Care Seeking for Newborn Illness a Changing Paradigm_Steve Wall_4.25.13Presentation Transcript
Care seeking for newbornillness: A changingparadigm?Steve WallSave the ChildrenCORE MeetingBaltimoreApril 25, 2013
0204060801990 1995 2000 2005 2010 2015 2020 2025 2030 2035Source: UN Inter-agency Group for Child Mortality Estimation, Levels and Trends in Child Mortality: Report 2011;UNICEF, Required Acceleration for Child Mortality Reduction beyond 2015, 2012; team analysisSNL/Save the Children team analysis for NMR projection for Call for Action meetingMortalityRate(deaths/1000births)2035Accelerated U5MR ARR = 5.1%Current U5MR ARR = 2.2%* ARR = annual rate of reductionMDG 4 target =34 U5MRGlobal Progress for child survivalU5MR and NMR decline 1990-2010, projected to 203515Current NMR ARR = 1.8%If 1-59 month mortality accelerates further but neonatal mortality continues onsame trend then with2 million child deaths in 2035, 1.5 million may be neonatal.
Why are we focused on newborn survival?Three killers –prematurity, asphyxia, and infections- account for 81%of all neonataldeaths3.1 millionSources: CHERG/WHO 2010. Estimates for 193 countries for 2008. Black R et al Lancet 2010. UNICEF, State of the Worlds Children, 2011.Causes of death in children under-five in developing countries –Newborn deaths are almost half of all deaths of children underfive
REGION Neonatal mortality rateAverage annual change1990-2010Africa 1.3%East Med 1.6%Southeast Asia 2.2%Western Pacific 4.2%Americas 3.6%Europe 3.6%Maternal mortality ratio = 4.2%1- 59 month mortality rate = 3%Neonatal mortality rate = 1.8%All 3 measures show increased progress since 2000Source: Lawn J,E. et al. 2012. Newborn survival: a multi-country analysis of a decade of change. Health Policy and Planning.27(Suppl. 3): iii6-ii28. Data sources: Oestergaard et al 2011 PLoS, UNICEF 2012 www.childinfo.org21652085Mortality average annual rate of reductionWHEN WILL REGIONS REDUCE NMR TOCURRENT RATE OF HIGH INCOMECOUNTRIES(3 per 1000)?
Care seeking for NBs: Our Original Assumptions• Home-based management of sicknewborns is effective and saves lives• Care seeking from qualified providersoutside the home is low, influenced byentrenched cultural beliefs and practices.– Seclusion, contamination– Evil eye– Traditional beliefs about illness and remedies– Lack of trust in “western” medicine
• Case identification in Projahnmo (Bangladesh)coincided with the days of scheduled post-natalhome visits “active” case detectionseemed neededBaqui et al. BMJ, 2009. Family acceptance of referral to facilities: Bangladesh – ~ 1/3 Pakistan – 20%Baqui et al. Lancet. 2008; Zaidi et al. XXX.Evidence “confirming” these assumptions
More recent evidence and program experience• Nepal:• MINI – FCHVs counseled family, who notifiedFCHVs of suspected newborn illness• FCHVs identified signs of PSBI, treated withcotrimoxazole and referred to gov‟t CHW forinjectable gentamicin• CHW provided 7 days of gentamicin• Initially at home; but families became willing to go tohealth posts/centers for gentamicin MINI model incorporated into 10-district pilot ofCommunity-Base Newborn Care Program (CBNCP) Recent CB NCP data show families infrequentlycontact FCHVs, but tend to directly seek care athealth posts/centers
More recent evidence and program experience - 2• Ethiopia• COMBINE (cRCT) introduced NBS management(amoxicillin + gentamicin x 7 days) by HealthExtension Workers (HEW) at Health Posts• Expectation of “active case detection” byvolunteers and HEWs• Initially, very low case identification in interventionareas.• Qualitative research identified barriers –cultural/religious taboos against taking newbornsoutside the home; lack of knowledge of newbornillness, treatment, and availability of suchtreatment at HPs.• Project worked with community/religiousleaders, volunteers to provide information.• Increased care seeking for sick newborns waslargely „self-referral‟
COMBINE care seeking for NB illnessTable 1: Expected births & care-seekingFor newborn illness2011 2012Q3 Q4 Q1 Q2 JulyIntervention Expected No. of births 2711 2395 2123 2468 880No. (%) seen at HP 8 (0.3) 28 (1) 131 (6.2) 170 (7.0) 54 (6.1)No. (%) seen at HC 0 (0) 8 (0.33) 102 (4.8) 38 (1.5) 12 (1.6)Control Expected No. of births 2731 2394 2068 2419 894No. (%) seen at HP5 (0.18) 6 (0.25) 16 (0.75) 7 (0.28) 8 (0.91)No. (%) seen at HC3 (0.1) 5 (0.2) 42 (2) 31 (1.3) 13 (1.5)
Implications• Families ARE willing to seek care for NBillness (from qualified providers) outsidethe home.– Taboos can be overcome (rapidly ?) iffamilies/communities have knowledge aboutpreventable newborn deaths, need for earlycare seeking, and availability of services– Services must be reliable (set times for healthworker at HP, medicines in stock)
Issues/Questions• Is care seeking timely enough for effectivetreatment? Any prior care seeking fromunqualified providers?• Can community participation and CHWrole(s) help “facilitate” care seeking?• How different might this care seekingpattern be in different regions or differentcountry contexts (eg, need for formativeresearch and pilots)?• How rapidly can community norms bechanged and will these changes besustained?
