Prevention of Prematurity and Stillbirth_Gravett_10.11.12


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  • -Not much out there-The wider reproductive, maternal, newborn and child health agenda is inextricably linked with preterm birth and stillbirth-Most interventions that prevent stillbirth, also prevent maternal and neonatal mortalityDo not need to create a new program
  • -Gap between what is known to work and what is done in practice- nearly all the deaths in babies born after 32 weeks could be prevented by essential newborn care
  • Basic care and infection case management interventions have an important effect on neonatal deaths and deaths among moderate and late preterm births2. More targeted care for preterm 38 to 32 weeks, including antenatal steroids and KMC reduces deaths3. Neonatal intensice care may be necessary to reduce death among very preterm babies (those before 28 weeks)
  • The continuum of care is a core principle of maternal, child and newborn health programs which considers the dimensions of time (over the lifespan) and place of care giving (level of care). Saving lives depends on high coverage and quality of integrated service=delivery packages throughout the continuum, with functional linkages between levels of care in the health system.Integrated service delivery packages within the continuum of care have many advantage: cost-effectiveness is enhanced; available human resources are maximized; and services are more family friendlyIdeally women in preterm labor would deliver in a facility, but in reality, there are many places when half of women deliver at home, so interventions aimed at reducing PTB and SB must be available at all levels.
  • Community level- behavior change, home-visit packages including breast feeding support and awareness of danger signs and when to seek careRisk factors for PTB- history of a previous preterm birth; insufficient cervix
  • We have the interventions, but to date, none has been successfully scaled up.
  • In large part the barriers and constraints to scale-up of interventions are the same as those encountered in the wider field of maternal newborn and child health. Specific to PTB and SB is stigma and prevailing myths and misconceptions about PTB and SB; and lack of visablilityAffordabilty barriers, delayed use of services, poor quality of care- poor standards of care, scarcity of trained workers, erratic supply of essential drugs and supplies, lack of referral system Need the right people with the right supplies at the right time
  • Effective implementation will require a focus on systems issues, especially human resources (like nursing skills for obstetrics and neonatal care); and increasing commodities for family planning, obstetric and newborn careAs mentioned, the existing proven interventions have yet to be successfully scaled up-Refer to GAPPS two by two chart-Context- rural vs urban; what are the causes of mortality- asyphixiavs infection
  • Afghanistan could reduce newborn deaths by 10% through public health approaches, or with increased focus on improved care of preterm newbornsCase management of infection and improved thermal care and feeding support would reduce death in places like India and ChinaBrazil- NICU care would halve neonatal mortality
  • Reduced preterm death unintentionally! Imagine what targeted strategies for reducing preterm death would do.
  • Government- strengthen health systems- commodities supply, workforce; strengthen community care and link to referral system; promote family planning servicesUN- define norms and guidelines for preventing and managing PTB and SB; work with partners to strengthen technical and programmatic support to prevent PTB and SB- help countries scale up high-impact interventionsDonors- support implementation researchPrivate sector- partner with public sector to improve service delivery and infrastucture (eg. Helping Babies Breathe)Research- ensure accurate data on PTB and SB outcomes is included in research studies assessing other pregnancy outcomes; understand mechanismsHealth care workers- adopt and adapt evidence based practices, implement training plus continuus education, share best practices, audit clinical practice; treat women and children with repect and sensitivity
  • Right people at the right time with the suppliesEnsure frontline workers are skilled in the care of premature babies and improve supplies of life-saving commodities
  • Prevention of Prematurity and Stillbirth_Gravett_10.11.12

    1. 1. Implementing Interventions to Reducethe Burden of Preterm and Stillbirth:How do we do it?Courtney Gravett, MPHResearch Associate IIGlobal Alliance to Prevent Prematurityand Stillbirth (GAPPS)Seattle Children’
    2. 2. Preterm deaths and Stillbirths canbe prevented now• Effective implementation of current, known interventions can reduce preterm deaths by 75% and stillbirths by 45%• Many preterm deaths and stillbirths are due to lack of action, or an inability to act• Prevention and intervention is possible all along the continuum of care
    3. 3. Many premature babies can be saved before intensive becomes available... Public health approaches Improved individual neonatal care eg feeding, warmth, hygiene, antibiotics, resuscitation Neonatal intensive care introduction and scale up Over 60% reduction can be achieved before neonatal intensive care and history shows the impact would be hugeData sources for UK and US historical data: (CDC, 2012, Office for National Statistics, 2012, NIH, 1985, Smith et al., 1983, Jamison et al., 2006, Lissauer and Fanaroff, 2006, Baker,2000, Philip, 2005, Wegman, 2001). With thanks to Boston Consulting Group
    4. 4. Continuum of Care Kerber K, et al. Continuum of care for maternal, newborn and child health: from slogan to delivery. Lancet 2007; 370:1358=69
