Mwebesa abwao newborn_health

WHO/UNICEF - Joint Statement Service Delivery & Program Implications Dr. Winnie Mwebesa Dr. Stella Abwao CORE Group Fall Meeting September 14-15, 2010

Service Delivery & Program Implications
Outline
Background
Rationale – why focus on PNC home visits?
Evidence
Recommendations
Malawi country experience
WHO/UNICEF - Joint Statement

Rationale 1: Neonatal deaths & MDG 4 Almost 40% of under 5 deaths are neonatal – 4 million a year MDG4 can be achieved if neonatal deaths are reduced Source: Lawn JE et al Lancet 2005 0 50 100 150 Mortality per 1000 births (global av) 1960 1980 2000 2020 Year Under-5 mortality rate Late neonatal mortality Early neonatal mortality Target for MDG-4

Rationale 2: When do newborn deaths occur? Up to 50% of neonatal deaths are in the first 24 hours 75% of neonatal deaths are in the first week – 3 million deaths Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths)

Rationale 3: Where do newborn deaths occur?
99% of all newborn deaths occur in developing countries
Most newborn deaths occur at home
47% of mothers and newborns do not receive skilled care during delivery (and those who do are sent home early)
72% of all babies born outside health facilities do not receive any postnatal care

Direct causes of 3.72 million neonatal deaths - almost all are due to preventable conditions Source: Lawn JE, Cousens SN, Zupan J Lancet 2005. 60 to 90% of neonatal deaths are in low birth weight babies, mostly preterm Rationale 4: What causes newborn deaths?

Evidence of Home Visits for Newborn Care

Recommendations: underlying principles
Core principle - continuum of care covering both lifecycle and home-to-hospital (and “back again”) dimensions
Home visit is a complementary strategy to facility-based postnatal care …. to improve newborn survival
Facility births: assess health of mother and baby before discharge and give specific return date
Non-facility births: Seek postnatal care from a skilled provider (in most places at facility) as soon as possible

Recommendation: Home Visits
At least two home visits for all home births:
First visit - within 24hrs of birth
Second visit - day 3
Third visit - day 7 (if possible)
At least two home visits for all babies born in a health facility :
First visit - soon as possible when mother returns home
Second visit - day 3
Third visit - day 7 (if possible)
NB: At least one home visit during antenatal period will be required

Recommendation: content of home visits
Ensure basic newborn care (or essential newborn care ):
Early & exclusive breastfeeding
Maintenance of warmth
Hygienic cord and skin care
Caretaker’s hand washing
Assess for danger signs and refer
Counsel on danger signs and prompt care seeking
Identification and support for newborns with conditions that require additional care
(e.g. LBW or sick baby, mother is HIV+)
Mother :
Ask and counsel about danger signs and prompt care seeking
Counsel on birth spacing and nutrition

Recommendation: Who should make visits?
Ideally - should be skilled health workers but….
Realistically it is:
Existing community health workers (paid and/or
volunteers)
Malawi - Health Surveillance Assistants
(HSAs)
Indonesia - Community midwives
India - Anganwadis and ASHAs
Nepal - Female community health volunteers
Ethiopia - Health Extension Workers (HEWs)
Rwanda - Female health worker (ASM)
Create new CHWs (paid and/or unpaid)
IT IS ESSENTIAL THAT CHWs HAVE KNOWLEDGE AND SKILLS TO ACCOMPLISH WELL DEFINED TASKS

Program implementation guidance
National PNC service delivery situation analysis
Policy dialogue and adoption
Potential policy changes for CHWs to:
Assess newborns
Coach mothers and families to practice KMC
Provide oral and/or injectable antibiotics
Manage asphyxia with resuscitation equipment
Adoption of PNC home care delivery strategy where appropriate
Recruit and/or train health workers or CHWs
Ensure continued professional development and motivation
Strengthen health system (logistics, supervision and referral linkages) to support PNC
Ensure community awareness and engagement in PNC services
Document the process and results especially community-based management of neonatal sepsis, LBW babies and asphyxia.