Additional questions for discussion?• In some countries(eg, India, Pakistan), care seeking fornewborn illness may be mostly fromprivate providers (many unqualified). Howto address this challenge?• What is care seeking pattern for sicknewborns in the first week of life, and howcan this be increased?– First week NBS is more lethalcondition, requires early identification andtreatment, and is more prevalent than laterneonatal NBS.
Further considerations• Roles of CHWs (SNL 2 experiences) inchanging household practices and careseeking• Role of community mobilization inchanging expectations &norms, household practices and careseeking, and care quality
Learning fromimplementation ofcommunity-basedmaternal & newborn healthprograms:The role of CHWsDeborah SitrinSave the ChildrenCORE Group MeetingBaltimoreApril 25, 2013
SNL2 VisionTo have reduced globalneonatal mortality byproviding catalyticassistance to develop, andimplement, effectiveevidence-based newborncare interventions at scale.
GuatemalaBoliviaIndonesiaVietnamBangladeshNepalIndiaPakistanAfghanistanSNL2: Where?South AfricaMozambiqueMalawiTanzaniaUgandaEthiopiaGhanaMaliNigeria60% of the world‟s 3.1 million neonataldeaths18 countries•Africa: 9•Asia: 7•Latin America: 2Global & Regional
Description of programsProgram elements:• Home visits by Community Health Workers during pregnancy & after birth to:Encourage ANC and facility deliveryPromote optimal care practices for newborn and motherCounsel families to identify danger signs and seek careIdentify sick newborns and refer to facilities (+ pre-referral oral antibiotic inNepal only)• Facility strengthening (varied)• Community engagement (varied)Data from pilot districts in 4 countries:• Malawi• Uganda• Nepal• Bangladesh
Community workers conducting home visitsDifferences across programs:• Population catchment size• Gender• Education level• Salaried governmentemployee vs. volunteer• Incentives• How workers are recruited• Residency• Time in community• Length of pre-service trainingSimilarities across programs:• Length of training inmaternal newborn healthpackage• Content of counseling onnewborn care practices• Made home visits duringpregnancy and soon afterbirthLESSON: Delivery platforms vary substantially and deliverysystems can change.
Implementation Questions1. How many women and newborns received home visits?2. What did CHWs do for newborns during visits?3. How many families sought timely and appropriate carewhen their newborns had danger signs?4. What was the role of CHWs in identifying and referringnewborns with danger signs?5. What have we learned about increasing uptake ofhealthy newborn care practices?
