Abhay Bang

SEARCH, Gadchiroli

Empowering people for

Saving Newborns and Children

SEARCH, Gadchiroli

Inspiration, Integration and Impact

Bombay

New Delhi

Maharashtra

Gadchiroli

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S E A R C H(Society for Education, Action and

Research in Community Health)

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SEARCH, Gadchiroli

Laboratory of 86 villages

IMR (1988) : 121 /1000 LB

Neonatal 39%

Pneumonia 20%

Diarrhoea 19%

Immunisable Diseases

15%

Malaria 7%

Why do children die ? Main causes

Malnutrition

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Before Treatment After Treatment

(1988-2003)

Percent Deaths due to Pneumonia

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0

10

20

30

40

50

60

70

80

90

NMR62

IMR : 80

The IMR in Gadchiroli ( 39 villages ) 1990

Newborns in India

27 million newborns are born each year

51 % born at home

Even the hospital delivered mother and newborns are sent home < 24 hr.

Newborn health care must visit where the neonates are.

*

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SEARCH, Gadchiroli

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Limitations of hospital care

• Inaccessible

• Costly

• Parents unwilling

• Not enough beds and neonatologists

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Home-Based Newborn Care

Goal : To reduce neonatal mortality by

developing a low-cost, home-based model

of primary newborn care by using the

human potential in villages.

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Baseline IMR 76 and NMR 60*

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How to provide HBNC

Mother

TBA

CHW

Supervisor

Training + Supervision + supplies + incentivesSEARCH, Gadchiroli

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•Health education for behavior change & care seeking

•Attending home delivery : with TBA

•Care of baby at birth

•Home visits and support in newborn care

•Monitor the newborns

•Management of NB sicknesses- Birth asphyxia- LBW / Preterm - Sepsis / Pneumonia

Interventions

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SEARCH, Gadchiroli

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Supervision: Every 15 days1. Is the work of CHW complete ?

2. Is the quality of work good ?

3. Are her skills up to the mark ?

4. Does she have the supplies ?

5. Are there any complications ?

6. Is the community satisfied & supportive ?

7. How much should she be paid ? SEARCH, Gadchiroli

SEARCH, Gadchiroli

Neonatal mortality rate (1993 to 2003)(intervention and control area)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

1993-95 1995-96 1996-97 1997-98 1998-01 2001-03Baseline Training

& visiting Interventions Full

InterventionsContinuation of care

Neonatal mortality rate

70 % reeducation in the NMR SEARCH, Gadchiroli

Effect of home-based newborn care on case fatality

(1995-96 Vs 1996-03)

11.3

4.9**

33.3

10.1**

18.5

6.9**

38.5

20.2*

0

5

10

15

20

25

30

35

40

45

Low birth weight Preterm Sepsis Asphyxia

1995-96, Before interventions 1996-03, With interventions

% case fatality

** p < 0.005, * p < 0.07SEARCH, Gadchiroli

The Infant Mortality Rate in Gadchiroli (1988 – 2007)

39 intervention villages

0

20

40

60

80

100

120

140

19881989

19901991

19921993

19941995

19961997

19981999

20002001

20022003-2007

Infant Mortality Rate

Pneumonia case management

Home-based newborn care

Year

Linear regression trend in IMR

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*

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How to transfer HBNCC from Gadchiroli to India ?

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ANKUR Project (2001-05)

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Supported by Save the Children, US

Selected study sites

SEARCH HQ

ANKUR Project

Villages : 91

Slums : 6

Total Population : 88, 311

Tribal

TribalRural

Rural

Rural

U.Slum

Rural

Nashik

Osmanabad

Sangli

Yawatmal

Nagpur

Gadchiroli

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(2001-05)

46

23

05

101520253035404550

Baseline Intervention 3rd Year

ANKUR : NMR

51 % reduction

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Neonatal 39%

Penumonia 20%

Diarrhoea 19%

Immunisable Diseases

15%

Malaria 7%

A combined package for children 0-5 years age : Home-Based Newborn and Child Care (HBNCC)

1 month – 5 yearCauses of death

IMCI + HBNC = HBNCCSEARCH, Gadchiroli

SEARCH, Gadchiroli

ANKUR Project in Mahatashtra

HBNCC Replication sites

ICMR Study: Government of India, five states.

