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Newborn survival lessons fromthe Western Pacific region –two stories from our knowledge hub workChris Morgan
The problem in certain settings in our region•  Places with the highest   maternal and newborn   mortality generally have ...
Provoked one stream of knowledge collation•    There are forms of community-based        Established packages for     care...
Site analyses
Collaboration with World Vision for an“evidence-based policy-advocacy’ study •  … on the potential of “Family and Communit...
An interventions and service delivery analysis ofFamily and Community Care for maternal andchild survival in PNG -
What we concluded•  In places where the maternal and   newborn mortality rates are still   relatively high…•  FCC interven...
Two ways to view familyand community care,provided by VHVs, inPNG•  A complement to the current investment in re-building ...
What came next
Another story – unique to East Asia andthe Western Pacific•  Most of the operational research demonstrating   the efficacy...
Rationale for early post-natal care andvaccination visits in homes- in Angoram District, East Sepik Province (our study si...
THE STUDY: A small feasibility trialof expanded health services, in adifficult but characteristic location •  To answer th...
MINIMAL POSTNATAL PACKAGEfor community or aid-post level•  Hepatitis B vaccine   –  within 24 hours of birth, w UnijectTM•...
Trainers                    Manual                  IEC brochure                      draftBoth translated into Tok Pisin
IMPLEMENTATION•  Training of staff and VHVs:   –  13 rural health staff (NOs & CHWs)   –  212 VHVs (175 female)•  Provisio...
Extract fromthe VHVbirth andpostnatalcare recordform
EVALUATION - POSITIVE OUTCOMES•  Coverage with birth-dose increased   –  83% overall (cf district average 24%)   –  74% (h...
EVALUATION -SURPRISES•  Births in health centres increased   –  often a VHV accompanied and      attended the birth in the...
Global extensions•  2009 WHO Position Paper adopted the policy led by   WPRO   –  “In all regions of the world, all infant...
WCH Knowledge Hubsupported WHOexpansion efforts•  WHO global consultation   on birth-dose held in   Melbourne, Dec 2010•  ...
Issues for newborns:                    To finish:-  timing of home visit-  preventive care only, or             Some crit...
The value ofkangaroo careMorgan and Rongong.Use of KangarooNursing Method inWestern Nepal;J Nepal Med Assoc, Jul-Sep 1997 ...
A short history of baby care•  BC 2000    –  “Just carry it next to your skin. Breastfeed it       whenever it is hungry.”...
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Chris Morgan, Burnet Institute

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Newborn survival and perinatal health in resource-constrained settings in Asia and the Pacific: Applying Global Evidence to Priorities Beyond 2015
12 April 2013

Published in: Health & Medicine
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Transcript of "Chris Morgan, Burnet Institute"

  1. 1. Newborn survival lessons fromthe Western Pacific region –two stories from our knowledge hub workChris Morgan
  2. 2. The problem in certain settings in our region•  Places with the highest maternal and newborn mortality generally have the worst access to services, and higher rates of home-birth.•  Most deaths of mothers and many deaths of babies occur on or near the day of birth,•  WHO and national strategies recommend childbirth care in Like Nepal a health facility, but this takes time to scale up –  PNG Maternal Task Force or PNG, plans 60% of all pregnant or Lao PDR women having skilled or…. attendant at delivery by 2015 and 80% by 2020
  3. 3. Provoked one stream of knowledge collation•  There are forms of community-based Established packages for care at childbirth, that could be newborn care (warmth, delivered by trained lay health workers hygiene, EBF), clean delivery or community-based staff kits;•  Some are interim measures to meet the immediate crisis in maternal deaths. Community mobilisation,•  Could maybe reduce maternal and facilitated referral; newborn deaths by 30% or more. Oxytocics from trained•  However, they must be introduced in a workers or self-administered; carefully measured fashion, using a systems approach, to monitor for impact Antibiotics from trained and unforeseen consequences. workers (lay or paid); and ? pre-filled injection devices Recognising the many other for vaccination or oxytocics. determinants, such as family planning, girls’ education and nutrition etc
