nsungwa-sabiiti: uganda

7/28/2019 Nsungwa-Sabiiti: Uganda

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Facility-based Newborn care – Country

Successes and Challenges

Dr. Jesca NsungwaAss. Commissioner, Child Health

Ministry of Health

UGANDA

MINISTRY OF HEALTH

17th April 2013



• Implementation arrangements

• Progress

• Successes

• Challenges

• Way forward

OUTLINE



Uganda at a glance

Total Population ≈ 32,000,000

MMR 438/100 000 LBs

U5MR 90/1000 LBs

NMR 27/1000 LBs

Number of Newborn Deaths 39,000Number of Stillbirths 38,000

Proportion of U5 deaths that are newborns 41%

NB Deaths due to prematurity 16,090

Stillbirths as a proportion of deaths 26%

Sources: UDHS 2011



STATUS : Trends in Mortality 1995-2011

33 29

27

85 8976

54

152 158

137

90

1995 2001 2006 2011

Neonatal Mortality Infant Mortality Under five Mortality



Causes of newborn deaths

Sources: UDHS 2011, Mbonye et al 2012

3 causes account for 90% of all newborn deaths



Implementation Arrangements - Process

1. Policy Framework for Implementation

2. Newborn Health Service Standards

• Facility level

• Community level (Village health Teams)

3. Quality Improvement Approach – mentoring, coaching, learning

sessions between different facilities

4. Linking Health facility and Village Health Teams



Policy Implementation Framework

Health Sector Strategic and InvestmentPlan 2010/11-2014/15

(1) Roadmap to Reduction of Maternaland newborn Mortality

(1) Child Survival Strategy

– Newborn Health ImplementationFramework

– Newborn Health ServiceStandards

– Integrated Community CaseManagement (includes newborn postnatal home visits)



Include the most relevant parameters and

service practices that need to be in place

for ensuring quality newborn health

services. Grouped into seven sections

standards for

1. Infrastructure and equipment

2. Management systems

3. Infection prevention

4. Information, Education and

Communication

5. Clinical Services

6. Client services

7. Village Health Teams

Newborn Service standards

Percent among facilities offering

delivery service (N=261) with items

available in delivery room



Example of page in the standards handbook



NEWBORN STANDARDS

How to verify

STANDARD

OPERATIONAL

DEFINITION

MEANS OF

VERIFICATION

Health facility has

infrastructure tocater for both high

risk and normal

babies

Resuscitation space

Nursery spaceKMC beds

Physical check for

their presence



1. Joint health facility Audit using service standards district and national team

(assessment teams, and tools)

2. On site mentoring of health workers (master trainers, mentoring diaries etc…)

3. Uganda adapted ”Helping Babies Breathe PLUS” Curriculum (PLUS action

plan, flip chart, Hand book, OSCE etc…)

4. Quality Improvement Collaborative (Team in facilities, best practice

identification, select indicators to show practice etc)

5. Facility death audits and response

Implementation Steps



12

New bo rn R e susci t a ti on

UGANDA HELPING BABIES BREATHE PLUS

American Academy of Pediatrics

American Academy of Pediatrics

PLUS = Es sen t ia l New bo rn Ca r e

ThreeAction Plan

- Infection

- Preterm

- Normal baby

Flip Chart

Learners Handbook



Present and demonstrateThe cord can present life threatening

complications if no t properly observed

and cared for.

Demonstrate how to clean the cord stump

•Wash hands before touching the stump•Wash with clean water only and put

nothing on the stump

•Keep cord stump dry and uncovered

•Do not apply anything on the cord stump

Demonstrate signs and treatment of umbilical infection

•Reddening around umbilicus or pus

draining from cord

•Treat infection with cleaning cord and

gentian violet

•Treat local umbilical infection three times a

day

Obsep

Practice with ActionPlan

Ask the learners to

practice

• Cleaning the cord

• Make sure the cord is

clean and dry

Follow the Action Plan:

Ask a learners to poin t out

•The action step “advise on

cord care”

Check yourself □Apply nothing on the cord

□ Baby powder and herbs

should be applied to facilitate

cord drying

□Umbilical redness is normal

□A cord should dry and fall off within a few days

Group discussion1. Experience with serious

umbilical cord infection or

tetanus?1.Local practices around

cutting, tying, and treating the

cord?

2.Availability treatment for cord

infection?

Background and educational advice:

Common cord prob lems are bleeding from the cord and infections. Infections of the cord in a newbornand can spread to the whole body causing disease and death. Thus it is important to prevent cord infections bypracticing good care for the cord.

