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Home visits for the newborn child

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  • 1. WHO/UNICEF Joint StatementHome visits for the newborn child: a strategy to improve survival
  • 2. E very year, about 3.7 million babies die in the first four weeks of life (2004 estimates). Most of these newborns are born in developing countries and most die at home. Up to two-thirds of these deaths can be prevented if mothersand newborns receive known, effective interventions (1). A strategy that promotesuniversal access to antenatal care, skilled birth attendance and early postnatal carewill contribute to sustained reduction in maternal and neonatal mortality.While both mothers and newborns need care during the period after birth, thisstatement focuses on the care of the newborn child, and the evidence for the same(2).* Studies have shown that home-based newborn care interventions can prevent30–60% of newborn deaths in high mortality settings under controlled conditions(3–7). Therefore, WHO and UNICEF now recommend home visits in the baby’s firstweek of life to improve newborn survival.Figure 1Causes of neonatal deaths Deaths among children under five Neonatal deaths Other 9% Congenital abnormalities 7% Deaths in older Diarrhoeal diseases infants and children Neonatal tetanus 3% 3% 63% Neonatal infections 25% Neonatal deaths 37% Birth asphyxia and birth trauma 23% Prematurity and low birth weight 31%Source: World Health Organization. The Global Burden of Disease: 2004 update. World Health Organization, Geneva, 2008.Nearly 40% of all under-five child deaths occur birth and during the newborn period (Figurein the first 28 days of life (the neonatal or 2), and a continuum of care from the home andnewborn period). Just three causes – infections, community, to the health centre and hospitalasphyxia, and preterm birth – together account and back again. Skilled care during pregnancy,for nearly 80% of these deaths (8) (Figure 1). childbirth and in the postnatal period preventsAdditionally, a baby born with low birth weight, complications for mother and newborn, andparticularly if preterm, is at much greater risk of allows their early detection and appropriatedying or getting sick than other newborns. management.The core principle underlying maternal, Three-quarters of all neonatal deaths occurnewborn and child health programmes should during the first week of life, 25–45% in the firstbe the “continuum of care”. This term has two 24 hours (9) (Figure 3). This is also the periodmeanings – a continuum in the lifecycle from when most maternal deaths occur. Fortyadolescence and before pregnancy, pregnancy, seven percent of all mothers and newborns in developing countries do not receive skilled care during birth (10), and 72% of all babies* This statement focuses on the care of the newborn child. born outside the hospital do not receive any Newborn child is defined in this document as a child less than four weeks of age. Care of the mother is addressed postnatal care (11). These are the critical gaps in in other WHO, UNICEF and UNFPA documents. the continuum of care.2
  • 3. Figure 2 The lifecycle continuum of care Postpartum Maternal health Adolescencce and Birth Pregnancy before pregnancy Postnatal (newborn) Infancy Childhood Figure 3 and where continuous professional care cannot Daily risk of death during the first month of life be assured, is that they should seek postnatal 10 care as soon as possible after birth (12).Daily risk of death (per 1000 survivors) Many mothers cannot comply with the above 8 recommendations because of financial, social or other barriers. The coverage of postnatal 6 care within 24 hours of birth among all women giving birth at home is only 13% (11). 4 Evidence: Studies conducted in Bangladesh, India and Pakistan have shown that home 2 visits can reduce deaths of newborns in high- mortality, developing country settings by 0 30 to 61% (3–7). The visits have improved 0 10 20 30 Day of life coverage of key newborn care practices such as early initiation of breastfeeding, exclusive Source: Lawn JE, Cousens S, Zupan J. 4 million neonatal breastfeeding, skin-to-skin contact, delayed deaths: When? Where? Why? Lancet 2005; 365:891–900. bathing and attention to hygiene, such as (Based on 47 DHS surveys conducted from 1995–2003). hand washing with soap and water, and clean umbilical cord care. This evidence complements the experience from developed country settings Even if birth occurs in a health facility, in which has shown that postnatal home visits are many settings, mothers and newborns are effective in improving breastfeeding rates and discharged within a few hours, and have no parenting skills (13–14). further contact with a health provider until the 6 week postpartum and immunization visit. Recommendation: Home visitations after birth Births at home pose an even greater challenge is a strategy to deliver effective elements of care for providing care to mothers and newborns to newborns and increase newborn survival. during the critical hours and days after birth. This This strategy has shown positive results in can be addressed by introducing home visits