  4. 4. Site analyses
  5. 5. Collaboration with World Vision for an“evidence-based policy-advocacy’ study •  … on the potential of “Family and Community Care” that is: care by family and community members, rather than by health professionals” –  Eg by “trained lay health workers” – aka VHVs •  We did a –  Comprehensive literature review of international publications to find interventions or packages delivered by FCC –  Determined a simple cost-effectiveness rating and excluded any that were not good value for money –  Researched their current or past application on PNG through publication and contacting experts
  6. 6. An interventions and service delivery analysis ofFamily and Community Care for maternal andchild survival in PNG -
  7. 7. What we concluded•  In places where the maternal and newborn mortality rates are still relatively high…•  FCC interventions could avert deaths: –  Up to one third of maternal deaths –  Up to two thirds of newborn deaths –  Up to half of child deaths•  PNG already has a variety of experiences with nearly all interventions researched
  8. 8. Two ways to view familyand community care,provided by VHVs, inPNG•  A complement to the current investment in re-building the health infrastructure, training more health workers (including midwives) and strengthening systems –  FCC can help engage communities in a stronger HSS process•  A stop-gap for get some high impact interventions to mothers and children, while the health system is being rebuilt –  Might require innovative approaches and some risk-benefit analysis
  9. 9. What came next
  10. 10. Another story – unique to East Asia andthe Western Pacific•  Most of the operational research demonstrating the efficacy of community-based newborn care has come from South Asia•  Meanwhile, in East Asia and the Pacific, it has been immunization programs that focused on the first 24 hours after birth –  The critical period during which vaccination against hepatitis B can interrupt perinatal transmission of hepatitis B (the form most likely to lead to chronic liver disease and death)•  Scale-up of this has been a major push for the WHO WPRO
  11. 11. Rationale for early post-natal care andvaccination visits in homes- in Angoram District, East Sepik Province (our study site)•  Coverage of HepB birth dose is low: –  National: 16% 2005 survey), 25% (2008 NHIS) –  East Sepik: 27% Prov, 18% Angoram (2008 NHIS)•  Proportions of childbirth occurring in health facilities had not increased for 10 years - between 30 and 40% –  But our partner, Save International PNG, has a good network of village health volunteers•  Maternal and newborn mortality is high and postnatal care underutilised•  Indonesia has supported hepatitis B vaccine in Uniject, –  makes injection by LHWs feasible
  12. 12. THE STUDY: A small feasibility trialof expanded health services, in adifficult but characteristic location •  To answer the questions: –  Can postnatal care be expanded for home births? –  Can birth-dose vaccination reach home births? –  Can combining the two result in synergy rather than fragmentation or competition? •  Providing –  birth-dose vaccination for hepatitis B vaccination (HBV) using UnijectTM in a real-world setting, including out-of-cold chain usage –  Integrated with early post-natal visits for home births in a remote district •  Provision by –  Trained lay Village Health Volunteers (VHV), –  Nursing Officers (NOs) and Community Health Workers (CHWs)
  13. 13. MINIMAL POSTNATAL PACKAGEfor community or aid-post level•  Hepatitis B vaccine –  within 24 hours of birth, w UnijectTM•  Essential information: –  breast-feeding and nutrition for the mother and baby –  warmth and hygiene (inc. cord care) –  signs of infection in mother/baby, how to prevent and respond•  Additional information and care –  weighing the baby and information on care of low-birth weight babies, especially for temperature control –  routine postnatal care for mother and baby, including further routine immunisations –  family planning•  Vitamin A for the mother
  14. 14. Trainers Manual IEC brochure draftBoth translated into Tok Pisin
