care seeking for newborn illness a changing paradigm_steve wall_4.25.13
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Care seeking for newborn
illness: A changing
paradigm?
Steve WallSave the Children
CORE MeetingBaltimore
April 25, 2013
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1990 1995 2000 2005 2010 2015 2020 2025 2030 2035
Source: UN Inter-agency Group for Child Mortality Estimation, Levels and Trends in Child Mortality: Report 2011; UNICEF, Required Acceleration for Child Mortality Reduction beyond 2015, 2012; team analysisSNL/Save the Children team analysis for NMR projection for Call for Action meeting
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Accelerated U5MR ARR = 5.1%Current U5MR ARR = 2.2%
* ARR = annual rate of reduction
MDG 4 target = 34 U5MR
Global Progress for child survivalU5MR and NMR decline 1990-2010, projected to 2035
15
Current NMR ARR = 1.8%
If 1-59 month mortality accelerates further but neonatal mortality continues on same trend then with
2 million child deaths in 2035, 1.5 million may be neonatal.
Why are we focused on newborn survival?
Three killers – prematurity,
asphyxia, and infections -
account for 81% of all neonatal
deaths3.1 million
Sources: CHERG/WHO 2010. Estimates for 193 countries for 2008. Black R et al Lancet 2010. UNICEF, State of the World's Children,
2011.
Causes of death in children under-five in developing countries –Newborn deaths are almost half of all deaths of children under five
REGION Neonatal mortality rateAverage annual change 1990-2010
Africa 1.3%
East Med 1.6%
Southeast Asia 2.2%
Western Pacific 4.2%
Americas 3.6%
Europe 3.6%
Maternal mortality ratio = 4.2%1- 59 month mortality rate = 3%Neonatal mortality rate = 1.8%
All 3 measures show increased progress since 2000
Source: Lawn J,E. et al. 2012. Newborn survival: a multi-country analysis of a decade of change. Health Policy and Planning. 27(Suppl. 3): iii6-ii28. Data sources: Oestergaard et al 2011 PLoS, UNICEF 2012 www.childinfo.org
2165
2085
Mortality average annual rate of reduction
WHEN WILL REGIONS REDUCE NMR TO CURRENT RATE OF HIGH INCOME
COUNTRIES (3 per 1000)?
Care seeking for NBs: Our Original Assumptions
• Home-based management of sick newborns is effective and saves lives
• Care seeking from qualified providers outside the home is low, influenced by entrenched cultural beliefs and practices.– Seclusion, contamination– Evil eye– Traditional beliefs about illness and remedies– Lack of trust in “western” medicine
• Case identification in Projahnmo (Bangladesh) coincided with the days of scheduled post-natal home visits “active” case detection seemed needed
Baqui et al. BMJ, 2009.
Family acceptance of referral to facilities: Bangladesh – ~ 1/3 Pakistan – 20%
Baqui et al. Lancet. 2008; Zaidi et al. XXX.
Evidence “confirming” these assumptions
More recent evidence and program experience
• Nepal:• MINI – FCHVs counseled family, who notified
FCHVs of suspected newborn illness• FCHVs identified signs of PSBI, treated with
cotrimoxazole and referred to gov’t CHW for injectable gentamicin
• CHW provided 7 days of gentamicin• Initially at home; but families became willing to go to
health posts/centers for gentamicin MINI model incorporated into 10-district pilot of
Community-Base Newborn Care Program (CB NCP)
Recent CB NCP data show families infrequently contact FCHVs, but tend to directly seek care at health posts/centers
More recent evidence and program experience - 2
• Ethiopia • COMBINE (cRCT) introduced NBS management
(amoxicillin + gentamicin x 7 days) by Health Extension Workers (HEW) at Health Posts
• Expectation of “active case detection” by volunteers and HEWs
• Initially, very low case identification in intervention areas.
• Qualitative research identified barriers – cultural/religious taboos against taking newborns outside the home; lack of knowledge of newborn illness, treatment, and availability of such treatment at HPs.
• Project worked with community/religious leaders, volunteers to provide information.