It is important to teach the mother how to observe the cord stump for any bleeding on the first day and

to prevent cord infection: Wash your hands with water and soap before caring for the cord, Use saline waterfor cleaning the cord if it is soiled, do not apply anything such as herbs, animal dung and other treatments on thecord, and do bandage the cord, cover it with a loose piece of clean cloth

The mothers should b e taught th e signs of cord in fection. She should seek medical care if any rednessaround the umbilicus or pus draining from the cord is observed

14



Mother Child Health Passport




• Successes

• Challenges• Way forward

OUTLINE



Coverage of facility interventions/packages

Helping Babies Breathe Plus

(HBB Plus)

Maternal and Perinatal DeathReviews (MPDR)

HBB Plus and ICCM

HBB Plus and MPDR

Integrated Community Case

Management



Successes

1. Zonal/regional master trainers and mentors formed to support MOH and district roll out

– working with national newborn steering committee2. HBB training adapted to cover essential newborn care (HBB Plus) for mentoring –

better counseling and treatment skills

3. Service standards useful for district planning and dialogue for health systems

strengthening + benchmarks for quality improvement

4. Common understanding how to roll out facility newborn care

5. Not only on building health worker skills - institutionalize quality improvement activities

many months after training through regular coaching, learning sessions

6. Newborn indicator manual – addendum of health sector indicator manual



Results from a maternal and newborn improvement

collaborative in Uganda

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

# of deliveries at a facility in which a

partograph was used265 382 635 966 1159 1270 1264 1779 2122 2149 2110 2335

Total # of women who delivered at the

facility2980 2664 2863 2743 2980 2793 2875 2827 3213 2979 2864 3094

% of mothers in labor monitored with

partograph9 14 22 35 39 45 44 63 66 72 74 75

% of mothers who developed

prolonged/obstructed labor4.7 3.5 3.0 2.9 3.6 2.9 3.0 3.6 3.2 2.9 2.8 3.9

0

10

20

30

40

50

60

70

80

Percent

Partograph use for monitoring labor (45 facilities)

Data reported in

1st learning session

Datareported in

2nd learning session

sensitized staff on

partograph use

reminders to use a

partograph for everymother in labor

IC methodology

introduced



Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Newborns that received ENC

package650 679 817 1118 1445 1540 1761 2342 2683 2751 2541 2636

Total live births at facility 2745 2668 2766 3070 3235 3290 3401 3405 3740 3688 3345 3528

% new born babies that received

ENC package24 25 30 36 45 47 52 69 72 75 76 75

0

20

40

60

80

Percent

New born babies that received ENC package (45 facilities)

IC methodologyintroduced

1st learning

session 2nd learning

session

Introduced a

checklist for

ENC services

OUTLINE



• Overview implementation

arrangements

• Progress so far

• Successes

• Challenges

• Way forward

OUTLINE



Model for Improving facil ity NBC

Improvement in

HW Skills

Strengthening

Health Facility

ClinicalManagement

Skills

Linkwith Village

Health Teams

FacilitySupport

Mentoring Teams Tools

Monitoring

VHTPNC visitsMentoringScaling Up

Standards AssessmentChecklist

Death AuditHF collaborative

Actions

h ll



Challenges• Health system challenges

– availability of medicine e.g. corticosteroids, antibiotic use at lower levels

• Capacity building

– H/Worker shortage, turnover or transfer constrain mentoring

– Training materials especially procurement dummies

• Lack of equipment – desirable to have all equipment and commodities soon after

training

– Procurement procedures e.g. competitive bidding

– Penguin suction bulbs

• Lack of data for planning and decision making

– Data driven process to solve problems and source support

– Routine HIS not able to report on QI processes, little information on premature births

– Poor staff reporting – e.g. more macerated compared to fresh still births

– Weak birth death registration

Ch ll



Challenges

• Low utilisation of facility services – combined communication activities needed

– Health facility delivery currently 57%

– Post natal care attendance 29%– Poor referral systems

• Coordinating available resources - it is important to map who is doing what, where and resources

– Piecemeal implementation of the core inputs

– Lesser investment in community mobilization– Human Resource – staffing, housing, poor salaries, training specific cadres

• Tapping other vehicles for NBC implementation – PMTCT, Malaria etc.

• Public private facility engagement

• Focus and awareness on newborn good – negative public reaction, media, politicization and

criminalization of maternal and newborn deaths. Need to have more inclusive implementation

OUTLINE




• Progress so far

• Successes

• Challenges

• Way forward

OUTLINE



Way Forward

• Nationwide health worker mentoring

• Re-equipping all health facilities (MNH)

• Advocacy on newborn survival and rights

• Pre-service training

• Institutionalize further death auditing and problem identification,

response

• Improve data systems for decision making

• Emphasis on preterm births and deaths

• Resource mobilization and better tracking/ synergies with otherinterventions

nsungwa-sabiiti: uganda

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