INCREASING SURVIVAL IN THE FIRST MONTH OF LIFE · • Essential Newborn Care ... Intrapartum-related 11% ... ESSENTIAL NEWBORN CARE Increasing Survival in the First Month of Life

INCREASING SURVIVAL IN THE FIRST MONTH OF

LIFE: A SEMINAR ON INNOVATIVE APPROACHES TO IMPROVING NEWBORN HEALTH

Overview agenda

• Overview of Newborn Health

• Specific technical areas

• Essential Newborn Care (ENC)

• Possible Severe Bacterial Infection (PSBI)

o Prevention with chlorhexidine

o Treatment with simplified anitbiotics

• Care of preterm and very small newborns

• Antenatal Care (ANC)/Postnatal Care (PNC) continuum of care

• Stillbirths

• Kushtia, Bangladesh case study

18 October 2016Increasing Survival in the First Month of Life 2

Overview of Newborn Health

• Origins of interest/concern about

newborn health

• Evidence generation phase

• Learning and Scale Up phase

318 October 2016Increasing Survival in the First Month of Life

Relatively lower rate of decline in newborn mortality

compared to under-five mortality


0

10

20

30

40

50

60

1-59 mo Newborn

1990-2015 Annual Rate

of Reduction (ARR)

1-59 months =3.37%

Newborn = 2.54%

Maternal = 2.3%

Mort

alit

y r

ate

per

1000 liv

e b

irth

s

Recent U5 and newborn cause of death estimates

5

Pneumonia

13%

Other 18%


Pneumonia 3%

Preterm birth

complications 16%

Intrapartum-related 11%

Sepsis 7%

Tetanus 0.5%

Congenital 5%

Diarrhea 0.5%

Other 3%

Neonatal

45%

Source: WHO and Maternal and Child Epidemiology Estimation Group (MCEE)

2015



newborn health




Breaking the myth: saving newborn lives without NICUs

7

Early evidence + advocacy by SNL/BMGF (and partners)

Home-based newborn care by community health

workers reduced NMR by 62%

Increasing Survival in the First Month of Life 18 October 2016


8


Community-based newborn-care package in

Sylhet district, Bangladesh, reduced NMR by 34%



9



“Of the 130 million babies born every year, about 4 million

die in the first 4 weeks of life –the neonatal period. A similar

number of babies are stillborn…”

Neonatal Survival

Newborn survival and interventions

gain global and country attention

18 October 2016

New efficacy evidence generates momentum

10Increasing Survival in the First Month of Life

CHLORHEXIDIN

E

NEONATAL

RESUSCITATION

SIMPLE

ANTIBIOTICTREATMEN

T



newborn health




Evidence to policy for scale up

12

Global Newborn Health Conference Johannesburg, SA 2013



13

Every Newborn Action Plan 2014



14

Global Maternal Newborn Health Conference, Mexico City, MX 2015


Country implementation: learning by doing

• ENAP country bottleneck

assessment to guide action

(UNICEF)

• Testing innovative models of

service delivery (Bangladesh

case study)

• Cross country sharing

• SNL and other partners

providing country TA support

• Implementation and learning

about achieving high

effective coverage at scale


Evidence based interventions


ADOLESCENCE AND BEFORE PREGNANCY

PREGNANCYLABOR AND

BIRTHPOSTNATAL CHILD

INTERSECTORAL: Improved living and working conditions, including housing, water and sanitation, and nutrition; education and

empowerment, especially of girls; folic acid fortification; safe and healthy work environments for women and pregnant women