Health system requirements
Health workers are from and/or live within communities
Functional linkage of community health workers and facilities (e.g., referral, transport, supervision & monitoring, quality assurance)
Integration of services delivered by health worker and first-level facility across the continuum
Pregnancy surveillance, antenatal visits & ANC, care at delivery, early postnatal care, community case management, immunization & nutrition
Integration with existing programs (eg, Safe Motherhood, IMCI, PMTCT)

Steps to implement Joint Statement
Countries should analyze policies, practices, and delivery platforms to identify potential of postnatal home visits to improve newborn survival.
Prioritize home visits where access to facility-based care is limited, including after discharge for facility births.
Utilize existing delivery platforms of community health workers and volunteers, ensure linkage of CHWs to health system and quality of referral care,
Monitor early PNC coverage and quality, key newborn care practices, and health outcome indicators.

Saving Newborn Lives: Home Visits Within National Delivery Platforms Bangladesh GoB and BRAC community health workers ANCC, PNC visits Pakistan GoP Lady Health Workers CM, ANCC, PNC; attendance home births (resus, LBW extra care, identify infection and begin antibiotics Nepal National Neonatal Health Strategy Female community health volunteers (FCHV) Indonesia GoI Community Midwives ( Bidan di desa ) Bidan di desas (community midwives) Malawi MOH policy; OR demonstrating “how” Health Surveillance Assistants Ethiopia National MOH standards Health Extension Workers LAC Regional Neonatal Health Strategy; OR demonstrating “how” Various cadres (CHWs, ANMs )

Country Experience
Background:
Population of ~14 million
Low resource country (GDP per capita - US$ 290)
HIV prevalence 12%
Inadequate numbers of health service providers/skilled birth attendants/low physician density
MALAWI:

Country Experience
Background cont:
Maternal mortality ratio - 807/100,000 live births (MICS 2006)
Neonatal mortality rate - 33 per 1,000 live births (MICS 2006)
Over 17,000 newborn deaths each year
MALAWI:

Causes of neonatal death (estimated for 2005) Source : Lawn JE et al. 2006 MALAWI: Three causes account for ~84% of neonatal deaths in Malawi

Coverage of key packages along the continuum of care Source: MICS 2006 Gap in coverage between poorest and least poor MALAWI:

Focus:
Increasing community knowledge and practice of key maternal and newborn health behaviours and demand for care.
Improving access, availability and quality of existing facility-based maternal and newborn care services along the household-to-hospital continuum of care, including training (IMNCI) and provision of equipment and supplies.
E valuating results of community-based maternal & newborn care in terms of program cost, feasibility and changes in behaviours and coverage of care .
Community Based Maternal & Newborn Care (CBMNC) Program MALAWI:

CBMNC Program
Program is implemented in partnership with:
MOH-RHU, CHAM, Save the Children, UNICEF,
MCHIP, WHO, Norwegian Church Aid and UNFPA
Started in 2007 - 3 year demonstration implemented in 3 districts to evaluate the feasibility, cost and outcomes of a CBMNC package
Scale-up of program interventions underway district-wide and in 4 other districts (7 total)
In the pipeline - 5 additional districts (12 of 28)
MALAWI:

CBMNC Program - Milestones
2006 - MOH representatives made a learning visit to SEARCH in India (Dr. Abhay Bang ). Success of this CBMNH program in Asia influenced and motivated Malawi policy makers
February 2007 - program design workshop held
2008-ongoing - training of HSAs in CBMNC & CM
2010 – Malawi government has mandated all partners interested in CMNH to use the CBMNC package
MALAWI:

CBMNC: Role of Health Surveillance Assistants (HSAs)
MNH services are promoted through community mobilization and structured home visits by HSAs
HSAs are trained to:
Facilitate community mobilization
Counsel pregnant and recently delivered women on importance of attending ANC, birth preparedness, clean delivery, delivery by skilled attendant, ENC, identify mothers and newborns with danger signs and refer
Make 3 home visits to pregnant women, then to women and newborns within 24 hours, at day 3 and day 8 post-delivery
MALAWI:

