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Sri Lanka & MDG 4: beyond 2015
- 1. Sri Lanka & MDG 4: beyond 2015 SAPA meeting:Lahore,Pakistan November 2014 Prof Dulanie Gunasekera University of Sri Jaywardnepura Sri Lanka
- 2. MDG & SL statistics • MDG-4
- 3. Causes of U-5 mortality Global (2010) Sri Lanka (2012) Source: feto-infant mortality report(2012) FHB Source: child health epidemiology group, Lancet;379(9832:2151-61 NND 54%
- 4. Causes of Infant deaths- SL (2012) Source: FHB 2012 Asphyxia 12% Sepsis 10% Prematurity & LWB 26% Congenital abnormalities 41% Other 11% Asphyxia Sepsis Prematurity & LWB Congenitial Abnormalities Other
- 5. Percentage distribution of infant deaths according to age at death 2012 (FHB) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2007 2008 2009 2010 2011 2012 Early neonatal deaths Late neonatal deaths Post neonatal deaths
- 6. Distribution of births in hospitals in SL(2010)- 99.9% births Babies die in hospitals
- 7. Prevention/ management of preterm births(26%) BOTTLENECKS • Timely use of cortico- steroids, AB for PROM • Rx of pre eccalmpsia • Transfer high risk mother to tertiary facility • Poor NN retrieval/transport system • Weak communication between referring institutions • implementation of guidelines/STP- further strengthened(SLCOG) • Improve AN transfer & NN retrieval services(PNSSL started) • Better communication/ ICU & NICU bed surveillance – initial system in place • Needs strengthening STRATEGIES & SOLUTIONS
- 8. Management of Birth Asphyxia(10%) Neonatal Resuscitation BOTTLENECKS • Standard training modules in place – BLS • No regular in service assessments • NNR not mandated as essential skill for all SBA’s • No revalidation process • Funding constraints- • accelerated ,sytematic training programmes by SLCP • strengthen monitoring/ evaluation • SLCP in process of mandating with MoH • MoH to initiate revalidation process • MoH to fund STRATEGIES & SOLUTIONS
- 9. Neonatal Resuscitation Advanced Neonatal Resuscitation Module BOTTLENECKS • For MO’s – NALS optional a present • Need to make requirement • Emergency equipment - not ideal in labour rooms/theaters • Training models – (mannikins) not freely available for simulation in units • MoH/SLCP – to mandate NALS for MO’s in SCBU • Regular training- MoH /SLCP • MoH - provide funding- for training, equipment (rather than WHO/UNICEF) • Stringent maintenance requirements (check lists) - implementation- MoH STRATEGIES & SOLUTIONS
- 10. Basic Newborn Care Essential newborn care Module BOTTLENECKS • Need to inculcate staff on ENC concepts - • to deliver the baby to mother’s abdomen • skin-to-skin contact • Temperature control (KMC) • Establishing breast feeding • Delayed cord clamping (small baby) • Mandatory training & re- validation of ENCC for SBA’s MoH /SLCP to initiate • Regular W/shops on ENCC • Promote clinical audit by medical & nursing staff STRATEGIES & SOLUTIONS
- 11. Basic newborn care Kangaroo Mother Care(KMC) BOTTLENECKS • Implementation of KMC at the facility level not ideal • Staff not confident • No system to deliver KMC at community level • KMC not scaled up as intervention. • Train/ motivate staff- paediatrician to play leadership role, scale up • PHM to educate/train PN mothers at home • Set up Mother-Baby Units(MBU)- low cost units, ideal for KMC STRATEGIES & SOLUTIONS
- 12. Prevention of neonatal infections(10%) barrier nursing principles BOTTLENECKS • hand washing protocol- poorly followed • Barrier nursing principles • Poor supplies of - • Antiseptic liquid soap (iodophore-iodine or chlorhexidine scrub) - • Single use clean, dry towels • Use of hand alcohol scrub – not universal • Infection control training • Adequate funding for consumables • Adequate supplies • Infection audits & check lists STRATEGIES & SOLUTIONS
- 13. Evidence Based Intervention; Clean Delivery Quality gap; Missed opportunity (Abeysekera, 2010)
- 14. Scaling up care for the Sick Newborn
- 15. Inpatient care for small and sick newborns NICU care, feeding support and safe oxygen BOTTLENECKS • Poor utilization of CPAP/ proper ventilation • Reluctance of initiation of early breast feeding • TPN – not freely available • Sick Newborn Manual – guidelines for NICU care- finalized: needs rolling out • Staff training: on concept of CPAP/ ventilation – W/shops • importance of trophic feeding/ assisted feeding • TPN- MoH to initiate facilities & funding • Paediatricians/SLCP to play key role in training STRATEGIES & SOLUTIONS
