thorough drying should be stimulated by rubbing the back 2–3 times before cord clamping and PPV initiation. Weak Not graded 50/85/90 50/70/85 15 40–42 PPV In newly born term or preterm (>32 weeks of gestation) babies requiring PPV, ventilation should be initiated with air. Strong Moderate 5/50/95 20/40/60 40 42–45 Oxygen therapy for preterm newborns Ventilation of preterm babies born at or before 32 weeks of gestation with oxygen therapy with 30% oxygen or air (if blended oxygen is not available). Strong Very low 0/15/60 0/50/75 RDS: 25
Asphyxia: 2546,47 Management: RDS Continuous positive airway pressure for newborns with RDS Continuous positive airway pressure therapy is recommended for the treatment of preterm newborns with RDS. Strong Low 0/2/20 0/50/70 RDS: 50
Asphyxia: 5046,47 Surfactant administration for newborns with RDS Surfactant replacement therapy is recommended for intubated and ventilated newborns with RDS. Conditional (health care facilities only with intubation, ventilator care, blood gas analysis, newborn nursing care and monitoring) Moderate 0/1/5 0/50/75 35 46,48 Management: neonatal sepsis Prophylactic antibiotics for prevention of sepsis A neonate with risk factors for infection (i.e., membranes ruptured > 18 hours before delivery, maternal fever > 38°C before delivery or during labor, or foul-smelling or purulent amniotic fluid) should be treated with the prophylactic antibiotics ampicillin and gentamicin for at least 2 days and reassessed if signs of sepsis or positive blood culture. Weak Very low Not modeled Empirical antibiotics for suspected neonatal sepsis Neonates with signs of sepsis should be treated with antibiotic treatment for at least 10 days. Strong Low 10/85/95 20/65/75 72 49,50 Management: NEC Antibiotics for treatment of NEC Young neonates with suspected NEC should be treated with intravenous or intramuscular ampicillin (or penicillin) and gentamicin as first-line antibiotic treatment for 10 days. Strong Low Not modeled Abbreviations: CHX, chlorhexidine; KMC, kangaroo mother care; IVH, intraventricular hemorrhage; LBW, low birth weight; MANDATE, Maternal and Neonatal Directed Assessment of Technology; NEC, necrotizing enterocolitis; PPV, positive pressure ventilation; RDS, respiratory distress syndrome; WHO, World Health Organization.
Assumptions Value Preterm births in sub-Saharan Africa, N 3,988,000 Delivery location in sub-Saharan Africa, % Home 50 Clinic 35 Hospital 15 Antenatal care location in sub-Saharan Africa, % Home 30 Clinic 65 Hospital 5 Preterm subconditions contributing to preterm mortality, Prevalence | Case fatality rate,a % Respiratory distress 20 | 35 Intraventricular hemorrhage 7 | 7.5 Necrotizing enterocolitis 1 | 25 Sepsis 9 | 40 Birth asphyxia 20 | 20 Preterm with no other conditions 43 | 2.1 Diagnostics, Baseline penetration | Baseline utilization | Efficacy for Home/Clinic/Hospital, % Preterm labor51–53 50/85/90 | 5/20/35 | 25/80/80 Respiratory distress syndrome46,54 50/85/90 | 40/60/95 | 75/95/95 Intraventricular hemorrhage54 50/85/90 | 5/40/70 | 25/45/45 Necrotizing enterocolitis54–56 50/85/90 | 5/40/70 | 25/85/85 Sepsis49,57,58 95/85/90 | 75/80/90 | 75/95/95 Low birth weight59 50/85/90 | 5/75/90 | 25/95/95 Abbreviation: MANDATE, Maternal and Neonatal Directed Assessment of Technology.
↵a The prevalence and case fatality rates assume no preventive or treatment interventions.
- TABLE 3.
Impact of ANCS and Other WHO-Recommended Interventionsa to Prevent Preterm Mortality From RDS, IVH, and NEC, Sub-Saharan Africa, 2015
Scenario No. Scenario Incremental Change Modelb Universal Coverage Modelc Preterm Deaths, No.d Preterm Deaths Prevented Compared With Current Level of Care, No. (%) Preterm Deaths, No. Preterm Deaths Prevented Compared With Current Level of Care, No. (%) 1 Current levels of prevention, diagnosis, and treatment 303,400 N/A 303,400 N/A Improved WHO single interventions 2 Increased surfactant in hospital settings for RDS 303,300 100 (<0.1) 303,100 300 (0.1) 3 Increased ANCS in hospital settings for RDS, IVH, and NEC 302,300 1,100 (0.4) 298,400 5,000 (1.7) 4 Increased oxygen/CPAP in hospital and clinical settings for RDS 295,300 8,100 (2.7) 261,100 42,300 (13.9) Improved diagnosis of preterm labor and transfer with current care 5 Increased diagnosis of preterm labor birth, with current levels of care for RDS, IVH, and NEC 302,400 1,000 (0.3) 299,900 3,500 (1.2) 6 Increased diagnosis of imminent preterm birth and transfer to hospitals, with current levels of care for RDS, IVH, and NEC 301,300 2,100 (0.7) 287,100 16,300 (5.4) Improved diagnosis and transfer with WHO single interventions 7 Increased diagnosis of respiratory distress, transfer, and surfactant (hospitals only) for RDS 299,900 3,500 (1.2) 282,800 20,600 (6.8) 8 Increased diagnosis of imminent preterm birth, transfer to hospitals, and ANCS (hospitals only) for RDS, IVH, and NEC 298,600 4,800 (1.6) 236,700 66,700 (22.0) 9 Increased diagnosis of respiratory distress, transfer, and oxygen/CPAP for preterm RDS 287,400 16,000 (5.3) 176,100 127,300 (42.0) Improved diagnosis and transfer with WHO packaged interventions 10 Improved diagnosis of imminent preterm birth, transfer to hospitals, ANCS (hospitals only), and treatment with surfactants (hospitals only) and oxygen/CPAP for RDS, IVH, and NEC 289,700 13,700 (4.5) 191,300 112,100 (37.0) 11 Increased diagnosis of respiratory distress, transfer to hospitals, and treatment, including surfactants (hospitals only) and oxygen/CPAP for RDS 286,900 16,500 (5.4) 155,700 147,711 (48.7) 12 Hospital delivery for all preterm birth, with ANCS (hospitals only), improved diagnosis and treatment of respiratory distress, including surfactants (hospitals only) and CPAP for RDS, IVH, and NEC 223,300 80,100 (26.4) 112,800 190,600(62.8) Abbreviations: ANCS, antenatal corticosteroids; CPAP, continuous positive airway pressure; IVH, intraventricular hemorrhage; NEC, necrotizing enterocolitis; RDS, respiratory distress syndrome; WHO, World Health Organization.
