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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.html7/28/2019 Wall: Newborn Care in Facilities Within the Household-To-Hospital Continuum of Care
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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