high mortality settings by reducing newborn as a complementary strategy to facility-based mortality and improve key newborn care postnatal care to increase coverage of care and practices. improve newborn survival. When should home visits be made? Home visits for care of the newborn Evidence: No evidence-based recommendation WHO and UNICEF recommend that care be has been established until now for the optimal provided by a skilled attendant during and timing and number of newborn care contacts. immediately after birth irrespective of where However, the first days of life are critical because the birth takes place. Women who give birth most neonatal deaths occur in this period – in a health facility and their newborns should 25−45% in the first 24 hours (9) and over 50% be assessed for problems and given a specific in the first 48 hours (9). Most neonatal deaths date to return for further postnatal care, even occurring after 48 hours can be prevented by if everything is going well, and advised to appropriate newborn care starting immediately return immediately if they notice any danger after delivery. All studies that support this signs (12). The recommendation for women statement included home visits on days 1 and 3 who give birth at home without skilled care, of life to ensure a postnatal contact and support 3
  • 4. for improved care. Evidence from Bangladeshsuggests that newborns who were visited within Newborn care during home visitsthe first 48 hours after birth at home had lower in the first week of lifesubsequent mortality than those visited later. It • Promote and support early (within the first houris also widely acknowledged that breastfeeding after birth) and exclusive breastfeeding;support is crucial during the first days after birth. • Help to keep the newborn warm – promote skin- to-skin care;Recommendation: For all home births a visit • Promote hygienic umbilical cord and skin care; • Assess for danger signs and counsel on theirto a health facility for postnatal care as soon prompt recognition and care seeking by theas possible after birth is recommended. In family (not feeding well, reduced activity,high mortality settings and where access to difficult breathing, fever or feels cold, fits or convulsions);facility based care is limited, WHO and UNICEF • Promote birth registration and timely vaccinationrecommend at least two home visits for all according to national schedules;home births: the first visit should occur within • Identify and support newborns who need24 hours from birth and the second visit on additional care (e.g. LBW, sick, mother HIV- infected).a If feasible, provide home treatmentday 3. If possible, a third visit should be made for local infections and some feeding problems.before the end of the first week of life (day 7). Maternal care during home visits inFor babies born in a health facility, the first the first week after birth ahome visit should be made as soon as possible • Ask about mother’s well beingafter the mother and baby come home. The • Ask about excessive bleeding, headache, fits,remaining visits should follow the same fever, feeling very weak, breathing difficulties, foul smelling discharge, painful urination, severeschedule as for home births. abdominal or perineal pain. If she has any of these symptoms, refer her to a health facility for care • Ask for swollen, red or tender breast or nipples,What should be done at a home visit? manage breastfeeding problems if possible, ifEvidence: Research has shown that families not, refer her to a health facility for care • Counsel about danger signs for mother andhave difficulties in recognizing signs of severe newborn and advise on where to seek early careneonatal illness, particularly in the first week when neededof life, and in seeking appropriate care. Studies • Provide birth spacing and nutrition counsellinghave found that home visits help families in a These interventions should be delivered byidentifying newborn problems early and in appropriately trained and supervised health workers.dealing with constraints to care seeking from If home visits are done by a midwife or another skilled professional, care of the mother should includeappropriate providers. Home visits have also additional interventions as recommended in WHObeen shown useful to promote practices to keep IMPAC guideline, Pregnancy, Childbirth, Postpartum andthe baby warm, promote exclusive breastfeeding Newborn Care: A guide for essential practice.and its early initiation, and to improve hygiene.Recommendation: Basic care for all newbornsshould include promoting and supportingearly and exclusive breastfeeding, keeping need greater support for keeping them warm,the baby warm, increasing hand washing and initiating early and exclusive breastfeeding,providing hygienic umbilical cord and skin care, and preventing infections. Clinically stableidentifying conditions requiring additional care LBW babies born in hospitals who are providedand counselling on when to take a newborn to exclusive breastfeeding and warmth througha health facility (see Box). Newborns and their skin-to-skin contact with the mother have amothers should be examined for danger signs at lower incidence of infections, feed better, andhome visits. At the same time, families should gain weight more rapidly compared to babiesbe counselled on identification of these danger provided care in incubators. In addition to thesigns and the need for prompt care seeking if postnatal care interventions for all newborns,one or more of them are present. those with LBW should be given: • Increased attention to keeping the newbornSpecial conditions warm, including skin-to-skin contact with the mother;Low birth weight (LBW) babies, particularlythose who are born earlier than term, need • Assistance with initiation of breastfeedingadditional care to survive and stay healthy. They within the first hour after birth. This may4