↵a Assumptions regarding baseline penetration and utilization of interventions including ANCS, surfactant, and CPAP as shown in Table 1. Assumptions regarding diagnostics and transfers found in Table 2.
↵b The incremental change model assumes 20% increase from baseline penetration and utilization.
↵c The universal coverage model assumes 98% penetration and utilization of interventions.
↵d All estimates rounded to nearest 100.
- TABLE 4.
Impact of WHO-Recommended Interventionsa to Prevent Preterm Mortality From Sepsis, Birth Asphyxia, and Low Birth Weight, Sub-Saharan Africa, 2015
Scenario No. Scenario Incremental Change Modelb Universal Coverage Modelc Preterm Deaths, No.d Preterm Deaths Prevented Compared With Current Level of Care, No. (%) Preterm Deaths, No. Preterm Deaths Prevented Compared With Current Level of Care, No. (%) 1 Current levels of prevention, diagnosis, and treatment 198,400 N/A 198,400 N/A Improved WHO single interventions 2 Oxygen/CPAP for birth asphyxia in clinics and hospitals 198,000 400 (0.2) 196,800 1,700 (0.9) 3 PPV for birth asphyxia in all settings 197,200 1,200 (0.6) 195,100 4,200 (2.1) 4 Drying and stimulation for birth asphyxia in all settings 196,486 1,900 (1.0) 195,400 3,000 (1.5) 5 Thermal care for LBW, including KMC in all settings and warmers in hospital settings 196,000 2,500 (1.3) 189,400 9,100 (4.6) 6 Antibiotics for suspected neonatal sepsis in all settings 192,100 6,300 (3.2) 180,300 18,200 (9.1) 7 Breastfeeding for sepsis and LBW in all settings 189,300 9,100 (4.6) 168,200 30,200 (15.2) 8 Chlorhexidine for sepsis in home settings and dry cord care in clinical settings 190,800 7,600 (3.8) 159,900 38,500 (19.4) Improved diagnosis and transfer with current care 9 Diagnosis of birth asphyxia and need for postresuscitation care, with current levels of care 197,200 1,300 (0.7) 196,500 1,900 (1.0) 10 Diagnosis of birth asphyxia and need for postresuscitation care and improved transfer to hospitals, with current levels of care 197,000 1,400 (0.7) 196,200 2,200 (1.1) 11 Diagnosis of sepsis, with current levels of care 194,700 3,700 (1.9) 194,300 4,200 (2.1) 12 Diagnosis of sepsis and transfer to hospitals, with current levels of care 187,400 11,000 (5.5) 184,100 14,300 (7.2) Improved diagnosis and transfer with WHO single treatment interventions 13 Diagnosis of birth asphyxia and need for postresuscitation care, transfer, and oxygen/CPAP 196,300 2,100 (1.1) 191,700 6,800 (3.4) 14 Diagnosis of birth asphyxia and need for postresuscitation care, transfer, and positive pressure ventilation 195,500 2,900 (1.5) 189,800 8,600 (4.3) 15 Diagnosis of sepsis, transfer, and antibiotics for suspected neonatal sepsis 180,800 17,600 (8.9) 169,800 28,600 (14.3) Improved diagnosis and transfer with WHO-packaged interventions 16 Drying and stimulation, diagnosis of birth asphyxia and need for postresuscitation care, transfer to hospitals, and treatment, including PPV and oxygen/CPAP 188,057 10,400 (5.2) 172,200 26,200 (13.2) 17 Cord care and breastfeeding, diagnosis of sepsis, transfer, and antibiotics for suspected neonatal sepsis 169,200 29,200 (14.7) 139,400 59,100 (29.8) 18 Packaged interventions 16 and 17, with increased thermal care and breastfeeding for LBW 159,300 39,100 (19.7) 104,000 94,400 (47.6) Abbreviations: CPAP, continuous positive airway pressure; KMC, kangaroo mother care; LBW, low birth weight; PPV, positive pressure ventilation; WHO, World Health Organization.
↵a Assumptions regarding baseline penetration and utilization of interventions including ANCS, surfactant, and CPAP as shown in Table 1. Assumptions regarding diagnostics and transfers found in Table 2.
↵b The incremental change model assumes 20% increase from baseline penetration and utilization.
↵c The universal coverage model assumes 98% penetration and utilization of interventions.
↵d All estimates rounded to nearest 100.
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