• Increased care seeking for sick newborns was largely ‘self-referral’
COMBINE care seeking for NB illnessTable 1: Expected births & care-seeking
For newborn illness 2011 2012
Q3 Q4 Q1 Q2 July
Intervention Expected No. of births 2711 2395 2123 2468 880
No. (%) seen at HP 8 (0.3) 28 (1) 131 (6.2) 170 (7.0) 54 (6.1)No. (%) seen at HC 0 (0) 8 (0.33) 102 (4.8) 38 (1.5) 12 (1.6)
Control Expected No. of births 2731 2394 2068 2419 894
No. (%) seen at HP 5 (0.18) 6 (0.25) 16 (0.75) 7 (0.28) 8 (0.91)
No. (%) seen at HC 3 (0.1) 5 (0.2) 42 (2) 31 (1.3) 13 (1.5)
Implications
• Families ARE willing to seek care for NB illness (from qualified providers) outside the home.– Taboos can be overcome (rapidly ?) if
families/communities have knowledge about preventable newborn deaths, need for early care seeking, and availability of services
– Services must be reliable (set times for health worker at HP, medicines in stock)
Issues/Questions
• Is care seeking timely enough for effective treatment? Any prior care seeking from unqualified providers?
• Can community participation and CHW role(s) help “facilitate” care seeking?
• How different might this care seeking pattern be in different regions or different country contexts (eg, need for formative research and pilots)?
• How rapidly can community norms be changed and will these changes be sustained?
Additional questions for discussion?
• In some countries (eg, India, Pakistan), care seeking for newborn illness may be mostly from private providers (many unqualified). How to address this challenge?
• What is care seeking pattern for sick newborns in the first week of life, and how can this be increased?– First week NBS is more lethal condition,
requires early identification and treatment, and is more prevalent than later neonatal NBS.
Further considerations
• Roles of CHWs (SNL 2 experiences) in changing household practices and care seeking
• Role of community mobilization in changing expectations & norms, household practices and care seeking, and care quality
Learning from implementation of community-based
maternal & newborn health programs:
The role of CHWs Deborah Sitrin
Save the Children
CORE Group MeetingBaltimore
April 25, 2013
SNL2 Vision
To have reduced global neonatal mortality by providing catalytic assistance to develop, and implement, effective evidence-based newborn care interventions at scale.
Guatemala
Bolivia
Indonesia
Vietnam
BangladeshNepal
India
Pakistan
Afghanistan
SNL2: Where?
South Africa
Mozambique
Malawi
Tanzania
Uganda
Ethiopia
Ghana
Mali
Nigeria
60% of the world’s 3.1 million neonatal deaths
18 countries•Africa: 9•Asia: 7•Latin America: 2
Global & Regional
Description of programs
Program elements:• Home visits by Community Health Workers during pregnancy & after birth to:
Encourage ANC and facility deliveryPromote optimal care practices for newborn and mother Counsel families to identify danger signs and seek careIdentify sick newborns and refer to facilities (+ pre-referral oral antibiotic in
Nepal only)
• Facility strengthening (varied)
• Community engagement (varied)
Data from pilot districts in 4 countries:• Malawi• Uganda• Nepal• Bangladesh
Community workers conducting home visits
Differences across programs:• Population catchment size• Gender • Education level• Salaried government
employee vs. volunteer• Incentives• How workers are recruited• Residency• Time in community• Length of pre-service training
Similarities across programs:
• Length of training in maternal newborn health package
• Content of counseling on newborn care practices
• Made home visits during pregnancy and soon after birth
LESSON: Delivery platforms vary substantially and delivery systems can change.
Implementation Questions
1. How many women and newborns received home visits?
2. What did CHWs do for newborns during visits?
3. How many families sought timely and appropriate care when their newborns had danger signs?
4. What was the role of CHWs in identifying and referring newborns with danger signs?
5. What have we learned about increasing uptake of healthy newborn care practices?
Percent of mothers/babies receiving home visits
FINDINGS:• Low in Malawi, higher in
Bangladesh and Nepal
• More received pregnancy visits than postnatal visits
• If a postnatal visit was received, it was usually within 3 days after birth
LESSON: Percent receiving home visits varied substantially and we need to consider what each community platform can handle.
Nepal (N=615)
Bangladesh (N=398)
Malawi (N=900)
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1 or more home visits during pregnancy1st postnatal home visit 0-3 days after birth1st postnatal home visit 4-7 days after birth
Percentage of mothers/newborns that re-ceived home visits
Data from interviews with mothers with a live birth in previous 12 months
What was done for newborns during postnatal home visits within 3 days after birth
FINDINGS:• Nearly all newborns that received an early postnatal home visit had
at least one key function done• Weighing baby low in Nepal, but FCHVs only instructed to weigh
babies not previously weighed at facility
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Nepal(N=307)
Malawi(N=95)
Percentage of newborns that received a postnatal home visit ≤3 days after birth and signal functions were performed by CHW
LESSON: When postnatal visits are done, CHWs performed key tasks. BUT need to monitor quality.