  15. 15. IMPLEMENTATION•  Training of staff and VHVs: –  13 rural health staff (NOs & CHWs) –  212 VHVs (175 female)•  Provision of services in four health centre catchments: –  UnijectTM HBV procurement and distribution via govt systems –  Services to more than 364 mothers•  Monitoring and supervision by a locally based project officer –  birth and postnatal visit record form, designed for use by VHVs –  calendar to ensure vaccine out of the cold chain < 30 days•  Evaluation –  using project databases - 2 for triangulation –  two visits with structured questionnaires for qualitative data gathering - involved National Dept of Health and WHO
  16. 16. Extract fromthe VHVbirth andpostnatalcare recordform
  17. 17. EVALUATION - POSITIVE OUTCOMES•  Coverage with birth-dose increased –  83% overall (cf district average 24%) –  74% (homebirths), 93% (health centre)•  Use of VHVs extended coverage: –  ~ 10 VHVs for every paid staff member•  VHVs vaccinated safely, using Uniject•  Out-of-cold chain management of HBV feasible and appropriate, vaccine vial monitors used appropriately•  Active VHVs credited the level of support provided by Save and Burnet VHV Unitha Longhi providing birth-dose vaccination w UnijectTM•  Most of postnatal package provided most of the time (but Vit A only 62%)•  Having a vaccine role motivated greater attendance at birth for VHVs•  Good community acceptance
  18. 18. EVALUATION -SURPRISES•  Births in health centres increased –  often a VHV accompanied and attended the birth in the health facility, with staff on stand-by•  UnijectTM use in health centres –  contributed to increased coverage there as well as at community level –  staff found it far easier the multi-dose vial•  Considerable new information regarding birth outcomes and care-seeking behaviour –  very high rates of obstetric complications and death persist –  our program could only really influence newborn outcomes and possibly puerperal sepsis
  19. 19. Global extensions•  2009 WHO Position Paper adopted the policy led by WPRO –  “In all regions of the world, all infants should receive the first dose of hepatitis B vaccine as soon as possible (<24 hours) after birth. This should be followed by two or three doses to complete the series.” –  Adopted as part of the World Health Assembly’s resolution on the control of viral hepatitis in 2010 –  New global hepatitis program established at WHO in 2011•  Implications for other regions –  African and South Asian settings with high home birth rates that have not yet introduced birth dose vaccination –  Can vaccination leverage better maternal/newborn care or will it be a burden on over-stretched systems?
  20. 20. WCH Knowledge Hubsupported WHOexpansion efforts•  WHO global consultation on birth-dose held in Melbourne, Dec 2010•  Systematic review of global practices to provide birth-dose vaccination –  A chance to ensure that integration with postnatal care for newborn and maternal survival was highlighted
  21. 21. Issues for newborns: To finish:-  timing of home visit-  preventive care only, or Some critical therapeutic as well service delivery-  integration with maternal and immunisation programs questions for us Issues for mothers: -  risk encouraging home births or distracting from facility care -  misoprostol - treatment or prevention; vs oxytocin, timing -  unknowns around puerperal sepsis in the communityIssues for both:-  introduce in concert with health system strengthening-  comprehensive PHC still offers best health system environment
  22. 22. The value ofkangaroo careMorgan and Rongong.Use of KangarooNursing Method inWestern Nepal;J Nepal Med Assoc, Jul-Sep 1997 (36): 320 -323
  23. 23. A short history of baby care•  BC 2000 –  “Just carry it next to your skin. Breastfeed it whenever it is hungry.”•  AD1660 –  “Breastfeeding is undignified. Hand it over to a wet- nurse.”•  AD 1850 –  “Wet-nurses are low class and have an undesirable Thank influence on the child. Get a good experienced you nanny to bottle feed it cow’s milk, and wean it on to a cup as soon as possible.”•  AD 1930 –  "Cow’s milk is unsuitable for babies. It must be bottle fed on a special infant formula.”•  AD 1950 –  “Bottle feeding at all hours is bad for the baby. Follow a strict routine, let it sleep in its own room and ignore it when it cries at other times.”•  AD 2000 –  “Bottle feeding is unsuitable, a strict time-table is nonsense, babies don’t like being alone, and crying is stressful. Just carry it next to your skin. Breastfeed it whenever it is hungry.” (Joan Norton, 2001)
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