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

1. Newborn survival lessons from
the Western Pacific region –
two stories from our knowledge hub work
Chris Morgan

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. 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. Site analyses

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. An interventions and service delivery analysis of
Family and Community Care for maternal and
child survival in PNG -

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. Two ways to view family
and community care,
provided by VHVs, in
PNG
• 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. What came next

10. Another story – unique to East Asia and
the 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. Rationale for early post-natal care and
vaccination 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. THE STUDY: A small feasibility trial
of expanded health services, in a
difficult 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. MINIMAL POSTNATAL PACKAGE
for 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. Trainers
Manual
IEC brochure
draft
Both translated
into Tok Pisin

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. Extract from
the VHV
birth and
postnatal
care record
form

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. 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. 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. WCH Knowledge Hub
supported WHO
expansion 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. 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 community
Issues for both:
- introduce in concert with
health system strengthening
- comprehensive PHC still offers
best health system environment

22. The value of
kangaroo care
Morgan and Rongong.
Use of Kangaroo
Nursing Method in
Western Nepal;
J Nepal Med Assoc, Jul-
Sep 1997 (36): 320 -
323

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)