Saving newborn lives: roles for Healthcare Professionals

Dr. Joy Lawn MB BS, MRCP, MPHSaving Newborn Lives/ Save the ChildrenFunded through the Bill & Melinda Gates Foundation

PMNCH Healthcare Professionals WorkshopBlantyre, Malawi, November 2007

1. Saving newborns?

2. Scaling up effective interventions – coverage and quality

3. Healthcare professionals and quality of care– what works?

Outline

Source: Graph Lawn JE et al 4 million neonatal deaths- where? When? Why? Lancet 2005. Data updated 2007 for progress until 2005 using UN data

79

300

50

100

150

200

250

1960 1970 1980 1990 2000 2010

Mor

talit

y ra

te p

er 1

000

birt

hs

Global mean under 5 mortality rate Global mean neonatal mortality rateGlobal mean neonatal mortality rate

Target for

MDG-432

Almost 40% of under-5 deaths are neonatalalmost 4 million each year

No measureable change in early neonatal mortality

Global progress for child survival: MDG4

To accelerate progress towards MDG 4 reducing deaths in the first month and especially the first week of life, is key – and this links closely with

maternal health and MDG 5

Progress to MDG 4 in Africa?

41

164

0

100

200

300

1960 1970 1980 1990 2000 2010

Mor

talit

y pe

r 1,

000

birt

hs

.

Neonatal Mortality RateUnder 5 Mortality Rate

Infant Mortality Rate

MDG 4 target for

2015

Source: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006

New hope for reducing under five deaths! BUT average annual rate of reduction < 1% (1990 to 2005)To meet MDG 4 requires > 8% av annual reduction (2006 to 2015)

Progress must increase ALMOST TEN FOLD – how can the data help us to see where

acceleration is most needed?

WHERE?Neonatal Mortality burden in countries

SASI Group and M. Newman 2006

BUT….Physician density in countries

SASI Group and M. Newman 2006

When?Birthday is the riskiest day of life

Up to 50%of neonatal

deaths are in the first 24 hours

75% of neonatal deaths are in

the first week –3 million deaths

Source: Lawn JE et al Lancet 2005 Based on analysis of 47 DHS datasets (1995-2003) 10 048 neonatal deaths)

Birth and first week is key: yet coverage of care is lowest

for mothers and babies Over 50 million women deliver

at home every year

Crucial time for midwives, obstetricians

and paediatricians to be an effective

team especially as very few

neonatologists in Africa

Neonatal deaths and equity in Nigeria

DHS data analysis, published in Opportunities for Africa’s newborns, Lawn JE, Kerber KJ eds 2006

Neonatal mortality rate (per 1000 live births)

Income quintile

23

Highest income quintile

59

Lowest income quintile

If all the families in Nigeria received the same care as the richest, then NMR would be halved:127, 000 fewer newborn deaths each yearHCPs can play a crucial role in both advocating

for care for the poorest families, but also advancing this in policy and action

4 million neonatal deaths:

Scaling up effective interventions – coverage

and quality

Preterm, 25%

Asphyxia, 24%

Tetanus, 6%

Diarrhoea, 4%

Congenital, 6%

Other, 7%

Sepsis/ pneumonia,

28%

Infections

39%

Source: Opportunities for Africa’s Newborns, 2006. Based on vital registration for one country and updated modeling using the CHERG neonatal methods for 45 African countries using 2004 birth cohort, deaths and predictor variables.

WHY?1.2 million African newborns deaths

3 causes account for 88%

of neonatal deaths

Reaching 90% of women and babies with 16 proven interventions delivered through

packages could reduce neonatal mortality by up to 67% saving up to 2.7 million deaths per year

The Lancet Neonatal Survival series (2005)LI

VES

Additional cost of providing these interventions isUS$ 4.1 billion annually or $0.96 per capita

70% of costs benefit mothers & older childrenCO

ST

Coverage along the continuum of care is low

6942

830

65

0

25

50

75

100

Antenatal care(at least one

visit)

Skilledattendant at

birth

Postnatal carewithin 2 days

for homebirths*

Exclusivebreastfeeding

<6 months

DPT3vaccination

Cove

rage

(%) f

or 4

6 co

untr

ies

in

sub-

Saha

ran

Afric

a

The days of highest risk for mother and childhave the lowest coverage of care

* Postnatal care is only measured for home births in most Demographic and Health Surveys.Source: Opportunities for Africa’s Newborns, inputs from 28 African DHS from 1998-2005

MaternalSeries2006 Repro-

ductiveHealthSeries2006

Proliferating interventions and proliferating Lancet series..

Child develop

ment series 2007

Newborn 2005

Child 2003

Over 190 single

interventions listed

Need to package the interventions and strengthen existing programmatic platforms to reach families.