Other NGOs

Africa

Other Countries

Total 49 Sites

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Other States

4 countries

11th Five Year Plan

• HBNCC Gadchiroli model to be the main strategy to reduce IMR in India.

• Introduce HBNCC in all districts with IMR > 45

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Guidelines of Ministry of Health

Govt. of India (2010)

ASHAs to provide HBNC

Educational Aids from SEARCH

Dialogue with Mother

Home Based Newborn Care

CHW Training Manual

Flip-Chart for Health Education of Mothers

A Film for Health Education of Mothers

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Policy change in Ethiopia

• Management of Pneumonia in children

• Home-Based Newborn Care

Global Policy Acceptance

Joint statement by WHO, UNICEF, US-AID and Save the Children ( 2009).

Endorsement of home visiting the neonates and management of sick neonates at home by trained worker if the referral is not possible.

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”

Margaret Mead

EVERY ONE OF US HAS POTENTIAL TO CHANGE

What can we do?

1. Make the Newborn Your Talisman

2. Don’t provide only health care

But, provide capacity to care for health

3. Empowerment of women is the most sustainable and best strategy

4. Don’t withhold distribution of medical knowledge and skills.

5. Introduce Home-Based Newborn and Child Care wherever you work.

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Question : Does HBNC conflict

Majority home deliveries is a fact.

After hospital delivery most mothers

discharged on the 2nd day.

Near complete absence of post-partum

care.

60 % maternal deaths occur in the PP period

with Safe Motherhood?

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How does HBNC fit with JSY ?

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Antenatal Delivery

Facility

Home

Post-natal

JSY HBNC

JSY & HBNC are complementary

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HBNC is necessary to all neonates whether born in

institution or at home.

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Does HBNC Affect Maternal Health?

Mortality ?

Morbidity ?

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Home-based

Post partum + Neonatal

care

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IMNCI

Welcome addition of the ‘N’ to IMCI

Training 8 days

NN care 4 days

Does not include

- Asphyxia mgt at birth

- Sepsis mgt with 2 antibiotics

i.e. nearly 60 % deaths

- Expected effect small. SEARCH, Gadchiroli

Integrated HBMNCC

HBNC

+

Maternal Care

+

IMCI

Home-based Mother-Newborn- Child care+ Referral of complicated cases.*

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Antenatal Delivery

Facility

Home

Post-natal

JSY HBNC

Mother-Newborn and Child Care

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Facility Based

Newborn care

Child Health

(IMCI)

ASHA + Training and supervision + Health System

Is it ethical ?

• First, advise referral

• Does the ethical responsibility stop with advice?

• What % actually go to hospital?

• What happens if not treated ?

• Case fatality 26 %

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Is it ethical ?

• Is it ethical to let the newborn die?

• Is it ethical to give antibiotic as a life saving emergency measure?

• Other situations

- Insulin for juvenile diabetic child

- Needles for drug addicts

- Cholera vaccineSEARCH, Gadchiroli

ASHA workbook ASHA progress book Story book on ASHAs

Feasibility of Home-based Sepsis Management

(1996-2003)

Parental acceptance

Agreed to hospitalise 2.6 %

Agreed to home-based treatment 91.1 %

Refused both 6.3 %

Proportion of total neonates in community treated by VHWs for sepsis 8.9 %

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We, the adults,

but are best protected by health care.

are at the lowest risk of death,*

*

We reproduce, giving birth to the most vulnerable human beings – the neonates,

*

In a just society, *we should all be hanged !*

and then let them die – 1 million in India, 3.6 million globally, every year

**

Neonatal Sepsis = Pneumonia (52% Deaths) Meningitis Septicemia

6 % to 10 % Neonates need treatment

2 Antibiotics : Oral + Injectable

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Payment to CHW

• Time spent : 1 hr 23 min. / day

per 1000 popl.

• Performance linked payment

• $ 4 Per mother-newborn

• Average $ 10 month

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Cost and cost-effectiveness of home-based neonatal care in Gadchiroli (2001-2003)

(1 US $=45 Indian Rs.)

Non-recurring costs (2002-03 prices ) US $

Annual recurring costs US $

Cost per village Training : 89

Equipments : 66

Total : 155 118

Cost per mother–newborn served

7

Cost per death averted

151

Cost per DALY saved

7

The preceding slides were presented at theCORE Group 2010 Fall Meeting

Washington, DC

To see similar presentations, please visit:www.coregroup.org/resources/meetingreports