    5. 5. Interventions for preterm birth and stillbirthalong the continuum of care PRE- PREGNANCY BIRTH POSTNATAL/ CHILDHOOD PREGNANCY NEWBORN •Family planning/ •Prevent & treat •Antenatal •Essential & Extra care birth spacing sexually steroids • Kangaroo Mother Care PTB •Prevent & treat transmitted •Tocolytics to •Management of sick sexually transmitted infections slow labor newborns infections •Nutrition •Identify preterm •Neonatal resuscitation •Nutrition babies •Prevent & treat •Screen& treat •Active management of •Postnatal sexually for syphilis labor follow-up transmitted •Nutrition •Emergency obstetric infections care, including c-section SB •Magnesium sulfate •Nutrition •Antibiotics •Induction of labor after 41 weeks
    6. 6. Prevention of preterm birth and stillbirth must be accelerated Care before and between pregnancy Implement: • Family planning strategies, including birth spacing and provision of adolescent-friendly services • Prevention and management of STIs and NCDs • Education and health promotion for girls and women of childbearing age • Promotion of healthy nutrition and addressing life-style risks like smoking
    7. 7. Prevention of preterm birth and stillbirth Care during pregnancy and childbirth Implement: • Antenatal care for all pregnant women • Screening & treatment of sexually transmitted infections, especially syphilis • Management of pregnant women at higher risk of preterm labor • Management of preterm labor with provision of essential equipment and drugs • Reduce non-medically indicated early induction of labor and cesarean • Promotion of healthy behaviors and life-style risks during pregnancy • Active management of the third stage of labor • Comprehensive emergency obstetric care
    8. 8. Care of the premature newborn COMMUNITY LEVEL/HOMEHome and low levels of health system• Essential newborn care (warmth, cleanliness, feeding)• Support for early breastfeeding and cup feeding if needed• Facilitated referral, transport schemesHospital• Kangaroo Mother Care FACILITY LEVEL/OUTREACH• Neonatal resuscitation with bag and mask if needed• Supportive care for RDS eg safe oxygen therapy• Other supportive care eg NG tube feeding, IV fluids• Treatment of infections with antibioticsReferral hospital• Increased nursing and medical support• Phased introduction of intensive care eg ventilation REFERRAL LEVEL/DISTRICT• Surfactant (cost issues)
    9. 9. Moving Forward to ReducePreterm Deaths andStillbirths
    10. 10. Examples of Barriers to Scaling UpInterventions• Community/Household level – Sociocultural barriers (eg stigma), financial constraints• Health service level – Lack of resources and trained providers• Health sector and management level – Weak supply management – Lack of competent district health management teams• Lack of political will
    11. 11. Prevention and management ofpreterm birth and stillbirth must beincluded in the wider agenda• Functional health systems are a prerequisite for comprehensive antenatal and childbirth care• Implementation research is needed• Must integrate with other RMNC health programs – Antenatal corticosteroids• The steps for scaling up interventions are highly context specific
    12. 12. Start where you are
    13. 13. 8 Countries have reduced pretermdeath in the last decade• Sri Lanka Contributing factors:• Turkey • National commitment to improved obstetric and• Belarus neonatal care• Croatia • Systematic referral systems for neonatal care• Ecuador• El Salvador • Strengthened equipment and personnel• Oman • Re-invigorated community-based healthcare• China • Promotion and training of skilled birth attendants
    14. 14. Some middle income countries have halved deaths due to preterm birth in a decade Sri Lanka • Lower middle-income country Turkey that reduced NMR from 13 to 10 and halved preterm• Upper middle-income country that reduced specific mortality NMR from 21 to 10 • Long term investment in primary care with free health• Implemented demand and supply strategies, care at government facilities including cash incentives for expectant women • Reinvigorated community- based care, including referral• Invested in quality care improvements, such as networks for women in focusing on nursing staff skills, resuscitation, preterm labor basic care of preterm babies • Recent introduction of advanced care at tertiary centers Source: Analysis conducted using data from Liu et al., 2012. Credit: Boston Consulting Group with the Global Preterm Birth Mortality Reduction Analysis Group
    15. 15. Factors contributing to successfulimplementation of interventions• Buy-in by key stakeholders• Intervention is context specific i.e., culturally sensitive, locally adapted to staffing levels, burden of disease, causes of mortality, etc.• Intervention builds on/ complements existing programs• Intervention is supported by national policies, service guidelines, training materials, job aids, supervisory systems and indicators to track outcomes• Robust supply chain
    16. 16. Who is involved?• Government and policy makers at local, national and global levels• United Nations and other multilateral organizations• Donors• Private Sector• Academic and research institutions• Healthcare workers and professional associationsCoordination, collaboration, and commitment among all the players is crucial to success
    17. 17. Conclusion: Advance a Coordinated Agendafor Preterm and Stillbirth Prevention andCare• Scale up what works – practical and feasible interventions for care• Improve integration with existing programs• Address common challenges in the wider reproductive, maternal, newborn and child health agenda: • Access and utilization of quality healthcare
    18. 18. Important Resources Global report on preterm birth & stillbirth: the foundation for innovative solutions and improved outcomes Born Too soon: The Global Action Report on Preterm Birth Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health entions/en/index.html
    19. 19. Increase Awareness and Visibility ofthe ProblemNovember 17th is World Prematurity DayFor more information visit the March of Dimes website:
    20. 20. Quality vs Coverage gap• Get from Jim