Data from interviews with mothers with a live birth in previous 12 months
Care-seeking for newborns with danger signs
Malawi Uganda Nepal Bangladesh
Endline Endline Baseline Endline Baseline Endline
NB with danger sign 23.4% 50.0% 21.4% 28.8% 52.3% 40.7%
Care-seeking for those with a danger sign:
Sought care (any source) 82.9% 94.2% 85.8% 98.9% 82.0% 88.3%
Sought care <=24 hours at a facility (public or private)
41.2% 48.3% 36.6% 67.8% NC 20.4%
FINDINGS:High levels of care-seeking• High in all countries (baseline & endline, intervention & comparison areas)
Yet fewer newborns taken to a facility within 24 hours after onset of danger signs• % newborns with danger signs taken to a facility within 24 hours increased in
Nepal, was moderate in Malawi and Uganda, low in Bangladesh
Data from interviews with mothers with a live birth in the previous 12 months
Care-seeking for newborns with danger signsLESSONS:
Families will leave the home and seek care.
Need to address delays in seeking care from a facility within 24 hours after onset of illness. Noting we found high levels of newborns with danger signs. Difficulty in relying on survey data – mothers may not accurately recall or report illnesses.
Need to ensure families are accessing appropriate care. Use of private facilities and pharmacies/drug shops high in Nepal, Bangladesh, and Uganda. We saw decreases in Nepal but no change in Bangladesh (no baseline information from Uganda or Malawi).
Access to full course of treatment for newborn sepsis
MALAWI
NEPAL
1 facility per 300,000 people
1 facility per 7,000 people
LESSON: Community-based programs may create demand, but treatment needs to be available closer to home
Role of CHWs in referring sick newborns
FINDINGS:
CHWs have good understanding of newborn danger signs and appropriate care• >95% of CHWs in Malawi and Nepal
could name 3+ newborn danger signs
BUT low volumes of CHW referrals of newborns with danger signs• Many newborn not visited by CHWs
within the first week after birth• Families going straight to facilities
when newborn has danger sign• Issues with CHWs not getting required
supplies/equipment
Data from interviews with mothers with a live birth in previous 12 months
Nepal (N=615)
Bangladesh (N=398)
Malawi (N=900)
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1 or more home visits during pregnancy1st postnatal home visit 0-3 days after birth1st postnatal home visit 4-7 days after birth
Percentage of mothers/newborns that re-ceived home visits
Role of CHWs in referring sick newborns
LESSONS:
Need appropriate expectations for the role of CHWs in identification and referral: Focusing on increasing family-initiated care-seeking may be more important and more feasible than detection by CHWs.
Examine role of CHW in follow-up and treatment completion: May be feasible and effective to involve CHWs in follow-up of sick newborns. Counter-referral systems are needed to implement follow-up.
Strengthen monitoring of referrals and outcomes: Weak systems to track referrals and referral outcomes.
Uptake of 4 key newborn care practices
Malawi* Nepal* Bangladesh Uganda*0
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Baseline Endline
Immediate breastfeeding
Malawi* Nepal* Bangladesh* Uganda*0
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Baseline Endline
Bathing delayed ≥6 hours
Malawi Nepal Bangladesh Uganda0
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Baseline Endline
Skin-to-skin contact
Malawi Nepal* Bangladesh* Uganda*0
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Baseline Endline
Nothing applied to cord after cutting
*Statistically significant at p<0.05Data from interviews with mothers with a live birth in previous 12 months
Newborn care practices
FINDINGS:• Practices improved over time with a few exceptions (immediate breastfeeding in
Bangladesh, applying nothing to cord in Malawi and Uganda)
• Practices increased in both intervention and comparison areas, though endline rates often higher in interventions areas. (Note: comparison area data only available in Bangladesh and Uganda.)
• Newborn care practices associated with receipt of home visits from CHW during pregnancy (except in Uganda)– Only statistically significant if mother received 3+ home visits during
pregnancy
LESSON: Home visits during pregnancy are an opportunity to improve newborn care practices and programs able to reach large numbers of women during pregnancy. BUT may be difficult to achieve 3+ visits.