- 16. Treatment of severe infections BOTTLENECKS • Not adhering to clear guidelines on use of AB • Overuse/ misuse of AB • Early identification of sepsis at facility level • delay in recognition of danger signs(community) and prompt referral • Ensure universal use of guidelines/ STP’s • Adherence to hospital Antibiotic policy - MoH to monitor • Strengthen early identification of danger signs by PHM/ MOH & timely referral STRATEGIES & SOLUTIONS
- 17. INFRASTRUCTURE distance to hospital /SCBU / NICU facility Curative care: hospital distributionDistance to hospitals with SCBU
- 18. Human resources & equipment BOTTLE NECKS • Staffing constrains • Adequate equipment • Standard setting for SCBU/NICU STRATEGIES & SOLUTIONS • Standard setting – Minimum requirements for levels of SCBU/NICU • Minimum staffing ratio – nurses, doctors, MW • EmNOC survey (2012) - did needs analysis- MoH to conform to needs
- 19. Reducing post neonatal causes • Congenital defects CHD (11%) • Neural tube defects(5%) • Severe RI (7%) • DHF(<1%) • Infrastructure • Human resources/ staffing • Financing • Pre-preg FA supplementation • Early detection • AB policy • Pneumococcal vaccine?
- 20. Dengue H’gic Fever • early case detection- clinical- public awareness lab – Dengue NS1 Ag test • Improving case management – staff training(WHO team, Thailand), incorporated into paediatric PG curriculum • Dengue corners in hospitals/wards • PREVENTION – vector control – breeding site surveillance • legal action taken • Dengue Task Force/ Centre for Clinical Mx of DHF
- 21. Other issues - Nutrition • Nutritional promotion & support – IYCF strategy • Supplementation – thriposha Vit A mega dose Iron(anemia in pregnancy and infancy) Folic Acid ( pre pregnancy) LBW 17%
- 22. Medical Information System(MIS) • Transition into real time data base- E-IMMR • Networking NICU/SCBU/maternity units • Bed surveillance system initiated • Feto- infant mortality survey & birth defect register initiated • NN morbidity/paed. death reviews to start soon
- 23. Policy Framework • National Policy on Maternal and Child Health, 2012 • Sri Lanka Code for Promotion, Breastfeeding and Marketing of Designated Products, 2002 • National Strategic Plan on Maternal and Newborn Health, 2012-2016 • National Nutrition Policy, 2010 • IYCF strategy – 2007 • LBW prevention strategy( being formulated)
- 24. Post 2015 agenda reduce NNMR • Improve facilities/staffing of the neonatal units • identify levels of NB care • Staff training -improve knowledge/skills • Establish NN retrieval system & proper communication – • Neonatal Forum established (2014) 24
- 25. Post 2015 agenda Reduce U-5 MR- post NN causes • Advanced Paediatric Life support • PICU bed surveillance system & increase PICU beds • Immunization - Pneumococcal vaccine? • Case management- Paediatric STPs, DHF training • Anaemia & nutritional support • Expand paediatric cardiology • Paediatric / neonatal retrieval system • Paediatric death reviews
- 26. Thank you • Acknowledgments: • Dr. Srilal de Silva • Dr. Dhammica Rowel • Family Health Bureau
- 27. NN information system New born formats used in all the hospitals Information from the same included into the eIMMR NICU surveillance & bed system(networking NICU’s) to be initiaited feto infant mortality surveillance/birth defect surveillance initiated NN morbidity audits – to be initiated
- 28. Born Too Soon Of the 6.9 million who die before their 5th birthday….. Preterm birth is the second leading cause of death for children under 5 years, after pneumonia 1.1 million babies die directly from complications of preterm birth Over 40% die in their first month Source: CHERG/WHO estimates for 2010, Li Liu et al Lancet in press, 2012
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- 30. Figure 1 Joy E. Lawn (2013) 74, 00-00. doi:10.1038/pr.2013.202
