increasing survival in the first month of life · • essential newborn care ......
TRANSCRIPT
INCREASING SURVIVAL IN THE FIRST MONTH OF
LIFE: A SEMINAR ON INNOVATIVE APPROACHES TO IMPROVING NEWBORN HEALTH
Overview agenda
• Overview of Newborn Health
• Specific technical areas
• Essential Newborn Care (ENC)
• Possible Severe Bacterial Infection (PSBI)
o Prevention with chlorhexidine
o Treatment with simplified anitbiotics
• Care of preterm and very small newborns
• Antenatal Care (ANC)/Postnatal Care (PNC) continuum of care
• Stillbirths
• Kushtia, Bangladesh case study
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Overview of Newborn Health
• Origins of interest/concern about
newborn health
• Evidence generation phase
• Learning and Scale Up phase
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Relatively lower rate of decline in newborn mortality
compared to under-five mortality
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0
10
20
30
40
50
60
1-59 mo Newborn
1990-2015 Annual Rate
of Reduction (ARR)
1-59 months =3.37%
Newborn = 2.54%
Maternal = 2.3%
Mort
alit
y r
ate
per
1000 liv
e b
irth
s
Recent U5 and newborn cause of death estimates
5
Pneumonia
13%
Other 18%
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Pneumonia 3%
Preterm birth
complications 16%
Intrapartum-related 11%
Sepsis 7%
Tetanus 0.5%
Congenital 5%
Diarrhea 0.5%
Other 3%
Neonatal
45%
Source: WHO and Maternal and Child Epidemiology Estimation Group (MCEE)
2015
Overview of Newborn Health
• Origins of interest/concern about
newborn health
• Evidence generation phase
• Learning and Scale Up phase
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Breaking the myth: saving newborn lives without NICUs
7
Early evidence + advocacy by SNL/BMGF (and partners)
Home-based newborn care by community health
workers reduced NMR by 62%
Increasing Survival in the First Month of Life 18 October 2016
Breaking the myth: saving newborn lives without NICUs
8
Early evidence + advocacy by SNL/BMGF (and partners)
Community-based newborn-care package in
Sylhet district, Bangladesh, reduced NMR by 34%
Increasing Survival in the First Month of Life 18 October 2016
Breaking the myth: saving newborn lives without NICUs
9
Early evidence + advocacy by SNL/BMGF (and partners)
Increasing Survival in the First Month of Life 18 October 2016
“Of the 130 million babies born every year, about 4 million
die in the first 4 weeks of life –the neonatal period. A similar
number of babies are stillborn…”
Neonatal Survival
Newborn survival and interventions
gain global and country attention
18 October 2016
New efficacy evidence generates momentum
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CHLORHEXIDIN
E
NEONATAL
RESUSCITATION
SIMPLE
ANTIBIOTICTREATMEN
T
Overview of Newborn Health
• Origins of interest/concern about
newborn health
• Evidence generation phase
• Learning and Scale Up phase
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Evidence to policy for scale up
12
Global Newborn Health Conference Johannesburg, SA 2013
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Evidence to policy for scale up
13
Every Newborn Action Plan 2014
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Evidence to policy for scale up
14
Global Maternal Newborn Health Conference, Mexico City, MX 2015
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Country implementation: learning by doing
• ENAP country bottleneck
assessment to guide action
(UNICEF)
• Testing innovative models of
service delivery (Bangladesh
case study)
• Cross country sharing
• SNL and other partners
providing country TA support
• Implementation and learning
about achieving high
effective coverage at scale
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Evidence based interventions
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ADOLESCENCE AND BEFORE PREGNANCY
PREGNANCYLABOR AND
BIRTHPOSTNATAL CHILD
INTERSECTORAL: Improved living and working conditions, including housing, water and sanitation, and nutrition; education and
empowerment, especially of girls; folic acid fortification; safe and healthy work environments for women and pregnant women
RE
FE
RR
AL
AN
D
TE
RT
IAR
Y L
EV
EL
FA
CIL
ITY Reproductive
health, including
family planning
Management of
pregnancy
complications
Skilled care at birth
Comprehensive
emergency
obstetric and
newborn care
Essential
newborn care
Emergency care
of small and sick
newborns
Hospital care of