Mobilizing communities for sustainable change in newborn health expectations, care giving practices, and care seeking
Angie Brasington, Save the ChildrenCORE Group SPRING MEETING
April 25, 2013
Mobilizing communities for improved maternal & newborn health: lessons and questions
Angie Brasington, Save the ChildrenCORE Group SPRING MEETINGApril 25, 2013
Outline:
CORE Group Newborn Health Survey CM for Newborn Health – what are we learning? Questions that need exploration
Carolyn Kruger, Ph.D.Sr. Advisor MNCH
PCI
CORE Group co-chair: Safe motherhood & reproductive Health Working Group
CORE GroupNewborn Health Survey Results
USAID Priority Countries: Supporting Newborn Care
BelizeDominican RepublicGuatemalaMexicoNicaragua
ColombiaEcuador Peru
EthiopiaKenyaSenegalSouth SudanMali
India
Newborn Health Areas Supported(18 Organizations)
Number of organizations
16
16
15
15
12
12
12
1110
10
9
9
8
7
6
53
2
2
1
Cross-Cutting Approaches• CHW capacity building - 100%
• Behavior change/communication - 78%
• Community mobilization - 70%
• Community health system strengthening - 70%
• Care groups - 50%
• mHealth approaches - 48%
• Mass communication - 42%
• C-IMCI/CCM - 38%
Innovative Strategies
• mHealth reminders on assessment of mothers and newborns
• Mobile job aids - counseling messages
• Newborn screening on birth defects
• Preconception care
• Casa Materna birthing home model
• Community Kangaroo Mother Care
• CHW capacity to recognize danger signs
• Involving fathers during pregnancy, delivery and PP care
• EBF among adolescent mothers using text messaging and support groups
Mobilizing Communities…..
Community-based Activities
=Community Mobilization
• Day celebrations, competitions, use of action cards to stimulate group dialogue are all examples of behavior change strategies.
• The process of stimulating a community to identify, plan and implement strategies and activities to achieve an agreed upon goal is community mobilization.
• CM often incorporates participatory behavior change strategies, however
• BC strategies can be effective without CM, so why…..
Mobilizing Communities…..
1. We have evidence it works:
WEWE problems
So, why mobilize communities?
Costello et al, Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster-randomized controlled trial. Lancet 2004; 364: 970 – 979. Baqui et al, Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomized controlled trial. Lancet 2008; 371: 1936–44. Kumar et al, Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomized controlled trial. Lancet 2008; 372: 1151–62.
Costello et al, Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomized controlled trial. Lancet 2010; 375: 1182-1192
2. The principles behind CM fit with our mission and context:
• Decentralization and democratization require increased community level decision-making --- CM is an entry point for civil society strengthening and democracy building.
• CM builds mechanisms and systems to sustain improvements in individuals’, families’ and communities’ well-being.
• Communities can apply political pressure to improve services. • CM can strengthen community members’ capacity to address
the underlying causes of poor health.f problems
So, why mobilize communities?
LESSONS: Men want to be involved Communities are able and
willing to contribute resources
Communities are changing rapidly
Communities take action: emergency transport systems and funds, advocacy for satellite clinics and staff, pregnancy surveillance.
What have we learned from communities lately?
Challenges and lessons
LESSONS:
Need appropriate expectations for the role of CHWs: MOH staff who are closest to the community are already thinly stretched.
• Should CHWs lead or only support CM efforts?
• Can existing community leaders, volunteers or members of civil society organizations feed input from communities to the health system?
• ‘Sharing the burden lightens the load’
Challenges and lessons
LESSONS:
Community mobilization competes with many other priorities (clinical training, infrastructure development) within a resource limited environment.
• Make every effort to integrate CM into broader national health strategies, especially when existing MOH policy calls for strong community engagement.
• When communities, CHWs and program managers experience results, the relative value of CM is compelling and support is more likely.
Challenges and lessons
LESSONS:
Community mobilization takes time. • Simplify the process as much as possible before you start and refine
further as you roll out. • As staff becomes more confident and skilled , CM processes speed up.
Good training is essential.• CM successes build momentum and can lead to organic expansion.• Communities and groups with prior experience organizing to solve
problems can move more quickly.
Challenges and lessons
LESSONS:
Community mobilization at scale takes thoughtful planning. It can be done when: • Designed with scale in mind• Effective training materials and guides are produced to support the
process• Financial and political support is available• Partners are interested in adopting the approach• Systems are in place to support capacity-building of program teams
(including monitoring and evaluation, training and ongoing technical assistance)
So how can we ensure communities are engaged?Questions:Why are communities consistently left out of the Household to
Hospital Continuum of Care (HHCC)?
What do we as PVOs/INGOs require to inspire and equip more partners to engage communities for improved MNH?
• More evidence on ‘how’ CM works?• More advocacy?