RE

FE

RR

AL

AN

D

TE

RT

IAR

Y L

EV

EL

FA

CIL

ITY Reproductive

health, including

family planning

Management of

pregnancy

complications

Skilled care at birth

Comprehensive

emergency

obstetric and

newborn care

Essential

newborn care

Emergency care

of small and sick

newborns

Hospital care of

childhood illness

FIR

ST

AN

D

TE

RT

IAR

Y L

EV

EL

FA

CIL

ITY Reproductive

health, including

family planning

Pregnancy care

Skilled care at birth

Basic emergency

obstetric and

newborn care

Essential newborn

care

Postnatal visits

Care of small and

sick newborns

Prevention and

management of

childhood illness

CO

MM

UN

ITY

Adolescent and

pre-conception

health care and

nutrition

Gender violence

prevention

Counselling and

birth preparedness

Home birth with

skilled care and

clean practices

Essential

newborn care

Postnatal home

visits for mothers

and newborns

Ongoing care for

the child at home

Source: Every Newborn Action Plan

thermal

stability

hygiene

exposures

feeding vigilance

ESSENTIAL NEWBORN CARE


18

CHLORHEXIDINE


1918 October 2016

Introduction/scale-up

Pilot introduction/policy alignment

Expressed interest

2016

Increasing Survival in the First Month of Life

20

POSSIBLE SEVERE

BACTERIAL

INFECTION (PSBI)

TREATMENT


PSBI Treatment: SATT and AFRINEST Studies

• AFRINEST Group et al. “Oral amoxicillin compared with injectable procaine

benzylpenicillin plus gentamicin for treatment of neonates and young infants

with fast breathing when referral is not possible: a randomized, open-label,

equivalence trial”

• ANFRINEST Group et al. “Simplified antibiotic regimens compared with

injectable procaine benzylpenicillin plus gentamicin for treatment of neonates

and young infants with clinical signs of possible serious bacterial infection

when referral is not possible: a randomised, open-label, equivalence trial”

• Baqui, A et al. “Safety and efficacy of alternative antibiotic regimens compared

with 7 day injectable procaine benzylpenicillin and gentamicin for outpatient

treatment of neonates and young infants with clinical signs of severe infection

when referral is not possible: a randomised, open-label, equivalence trial”


PSBI Treatment Global Policy & Guidelines


PSBI/ Early implementation countries


CARE OF PRETERM AND VERY SMALL

NEWBORNS

18 October 2016 24Increasing Survival in the First Month of Life

25

ANTENATAL

CARE



InterventionsMaternal

deaths

Newborn

deaths

Still-

birthsPre-term IUGR Other

Nu

trit

ion

Breast-feeding early

initiation

↓↓

Iron supplementation ↓ ↓ ↓ ↓

Calcium supplementation ↓ ↓↓ ↓

PN vitamin A (adv distrib) ↓ late infant deaths

Iodized salt use ↓ cognitive disability

Infe

cti

on

IPTp/ITNs ↓ ↓ ↓ ↓

tetanus toxoid ↓

chlorhexidine ↓

Syphilis screen & treat ↓ ↓ ↓

HIV-PMTCT ↓ infant & child deaths

Ob

ste

tric

al &

oth

er

Clean delivery ↓

Thermal care ↓↓

Birth preparedness ↓ ↓

Misoprostol (adv distrib)

Pre-eclampsia screen &

treat

↓↓ ↓↓ ↓↓

Tobacco/ alcohol ↓ ↓ ↓ ↓

FP counseling ↓

Impact of simple interventions delivered in pregnancy

Source: Hodgins S et al. PLoS One 2016:11(8): e0160562

POSTNATAL PERIOD


28

STILLBIRTHS


Development and Demonstration of Bangladesh’s Comprehensive

Newborn Care Package for National Scale-up

SAVING NEWBORN

LIVESKUSHTIA,

BANGLADESH

30

73000 newborn deaths in

2015

28 deaths per 1000 live births

61% of all under-five deaths

Major newborn killers

• Prematurity-related complications

• Birth asphyxia

• Infection


NEWBORN

MORTALITYIN

BANGLADESH

District Learning Laboratory

• In 2013 Government of Bangladesh declared its commitment for Ending Preventable

Child Deaths and identified a set of evidence-based newborn health interventions to

achieve its commitments

• Later the Ministry of Health (MOH) decided to develop a Comprehensive Newborn Care

Package (CNCP) and to demonstrate in a typical public health setting with technical and

catalytic support from SNL.

31

Development and demonstration of comprehenisve newborn care package (CNCP) in public health

settings.

Interventions: • SBCC for promotion of

• Healthy MNH behavior and care seeking• Care for all newborn

• Immediate and Essential newborn care including application of CHX NB cord• Postnatal care

• Care for sick newborn and newborn with complications• Resuscitation (HBB)• PSBI Management• Kangaroo Mother Care

• Care for prevention of preterm complication • Use of Antenatal Corticosteroid


Background:

Why the District Learning Laboratory for CNCP?