A paradigm shift to MNCH continuum of care

Nutrition series

ChildhoodNewborn/postnatalPre-pregnancy Pregnancy

Fam

ily/c

omm

unity

Out

reac

h/ou

tpat

ient

Clin

ical

Pr

imar

y /

Firs

t re

ferr

al

Ref

erra

lDelivery of interventions

Source: Lawn JE DCP chapter adapted for Lancet neonatal series executive summary

Birth

ChildhoodNewborn/postnatalPre-pregnancy Pregnancy

Fam

ily/c

omm

unity

Out

reac

h/ou

tpat

ient

Clin

ical

Pr

imar

y /

Firs

t re

ferr

al

Ref

erra

l

ANTENATAL CARE

- 4-visit focused package

- IPTp and ITN for malaria

- PMTCT for HIV/AIDS

POSTNATAL CARE–Promotion of healthy behaviours

–Early detection and referral of complications–Extra care of LBW babies–PMTCT for HIV

–Knowledge newborn care and breastfeeding

–Emergency preparedness

–Healthy home care including: promotion of exclusive breastfeeding, hygienic cord/skin care, keeping the baby warm, danger sign recognition and careseeking for illness

–Where referral is not available consider case management for pneumonia malaria, neonatal sepsis

–Where skilled care is not available, clean delivery and immediate newborn care including hygiene, warmth and early initiation of breastfeeding

–Adolescent and pre-pregnancy nutrition

–-Education

–Prevention of HIV and STIs

Integrated MNCH packages in the continuum of care

PREVENTIVE CHILD CARE

–Immunisations

–Malaria ITN

–Nutrition

–Care of children with HIV including cotrimoxazole

Source: Kerber KJ, Lawn JE et al Lancet in press

CHILDBIRTH CARE

–Emergency obstetric care

–Skilled obstetric care and immediate newborn care (hygiene, warmth, breastfeeding) and resuscitation, PMTCT

EMERGENCY NEWBORN AND CHILD CARE - Integrated management of childhood illness (IMNCI)

–Extra care of preterm babies including kangaroo mother care

–Emergency care of sick newborns

–Care of children with HIV

- Post-abortion care, TOP where legal

- STI case mx

REPRODUCTIVE HEALTH CARE

- Family planning

- Prevention & management of STI & HIV

- Folic acid

Birth

Childbirth care

Antenatal care

Adol-escenthealth

Postnatal care

Child health care

ChildhoodNewborn/postnatalPre-pregnancy Pregnancy

Fam

ily/c

omm

unity

Out

reac

h/ou

tpat

ient

Clin

ical

Pr

imar

y /

Firs

t re

ferr

al

Ref

erra

l

ANTENATAL CARE

- 4-visit focused package

- IPTp and ITN for malaria

- PMTCT for HIV/AIDS

POSTNATAL CARE–Promotion of healthy behaviours

–Early detection and referral of complications–Extra care of LBW babies–PMTCT for HIV

–Knowledge newborn care and breastfeeding

–Emergency preparedness

–Healthy home care including: promotion of exclusive breastfeeding, hygienic cord/skin care, keeping the baby warm, danger sign recognition and careseeking for illness

–Where referral is not available consider case management for pneumonia malaria, neonatal sepsis

–Where skilled care is not available, clean delivery and immediate newborn care including hygiene, warmth and early initiation of breastfeeding

–Adolescent and pre-pregnancy nutrition

–-Education

–Prevention of HIV and STIs

Reality for the delivery of integrated care

PREVENTIVE CHILD CARE

–Immunisations

–Malaria ITN

–Nutrition

–Care of children with HIV including cotrimoxazole

Source: Lawn JE DCP chapter adapted for Lancet neonatal series executive summary

CHILDBIRTH CARE

–Emergency obstetric care

–Skilled obstetric care and immediate newborn care (hygiene, warmth, breastfeeding) and resuscitation, PMTCT

EMERGENCY NEWBORN AND CHILD CARE - Integrated management of childhood illness (IMNCI)

–Extra care of preterm babies including kangaroo mother care

–Emergency care of sick newborns

–Care of children with HIV

- Post-abortion care, TOP where legal

- STI case mx

REPRODUCTIVE HEALTH CARE

- Family planning

- Prevention & management of STI & HIV

- Folic acid

Birth

Childbirth care

Postnatal care

Antenatal care

Adol-escenthealth

Child health care

Sick baby and child care in

hospital

Antenatal care

Emergency obstetricand neonatal care

Skilled attendance

IMCI

Behaviour Change and community mobilisation, community IMCI

PMTCT of HIV

Malaria programmes

Familyplanning

Adol-escent & school

programs

RoutinePostnatal

care

Nutrition programmes

Behaviour change and community mobilisation, community IMCI

Routinepostnatal

care

Ingredients for quality of care• Health system components (HARDWARE)

– Staff: numbers and skill mix, – Sites: infrastructure and equipment– Supplies: drugs and disposables

• Quality improvement process (SOFTWARE)– Norms, standards – Guidelines, training (nb preservice) and supervision– Review: audit including mortality review– Accountability for action (audit loop), and

rewards/motivation

Multiple approaches to quality improvement QI, QAP, TQM, PDQ, CORE……

Similar ingredients and process yet each like a separate sect!