- 31. Where do we stand? MDG 4 - Reduce child mortality – Under 5 mortality fell 41% from 1990 – Sub-Saharan Africa doubled its average rate of reduction : 1.2 % in 1990-2000 to 2.4 per cent during 2000-2010 MDG 5a - Improve maternal health Maternal mortality fell 47% from 1990 MDG 5b - Universal access to reproductive health By 2008, more than 50%women aged 15 -49yrs were using contraception MDG 6 - HIV/AIDS, malaria and other diseases New HIV infections declined; Proportion of women living with HIV remains stable at 50%
- 32. SRILANKA MDG 4: child mortality - Starting at a baseline of 21.5/1,000 live births in 1990, the country has made progressed to 9.6/1,000 live births in 2010, very slightly off track to meeting the goal of 7/1,000 for 2015. MG 5: maternal health - Sri Lanka’s initial maternal mortality ratio of 85/100,000 live births in 1990 decreased to 35/100,000 by 2010. This is on track to meeting the MDG target of 21/100,000 maternal deaths by 2015. 32
- 33. Intervention packages for reduction of neonatal deaths by current mortality rates Estimated effect of the number of neonatal lives saved by the different intervention packages by the year 2025 33 The Lancet Newborn Interventions Review Group and The Lancet Every Newborn Study Group . Every Newborn 3 - Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet Early Online Publication, 23 June 2014. doi:10.1016/S0140-6736(14)61001-1
- 34. Monitoring for quality issues PRIORITY BOTTLENECKS • Administrative, procurement and proper resource allocation issues. • Out of pocket payments required by clients • Quality issues and lack of proper monitoring / accountability mechanism STRATEGIES AND SOLUTIONS STRATEGIES AND SOLUTIONS • Proper record keeping, monitoring / accountability mechanism in place • Child Death audit have not initiated in the facilities (SCNUs) managing severe infections
- 35. Goal 4: Reduce Child Mortality MDG 4 Target Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Indicator Under-five mortality rate Infant mortality rate Proportion of 1 year-old children immunized against measles 35
- 36. Causes of Under 5 mortality In Sri Lanka Globally Neonatal 75.1 Child Health Epidemiology Reference Group. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000, 2012. Lancet; 379 (9832):2151-61 Global causes of childhood deaths in 2010 WHO Regional Office for South East Asia. Situation of Newborn and Child Health in South East Asia, Progress towards MDG 4, 2014 Causes of under 5 mortality in Sri Lanka
- 37. Progress towards MDGs in SEA Region countries-2010 37
- 38. RH services- preconception BOTTLE NECKS • Preconception folic acid • Family counseling by PHM STRATEGIES & SOLUTIONS • In place – compliance? • Strengthen awareness- publicity campaigns • Mass media
- 39. Causes of Child(u-5) Mortality SL - 2009 Source: Registrar General’s Office
- 40. Treatment of severe infections PRIORITY BOTTLENECKS STRATEGIES AND SOLUTIONS STRATEGIES AND SOLUTIONS • late identification and referral to facility for treatment • Not following guidelines on use of antibiotics • Overuse and misuse of antibiotics • Clear identification of early and late sepsis at facility level • Poor care seeking behavior - (delay in recognition of danger signs and prompt referral) of the community • Strengthen on early identification of danger signs by PHM and MOH, timely referral • application of Standard Treatment Protocols • Adhere to antibiotic policy
- 41. 13th Annual Academic Sessions Perinatal Society of Sri Lanka 2014 41 Goal 4: Reduce Child Mortality Indicator Data Source Baseline Current Target Under-five mortality rate (per 1000 live births) SL 22.2 (1991) 12.1(2009) 8 UN IGME 21(1990) 10(2012) 7 Infant mortality rate (per 1000 live births) SL 17.7 (1991) 9.7(2009) 6 UN IGME 18(1990) 8(2012) 6 Proportion of 1 year- old children immunised against measles 84 % (1990) 97.2% (2006/7) 100%
- 42. Care around the time of birth; a triple return on investment Source: Special analysi;The Lancet ,Every Newborn Series,,May 2014 More than 3 million babies and women could be saved each year through investing in quality care around the time of birth.
- 43. Causes of Under 5 mortality Sri Lanka Globally Neonatal 75.1 Child Health Epidemiology Reference Group. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000, 2012. Lancet; 379 (9832):2151-61 Global causes of childhood deaths in 2010 Source: Registrar General 2009 Causes of under 5 mortality in Sri Lanka 2009 54%
- 44. Trends in IMR & NNMR - SL Source – FHB,SL: 2012