  • 5. mean helping the mother to express breast prophylaxis for opportunistic infections, milk and feed the newborn with a cup if the and antiretroviral treatment when indicated. baby is not strong enough to suckle. If a baby Community health workers particularly need to is unable to accept cup feeds, he/she should be aware of the issues around infant feeding so be referred to a hospital; that they can promote and support appropriate feeding practices, and understand that many• Extra attention to hygiene, especially hand HIV-infected newborns are born premature and washing; are more susceptible to infections.• Extra attention to danger signs and the need for early care seeking and referral; Who can make the home visits?• Additional support for breastfeeding and Postnatal care should be provided by skilled monitoring growth. health workers. These are also best suited toSick newborns need urgent treatment to make home visits for newborn care. They canprevent death. Treatment for local infections perform all the essential tasks for providingand some feeding problems can be provided preventive and curative care. In many settings,at a health facility or at home. The families of this option is not feasible due, for example,newborns identified as having severe illness at to shortages of skilled health workers, lack ofhome visits should be assisted to seek hospital transportation, or a workload that does notor facility-based care. In situations where allow them to make timely and repeated homereferral to a hospital is not possible, treatment visits. In such settings, many of the essentialwith antibiotic injections should be provided in tasks for basic newborn care can be carried outfirst-level health facilities on an outpatient basis. by trained auxiliary health workers or trainedIn a setting in Nepal where referral to hospital community health workers who are eitherwas not possible for most families, a study part of the health care delivery system or areshowed that recognition of severe illness and linked to it. Examples of workers in existingadministration of oral antibiotics by community government programmes who have been givenhealth workers and referral to facility-based the responsibility of making home visits forhealth workers for provision of daily antibiotic newborn care include:injections substantially improved access to • Community midwives in Indonesia: Overtreatment. Research studies conducted in two-thirds of births in Indonesia are assistedBangladesh and India in areas with poor access by skilled birth attendants, a substantialto health facilities have successfully used proportion by community midwives (Bidanappropriately trained and well-supervised di Desas). These midwives are mandated tocommunity health workers to give antibiotic provide maternal and newborn care throughinjections at home. This, together with other follow-up home visits.interventions, has been shown to reducesignificantly mortality in controlled settings. • Community workers in IntegratedBefore they can be recommended by WHO and Management of Neonatal and ChildhoodUNICEF for inclusion in programmes, however, Illness (IMNCI) programme in India: Indiathe safety and long-term sustainability of these has adapted the Integrated Management ofapproaches need to be further evaluated in Childhood Illness (IMCI) strategy to includestudies in routine settings. an additional focus on newborn health, renaming it IMNCI. The IMNCI strategyNewborns of HIV-infected mothers need special includes postnatal home visits by villagecare. To prevent mother-to-child transmission level workers (Anganwadi workers and, inof HIV and strengthen the continuum of care, some sites, by the newly created cadre ofmothers should be provided with information ASHAs).and support to enable HIV-infected womenand their newborn to access additional care • Female community health volunteers inand services available at the health facility, Nepal: Female community health volunteerssuch as antiretroviral prophylaxis to mothers (FCHVs) in Nepal have been used in pilotand newborn infants, lifelong antiretroviral programmes to deliver home-based maternaltreatment for mothers when indicated, and newborn care. FCHVs are members ofinfant feeding counselling and support, HIV- the communities they serve and are alreadytesting and care of exposed infants, including providing support for immunization, vitamin 5