Percent of mothers/babies receiving home visitsFINDINGS:• Low in Malawi, higher inBangladesh and Nepal• More received pregnancyvisits than postnatal visits• If a postnatal visit wasreceived, it was usually within3 days after birthLESSON: Percent receiving home visits varied substantiallyand we need to consider what each community platformcan handle.020406080100Nepal(N=615)Bangladesh(N=398)Malawi(N=900)1 or more home visits during pregnancy1st postnatal home visit 0-3 days after birth1st postnatal home visit 4-7 days after birthPercentage of mothers/newborns thatreceived home visitsData from interviews with mothers with a live birth in previous 12 months
What was done for newborns during postnatal homevisits within 3 days after birthFINDINGS:• Nearly all newborns that received an early postnatal home visit hadat least one key function done• Weighing baby low in Nepal, but FCHVs only instructed to weighbabies not previously weighed at facility020406080100Checked cord Breastfeeding supportChecked temperature Weighed baby All 4 functionsNepal(N=307)Malawi(N=95)Percentage of newborns that received a postnatal home visit ≤3 days after birth and signal functions wereperformed by CHWLESSON: When postnatal visits are done, CHWs performedkey tasks. BUT need to monitor quality.Data from interviews with mothers with a live birth in previous 12 months
Care-seeking for newborns with danger signsMalawi Uganda Nepal BangladeshEndline Endline Baseline Endline Baseline EndlineNB with danger sign 23.4% 50.0% 21.4% 28.8% 52.3% 40.7%Care-seeking for those with a danger sign:Sought care (any source) 82.9% 94.2% 85.8% 98.9% 82.0% 88.3%Sought care <=24 hours ata facility (public or private)41.2% 48.3% 36.6% 67.8% NC 20.4%FINDINGS:High levels of care-seeking• High in all countries (baseline & endline, intervention & comparison areas)Yet fewer newborns taken to a facility within 24 hours after onset ofdanger signs• % newborns with danger signs taken to a facility within 24 hours increased inNepal, was moderate in Malawi and Uganda, low in BangladeshData from interviews with mothers with a live birth in the previous 12 months
Care-seeking for newborns with danger signsLESSONS: Families will leave the home and seek care. Need to address delays in seeking care from a facility within 24hours after onset of illness. Noting we found high levels ofnewborns with danger signs. Difficulty in relying on survey data –mothers may not accurately recall or report illnesses. Need to ensure families are accessing appropriate care. Use ofprivate facilities and pharmacies/drug shops high in Nepal,Bangladesh, and Uganda. We saw decreases in Nepal but no changein Bangladesh (no baseline information from Uganda or Malawi).
Access to full course of treatment for newborn sepsisMALAWINEPAL1 facility per300,000 people1 facility per7,000 peopleLESSON: Community-basedprograms may createdemand, but treatment needsto be available closer to home
Role of CHWs in referring sick newbornsFINDINGS:CHWs have good understandingof newborn danger signs andappropriate care• >95% of CHWs in Malawi and Nepalcould name 3+ newborn danger signsBUT low volumes of CHWreferrals of newborns with dangersigns• Many newborn not visited by CHWswithin the first week after birth• Families going straight to facilitieswhen newborn has danger sign• Issues with CHWs not gettingrequired supplies/equipmentData from interviews with mothers with a live birth inprevious 12 months020406080100Nepal(N=615)Bangladesh(N=398)Malawi(N=900)1 or more home visits during pregnancy1st postnatal home visit 0-3 days after birth1st postnatal home visit 4-7 days after birthPercentage of mothers/newborns thatreceived home visits
Role of CHWs in referring sick newbornsLESSONS: Need appropriate expectations for the role of CHWs in identificationand referral: Focusing on increasing family-initiated care-seeking maybe more important and more feasible than detection by CHWs. Examine role of CHW in follow-up and treatment completion: May befeasible and effective to involve CHWs in follow-up of sick newborns.Counter-referral systems are needed to implement follow-up. Strengthen monitoring of referrals and outcomes: Weak systems totrack referrals and referral outcomes.
Uptake of 4 key newborn care practices020406080100Malawi* Nepal* Bangladesh Uganda*Baseline EndlineImmediate breastfeeding020406080100Malawi* Nepal* Bangladesh* Uganda*Baseline EndlineBathing delayed ≥6 hours020406080100Malawi Nepal Bangladesh UgandaBaseline EndlineSkin-to-skin contact020406080100Malawi Nepal* Bangladesh* Uganda*Baseline EndlineNothing applied to cord after cutting*Statistically significant at p<0.05Data from interviews with mothers with a live birth in previous 12 months
Newborn care practicesFINDINGS:• Practices improved over time with a few exceptions (immediate breastfeeding inBangladesh, applying nothing to cord in Malawi and Uganda)• Practices increased in both intervention and comparison areas, though endlinerates often higher in interventions areas. (Note: comparison area data onlyavailable in Bangladesh and Uganda.)• Newborn care practices associated with receipt of home visits from CHW duringpregnancy (except in Uganda)– Only statistically significant if mother received 3+ home visits during pregnancyLESSON: Home visits during pregnancy are an opportunity to improvenewborn care practices and programs able to reach large numbers ofwomen during pregnancy. BUT may be difficult to achieve 3+ visits.
