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Facility-Based Maternal &

Newborn Care in Facilities

within the Household-to-

Hospital Continuum ofCare (HHCC)

Steve Wall

Save the Children

Global Newborn Health Conference

Johannesburg

April 15, 2013

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Outline

I. Global shift in care seeking toward facilities

I. Quality of facility-based MNH care

I. Linkages to community/household care

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High income countries

~11 million births

Middle income countries

~34 million births

~40 million facility births~50 million births at home

135

million

live births

per year

2010One in 4

newborns is

African

2035One in 3 will be

African

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Institutional delivery varies greatly by region

Percentage of births delivered in a health facility, 20072012

Source: SOWC 2013, UNICEF global databases 2012, from MICS, DHS and other nationally representative sources. http://www.childinfo.org/delivery_care.html

Note: Global estimates are based on a subset of 110 countries, covering 82% of births in the developing world. Regional estimates represent data from countriescovering at least 50% of regional births. Data coverage was insufficient to calculate the regional average for CEE/CIS.

http://www.childinfo.org/delivery_care.htmlhttp://www.childinfo.org/delivery_care.htmlhttp://www.childinfo.org/delivery_care.html

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Increasing coverage of skilled attendance

12 11

18

56

39

27

3639

71

59

0

10

20

30

40

50

60

70

80

90

100

Bangladesh Nepal Pakistan Malawi Uganda

Covera

ge(%)

Around the year 2000

Around the year 2010

Source: Newborn survival decade of change analysis: Health Policy and Planning. 27(Suppl. 3) papers 3 to 7

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55

73

0

10

20

30

40

50

60

70

80

90

100

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Covera

ge(%)

Source: Malawi DHS 1992, 2000, 2004, preliminary 2010. Malawi MICS 2006

Increased by 16% over the last 5 yearsMultiple approaches both supply and demand

> 30% increase in numbers of nurse/midwives

Changes in skilled birth attendance

for Malawi, 1990-2010

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Increasing facility deliveries

State in India % Institutional Deliveries

Assam 55.5

Bihar 47.7

Chattisgarh 34.9

Jharkhand 37.6

Madhya Pradesh 76.1

Odisha 71.3

Rajasthan 70.2

Uttar Pradesh 45.6

Uttarkhand 50.5

Source: Indian Annual Health Survey, 2011.

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Contributing factors to this rapid increase

Incentives for CHWs and families

Changing community and practices

Service availability, including

appropriate drugs and tools

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Not all facilities are created equal

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Babies born in facilities with trained staff and equipment for

neonatal resuscitation

65%

49%

40%

28%

47%

41%

8%

12%

7% 2% 6%8%

17%19%

22%

10%8%

15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Egypt Ghana Kenya Rwanda Tanzania Uganda

Percentage

% of all babies born at facilities

% of all babies born by staff trained in neonatal

resuscitation

% of all babies born in facilities with equipment

for newborn respiratory support

Missed Opportunities

Quality Gap in Facilities

Only 1 of 5 babies born inhospitals have access to

Neonatal Resuscitation

Original data source: National Service Provision Assessment Surveys, years ranging 2002-2006

Source: Wall S et al, IJGO 2009

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Facility Birth quality MN care . . . unless there is

Respectful care

Skilled staff 24/7

Functional equipment

Essential medicines in stock

Newborn routine andemergency care signalfunctions with B/EmOC

Standard protocols used

Quality control in place

Data

Action

Measurement

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Newborns need basic care,

and special care for complictions

Basic newborn care - Hygiene, warmth, immediate/exlusivebreastfeeding, cord care

Intrapartum complications:

Prevention: Quality obstetric care and labor monitoring

Treatment: Stimulation/resuscitation, if not breathing

Prematurity/low birth weight:

Prevention of complications: Steroids to mother during premature labor

Management: Kangaroo Mother Care

Infection

Prevention: clean delivery, cord care, handwashing, breastfeeding;

chlorhexidine

Detection and treatment: antibiotics (including at health centers/posts)

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New opportunities for facility-based NB care

Neonatal resuscitation in peripheral facilitiesHelpingBabies Breathe (and similar programs)

Antenatal corticosteroidsidentification of PTL and1st doseACS at peripheral facility, referral

KMCprovide space, support to mothers/families

Chlorhexidine? high mortality settings, poor hygiene, earlydischarge

Safe birth checklist? Increase newborn health components

Treatment of routine sepsis/pneumonia at healthcenters/posts (pending evidence from simplified antibiotictrials (2013-14)

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Safe birth checklist

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Ending harmful facility practices

- Oxytocin augmentation of labor (without monitoring) risk of

uterine rupture, intrapartum stillbirth, birth asphyxia

- Routine suctioning of all newborns potential to depress breathing

and heart rate needlessly; use only when necessary, as indicated

- Routine or frequent separation of mothers and newborns

immediately after birth (all too common with newborn corner,

stabilization units, etc)

- Elective c-section prior to 39 weeks major contributor to high

preterm rates, increased newborn morbidity and mortality

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Referrals

Community referral systems

Community awareness and leadership Birth/emergency preparedness,

Transport

Community funds

Trained CHWs to accompanymothers/newborns

Primary to referral facilities

Pre-referral care and referral protocols

Ambulance services Mobile technologieshotline

High quality emergency care 24/7 atreferral facility.

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Facility linkages to community/home

Many/most mothers & newborns are

discharged (or leave facility) within hours ofdelivery

Need to ensure pre-discharge examination ofmother & baby (including breastfeeding);counseling to mother re: home care practices,danger signs; contact CHW for home visit

Need to ensure early postnatal home visits (ie,within 1- 2 days) by trained health worker - checkon mother and baby, refer for danger signs,counsel on home care practices

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Missed opportunities: Post-discharge counseling

Integrated Family Health Initiative (Bihar, India). Facility Assessment DirectObservation: Baseline 2012

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Missed opportunities: Post-discharge counseling

Integrated Family Health Initiative (Bihar, India). Facility Assessment DirectObservation: Baseline 2012

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Simple approaches to improve MNH in HHCC

Pre-discharge checklist

Breastfeeding assessment

Assess mother & baby

Provide counseling (eg, danger signs)

M-health SMS to link facility discharge to early CHW home

visit

Postnatal home visit checklist M health tools

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Monitoring facility based care

Need impact/outcome indicators of quality of

facility-based MNH care Possible new indicator: neonatal death in fist day +

fresh stillbirths

Improve routine monitoring Process indicators (esp for newborn care signal

functions)

Capacities to collect and use data for decision making

Expanding death audits: maternal, newborn,fresh stillbirths

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We can make it happen:

High coverage, high quality, and high demand for

facility-based maternal-newborn care

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(From the SNL evaluation team visit to Nysamba Hospital, Uganda)

SNL supported training of midwives, nurses, clinical officers, andphysicians in management of labor & delivery and essential newborncare.

Facility staff reflection re neonatal resuscitation:

Now we are not afraid of handling this tiny human being.Previously we used not to audit those deaths, but would just say,Sorry, sorry without establishingthe cause of the problem. No

one was responsible or accountable.

Now we expect the woman who comes to deliver to go awaywith a live baby.

23

Changing expectations

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Much to do

- Together we can make ithappen.

- Thanks