Infant, Newborn

GBD 2019 estimated each epidemiological quantity of interest—incidence, prevalence, mortality, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs)—for 23 age groups; males, females, and both sexes combined; and 204 countries and territories that were grouped into 21 regions and seven super-regions. For GBD 2019, nine countries and territories (Cook Islands, Monaco, San Marino, Nauru, Niue, Palau, Saint Kitts and Nevis, Tokelau, and Tuvalu) were added, such that the GBD location hierarchy now includes all WHO member states. GBD 2019 includes subnational analyses for Italy, Nigeria, Pakistan, the Philippines, and Poland, and 16 countries previously estimated at subnational levels (Brazil, China, Ethiopia, India, Indonesia, Iran, Japan, Kenya, Mexico, New Zealand, Norway, Russia, South Africa, Sweden, the UK, and the USA). All subnational analyses are at the first level of administrative organisation within each country except for New Zealand (by Māori ethnicity), Sweden (by Stockholm and non-Stockholm), the UK (by local government authorities), and the Philippines (by province). In this publication, we present subnational estimates for Brazil, India, Indonesia, Japan, Kenya, Mexico, Sweden, the UK, and the USA; given space constraints, these results are presented in appendix 2. At the most detailed spatial resolution, we generated estimates for 990 locations. The GBD diseases and injuries analytical framework generated estimates for every year from 1990 to 2019.
Diseases and injuries were organised into a levelled cause hierarchy from the three broadest causes of death and disability at Level 1 to the most specific causes at Level 4. Within the three Level 1 causes—communicable, maternal, neonatal, and nutritional diseases; non-communicable diseases; and injuries—there are 22 Level 2 causes, 174 Level 3 causes, and 301 Level 4 causes (including 131 Level 3 causes that are not further disaggregated at Level 4; see appendix 1 sections 3.4 and 4.12 for the full list of causes). 364 total causes are non-fatal and 286 are fatal. For GBD 2019, 12 new causes were added to the modelling framework: pulmonary arterial hypertension, eye cancer, soft tissue and other extraosseous sarcomas, malignant neoplasm of bone and articular cartilage, and neuroblastoma and other peripheral nervous cell tumours at Level 3, and hepatoblastoma, Burkitt lymphoma, other non-Hodgkin lymphoma, retinoblastoma, other eye cancers, and two sites of osteoarthritis (hand and other joints) at Level 4.

We updated the CCC classification system in 5 steps. First, we reviewed publications that either used or evaluated the CCC v1 system, identifying ICD-9 codes that have been found to be omitted in the CCC v1 system but likely to indicate CCC status, and incorporated these codes. Second, we translated ICD-9 to ICD-10 codes by using GEMs (General Equivalence Mappings) forward mapping. The GEMs for the diagnosis codes are developed by the National Center for Health Statistics (NCHS); the GEMs for the procedure codes are developed by the Centers for Medicare & Medicaid Services (CMS). They are the authoritative source for translation between ICD-9 and ICD-10 codes (http://www.cdc.gov/nchs/icd/icd10cm.htm.). Third, two member of the team (CF and JF), both experienced clinicians who care exclusively for children with CCCs, independently reviewed all codes in the ICD-9 and ICD-10 taxonomies to identify neonatal conditions, specifically those arising in the perinatal period (including very low birth weight) that have a high likelihood of meeting the CCC definition. All discrepancies were resolved through further query of the detailed ICD taxonomies (http://www.who.int/classifications/icd/en/). Fourth, in a similar manner but this time focusing on technology dependence and transplantation status, the same team members (CF and JF) reviewed ICD-9 and ICD-10 codes, as well as existing publications [10 (link),28 (link),29 (link)], to identify codes indicative of persons who likely have a CCC. Fifth, with the provisional set of all CCC v2 codes, we used the v2 system to classify all cases in the CDC Multiple Cause of Death data for 1996 (http://wonder.cdc.gov/mortSQL.html), 2009 Kids’ Inpatient Database (KID), and 2010 Nationwide Emergency Department Sample (NEDS) datasets (http://www.hcup-us.ahrq.gov/databases.jsp), and reviewed all cases classified as not having a CCC to determine whether any codes in the CCC v2 system had been either incorrectly specified or omitted, and then we corrected these errors.

A questionnaire with 22 questions (see Additional file 2) for assessing staff knowledge on definitions of the perinatal and neonatal period (n = 2), antenatal care (n = 7) and postpartum care (n = 13) was developed based on the National Guidelines in Reproductive Health Care [38 ] and administered to health workers involved in the provision of care to pregnant and birthing women, newly delivered women and their newborns at the onset of the study and the end of the 12-month intervention.

The basic feature of the PeriKIP social innovation was that trained facilitators supported local stakeholder groups at the commune level and at district and provincial hospital levels in their efforts to improve perinatal healthcare practices. Seven laywomen from the Women’s Union were recruited as facilitators on the commune level. Facilitator positions were advertised openly, and recruitment was based on applicants’ previous experience with community activities and communication skills. A retired director (physician) of the Reproductive Health Centre on the provincial level in Cao Bang was recruited and trained to take the role as facilitator in the participating four hospitals. The project was implemented within the existing healthcare system [37 (link)] to increase the local accountability and ownership of quality improvement among stakeholders responsible for health (see Table 1). The PeriKIP groups at the three different levels were expected to meet once a month for the project’s duration. Participating in meetings and actions within PeriKIP was expected to be part of the stakeholders’ duties. Therefore, none was paid for their engagement besides the village health worker and the Women’s Union worker from the village level, who were reimbursed for travel expenses enabling them to attend monthly meetings.Table 1

PeriKIP group stakeholders at three health system levels

Stakeholder groups at the commune level: Each commune has one Commune Health Centre providing primary healthcare. In each of the communes in the study area (n=48), one PeriKIP group was established with the following eight participants: three Commune Health Centre staff (head of Community Health Centre, midwife and nurse), one village health worker, one vice chairperson of the Peoples committee, one women union representative from community level, one women union representative from village level and one population officer

District and provincial hospital level: In each of the district hospitals in the study area (n=3) and in the provincial hospital (n=1), one PeriKIP group was established with the following eight participants: one midwife from the antenatal care clinic, one midwife from the labour ward, the head nurse of the paediatric department, the head of the obstetric department (physician), the head of the paediatric department (physician), the head of the general planning department, the leader of the hospital director board and one representative from Reproductive Health Centre at district or provincial level

During 2 weeks, the research group trained locally recruited facilitators with theoretical sessions, group discussions and role-play activities. Topics covered group dynamics and quality improvement methods (brainstorming and the PDSA cycle). To facilitate discussions about perinatal care, the facilitators were introduced to basic evidence-based neonatal care per recommendations in the Vietnamese National Guidelines in Reproductive Health Care [38 ]. Also, facilitators were briefed on the current health situation in their respective districts and the function of the healthcare system concerning reproductive health. Guides on facilitators’ roles, attitudes, responsibilities and how to handle challenging situations were based on the i-PARIHS framework [24 ] and modified materials from the NeoKIP project [39 (link)]. At the end of the training, facilitators practised their skills in rural communes and district hospitals outside the study area followed by feedback discussions on performance. One person with reproductive health responsibilities from each district was recruited as a mentor of the facilitators working in the communes of that district. These persons attended the facilitator training and participated in separate sessions focusing on how to mentor facilitators. A guide describing the role of the mentors was also developed and used to support the mentors in their roles. Members of the research group were not involved in delivering the intervention to the local stakeholder groups. Trained facilitators within PeriKIP received a monthly salary.