Mobilizing communities for sustainable change in newbornhealth expectations, care giving practices, and care seekingAngie Brasington, Save theChildrenCORE Group SPRING MEETINGApril 25, 2013Mobilizing communities for improved maternal & newbornhealth:lessons and questionsAngie Brasington,Save the ChildrenCORE GroupSPRING MEETINGApril 25, 2013
Outline: CORE Group Newborn Health Survey CM for Newborn Health – what are we learning? Questions that need exploration
Carolyn Kruger, Ph.D.Sr. Advisor MNCHPCICORE Group co-chair: Safe motherhood &reproductive Health Working GroupCORE GroupNewborn Health Survey Results
Newborn Health Areas Supported(18 Organizations)Number of organizations161615151212121110109987653221
Cross-Cutting Approaches• CHW capacity building - 100%• Behavior change/communication - 78%• Community mobilization - 70%• Community health system strengthening - 70%• Care groups - 50%• mHealth approaches - 48%• Mass communication - 42%• C-IMCI/CCM - 38%
Innovative Strategies• mHealth reminders on assessment of mothers and newborns• Mobile job aids - counseling messages• Newborn screening on birth defects• Preconception care• Casa Materna birthing home model• Community Kangaroo Mother Care• CHW capacity to recognize danger signs• Involving fathers during pregnancy, delivery and PP care• EBF among adolescent mothers using text messaging and support groups
Community-based Activities=Community Mobilization• Day celebrations, competitions, use of action cards to stimulategroup dialogue are all examples of behavior change strategies.• The process of stimulating a community to identify, plan andimplement strategies and activities to achieve an agreed upongoal is community mobilization.• CM often incorporates participatory behavior changestrategies, however• BC strategies can be effective without CM, so why…..Mobilizing Communities…..
1. We have evidence it works:WEWE problemsSo, why mobilize communities?Costello et al, Effect of a participatory intervention with women’s groups on birth outcomesin Nepal: cluster-randomized controlled trial. Lancet 2004; 364: 970 – 979.Baqui et al, Effect of community-based newborn-care intervention package implementedthrough two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomized controlled trial. Lancet 2008; 371: 1936–44.Kumar et al, Effect of community-based behaviour change management on neonatalmortality in Shivgarh, Uttar Pradesh, India: a cluster-randomized controlled trial. Lancet2008; 372: 1151–62.Costello et al, Effect of a participatory intervention with womens groups on birth outcomesand maternal depression in Jharkhand and Orissa, India: a cluster-randomized controlledtrial. Lancet 2010; 375: 1182-1192
2. The principles behind CM fit with our mission and context:• Decentralization and democratization require increasedcommunity level decision-making --- CM is an entry point for civilsociety strengthening and democracy building.• CM builds mechanisms and systems to sustain improvements inindividuals’, families’ and communities’ well-being.• Communities can apply political pressure to improve services.• CM can strengthen community members’ capacity to address theunderlying causes of poor health.f problemsSo, why mobilize communities?
LESSONS: Men want to be involved Communities are able andwilling to contributeresources Communities are changingrapidly Communities take action:emergency transportsystems and funds, advocacyfor satellite clinics andstaff, pregnancy surveillance.What have we learned from communities lately?
Challenges and lessonsLESSONS: Need appropriate expectationsfor the role of CHWs: MOHstaff who are closest to thecommunity are already thinlystretched.• Should CHWs lead or onlysupport CM efforts?• Can existing communityleaders, volunteers or membersof civil society organizationsfeed input from communities tothe health system?• ‘Sharing the burden lightens theload’
Challenges and lessonsLESSONS: Community mobilization competes with many other priorities(clinical training, infrastructure development) within a resourcelimited environment.• Make every effort to integrate CM into broader national healthstrategies, especially when existing MOH policy calls for strong communityengagement.• When communities, CHWs and program managers experience results, therelative value of CM is compelling and support is more likely.
Challenges and lessonsLESSONS: Community mobilization takes time.• Simplify the process as much as possible before you start and refinefurther as you roll out.• As staff becomes more confident and skilled , CM processes speed up.Good training is essential.• CM successes build momentum and can lead to organic expansion.• Communities and groups with prior experience organizing to solveproblems can move more quickly.
Challenges and lessonsLESSONS: Community mobilization at scale takes thoughtful planning.It can be done when:• Designed with scale in mind• Effective training materials and guides are produced to support theprocess• Financial and political support is available• Partners are interested in adopting the approach• Systems are in place to support capacity-building of program teams(including monitoring and evaluation, training and ongoing technicalassistance)
So how can we ensure communities areengaged?Questions:Why are communities consistently left out of the Household toHospital Continuum of Care (HHCC)?What do we as PVOs/INGOs require to inspire and equip morepartners to engage communities for improved MNH?• More evidence on ‘how’ CM works?• More advocacy?