Global Network for Women’s and Children’s
Health Research
Resuscitation: How to Save One Million Lives
Per Year
Albert Manasyan, MD; Wally Carlo, MD and the
FIRST BREATH Study Group
For the Global Network for Women’s and
Children’s Health Research
Stillbirth and Neonatal Deaths Per Year
• 98% of all stillbirths and neonatal deaths occur
in developing countries
 ~ 2.6 million stillbirths
 ~ 3.5 million neonatal deaths
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•
•
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Preterm
Birth asphyxia
Sepsis
Other
1.0 mil
0.8 mil
0.5 mil
1.2 mil
Background: Essential Newborn Care
•
The WHO developed Essential Newborn Care (ENC)
course sets minimum standards for training birth
attendants in neonatal care including:
•
•
•
•
•
•
•
•
Basic resuscitation
Universal precautions
Routine neonatal care
Thermoregulation
Breastfeeding
Kangaroo mother (skin-to-skin) care
Care of the small baby
Danger signs
First Breath Protocols
The First Breath protocols were designed to
address the impact of Essential Newborn Care
(ENC) on perinatal mortality:
•First Breath: Clinic Study
•First Breath: Common Protocol
Comparison of First Breath Protocols
First Breath:
Clinic Study
Setting
First Breath:
Common Protocol
Institution-based
Community-based
(first level health clinics)
Birth Attendants Formally-trained
midwives
All birth attendants
including MDs, RNs,
MWs, TBAs
Outcomes
Early neonatal mortality Early neonatal mortality
(7 days), stillbirths,
(7 days), stillbirths,
perinatal mortality
perinatal mortality
Timeline
2004 – 2006
2007 – 2008
First Breath: Clinic Study
Design:
Pre-Post controlled study with
active baseline data collection
Setting:
Level 1 health delivery centers in
Zambia
Interventions: WHO ENC (including
resuscitation training) and NRP
Patients:
71,689 low risk newborns
Carlo W et al. Pediatrics 126:e1064-71, 2010.
First Breath: Clinic Study
Results
Pre-ENC Post-ENC p value
All cause 7-day mortality/1000
11.5
6.8
p<0.001
Perinatal mortality/1000
18.3
12.9
p=0.002
Mortality due to asphyxia/1000
3.4
1.9
p=0.02
Mortality due to infection/1000
2.2
0.8
p=0.02
Mortality < 1500/1000gr
576
407
p=0.049
SB rate/1000
4.9
4.9
NS
Carlo W et al. Pediatrics 126:e1064-71, 2010.
Delivery by Birth Attendant
Family members
19%
Birth
Attendant Home
10%
Physician
16%
Clinic 9%
TBA
37%
Home 56%
Nurse/Midwife
28%
Carlo et al. N Engl J Med. 362:614-23, 2010.
Hospital 25%
First Breath: Common Protocol
1. Population-based prospective study
2. 96 communities in 6 countries (7 clinical
sites) in South America, Africa, and Asia
3. 3,676 birth attendants trained in data
collection and clinical measures (fetal heart
rate monitoring, Apgar scoring etc.)
4. Active baseline data collection
5. Training in ENC
6. Post-ENC data collection
First Breath: Common Protocol
Results
Pre-ENC
Rate/1000
Post-ENC
Rate/1000 RR (CI)
Stillbirth
23.0
15.9
0.69 (0.54 ,0.88)
All cause 7-day mortality
23.4
23.2
0.99 (0.81, 1.22)
Perinatal mortality
45.9
38.9
0.85 (0.70, 1.02)
Carlo et al. N Engl J Med. 362:614-23, 2010.
Perinatal Mortality
Pre-Post ENC Perinatal Mortality Rates by
Birth Attendant
Family/
Unattended
Traditional Birth
Attendant
Nurse/Midwife
Physician
All Birth
Attendants
*
*
Carlo et al. N Engl J Med. 362:614-23, 2010.
Methods: Cost Analysis
•
Cost-effectiveness was calculated as follows:
Cost per life saved =
•
Cost
Reduction in death
Cost per disability-adjusted life years (DALY) was
calculated as follows:
Cost per DALY =
Cost per life saved
Life expectancy
Results: DALY
Cost per DALY = Cost per life saved
Life expectancy
Cost per DALY =
Cost per DALY =
$208
39.7 years
$5.24
Final Conclusions
1. WHO ENC training of midwives in first level
centers reduced neonatal mortality by ~10/1000
2. This intervention was very cost-effective in first
level facilities ($5 per DALY)
3. In communities, ENC reduced fresh stillbirths
and perinatal mortality without increasing
neonatal mortality
4. Survivors of birth asphyxia have low rates of
impairment
Acknowledgement
Support for this project
from the Eunice Kennedy
Shriver National Institute
of Child Health and
Human Development
(NICHD), part of the
National Institutes of
Health within the U.S.
Department of Health and
Human Services, and the
Bill and Melinda Gates
Foundation