CBMNC - HSA Training
HSAs undergo a 10-day CBMNC training and 8-day CM training.
Trainings to date
CBMNC 60 trainers; 1079 HSAs trained
Community Mobilization 66 trainers; 913 HSAs
Other related trainings held on Kangaroo Mother Care (KMC)
MALAWI:

CBMNC: Moving to Scale
MOH-RHU has taken a leadership role
Feb. 2010 mandated all partners implementing CBMNC to use the integrated national package
July 2010 national dissemination of integrated CBMNC package to facilitate scale up
UNICEF contributed to the production of CBMNC training manuals for national use and procured equipment and supplies
DHO/district and health center teams responsible for supervision
Media products developed to facilitate dissemination
MALAWI:

CBMNC: Challenges
Resource constraints
Training pace slower than anticipated
CBMNC scale-up to other districts delayed
Some partners resistant
Logistics
Many HSAs reside outside their catchment areas
No transportation available to facilitate home visits and supervision
Work overload for HSAs heavily tasked with community and facility duties
MALAWI:

CBMNC: Challenges cont
M&E and Supervision
Poor data flow at all levels
Delays in flow of data from peripheral to central level
Some newborn indicators not integrated with the HMIS
No transportation available to facilitate HSA supervision
Health facility services
Overwhelming demand for labour and delivery services at health facilities
Work overload for midwives and constrained resources at health facilities
How to maintain quality of services while moving to scale
Cultural issues
Women hide their pregnancies in first trimester for fear of witchcraft, hence late ANC attendance
MALAWI:

CBMNC: Lessons Learned
Need to improve data flow, data use and integration with HMIS
District Health Offices (DHOs) to aggressively pursue strategies to ensure HSAs reside in their catchment areas
Successes in implementing CBMNC creates challenges at H/F level leading to congestion accompanying severe understaffing
MALAWI:

CBMNC : Lessons Learned cont .
To promote institutionalization of CBMNC
Involvement of government and key partners is crucial from the start
Implementation within prevailing structures and staffing structures of the MOH reduces perception of CBMNC as a parallel program
Key involvement of DHMTs and Zonal Offices in planning, implementation and M&E processes, strengthens ownership and facilitates scale up
MALAWI:

CBMNC: Conclusions
Mid-term evaluation of the 3 demonstration districts showed that it is feasible to equip HSAs with knowledge and skills to provide key MNH interventions related to structured home visits.
LQAS showed HSA coverage of home visits: ANC 70%, PNC 60%
Home visits by CHW have led to improved MNH household care-seeking practices
Structured CHWs home visits can be adopted and scaled-up to improve MNH services
CBMNC can move to scale within integrated packages and effective partnerships with efforts directed towards the following: a dedicated CBMNC taskforce; appropriate program design; CHW training; availability of community materials and supplies; implementation support; evaluation of interventions; and costing
MALAWI:

Service Delivery & Program Implications
What Next?
Although home visits are underway in several countries, several challenges still exist and work is not completed yet
So……….
What can PVOs, Partners and Programs do to reach the unreached?

What Next: Considerations
How can PVOs/Programs help improve/ensure the
following?
Training of CHWs
Length of trainings and integration into other related basic CHW training
Quality of trainings in the context of district wide/country wide scale up
CHW quality service delivery
Ensure CHWs focus on community services/home visits
Strengthen supervision and performance reviews of HSAs
Referral and health facility system overload
MNH data - c ommunity to district/central levels
Data collection, data flow and data use within programs and integration within HMIS
Use of new technology e.g. cell phone
Logistics management and support
Supplies and equipment
Transportation

Thank you!

Group Discussion Session
GRP 1 : Discuss and share information regarding current models for effectively reaching mothers and newborns during pregnancy and postnatal period through home visits. Highlight successes, challenges and gaps
GRP 2 : How can PNC/PPC be incorporated and/or strengthened within current or upcoming programs? Provide program and country examples if possible
GRP 3 : In countries where MNCH national programs exist, what critical role or contributions can PVO and partners make towards scale-up of such PNC/PPC interventions?
Consider needs related to funding, technical assistance and other support as would be needed

Mwebesa abwao newborn_health

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