childhood illness
FIR
ST
AN
D
TE
RT
IAR
Y L
EV
EL
FA
CIL
ITY Reproductive
health, including
family planning
Pregnancy care
Skilled care at birth
Basic emergency
obstetric and
newborn care
Essential newborn
care
Postnatal visits
Care of small and
sick newborns
Prevention and
management of
childhood illness
CO
MM
UN
ITY
Adolescent and
pre-conception
health care and
nutrition
Gender violence
prevention
Counselling and
birth preparedness
Home birth with
skilled care and
clean practices
Essential
newborn care
Postnatal home
visits for mothers
and newborns
Ongoing care for
the child at home
Source: Every Newborn Action Plan
thermal
stability
hygiene
exposures
feeding vigilance
ESSENTIAL NEWBORN CARE
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Introduction/scale-up
Pilot introduction/policy alignment
Expressed interest
2016
Increasing Survival in the First Month of Life
20
POSSIBLE SEVERE
BACTERIAL
INFECTION (PSBI)
TREATMENT
18 October 2016Increasing Survival in the First Month of Life
PSBI Treatment: SATT and AFRINEST Studies
• AFRINEST Group et al. “Oral amoxicillin compared with injectable procaine
benzylpenicillin plus gentamicin for treatment of neonates and young infants
with fast breathing when referral is not possible: a randomized, open-label,
equivalence trial”
• ANFRINEST Group et al. “Simplified antibiotic regimens compared with
injectable procaine benzylpenicillin plus gentamicin for treatment of neonates
and young infants with clinical signs of possible serious bacterial infection
when referral is not possible: a randomised, open-label, equivalence trial”
• Baqui, A et al. “Safety and efficacy of alternative antibiotic regimens compared
with 7 day injectable procaine benzylpenicillin and gentamicin for outpatient
treatment of neonates and young infants with clinical signs of severe infection
when referral is not possible: a randomised, open-label, equivalence trial”
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PSBI Treatment Global Policy & Guidelines
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PSBI/ Early implementation countries
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CARE OF PRETERM AND VERY SMALL
NEWBORNS
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18 October 2016 26Increasing Survival in the First Month of Life
InterventionsMaternal
deaths
Newborn
deaths
Still-
birthsPre-term IUGR Other
Nu
trit
ion
Breast-feeding early
initiation
↓↓
Iron supplementation ↓ ↓ ↓ ↓
Calcium supplementation ↓ ↓↓ ↓
PN vitamin A (adv distrib) ↓ late infant deaths
Iodized salt use ↓ cognitive disability
Infe
cti
on
IPTp/ITNs ↓ ↓ ↓ ↓
tetanus toxoid ↓
chlorhexidine ↓
Syphilis screen & treat ↓ ↓ ↓
HIV-PMTCT ↓ infant & child deaths
Ob
ste
tric
al &
oth
er
Clean delivery ↓
Thermal care ↓↓
Birth preparedness ↓ ↓
Misoprostol (adv distrib)
Pre-eclampsia screen &
treat
↓↓ ↓↓ ↓↓
Tobacco/ alcohol ↓ ↓ ↓ ↓
FP counseling ↓
Impact of simple interventions delivered in pregnancy
Source: Hodgins S et al. PLoS One 2016:11(8): e0160562
Development and Demonstration of Bangladesh’s Comprehensive
Newborn Care Package for National Scale-up
SAVING NEWBORN
LIVESKUSHTIA,
BANGLADESH
30
73000 newborn deaths in
2015
28 deaths per 1000 live births
61% of all under-five deaths
Major newborn killers
• Prematurity-related complications
• Birth asphyxia
• Infection
18 October 2016Increasing Survival in the First Month of Life
NEWBORN
MORTALITYIN
BANGLADESH
District Learning Laboratory
• In 2013 Government of Bangladesh declared its commitment for Ending Preventable
Child Deaths and identified a set of evidence-based newborn health interventions to
achieve its commitments
• Later the Ministry of Health (MOH) decided to develop a Comprehensive Newborn Care
Package (CNCP) and to demonstrate in a typical public health setting with technical and
catalytic support from SNL.
31
Development and demonstration of comprehenisve newborn care package (CNCP) in public health
settings.
Interventions: • SBCC for promotion of
• Healthy MNH behavior and care seeking• Care for all newborn
• Immediate and Essential newborn care including application of CHX NB cord• Postnatal care
• Care for sick newborn and newborn with complications• Resuscitation (HBB)• PSBI Management• Kangaroo Mother Care
• Care for prevention of preterm complication • Use of Antenatal Corticosteroid
18 October 2016Increasing Survival in the First Month of Life
Background:
Why the District Learning Laboratory for CNCP?