4 million neonatal deaths:

Roles for HCPs in improving quality of care to save newborn lives –

what works?

HCPs and newborns

IPA and SNL joint initiativeGlobal movement for paediatricians to

advocate and act for newborn survival and health

• Obstetricians

• Paediatricians

• Midwives• Nurses• Other cadres can also play a key role

especially with HR crisis – eg extension workers such as HEWs and HSAs

• Assess the situation and act– Provide technical support for national planning and for

public health policy (standards, norms and guidelines) and use/adapt guides such as:• Hospital Pocket book (WHO, CAH)• Managing Newborn problems (WHO, MPS)• IMCI young infant algorithm (WHO, CAH)• Essential newborn care and Kangaroo mother care (

• Audit deaths and quality of care

• Advocate and promote and accountability– Better facilities, better supplies, better access

especially for the poorest– Promote and enable appropriate community

involvement and care

• Applied research

What can HCPs do?

69% 54% 59% 10% 11% 11%0%

25%

50%

75%

100%

Antenatalcare (at least

1 visit)

Antenatalcare (4visits)

TetanusToxoid

IPTp (malaria)

PMTCT forHIV (mother

dose)

PMTCT forHIV (baby

dose)

Cov

erag

e

.

Missed opportunity

Improving quality in existing high coverage packages eg Antenatal care

Source: Opportunities for Africa’s Newborns, Lawn JE, Kerber KJ eds 2006

Use Audit Eg. Perinatal audit in South Africa

• Facility-based mortality audit using standard format and free software (Perinatal Problem Identification Programme (PPIP))

• Each site meets for regular perinatal mortality review with all team members

• Data used for: – local quality improvement – national database held by Medical Research Council, with 3 yearly

publication linked to National and Provincial Departments of Health

• Started in October 1999, now includes 164 sites covering ~20% ofthe national births

• As of 2005 also have child audit - Child PIP

Source: Saving Babies V: Fifth perinatal care survey of South Africa (2003 to 2005) www.ppip.co.za

Avoidable causes of perinatal death (21,525 perinatal deaths, 2003 – 2005)25% have a defined avoidable cause

Source: Saving Babies V: Fifth perinatal care survey of South Africa (2003 to 2005) www.ppip.co.za

35%Inadequate intrapartum fetal monitoring / delaysInadequate neonatal management plan / delaysAntenatal steroids not given

Personnel & practices

19%Delay in transport Inadequate facilities/equipmentStaff not enough or not correctly trained or rotated too oftenLaboratory facilities/tests not available egsyphilis

Policy & admin

38%No antenatal careDelay in careseeking for danger signs

Patient & family

% of avoid-able deaths

ExamplesWhere in system?

Example of change through audit for intrapartum care

Problem• Acute intrapartum complications identified as the 2nd most common cause of

stillbirth and pre-discharge neonatal deaths

Avoidable causes identified to address• Inadequate intrapartum monitoring, delay in responses• Pinard fetoscope not used or used incorrectly and lack of robust, user friendly

doppler fetal heart monitors as an alternative especially for rural areas

Actions• Distance learning materials (Perinatal Education Programme) with modules for

intrapartum care• Develop and test prototype wind up powered doppler fetal heart monitor

Results• More than 50,000 nurses in South Africa have passed PEP course exams• Doppler fetal heart monitor about to be produced at low cost in early 2008

Saving Babies V: Fifth perinatal care survey of South Africa (2003 to 2005) www.ppip.co.zaPerinatal Education Programme www.pepcourse.co.zaTheron GB. Improved practical skills of midwives practicing in the Eastern Cape Province of the Republic of South Africa through the study of a self-education manual. J Perinatology 2000;20:184-8

Newspaper headline August 2007

Influence public knowledge about quality of care

Happy result – Paediatricians, Save the

Children and others worked with

government to run a newspaper

supplement on Kangaroo Mother Care as

a simple, low cost solution

Everyone has a role to play…Ambassador Mongella, President of the Pan-African Parliament, 2006

“As government officials to lead

As policy makers to guarantee essential interventions and equity

As partners and donors to support programmes

As health workers to provide

Let us all play our part!

Source: Opportunities for Africa’s Newborns, Lawn JE, Kerber KJ eds 2006

Zikomo kwambiri! Asante sana, Ye dewaesepii! Danke! Merci beaucoup! Obligado!

Thank you !