  • 6. A distribution and treatment of diarrhoea • Ensuring continued professional develop- and pneumonia. A national strategy to scale ment and motivation of health workers, up home-based newborn care has been including community health workers; developed. The newborn care programme • Strengthening the health system to support will have FCHVs present at the birth and health workers to deliver postnatal newborn visiting on days 3 and 7 after birth to services and care, including regular supplies, promote healthy practices and to recognize supervision and referral links; illness and arrange treatment. • Supporting communication efforts for• Health Surveillance Assistants (HSAs) in community awareness and involvement in Malawi: In six districts, as part of a phase- postnatal care. in approach for scaling up, HSAs are being trained to carry out home visits during pregnancy and immediately after delivery Recommendations for countries to improve maternal and newborn care practices, awareness of danger signs and 1. All newborns should receive appropriate care early care seeking. especially in the first hours and week of life when they are most vulnerable. Additional• Health extension workers in Ethiopia: These services and care should be provided for workers, who deliver a basic package of care, special conditions such as low birth weight, are supported by community volunteers HIV infection in mothers and newborn for many health promotion activities. illnesses. Again, these front line health workers and volunteers are being used to provide home- 2. Each country should analyse the current based maternal and newborn care after policies and practices related to pregnancy, appropriate training. childbirth and postnatal care, including facility-based delivery, discharge from facilities after birth, care for mother givingProgramme components required for birth at home, and the potential role of homeimplementation of home visits for visits to improve newborn survival.newborn care strategy 3. A home visitation program is recommended• Adopting the policy of providing home visits where access to facility-based skilled for newborn care in the first week of life; care is limited. The assignment of health workers to such programs will depend on• Identifying the best channel of delivering the current level of distribution of staff, their postnatal home care based on cost competencies to deliver this service and effectiveness and sustainability; the availability of supplies and supervision.• Assessing the current level and distribution Whenever skilled health workers are not of staff and their competencies to deliver available, countries should explore the the required services and care for newborn potential involvement of community survival; health workers in the care for mothers and newborns in the days and hours after birth.• Where appropriate, adopting the strategy of providing home visits for newborn care 4. The content of a home visit program will in the first week of life by community health depend upon the skilled care in pregnancy, workers as a complementary strategy childbirth and postnatal care available in the to facility-based and home-based care specific context. by skilled health workers. If necessary, a. For births in health facilities, repeated adjust regulatory and legal framework check-ups and counselling (care practices, for community health workers to provide danger signs) for the mother and baby postnatal care. before discharge and ageeing to a return• Recruiting, training and deploying health date for follow-up or a home visit. workers, including community level workers, b. For home births, repeated check-ups and to provide newborn care through postnatal counselling (care practices, danger signs) home visits; for the mother and baby should be part of the routine care.6
  • 7. 5. Home visits should be initiated as soon as References possible after birth or after returning home 1. Darmstadt GL et al. Lancet Neonatal Survival from the facility. A visit within the first 24 Steering Team. Evidence-based, cost-effective hours after birth is likely to be most effective in interventions: how many newborn babies can we reducing newborn mortality. Additional visits save? Lancet, 2005 Mar 12–18, 365(9463):977–88. on day 3 and, if possible, on day 7 can improve 2. Making pregnancy safer: The critical role of the home care practices and identify danger signs skilled attendant: a joint statement by WHO, ICM or illness. Home visits can be done by health and FIGO. World Health Organization, Geneva, professionals or by appropriately-trained 2004. community health workers. 3. Bang AT et al. Effect of home-based neonatal care and management of sepsis on neonatal6. Programmes should emphasize the mortality: field trial in rural India. Lancet, 1999, importance of increasing community 354(9194):1955–61. awareness and knowledge of home-based 4. Bang AT (unpublished, personal communication). care practices to improve newborn survival. 