32
Development and demonstration of comprehenisve newborn care package (CNCP) in public health
settings.
18 October 2016Increasing Survival in the First Month of Life
Objective of DLL for CNCP
Implementation
– For national scale-up
preparedness
– Identify challenges as well as
the solutions to achieve
effective coverage of
interventions
– Ultimately having a SOP for
CNCP national scale-up
Focus area to identify
challenges & solutions
Capacity building and skill
retention
Ensure availability of
commodities and
equipment's in health
system
Functional M&E, HMIS and
Quality of Care
Effective SBCC approaches
for healthy MNH behavior
and demand generation
33
BANGLADESH NEW GUIDELINE FOR PSBI
MANAGEMENT: KEY PATHWAYS
Promotion of
Healthy MNH
behavior &
proper care
seeking
Day-4
Day-8
Use of simplified antibiotic regimen
tested in recent studies (RCTs)
supported by SNL, USAID, WHO and
other partners in 5 different countries in
Asia and Africa
Increasing Survival in the First Month of Life 18 October 2016
Programmatic Inputs
Supply side • Capacity building and skill retention
• CNCP training• Refreshers
• Ensure availability of supplies
• Ensure equipment, job aids & medicine
• Advocacy & TA to include routine procurement mechanism
• Establishing supply system
• Establishing routine monitoring system
• Development, pretesting, finalization
• Capacity building on data management
• Functional routine HMIS with use of data
• Strengthen supervision and mentoring support for quality improvement
34
Demand side • SBCC activities
• Promotion of newborn danger
signs recognition
• Promotion of proper care
seeking by families
18 October 2016Increasing Survival in the First Month of Life
35
Knowledge of the Recently Delivered Women
on Newborn Danger Signs: December 15 and May 16
98
64
87
61
88
54
42
66
99
75
95
71
89
5648
77
No
t fe
ed
ing
we
ll/h
isto
ry o
fd
iffi
cu
lty in
feed
ing
Lo
w b
od
y t
em
pe
ratu
re
Fe
ve
r o
r h
igh
te
mp
era
ture
Fa
st
bre
ath
ing
Se
vere
ch
es
t in
dra
win
g
Mo
ve
me
nt
on
ly w
hen
sti
mu
late
d
His
tory
of
co
nv
uls
ion
Um
bilic
al re
dn
es
s e
xte
nd
sto
sk
in o
r fo
ul sm
ellin
gd
isch
arg
e f
rom
um
bilic
us
Pe
rce
nta
ge
Round 1 (N=1290)
Round 2(N=847)
Data Source: icddr,b survey
Increasing Survival in the First Month of Life 18 October 2016
36
Sustaining Facility ReadinessOctober 15 and May 16
0
10
20
30
40
50
60
70
80
90
100P
rovis
ion
of
Safe
Dri
nkin
g
wate
r
Availab
ilit
y o
f ele
ctr
icit
y
Am
oxic
illin
Ped
dro
p
Inj. G
en
tam
ycin
Th
erm
om
ete
rs
I C
C S
yri
nge
Weig
hin
g m
ach
ine(B
ab
y)
Sic
k N
ew
bo
rn R
egis
ter
Pre
scri
pti
on
wit
h r
efe
rral sl
ip
Do
se C
alc
ula
tio
n T
ab
le-
An
tib
ioti
cs
for
Sep
sis
Man
agem
en
t
Vis
ible
Alg
ori
thm
fo
r S
ep
sis
Man
agem
en
t
Environment Drugs Equipment Logistics
%
Round 1
Round 2
Data
So
urc
e: i
cd
dr,
b s
urvey
Increasing Survival in the First Month of Life 18 October 2016
Cases Managed in Union Level facilities in Kushtia
October 15- August 16
0
50
100
150
200
250
300
350
400
Oct Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16
Expected Case #
Data Source: Routine HMIS
Increasing Survival in the First Month of Life 18 October 2016 37
Scaling up of PSBI management in Bangladesh
• Bangladesh Government is
planning to scale-up CNCP
including PSBI management (in
Union level facilities)
• These interventions are included in
the Essential Service Package
• Planning has been going on to
incorporate in various Operation
Plans of 4th HNP sector program
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