32

Development and demonstration of comprehenisve newborn care package (CNCP) in public health

settings.


Objective of DLL for CNCP

Implementation

– For national scale-up

preparedness

– Identify challenges as well as

the solutions to achieve

effective coverage of

interventions

– Ultimately having a SOP for

CNCP national scale-up

Focus area to identify

challenges & solutions

Capacity building and skill

retention

Ensure availability of

commodities and

equipment's in health

system

Functional M&E, HMIS and

Quality of Care

Effective SBCC approaches

for healthy MNH behavior

and demand generation

33

BANGLADESH NEW GUIDELINE FOR PSBI

MANAGEMENT: KEY PATHWAYS

Promotion of

Healthy MNH

behavior &

proper care

seeking

Day-4

Day-8

Use of simplified antibiotic regimen

tested in recent studies (RCTs)

supported by SNL, USAID, WHO and

other partners in 5 different countries in

Asia and Africa


Programmatic Inputs

Supply side • Capacity building and skill retention

• CNCP training• Refreshers

• Ensure availability of supplies

• Ensure equipment, job aids & medicine

• Advocacy & TA to include routine procurement mechanism

• Establishing supply system

• Establishing routine monitoring system

• Development, pretesting, finalization

• Capacity building on data management

• Functional routine HMIS with use of data

• Strengthen supervision and mentoring support for quality improvement

34

Demand side • SBCC activities

• Promotion of newborn danger

signs recognition

• Promotion of proper care

seeking by families


35

Knowledge of the Recently Delivered Women

on Newborn Danger Signs: December 15 and May 16

98

64

87

61

88

54

42

66

99

75

95

71

89

5648

77

No

t fe

ed

ing

we

ll/h

isto

ry o

fd

iffi

cu

lty in

feed

ing

Lo

w b

od

y t

em

pe

ratu

re

Fe

ve

r o

r h

igh

te

mp

era

ture

Fa

st

bre

ath

ing

Se

vere

ch

es

t in

dra

win

g

Mo

ve

me

nt

on

ly w

hen

sti

mu

late

d

His

tory

of

co

nv

uls

ion

Um

bilic

al re

dn

es

s e

xte

nd

sto

sk

in o

r fo

ul sm

ellin

gd

isch

arg

e f

rom

um

bilic

us

Pe

rce

nta

ge

Round 1 (N=1290)

Round 2(N=847)

Data Source: icddr,b survey


36

Sustaining Facility ReadinessOctober 15 and May 16

0

10

20

30

40

50

60

70

80

90

100P

rovis

ion

of

Safe

Dri

nkin

g

wate

r

Availab

ilit

y o

f ele

ctr

icit

y

Am

oxic

illin

Ped

dro

p

Inj. G

en

tam

ycin

Th

erm

om

ete

rs

I C

C S

yri

nge

Weig

hin

g m

ach

ine(B

ab

y)

Sic

k N

ew

bo

rn R

egis

ter

Pre

scri

pti

on

wit

h r

efe

rral sl

ip

Do

se C

alc

ula

tio

n T

ab

le-

An

tib

ioti

cs

for

Sep

sis

Man

agem

en

t

Vis

ible

Alg

ori

thm

fo

r S

ep

sis

Man

agem

en

t

Environment Drugs Equipment Logistics

%

Round 1

Round 2

Data

So

urc

e: i

cd

dr,

b s

urvey


Cases Managed in Union Level facilities in Kushtia

October 15- August 16

0

50

100

150

200

250

300

350

400

Oct Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16

Expected Case #

Data Source: Routine HMIS

Increasing Survival in the First Month of Life 18 October 2016 37

Scaling up of PSBI management in Bangladesh

• Bangladesh Government is

planning to scale-up CNCP

including PSBI management (in

Union level facilities)

• These interventions are included in

the Essential Service Package

• Planning has been going on to

incorporate in various Operation

Plans of 4th HNP sector program


Documents

INCREASING SURVIVAL IN THE FIRST MONTH OF LIFE · • Essential Newborn Care ... Intrapartum-related 11% ... ESSENTIAL NEWBORN CARE Increasing Survival in the First Month of Life