5. Baqui AH et al. Projahnmo Study Group. Effect7. Postnatal home care by community health of community-based newborn-care intervention workers should be linked to the health package implemented through two service- system and the full continuum of care. delivery strategies in Sylhet district, Bangladesh: Health services should try to bring postnatal a cluster-randomised controlled trial. Lancet, 2008 371(9628):1936–44. care as close as possible to the home and the family. Gaps in services including 6. Kumar V et al. Saksham Study Group. Effect skilled attendance at birth and treatment of of community-based behaviour change management on neonatal mortality in Shivgarh, newborn illness need to be addressed as Uttar Pradesh, India: a cluster-randomised part of a programmatic approach. This will controlled trial. Lancet, 2008, 372(9644):1151–62. often include increasing and strengthening 7. Bhutta ZA et al. Implementing community- human resources for health, increasing based perinatal care: results from a pilot study financial resources allocated to postnatal in rural Pakistan. Bull World Health Organ, 2008, care, ensuring availability of medicines and 86(6):452–9. other supplies, monitoring and supervision, 8. World Health Organization. The Global Burden of improving the referral system and removing Disease: 2004 update. World Health Organization, barriers to access srvices. Geneva, 2008 (ISBN 978 92 4 156371 0). 9. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet, 2005,UNICEF, WHO and partners will 365:891–900.support these actions by: 10. Countdown to 2015. Tracking progress in1. Advocating, assisting and investing maternal, newborn & child survival: the 2008 resources for country adoption of these report. New York, United Nations Children’s Fund, 2008 (http://www.countdown2015mnch.org/). recommendations and adaptation to local health systems contexts and cadres; 11. Fort Al, Kothari MT, Abderrahim N. Postpartum care: levels and determinants in developing2. Working with governments and non-govern- countries. DHS Comparative Report No. 15. Macro ment organizations to rapidly disseminate International Inc. Maryland, 2006. these recommendations and encourage gov- 12. World Health Organization. Pregnancy, childbirth, ernments, NGOs and communities to adopt postpartum and newborn care: a guide for these recommendations; essential practice. World Health Organization, Geneva, 2006 (ISBN 92 4 159084 X).3. Assisting capacity building and functioning 13. Hannula L, Kaunonen M, Tarkka MT. Helsinki of health care providers and community Polytechnic Stadia, Health Care and Social health workers to provide home-based Services A systematic review of professional newborn care through development and use support interventions for breastfeeding. J Clin of guidelines and training materials and other Nurs. 2008;17(9):1132–43. activities as needed; 14. Olds DL, Kitzman H. Can home visitation4. Helping with communication efforts aimed improve the health of women and children at environmental risk? Pediatrics. 1990;86(1):108–16. at promoting antenatal care, skilled care at birth and postnatal care for mothers and newborns. 7
  • 8. This WHO-UNICEF Joint Statement is supported by the following agencies: Process of development of this statementA technical consultation on community-based newborn care and treatment of neonatal sepsis wasjointly organized by WHO, Save the Children (SC) and USAID in London, in September 2007. Allpublished and unpublished research studies evaluating home-based newborn care interventionsin high-mortality settings were presented and reviewed by an independent panel of experts. Theexperts declared not to have any conflicts of interest. The key conclusions of the expert panel werethat community-based interventions reduced neonatal mortality, including early neonatal mortality,and that home visits by community health workers were common to almost all studies. Followingthe technical consultation, WHO’s Department of Child and Adolescent Health and Developmentcommissioned a systematic review of literature on this issue, which confirmed the conclusions ofthe consultation. Based on the above, this Joint Statement was drafted by WHO and UNICEF staff,and was reviewed by SC and USAID staff. The draft was reviewed by the expert panel and theircomments were incorporated into the final version. This statement will be reviewed and updated two years after publication.World Health Organization United Nations Children’s FundDepartment of Child and Adolescent Health and Health Section, Programme Division Development 3 United Nations Plaza20 Avenue Appia, 1121 Geneva 27 New York, NY 10017Switzerland USATel: +41 22 791 3281 Tel: +1 212 326 7000Fax: +41 22 791 4853 www.unicef.orgE-mail: cah@who.intwww.who.intWHO/FCH/CAH/09.02© World Health Organization 2009All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World HealthOrganization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercialdistribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int).All reasonable precautions have been taken by the World Health Organization to verify the information contained in thispublication. However, the published material is being distributed without warranty of any kind, either expressed or implied.The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World HealthOrganization be liable for damages arising from its use.Cover: © UNICEF/NYHQ2006-2706/Noorani8

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